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Differentiation of diffuse malignant mesothelioma (DMM) from pleural carcinomatous metastases, e.g., of lung cancer (LC) may be difficult both for the clinician and the pathologist [1, 2] because of the limited diagnostic accuracy of radiologic criteria and conventional light microscopy including histochemistry [3,4]. Immunohistochemical detection of carcinoembryonic antigen (CEA) in tumor biopsy material has been shown to be a valuable diagnostic adjunct, as DMMs, unlike LCs and other carcinomas, express this antigen only rarely (9-11%) [5]. In some cases, however, the only method of obtaining suitable biopsy material is by open thoracotomy [2, 6]. Moreover, immunohistochemical examinations are expensive and not generally readily available. We therefore decided to find out what conclusions may be drawn from the much simpler determination of CEA levels in serum and in pleural effusion fluid (EF).We measured CEA in serum and EF using our own, and five commercially available radioimmunoassays or enzyme immunoassays (Abbott, Behringwerke, CIS, Roche, Pharmacia) with a serum level of 3 mg/L as the upper limit of reference values. In an initial partly retrospective study (learning phase), we examined patients with histologically proven DMM (n = 94) or LC (n = 79). Using ROC analysis, cutoff levels (serum CEA: 5.2 rag/L, EF CEA: 4.5 mg/L) were set so as to produce the most statistically significant differentiation (x2-test) between DMM and LC ( Table 1). The discrimination values specified and published [7] after the learning phase were then evaluated in a strictly prospective fashion in two additional sets of patients. From 1991 to 1992, we determined serum and EF CEA levels in 146 patients participating in the multicentric German DMM study, in all of whom the diagnosis of DMM had been reviewed by a panel of experienced pathologists. For comparison, we analyzed 124 patients who had presented with pleural effusions of unknown aetiology and had subsequently been shown to be suffering from metastatic carcinoma. There was a statistically significant difference between the DMM and the metastatic carcinoma group in terms of the frequency of elevated CEA levels (x2-test, p < 0.01) ( Table I). These results show that simple determination of CEA provides information that is useful for distinguishing between DMM

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Thirty-five non-pretreated patients (29 male, six female) with malignant pleural mesothelioma, median age of 68.5 years (range, 29 to 78 years) and a median performance status of 80% (range, 60% to 100%) were treated with 70 mg/m2 Pirarubicin. The treatment was repeated every 3 to 4 weeks (median duration per cycle, 23 days) up to progression or severe toxicity. The median cumulative dose given was 294 mg/m2, or 4.5 cycles. All patients were evaluable regarding response. Three partial remissions were achieved, leading to a remission rate of 8.6%. The median duration of remission was 6 months. Five patients achieved minor response, and a further 14 patients were stable under treatment with Pirarubicin. The median survival time was 10.5 months. Leukocytopenia was the main dose-limiting factor and 20% of the patients experienced World Health Organization (WHO) Grades III and IV. Anemia and thrombocytopenia were mild. Nausea and vomiting, WHO Grades I and II, were observed in 46% of all patients. Alopecia, Grades I and II, was seen in 47% and Grade III in 6%. No signs of cardiac dysfunction were detectable, except for cardiac arrhythmia in four patients (11%). Pirarubicin is an active drug in the treatment of pleural mesothelioma with fewer severe side effects than doxorubicin.