Malignant pleural mesothelioma. C. Boutin, M. Schlesser, C. Frenay, Ph. Astoul. ERS Journals Ltd 1998.

ABSTRACT: The incidence of malignant pleural mesothelioma (MPM) has risen for some decades and is expected to peak between 2010 and 2020. Up to now, no single treatment has been proven to be effective and death usually occurs within about 12–17 months after diagnosis. Perhaps because of this poor prognosis, early screening has incited little interest. However, certain forms may have a better prognosis when diagnosed early and treated by multimodal therapy or intrapleural immunotherapy. Diagnosis depends foremost on histological analysis of samples obtained by thoracoscopy. This procedure allows the best staging of the pleural cavity with an attempt to detect visceral pleural involvement, which is one of the most important prognostic factors. Although radiotherapy seems necessary and is efficient in preventing the malignant seeding after diagnostic procedures in patients, there has been no randomized phase III study showing the superiority of any treatment compared with another. However, for the early-stage disease (stage I) a logical therapeutic approach seems to be neoadjuvant intrapleural treatment using cytokines. For more advanced disease (stages II and III) resectability should be discussed with the thoracic surgeons and a multimodal treatment combining surgery, radiotherapy and chemotherapy should be proposed for a randomized controlled study. Palliative treatment is indicated for stage IV. In any case, each patient should be enrolled in a clinical trial. Eur Respir J 1998; 12: 972–981.

The term "mesothelioma" was first used in 1921 by EASTWOOD and MARTIN [1]to describe primary tumours of the pleura. At that time, the primary nature of these tumours was controversial without confirmation by autopsy. Today, the histological diagnosis of mesothelioma remains problematic and differential diagnosis against adenocarcinoma is difficult in 10–15% of cases despite the routine use of histochemistry.

The first evidence implicating asbestos in the pathogenesis of mesothelioma was presented in 1960 by WAGNER [2] in South African miners. The incidence of malignant pleural mesothelioma (MPM) has risen for some decades and is expected to peak sometime between 2010 and 2020 [3, 4]. This increase has been attributed to the widespread use of asbestos in the period from World War II until the end of the 1970s [5]. Pleural mesothelioma is more frequent than peritoneal mesothelioma, possibly because in-halation is the usual route of the pathogenic fibres.

No single treatment has been proven to be effective for malignant mesothelioma. Chemotherapy alone has no effect, radiation therapy simply provides palliation against pain, and surgery (even when performed at a relatively early stage) is controversial [6–10]. The value of the current staging system is questionable: after the first classification by BUTCHART et al. [8] the number of successive classifications provides evidence for the difficulty in distinguishing between the various stages of the disease [11–13].

Recent studies have reported good results using immunotherapy and surgery in patients graded as "early stage" according to a new system of classification [14, 15]. The purpose of the present article is to describe the current knowledge on mesothelioma.