Today we discussed the evaluation of a new pleural effusion in the context of a history of smoking and possible occupational asbestos exposure. The approach to pleural effusions is reviewed here.
One interesting disease that was brought up today was malignant mesothelioma. Although most commonly found as a pleural based malignancy, mesothelioma is probably best described as a cancer of serosal surfaces and can rarely present as peritoneal disease with ascites or pericardial disease.
The incidence of malignant mesothelioma is expected to rise until at least 2020, an epidemiologic phenomenon that lags behind known exposure to asbestos. In fact, in parts of the developing world, asbestos is an ongoing exposure, and therefore mesothelioma may be an ongoing problem for many years.
The diagnosis of mesothelioma can be difficult, and the sensitivity of cytology of pleural or ascitic fluid is quite variable, ranging from 33-84%, often necessitating needle or thorascopic biopsy. The disease usually presents at an advanced stage when large effusions have reached the point of symptoms, and median survival is less than one year from the time of diagnosis. Management is typically palliative, and may include local management such as pleurodesis or chronic drainage, or systemic therapy. Occasionally surgery is required to manage complications of locally advanced disease.
A good NEJM review is available.
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