🔬 Malignant pleural mesothelioma (MPM) is a rare but aggressive tumour of the pleura.
🧱 Strongly associated with asbestos exposure (occupational in 70–80%).
⚠️ Long latency (20–50 years) between exposure and disease.
🚬 Smoking increases risk when combined with asbestos.

⚙️ Aetiology

☣️ Direct or indirect exposure to asbestos dust (shipbuilding, insulation, construction).
🏭 High-risk industries: shipyard workers, construction, asbestos miners.
Family members may be exposed indirectly (dust on work clothes).

🧑‍⚕️ Clinical Features

🫁 Thoracic: chest pain, pleuritic pain, dyspnoea, cough, weight loss, recurrent pleural effusions.
📉 Abdominal (peritoneal mesothelioma): pain, ascites, abdominal masses, weight loss.
❤️ Pericardial: chest pain, dyspnoea, pericardial effusion, arrhythmia.
General: fatigue, cachexia, anorexia.

CT scan of mesothelioma encasing the lung

🔬 Investigations

🧪 Bloods: FBC, U&E, LFTs, ESR (nonspecific).
🩻 CXR: pleural effusion, pleural thickening, asbestos plaques.
📊 CT chest: defines pleural masses, chest wall/mediastinal invasion, staging.
🧴 Pleural fluid cytology: often nondiagnostic.
🔎 Pleural biopsy: gold standard for histological confirmation.

💊 Management

🔪 Surgery: Extrapleural pneumonectomy (EPP) or pleurectomy/decortication in selected fit patients (usually combined with chemo ± radiotherapy).
💉 Chemotherapy: platinum analogues + pemetrexed (first-line). Improves survival and symptom control. Other agents: raltitrexed, doxorubicin.
☢️ Radiotherapy: palliative role for pain and symptom relief; may be adjuvant post-op.
🤲 Palliative care: repeated pleural drainage, indwelling pleural catheter, pain control, psychosocial support.

📌 Prognosis & Clinical Pearls

⏳ Median survival: ~9–18 months from diagnosis.
⚠️ Often presents late; cure is rare.
📍 Key OSCE pearl: pleural tumour in an older man with asbestos exposure → think mesothelioma.
💡 Histology types: epithelioid (better prognosis), sarcomatoid (worse), biphasic (mixed).
⚖️ Distinguish from benign asbestos-related pleural disease (plaques without invasive tumour).

📚 References

Malignant Pleural Mesothelioma: ESMO Clinical Practice Guidelines
Kumar & Clark’s Clinical Medicine, 10th edition.

🧾 Clinical Case Examples – Mesothelioma

Case 1 – Occupational Exposure 👷‍♂️ A 68-year-old retired shipyard worker presents with progressive shortness of breath, dull right-sided chest pain, and weight loss. Exam: reduced breath sounds and stony dullness to percussion over the right lower chest. Chest X-ray: large unilateral pleural effusion. Pleural aspiration: exudative, cytology inconclusive. 👉 Diagnosis: Likely malignant mesothelioma (confirmed on VATS biopsy). 👉 Key points: Strong asbestos exposure history, unilateral effusion, poor prognosis. 👉 Management: Palliative - pleurodesis for effusion control, chemotherapy (pemetrexed + cisplatin), symptom management.

Case 2 – Chest Wall Invasion 🫁 A 72-year-old man with past asbestos insulation work presents with severe chest wall pain, breathlessness, and fatigue. Exam: palpable hard mass over the left lateral chest wall, reduced chest expansion, clubbing. CT thorax: irregular pleural thickening encasing the lung, with invasion into chest wall muscles. Histology from pleural biopsy: epithelioid mesothelioma. 👉 Key points: Advanced disease with local invasion, chest pain dominant symptom. 👉 Management: Palliative care - analgesia (including nerve blocks), radiotherapy for pain, chemotherapy considered if fit.

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Malignant pleural mesothelioma

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