A Critique of the Criteria for the Diagnosis of Diffuse Malignant Mesothelioma

Our plain-English summary of A Critique of the Criteria for the Diagnosis of Diffuse Malignant Mesothelioma, by M. Kannerstein, W.T.E. McCaughey, J. Churg, et al (1977).

The study

• Authors: M. Kannerstein, W.T.E. McCaughey, J. Churg, I.J. Selikoff
• Published: The Mount Sinai Journal of Medicine 44(4):485-494 (1977)
• Type of article: Journal article
• Our copy: from Johns-Manville's own medical library. The article is still under copyright, so we describe it here rather than post it.

In plain English

This 1977 article is a critique, or expert review, of how diffuse malignant mesothelioma of the pleura (lining of the chest) and peritoneum (lining of the abdomen) is diagnosed. It reported no new statistical data. The authors drew on their combined experience of studying approximately a thousand cases diagnosed as mesothelioma, or tumors resembling it that were rejected. They wrote that the link between asbestos and this cancer requires accurate monitoring of how often it occurs, and that diagnostic errors could lead to over- or underestimating its frequency. They reviewed clinical signs, fluid tests, biopsy, the tumor's appearance to the eye and under the microscope, special stains, electron microscopy and autopsy. In their experience needle biopsy only rarely allowed a definite diagnosis, and even experts differed in their readings. Some other cancers, particularly peripheral lung adenocarcinoma, can imitate pleural mesothelioma. They ranked microscopic appearance first among the elements of diagnosis. The authors concluded that when features are uncharacteristic or contradictory the diagnosis must be qualified, and that the degree of certainty should be stated in the diagnosis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Expert review and critique of diagnostic criteria, based on the authors' collective experience and the published literature; no new quantitative study
• Who was studied: Approximately a thousand cases studied by the authors over a period of years, either diagnosed as mesothelioma with varying certainty or tumors resembling mesothelioma that were rejected. Localized mesothelioma and mesotheliomas of the pericardium and tunica vaginalis testis were not considered.
• Exposure: Asbestos exposure was not studied. It was mentioned only as the reason accurate diagnosis and monitoring of incidence are needed.
• Main results:
  • In the authors' experience, needle biopsy only rarely permitted a definite diagnosis of mesothelioma.
  • The authors wrote that, in their experience, there is a not insignificant variation between observers in diagnosing mesothelioma, even at a high level of expertise.
  • Peripheral pulmonary adenocarcinoma was described as the best documented imitator of pleural mesothelioma. In women, papillary serous adenocarcinoma of the ovary was an occasional problem in the peritoneum.
  • In fluid from effusions, a concentration of acid mucopolysaccharide (AMP) over 120 ug/l (as printed in the scan) that can be shown to be hyaluronic acid was called suggestive evidence of mesothelioma. The rest of this sentence is lost in the scan.
  • Unequivocal positive staining for epithelial (neutral) mucosubstance is held to exclude mesothelioma. The authors found the PAS stain after diastase (DPAS) more reliable than mucicarmine.
  • If material stained for acid mucosubstance is removed by hyaluronidase in whole or in significant part, the authors stated that the diagnosis of mesothelioma is confirmed.
  • The authors wrote that electron microscopy will probably not by itself allow definite categorization of all cases.
  • Autopsy was described as the most convincing way to exclude another primary tumor, but missing a hidden (occult) primary tumor remains a well-known hazard.
  • The authors ranked the elements of diagnosis with microscopic morphology first, followed by gross morphology, studies excluding another primary source, and history and other clinical aspects. If a tumor is very uncharacteristic microscopically or undifferentiated, the diagnosis should be qualified as probable at most.
• The authors' conclusion: The authors concluded that additional information beyond microscopic appearance is often needed, that the diagnosis must be qualified when features are uncharacteristic or contradictory, and that the degree of certainty should be specified in the diagnostic statement. They also stated that the association with asbestos demands reliable monitoring of trends in incidence.
• Limitations the authors state:
  • The authors noted that the extent to which mesothelioma cases go unrecognized is not well documented.
  • The authors stated it is not yet certain how far electron microscopy will clarify cases that cannot be diagnosed definitely by light microscopy.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleura, Peritoneum, Biopsy, Autopsy, Needle Biopsy, Lung Adenocarcinoma, Pleural Mesothelioma.

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