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British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma
  1. Ian Woolhouse1,
  2. Lesley Bishop2,
  3. Liz Darlison3,
  4. Duneesha De Fonseka4,
  5. Anthony Edey5,
  6. John Edwards6,
  7. Corinne Faivre-Finn7,
  8. Dean A Fennell8,
  9. Steve Holmes9,
  10. Keith M Kerr10,
  11. Apostolos Nakas11,
  12. Tim Peel12,
  13. Najib M Rahman13,
  14. Mark Slade14,
  15. Jeremy Steele15,
  16. Selina Tsim16,
  17. Nick A Maskell17
  1. 1Department of Respiratory Medicine, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
  2. 2Respiratory, Queen Alexandra Hospital, Portsmouth, UK
  3. 3Respiratory Medicine, University Hospitals of Leicester, Leicester, UK
  4. 4Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
  5. 5North Bristol NHS Trust, Bristol, UK
  6. 6Sheffield Teaching Hospitals, Sheffield, UK
  7. 7Division of Cancer Services, University of Manchester, Manchester, UK
  8. 8University of Leicester & University Hospitals of Leicester, Leicester, UK
  9. 9The Park Medical Practice, Shepton Mallet, Somerset, UK
  10. 10University of Aberdeen, Pathology, Aberdeen, UK
  11. 11Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
  12. 12North Tyneside General Hospital, North Shields, UK
  13. 13Oxford NIHR Biomedical Research, University of Oxford, Oxford, UK
  14. 14Papworth Hospital, Thoracic Oncology, Cambridge, UK
  15. 15Cancer, St Bartholomew’s Hospital, London, UK
  16. 16Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, UK
  17. 17Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
  1. Correspondence to Professor Nick A Maskell, Academic Respiratory Unit, Bristol Medical School, University of Bristol, BS10 5NB, UK; nick.maskell{at}

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Summary of recommendations and good practice points

Section 3: Clinical features which predict the presence of mesothelioma


  • Do not rule out a diagnosis of malignant pleural mesothelioma (MPM) on the basis of symptoms and examination findings alone. Grade D.

  • Offer an urgent chest X-ray to patients with symptoms and signs as outlined in the National Institute for Health and Care Excellence (NICE) NG12. Grade D.

  • Refer all patients with a chest X-ray suggestive of MPM urgently (via the 2-week wait suspected cancer pathway in England and Wales). Consider referral for further investigation in patients with persistent symptoms and history of asbestos exposure despite normal chest X-ray. Grade D.

  • A thorough occupational history should be taken to cover all occupations throughout life. It is important to elicit para exposure by exploring details of relative and/or partner occupations. Grade D.

Section 4: Staging systems


  • Record staging of MPM according to the version 8 of the International Association for the Study of Lung Cancer (IASLC) staging proposals. Grade D.

Section 5: Imaging modalities for diagnosing and staging


  • Offer CT thorax with contrast (optimised for pleural evaluation) as the initial cross-sectional imaging modality in the evaluation of patients with suspected MPM. Grade D.

  • Use of positron emission tomography (PET)-CT for aiding diagnosis of MPM is not recommended in patients who have had prior talc pleurodesis and caution should be employed in populations with a high prevalence of TB. Grade D.

  • In patients where differentiating T stage will change management, consider MRI. Grade D.

  • In patients where excluding distant metastases will change management, offer PET-CT. Grade D.

Section 6: Pathological diagnosis


  • Immunohistochemistry (IHC) is recommended for the differential diagnosis of MPM in both biopsy and cytology-type specimens. Grade D.

  • A combination of at least two positive mesothelial (calretinin, cytokeratin 5/6, Wilms tumour 1, D-240) and at least two …

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