Synopsis
Identify malignant pleural mesothelioma, obtain adequate tissue without avoidable procedural harm, and integrate pleural symptom control, oncological treatment and occupational support.
- Malignant pleural mesothelioma is a tumour of mesothelial surfaces, strongly associated with previous asbestos exposure and often appearing decades after the relevant work or environmental contact.
- Ask beyond job titles: construction, shipyards, lagging, demolition, railway work, boiler maintenance, asbestos-contaminated clothing and renovation of older buildings can all reveal exposure.
- Progressive unilateral chest pain, dyspnoea, weight loss and a recurrent unilateral pleural effusion are common; chest-wall restriction may become prominent as the pleura encases the lung.
Key red flags
Unilateral pleural effusion with nodular thickening, circumferential rind, mediastinal pleural involvement, fissural nodularity, volume loss or chest-wall invasion is concerning. Pleural plaques support asbestos exposure but neither prove nor exclude mesothelioma.
Investigation priorities
Confirm fluid and choose a safe pleural access site.
Management branches
Unexplained unilateral effusion or pleural thickening with clinical concern for malignancy.
- Take a detailed occupational, household and environmental exposure history while arranging thoracic ultrasound and contrast-enhanced pleural CT through the local rapid pleural pathway.
- Sample fluid once if present for biochemical, microbiological and cytological assessment, but anticipate that mesothelioma often requires tissue and avoid serial low-yield aspirations.
Key medicines
Nivolumab plus ipilimumabAdminister only in a specialist oncology service using the current authorised schedule, NICE eligibility criteria and local immunotherapy protocol.
Platinum plus pemetrexed chemotherapyUse the current oncology regimen with renal, marrow and performance-status assessment plus protocol-mandated folate, vitamin and antiemetic support.