Malignant mesothelioma

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Malignant mesothelioma
Diagnosis in short

Malignant mesothelioma. H&E stain.

LM infiltrative atypical cells (epithelioid, spindled or both)
Subtypes biphasic mesothelioma, epithelioid mesothelioma, desmoplastic mesothelioma, sarcomatoid mesothelioma.
LM DDx mesothelial hyperplasia, fibrosing pleuritis, adenocarcinoma - esp. lung, serous carcinoma
IHC calretinin +ve, D2-40 +ve, CK5/6 +ve, WT-1 +ve, CK7 +ve, CEA -ve, TTF-1 -ve
Molecular +/-p16 deletion
Site lung, peritoneum, omentum, pericardium

Associated Dx asbestosis
Clinical history +/-asbestos exposure
Prevalence rare
Prognosis very poor

Malignant mesothelioma, also mesothelioma, is a form of cancer. It arises from the mesothelium.

It should not be confused with benign multicystic mesothelioma and benign papillary mesothelioma.


  • Incidence
    • Rare tumor accounting for 4-7 cases per million individuals.
    • More common in men in 5th and 6th decades of life.
  • Poor prognosis[1] - median survival <12 months.[2]



  • Strong association with asbestos exposure.


  • +/-Surgical debulking (cytoreduction) with heated chemotherapy - for intraperitoneal mesothelioma.[4]



Conditions associated with asbestos exposure (mnemonic PALM):[6]

Possible association with asbestos exposure:



  • Infiltrative atypical cells - key feature.
    • Infiltration into fat - diagnostic.
    • +/-Epithelioid cells - may be cytologically bland, i.e. benign appearing.
      • Variable architecture: sheets, microglandular, tubulopapillary.
      • +/-Psammoma bodies.
    • +/-Spindle cells.
  • +/-Ferruginous body - strongly supportive.[9]
    • Looks like a (twirling) baton - segemented appearance, brown colour.
    • Thin (asbestos) fiber in the core.


  • Asbestos body is not strictly speaking a synonym for ferruginous body.
  • Don't diagnose mesothelioma in situ.[citation needed]

DDx:[10] [11]




List of subtypes - mnemonic BEDS:[10][8]

  • Biphasic mesothelioma.
    • 10%+ of epithelioid & 10%+ sarcomatoid.
  • Epithelioid mesothelioma.
  • Desmoplastic mesothelioma.
    • Should be 50%+ dense tissue with storiform pattern & atypical cells.
  • Sarcomatoid mesothelioma.


  • Small cell mesothelioma.[12]


  • PASD -ve.
  • Mucicarmine -ve.
    • Typically +ve in adenocarcinoma.


Mesothelioma versus mesothelial hyperplasia


  • EMA +ve ~100% (vs. ~10%).
  • Desmin -ve ~5% (vs. ~85%).
  • GLUT1 +ve ~50% (vs. ~10%).
  • p53 +ve ~50% (vs. ~2%).
  • BAP1 -ve[14] ~57%.[15]


  • The above are not very useful in individual cases.
  • A simple pankeratin is useful for seening where epithelial cells are.

Mesothelioma versus adenocarcinoma

  • Several panel exists - no agreed upon best panel.[16]
    • Usually two carcinoma markers + two mesothelial markers.


  • Mesothelial markers:
    • Calretinin.
    • WT-1.
    • D2-40.
    • CK5/6.
  • Carcinoma markers:

Other carcinoma markers



  • p16 IHC does not give the same result.
  • Sensitivity of p16 deletion is low.

Sign out

Pleural Tissue of Right Lung, Removal:
- MALIGNANT MESOTHELIOMA, epithelioid type.

IHC confirms the morphologic impression. 

The tumour stains as follows:
POSITIVE: calretinin (very strong), CK5/6.

See also


  1. Haber, SE.; Haber, JM. (2011). "Malignant mesothelioma: a clinical study of 238 cases.". Ind Health 49 (2): 166-72. PMID 21173534.
  2. Mineo, TC.; Ambrogi, V. (Dec 2012). "Malignant pleural mesothelioma: factors influencing the prognosis.". Oncology (Williston Park) 26 (12): 1164-75. PMID 23413596.
  3. Sardar, MR.; Kuntz, C.; Patel, T.; Saeed, W.; Gnall, E.; Imaizumi, S.; Lande, L. (2012). "Primary pericardial mesothelioma unique case and literature review.". Tex Heart Inst J 39 (2): 261-4. PMID 22740748.
  4. Wong J, Koch AL, Deneve JL, Fulp W, Tanvetyanon T, Dessureault S (May 2014). "Repeat cytoreductive surgery and heated intraperitoneal chemotherapy may offer survival benefit for intraperitoneal mesothelioma: a single institution experience". Ann. Surg. Oncol. 21 (5): 1480–6. doi:10.1245/s10434-013-3341-7. PMID 24158467.
  5. Offermans, NS.; Vermeulen, R.; Burdorf, A.; Goldbohm, RA.; Kauppinen, T.; Kromhout, H.; van den Brandt, PA. (Jan 2014). "Occupational asbestos exposure and risk of pleural mesothelioma, lung cancer, and laryngeal cancer in the prospective Netherlands cohort study.". J Occup Environ Med 56 (1): 6-19. doi:10.1097/JOM.0000000000000060. PMID 24351898.
  6. Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 375. ISBN 978-1416054542.
  7. Reid, A.; Heyworth, J.; de Klerk, N.; Musk, AW. (Nov 2009). "Asbestos exposure and gestational trophoblastic disease: a hypothesis.". Cancer Epidemiol Biomarkers Prev 18 (11): 2895-8. doi:10.1158/1055-9965.EPI-09-0731. PMID 19900938.
  8. 8.0 8.1 Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 156. ISBN 978-0781765275.
  9. URL: Accessed on: 4 November 2011.
  10. 10.0 10.1 Corson, JM. (Nov 2004). "Pathology of mesothelioma.". Thorac Surg Clin 14 (4): 447-60. doi:10.1016/j.thorsurg.2004.06.007. PMID 15559051.
  11. Bégueret, H.; Galateau-Salle, F.; Guillou, L.; Chetaille, B.; Brambilla, E.; Vignaud, JM.; Terrier, P.; Groussard, O. et al. (Mar 2005). "Primary intrathoracic synovial sarcoma: a clinicopathologic study of 40 t(X;18)-positive cases from the French Sarcoma Group and the Mesopath Group.". Am J Surg Pathol 29 (3): 339-46. PMID 15725802.
  12. Mayall, FG.; Gibbs, AR. (Jan 1992). "The histology and immunohistochemistry of small cell mesothelioma.". Histopathology 20 (1): 47-51. PMID 1310669.
  13. Hasteh, F.; Lin, GY.; Weidner, N.; Michael, CW. (Apr 2010). "The use of immunohistochemistry to distinguish reactive mesothelial cells from malignant mesothelioma in cytologic effusions.". Cancer Cytopathol 118 (2): 90-6. doi:10.1002/cncy.20071. PMID 20209622.
  14. Pulford E, Huilgol K, Moffat D, Henderson DW, Klebe S (2017). "Malignant Mesothelioma, BAP1 Immunohistochemistry, and VEGFA: Does BAP1 Have Potential for Early Diagnosis and Assessment of Prognosis?". Dis Markers 2017: 1310478. doi:10.1155/2017/1310478. PMC 5612603. PMID 29085180.
  15. Andrici J, Sheen A, Sioson L, Wardell K, Clarkson A, Watson N, Ahadi MS, Farzin M, Toon CW, Gill AJ (October 2015). "Loss of expression of BAP1 is a useful adjunct, which strongly supports the diagnosis of mesothelioma in effusion cytology". Mod Pathol 28 (10): 1360–8. doi:10.1038/modpathol.2015.87. PMC 4761613. PMID 26226841.
  16. 16.0 16.1 Marchevsky AM (March 2008). "Application of immunohistochemistry to the diagnosis of malignant mesothelioma". Arch. Pathol. Lab. Med. 132 (3): 397-401. PMID 18318582.
  17. Lee M, Alexander HR, Burke A (August 2013). "Diffuse mesothelioma of the peritoneum: a pathological study of 64 tumours treated with cytoreductive therapy". Pathology 45 (5): 464–73. doi:10.1097/PAT.0b013e3283631cce. PMID 23846294.
  18. Ohta Y, Sasaki Y, Saito M, et al. (October 2013). "Claudin-4 as a marker for distinguishing malignant mesothelioma from lung carcinoma and serous adenocarcinoma". Int. J. Surg. Pathol. 21 (5): 493–501. doi:10.1177/1066896913491320. PMID 23775021.
  19. Pu, RT.; Pang, Y.; Michael, CW. (Jan 2008). "Utility of WT-1, p63, MOC31, mesothelin, and cytokeratin (K903 and CK5/6) immunostains in differentiating adenocarcinoma, squamous cell carcinoma, and malignant mesothelioma in effusions.". Diagn Cytopathol 36 (1): 20-5. doi:10.1002/dc.20747. PMID 18064689.
  20. Chu, PG.; Arber, DA.; Weiss, LM. (Jul 2003). "Expression of T/NK-cell and plasma cell antigens in nonhematopoietic epithelioid neoplasms. An immunohistochemical study of 447 cases.". Am J Clin Pathol 120 (1): 64-70. doi:10.1309/48KC-17WA-U69B-TBXQ. PMID 12866374.
  21. Hwang H, Tse C, Rodriguez S, Gown A, Churg A (May 2014). "p16 FISH deletion in surface epithelial mesothelial proliferations is predictive of underlying invasive mesothelioma". Am. J. Surg. Pathol. 38 (5): 681–8. doi:10.1097/PAS.0000000000000176. PMID 24503757.