Synopsis
Recognise asbestos-related pleural malignancy, obtain adequate image-guided or thoracoscopic tissue, control recurrent effusion and pain and coordinate systemic, local, occupational and palliative care.
- Malignant pleural mesothelioma is a diffuse pleural cancer strongly linked to asbestos exposure after a latency often exceeding several decades.
- Key features are progressive unilateral chest pain, breathlessness, recurrent unilateral exudative effusion, pleural nodularity or rind and loss of hemithoracic volume.
- Take a detailed lifetime exposure history including job tasks, employers, dates, work clothing, home renovation and para-occupational contact; smoking does not cause mesothelioma.
- First-line imaging is contrast-enhanced CT thorax with pleural protocol and upper-abdominal coverage; ultrasound guides fluid and pleural sampling.
- Histological core or thoracoscopic pleural biopsy is the diagnostic reference when the patient can tolerate it; do not rely on negative or equivocal cytology alone.
- For recurrent symptomatic effusion, choose talc pleurodesis when lung expands or an indwelling pleural catheter when trapped lung, preference or outpatient control favours it.
- Systemic treatment is selected from platinum-pemetrexed and current immunotherapy options by histology, performance, comorbidity and NICE eligibility; radical surgery is not routine.
- Offer early specialist pain and palliative care and discuss occupational documentation, compensation and benefit routes without making legal support a substitute for clinical treatment.
Key red flags
Progressive unilateral chest pain and breathlessness with a recurrent unilateral pleural effusion or diffuse pleural thickening requires urgent pleural investigation.
A history of construction, shipyard, insulation, boiler, railway, military, factory or secondary household asbestos exposure matters even decades later.
Severe breathlessness or mediastinal shift after a pleural procedure raises pneumothorax, haemothorax or re-expansion complication.
Fever, purulent drainage, pleuritic pain or sepsis with an indwelling pleural catheter suggests pleural infection.
New leg swelling, pleuritic pain, syncope or unexplained oxygen requirement raises cancer-associated venous thromboembolism.
Acute hypoxaemia, severe pain, bleeding or sepsis after biopsy, drain or catheter requires urgent pleural and surgical assessment.
Investigation priorities
Characterise pleural tumour, fluid, lung, nodes and invasion and identify a safe biopsy site.
Management branches
CT and clinical features suggest mesothelioma.
- Take a lifetime task-based asbestos history, assess performance and goals and review contrast CT with the pleural MDT.
- Drain only the amount needed for symptoms and diagnosis while planning image-guided core or thoracoscopy that will provide adequate tissue and stage information.
- Classify epithelioid, sarcomatoid or biphasic disease with specialist pathology and complete only the staging tests capable of changing treatment.