Pleural Mesothelioma Diagnosis for the Pulmonologist: Steps Along the Way

Our plain-English summary of Pleural Mesothelioma Diagnosis for the Pulmonologist: Steps Along the Way, by A. Fantin, N. Castaldo, E. Crisafulli, et al (Cancers, 2025).

The study

• Authors: A. Fantin, N. Castaldo, E. Crisafulli, G. Sartori, F. Patrucco, H.B. Grosu, P. Vailati, G. Morana, V. Patruno, S. Kette, A. Aujayeb, A. Rozman
• Journal: Cancers
• Published: 2025;17(23)
• Type of article: Review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background/Objectives: Malignant pleural mesothelioma (MPM) is a rare, aggressive tumor with a poor prognosis and complex diagnostic pathways. Pulmonologists often play a central role in its initial recognition and investigation. This narrative review synthesizes the current evidence on the diagnostic approach to MPM, with emphasis on imaging, tissue sampling, histopathology, and emerging diagnostic innovations relevant to clinical pulmonology. Methods: English-language studies published between January 2005 and June 2025 were identified from PubMed and Scopus. International guidelines and consensus documents were also reviewed to provide an updated overview of diagnostic strategies. Results: Diagnosis of MPM relies on a stepwise integration of clinical, radiological, and pathological information. Thoracic ultrasound, computed tomography, positron emission computed tomography and magnetic resonance imaging complement each other across different stages of the diagnostic pathway. Image-guided pleural biopsy and medical thoracoscopy remain the gold standard for tissue confirmation, supported by immunohistochemistry and molecular testing. The 2021 World Health Organization classification of pleural tumors and the International Association Study of Lung Cancer 9th Edition Tumour-Node-Mestastatis system have refined histologic and staging criteria, thereby improving reproducibility and prognostic accuracy. Emerging tools, including liquid biopsy, novel serum and molecular biomarkers, artificial-intelligence-based radiomics, and breathomics, offer promise for earlier and less invasive diagnosis but require prospective validation. Conclusions: Current advances are redefining MPM diagnosis toward integrated, multidisciplinary, and precision-based models. Future priorities include standardizing diagnostic algorithms, validating minimally invasive biomarkers, and integrating AI and molecular profiling into clinical workflows to enhance patient stratification.

In plain English

This narrative review, written for lung specialists (pulmonologists), described how malignant pleural mesothelioma (MPM), a cancer of the lining around the lungs, is diagnosed. The authors searched PubMed and Scopus for English-language studies in adults published from January 2005 to June 2025, reviewed international guidelines, and added other references they considered significant. The review stated that occupational asbestos exposure remains the principal cause of MPM. It covered imaging, fluid and tissue sampling, tissue classification, staging and newer tests. Drawing on earlier studies, it reported sensitivities for MPM of 6% to 45% for pleural fluid cytology, 80–88% for CT-guided biopsy and 40–83% for ultrasound-guided biopsy. For medical thoracoscopy it gave 92–95% for detecting pleural malignancy in general, including MPM. It described thoracoscopy as having a complication rate of 2–7% when performed by experienced operators. Tumor seeding along procedure tracts in MPM was reported in up to 26%. Artificial-intelligence tools were called investigational, and a cited guideline said no blood biomarker should replace tissue diagnosis. The authors concluded that future progress depends on standardizing diagnostic algorithms. They noted their reference list was not necessarily all-encompassing.

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: Narrative review of the literature and international guidelines on the diagnosis of malignant pleural mesothelioma
• Who was studied: Published English-language human studies in adults on the diagnostic pathway of MPM, from PubMed and Scopus, January 2005 to June 2025, plus guidelines and other references the authors considered significant. The number of included studies is not stated in the text.
• Exposure: The review focused on diagnosis rather than exposure. It stated that occupational asbestos exposure is the principal cause of MPM. It named no specific asbestos fiber types, and it mentioned erionite fibers and ionizing radiation as other potential contributors.
• Main results:
  • Citing earlier studies, the review reported that the sensitivity of pleural fluid cytology for MPM ranged from 6% to 45%.
  • Citing earlier studies, the section on biopsy in MPM reported a sensitivity of 80–88% for CT-guided pleural biopsy and 40–83% for ultrasound-guided pleural biopsy.
  • Citing earlier studies, the review reported that medical thoracoscopy had a sensitivity of 92–95% for detecting pleural malignancy in general (including MPM, not MPM alone), with specificity approaching 100%.
  • The review described medical thoracoscopy as having a complication rate of 2–7% and mortality below 0.1% when performed by experienced operators.
  • Tumor tract seeding was reported as more frequent in MPM than in other tumor types, reaching up to 26%.
  • The review reported that the British Thoracic Society guideline recommends that no circulating biomarker replace tissue diagnosis, because of low sensitivity and specificity.
  • The authors stated that artificial-intelligence-based tools should still be regarded as investigational.
• The authors' conclusion: The authors concluded that MPM diagnosis still faces challenges in earlier and more accurate detection. In their view, future progress depends on standardizing diagnostic algorithms, expanding multicenter collaborations, and embedding AI-driven analysis into clinical workflows.
• Limitations the authors state:
  • The authors stated that the list of included references is not necessarily all-encompassing.
  • Beyond the database search, the authors added other references they considered significant.

Topics

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Prognosis, Histopathology, Pulmonology, Ultrasound, Pleural Biopsy, Medical Thoracoscopy, Immunohistochemistry.

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