Practical approaches to diagnose and treat for T0 malignant pleural mesothelioma: a proposal for diagnostic total parietal pleurectomy

Abstract

Malignant pleural mesothelioma (MPM) remains suffering poor prognosis in spite of recent diagnostic and therapeutic progress. Although there is currently no established evidence, early diagnosis and early intervention may play a key role to improve prognosis of MPM, similarly to other malignancies. As pleural effusion is usually the first clinical sign of MPM, pleural effusion cytology is often the first diagnostic examination to be carried out. Since the sensitivity of pleural effusion cytology is approximately 60%, however, false-negative diagnosis is given to almost half of true MPM patients at this clinical step. One practical way to reduce the number of misdiagnosed MPM is to encourage performing thoracoscopic pleural biopsy unless definitive diagnosis other than MPM is established. There still remain a considerable number of patients with radiological/thoracoscopic T0 MPM who are misdiagnosed with nonspecific pleuritis after a complete investigation including thoracoscopic biopsies. Such patients will turn out to be malignant during follow-up period, although they have the best opportunity for long-term survival if only early therapeutic intervention is given. Currently, we are performing diagnostic total parietal pleurectomy in highly selected patients, who are characterized with strong clinical suspicion, positive pleural effusion cytology but uncertain pathological diagnosis, excellent cardiopulmonary reserve, and with written informed consent for highly invasive diagnostic surgery for pathologically unproven disease.

Analysis of early pleural fluid samples in patients with mesothelioma: A case series exploration of morphology, BAP1, and CDKN2A status with implications for the concept of mesothelioma in situ in cytology

“…It has been suggested that this early identification may allow for treatment before the development of invasive disease 23 . Surgical interventions, such as total parietal pleurectomy, have been proposed for T0 mesothelioma in the past 35 . A recent survey of pathologists working within the field of mesothelioma regarding their knowledge of treatments used in the management of patients with MIS described a range—with most patients having no intervention, some having radiation, others receiving chemotherapy and various surgical procedures, including decortication and extrapleural pneumonectomy 36 .…”

Metastasis of Sarcomatoid Malignant Mesothelioma With p16/CDKN2A Deletion Manifested as a Subcutaneous Mass in the Back: A Case Report and Review of Literature

“…8 Sometimes, a video-assisted thoracoscopic surgery is necessary for a deep and large biopsy and assessment of its respectability. 9,10 The International Mesothelioma Interest Group recommends that at least 2 mesothelial (calretinin, CK5 or 5/6, WT1, and podoplanin) and 2 carcinoma markers (Claudin 4, MOC31, CEA, BER-EP4, BG8, TTF-1, and Napsin A) for IHC differential diagnosis. 11 Recent studies showed that BRCA1-associated protein-1 (BAP-1) mutations and p16 deletions by FISH were reliable in differentiating MMs from benign reactive mesothelial proliferations.…”

Metastasis of Sarcomatoid Malignant Mesothelioma With p16/CDKN2A Deletion Presented as a Subcutaneous Mass in the Back: a Case Report and Review of Literature

“…In many cases, only cytological material or a limited amount of tissue is available for pathologic evaluation [8]. Sometimes, video-assisted thoracoscopic surgery (VATS) is necessary for a deep and large biopsy and assessment of its respectability [9,10]. The International Mesothelioma Interest Group recommends that at least 2 mesothelial (calretinin, CK 5 or 5/6, WT1 and podoplanin) and 2 carcinoma markers (Claudin 4, MOC31, CEA, BER-EP4, BG8, TTF-1 and Napsin A) for IHC differential diagnosis [11].…”