Introduction Mesothelioma is often associated with areas of heavy industry. These areas generally have easy access to cardiothoracic facilities providing comprehensive services. We reviewed our experience of mesothelioma in the most rural part of Scotland to identify associated occupations and establish what effect configuration of local services, and the distance to the nearest thoracic surgical service had on clinical management.

Methods From 2010 the details of all patients in Highland with pleural mesothelioma have been recorded. The case notes of these patients were reviewed. Those who had presented and been investigated elsewhere were excluded. Information on occupation, investigations selected, treatment given, and survival were recorded.

Results We identified 47 mesothelioma patients. Of these 10 patients were excluded because of non-availability of notes, peritoneal mesothelioma, or presentation and investigation elsewhere. Of the remaining 37 cases the mean age at diagnosis was 71 years, 86% were male, and occupations included electricians, engineers, sheet metal workers, plumbers, joiners, builders, and shipyard workers. Two patients had been exposed in the nuclear industry. Fourteen patients underwent Abram’s pleural biopsy, of which 2 (14%) were diagnostic, 18 patients had CT guided biopsy of which 12 (67%) were diagnostic, and 13 patients had thorascopic biopsy of which 10 (77%) were diagnostic. Median survival was 10.9 months (interquartile range 12.6 months). Those with performance status (PS) 0 had median survival of 31.7 months, and PS 1, 8.8 months (P < 0.001 PS 0 Vs PS 1). For patients PS 0–2 who received at least 1 cycle of chemotherapy median survival was 12.9 months compared with 5 months without. All were discussed in MDT meetings. 25 patients had identifiable asbestos exposure, but only in 9 of these (36%) was there clear documentation that asbestos compensation advice had been given.

Conclusions The Scottish Highlands is affected by mesothelioma despite the rural setting. Abram’s pleural biopsy is not an effective technique for suspected mesothelioma and is not appropriate even if access to thorascopic biopsy involves considerable travel. The prognosis remains poor, and although survival is better in patients who receive chemotherapy, this could be explained by pre-existing differences in those selected for chemotherapy.