Imaging of Malignant Pleural Mesothelioma:

Pearls and Pitfalls

Chad D. Strange, MD, Girish S. Shroff, MD, Jitesh Ahuja, MD, Ioannis Vlahos, MD,
Marcelo F.K. Benveniste, MD, and Mylene T. Truong, MD

Malignant pleural mesothelioma is a rare tumor arising from the pleural mesothelial cells.
Imaging plays a crucial role in the diagnosis, staging, and management of patients with
mesothelioma. Accurate staging to stratify patients into homogeneous groups is required to
evaluate the effectiveness of multimodality therapeutic regimens. CT and PET/CT are rec-
ommended for the initial staging of MPM. MRI adds value to further assess invasion of the
tumor into the diaphragm, chest wall, and mediastinum. This review will discuss pearls and
pitfalls in the imaging of mesothelioma with emphasis on the roles of CT, MRI, and PET/CT.
Semin Ultrasound CT MRI 42:542-551 © 2021 Elsevier Inc. All rights reserved.

Introduction homogeneous groups is required to evaluate the effectiveness

of multimodality therapeutic regimens. Imaging plays a cru-

M alignant mesothelioma is a rare tumor that arises from

the mesothelial cells lining the pleura, pericardium,
peritoneum and tunica vaginalis.1 Malignant pleural meso-
thelioma (MPM) is not only the most common, accounting
for 70%-90% of all malignant mesotheliomas, and but also
the most common primary pleural neoplasm. In the United
States, approximately 3000 new cases are diagnosed each
year. The median overall survival of patients with advanced
surgically unresectable disease is approximately 12 months.2
Due to the rarity of this tumor, large randomized trials, par-
ticularly for mesothelioma surgical treatment, are not feasi-
ble. For the majority of patients, the mainstay of treatment is
systemic chemotherapy. For the minority of patients who are
surgical candidates, surgery is performed as part of multimo-
dality treatment regimens comprising chemotherapy with or
without radiation therapy. The greatest survival benefit in
patients with MPM after surgery is seen in those with epithe-
lial histology, a primary tumor that is limited in extent, and
no nodal metastases. Conversely, patients with sarcomatoid
histology and nodal metastases have a poor survival benefit
after surgery and are typically primarily treated with palliative
chemotherapy. Accurate staging to stratify patients into
Department of Thoracic Imaging, MD Anderson Cancer Center, Houston,
TX.
Address reprint requests to Chad D. Strange, MD, Department of Thoracic
Imaging, MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit
1478 FCT 15.5078, Houston TX, 77030-4008. E-mail:
cdstrange@mdanderson.org
cial role in the diagnosis, staging, and management of
patients with malignant pleural mesothelioma. Computed
tomography (CT) and F-18 fluorodeoxyglucose positron
emission tomography /computed tomography (FDG PET/
CT) are recommended for the initial staging of MPM. Mag-
netic resonance imaging (MRI) adds value to further assess
invasion of the tumor into the diaphragm, chest wall, and
mediastinum. This review will discuss pearls and pitfalls in
the imaging of malignant pleural mesothelioma with empha-
sis on the roles of CT, MRI, and PET/CT and the descriptors
outlined in the eighth edition of the Tumor Node Metastasis
(TNM) staging system.
Clinical Presentation and Risk
Factors
The relationship between asbestos exposure and mesotheli-
oma varies with gender, type of asbestos fiber, and source of
exposure. MPM occurs more frequently in men than women
with a ratio of 4:1. The risk of MPM from the three forms of
asbestos is approximately 1:100:500 for chrysotile, amosite,
and crocidolite, respectively 3. However, chrysotile is more
widely used, and thus, accounts for the majority of cases.
Occupations at highest risk include insulation work, asbestos
production and manufacture, heating industry, shipyard
work, construction, and automotive brake-lining manufac-
ture and repair. Occupational exposure to asbestos accounts

542 https://doi.org/10.1053/j.sult.2021.04.011
0887-2171/© 2021 Elsevier Inc. All rights reserved.
Imaging of Malignant Pleural Mesothelioma 543

Figure 1 Pleural thickening and pleural effusion. A 69-year-old woman with right pleural thickening and small right
pleural effusion. Noncontrast CT (A) shows a small right pleural effusion. Thoracentesis showed no malignant cells.
Axial PET/CT (B) shows FDG avid focus localized to the right lateral pleural thickening (arrow) just above the dia-
phragm concerning for malignancy. Due to the suspicious PET/CT finding, the patient proceeded to video-assisted
pleural biopsy which confirmed malignant cells. PET/CT is useful to guide pleural biopsy if clinical suspicion is high
and thoracentesis is negative.

for 85%-90% of men with MPMs and 40% of women with
MPMs.4 The overall incidence of MPM is approximately 1 in
100,000 in the United States and 1-3 in 100,000 in Europe.
Due to the long latency period of approximately 20-40 years
from the time of asbestos exposure, patients are typically
older at presentation, with a median age of 63 years.
Patients present with progressive symptoms of dyspnea,
chest wall pain and/or pleurisy.5,6 The disease is typically
confined to the ipsilateral pleura. The mainstay of the diag-
nostic workup involves a detailed occupational history, imag-
ing and tissue diagnosis.
Tissue Diagnosis
Patients with malignant pleural mesothelioma present with
pleural effusion or pleural thickening. Tissue diagnosis is
important in the evaluation of patients with suspected malig-
nant pleural mesothelioma. The most recent and largest pro-
spective study of 921 patients showed the overall sensitivity
of pleural fluid cytology was 46%, with variation according
to the tumor of origin: mesothelioma (6%), squamous cell
lung cancer (14%), and sarcomas (0%) having significantly
lower sensitivities.7 Specifically, in male patients with prior
exposure to asbestos and exudative pleural effusions, in
whom the likelihood of mesothelioma was at least 60%,
pleural fluid cytological sensitivity was only 11% in the study
by Arnold et al.7 According to the American Society of Clini-
cal Oncology (ASCO) Clinical Practice Guideline, the diagno-
sis of mesothelioma should be based on pleural biopsies
obtained via thoracoscopy or CT guidance.8 Cytologic evalu-
ation of pleural fluid can be an initial screening test for meso-
thelioma, but it is not a sufficiently sensitive diagnostic test.
In patients for whom antineoplastic treatment is planned, it
is strongly recommended that a thoracoscopic biopsy should
be performed to (1) enhance the information available for
clinical staging; (2) allow for histologic confirmation of the
diagnosis; (3) enable more accurate determination of the
pathologic subtype of mesothelioma (epithelial, sarcomatoid,
biphasic); and (4) make material available for additional
studies (eg, molecular profiling).8 In this regard, PET/CT can
add value by identifying sites with the highest yield for pleu-
ral biopsy (Fig. 1). Immunohistochemical analysis of tumor
biomarkers helps to distinguish malignant pleural mesotheli-
oma from pleural metastatic disease and benign, reactive
mesothelial proliferations.
Imaging of Pleural Disease
Chest radiography is often the initial imaging modality to
suggest MPM. Unilateral pleural effusions are the most com-
mon finding, seen in 30%-80% of patients. Pleural thicken-
ing is seen in 60% of patients followed by pleural masses in
45%-60%.9 Curvilinear calcified pleural plaques represent
benign asbestos-related pleural disease.10 Imaging features
that favor a malignant etiology include nodular or circumfer-
ential pleural thickening, greater than 1 cm in pleural thick-
ness, and involvement of the mediastinal pleura (Fig. 2).11
CT
CT is the primary imaging modality in the evaluation of
MPM and contrast-enhanced CT chest is recommended by
the ASCO guidelines for initial staging. CT is used to deter-
mine the extent of the primary tumor including local inva-
sion of the mediastinum, pericardium, diaphragm or chest
wall, intrathoracic adenopathy, and extrathoracic spread.
Unilateral pleural effusions (74%) and nodular pleural thick-
ening (92%) are the most common CT findings in MPM.12
MPM arises from the parietal pleura and spreads along the
pleural surfaces including the fissures if the visceral pleura is
involved, growing as a “rind” along the pleura.13 Mediastinal
invasion is suggested when there is loss of normal fat and
544 C.D. Strange et al.

Figure 2 CT features of malignant pleural disease. A 39-year-old man with right MPM. Frontal chest radiograph (A) and
axial contrast enhanced CT (B) show the features of malignant pleural disease, including nodular configuration, cir-
cumferential distribution (white asterisks) with extension into the fissure (one black asterisk for minor fissure, two
black asterisks for major fissure), and pleural thickness greater than 1 cm. Right nodular pleural thickening forms a
rind of tumor encasing the right lung.

tissue planes and the trachea or esophagus is encased by
more than 50%.14 Pericardial invasion manifests as pericar-
dial effusion, pericardial thickening, and pericardial nodular-
ity or masses. Tumor extension into the inner surface of the
pericardium or into the myocardium suggests transmural
pericardial invasion while preservation of epicardial fat sug-
gests nontransmural pericardial disease (Fig. 3).
CT is the primary imaging modality to evaluate nodal
involvement. Knowledge of the complex lymphatic drainage
system of the pleura and diaphragm aids in the detection of
nodal metastases. The visceral pleural lymphatics follow the
same drainage pattern as the lungs. In contrast, the parietal
pleural lymphatic drainage system is different. The anterior
parietal pleura is drained by the internal mammary and peri-
diaphragmatic nodes while the posterior parietal pleura is
drained by the extrapleural/intercostal lymph nodes. The
anterior and lateral diaphragm is drained by the internal
mammary and anterior diaphragmatic nodes while the poste-
rior diaphragm is drained by the para-aortic and posterior
mediastinal nodes. The anterior and lateral chest wall is
drained by the anterior or sub pectoral nodes while the pos-
terior chest wall is drained by the axillary nodes.15,16 There
is communication between lymphatics on both sides of the
diaphragm, including in the retrocrural, inferior phrenic, gas-
trohepatic, and celiac axis regions.
In terms of metastatic disease, CT can demonstrate ipsilat-
eral or contralateral pulmonary nodules, lymphangitic spread
of tumor, and extrathoracic sites including solid organs and
bones.
In terms of future directions, tumor volume analysis in
MPM has been shown to correlate with T stage, N stage, and
survival and to be superior to TNM, Response Evaluation

Figure 3 Transmural pericardial invasion. A 59-year-old man with left malignant pleural mesothelioma undergoing pre-
operative evaluation for extrapleural pneumonectomy. Axial CT without contrast (A), with contrast (B) and PET/CT
(C) show left MPM. The FDG avid 2 cm nodular left mediastinal pleural lesion (arrow) shows transmural pericardial
invasion (T4 descriptor). The presence of transmural pericardial involvement precluded surgery, and the patient was
treated with chemotherapy.
Imaging of Malignant Pleural Mesothelioma 545

Figure 4 Multiple sites of chest wall invasion. A 69-year-old male sheet metal worker with right malignant pleural meso-
thelioma undergoing preoperative evaluation for extrapleural pneumonectomy. Axial contrast enhanced CT (A) shows
the primary tumor presents as circumferential nodular right pleural thickening (asterisks). Note left anterior calcified
pleural plaque (arrow) is consistent with prior exposure to asbestos. Sagittal T1 weighted MRI (B) shows abnormal sig-
nal intensity in the right 3rd rib (black arrow) and multiple foci of chest wall invasion (white arrows). MRI is superior
to CT in the detection of chest wall invasion. In terms of staging, a single focus of chest wall invasion is resectable and
multifocal disease as in this case is unresectable.

Criteria in Solid Tumors (RECIST), and modified Response
Evaluation Criteria in Solid Tumors (mRECIST) for staging
and assessment of therapy response, respectively. With
advances in segmentation software, tumor volume analysis is
feasible in routine practice.17
MRI
When CT findings are equivocal, the superior contrast and
spatial resolution of MRI adds value in terms of determining
surgical resectability. According to the ASCO guidelines, an
MRI (preferably with intravenous contrast) may be obtained
to further assess invasion of the tumor into the diaphragm,
chest wall, mediastinum, and other areas.8 Heelan et al.
showed the superiority of MRI over CT in the evaluation of
invasion of the endothoracic fascia/single chest wall focus
(accuracy 69% vs 46%) and the diaphragm (accuracy 82% vs
55%). 18 Chest wall invasion manifests as loss of the normal
extrapleural fat plane, invasion of intercostal muscles and
bones (Fig. 4). In terms of diaphragmatic invasion, preserva-
tion of a fat plane between the undersurface of the diaphragm
and the adjacent abdominal organ suggests disease is con-
fined to the thoracic cavity.19 However, cross-sectional imag-
ing has limitations in the detection of small volume
abdominal disease. According to the ASCO guidelines, in
patients with suspicious findings for intra-abdominal disease
on imaging and no other contraindications to surgery, it is
strongly recommended that a laparoscopy be performed
(Fig. 5).8
In terms of future directions, studies suggest that paramet-
ric images based on dynamic contrast-enhanced MRI can
show the extent of pleural lesions and heterogeneous tumor
vascularization. Pharmacokinetic parameters of pleural
enhancement can be used to predict treatment response.20
The apparent diffusion coefficient of epithelial MPM has
been shown to be higher than the apparent diffusion coeffi-
cient of sarcomatoid MPM, suggesting that MRI can be used
as a surrogate biomarker.21
PET/CT
By combining the metabolic information obtained by the uptake
of the radiopharmaceutical F-18 fluorodeoxyglucose (FDG) on
PET with the anatomic information provided by CT, FDG PET/
CT plays an important role in the diagnosis and staging of
MPM. FDG uptake, as measured by the standardized uptake
value (SUV), in MPM is significantly higher than in benign pleu-
ral disease.22 According to the ASCO guidelines, an FDG PET/
CT should usually be obtained for initial staging of patients
with mesothelioma but may be omitted in patients who are not
being considered for definitive surgical resection.8 PET/CT has
been shown to be more accurate than CT, MRI, and PET alone
in the staging of MPM. For stage II and III disease, PET/CT
accuracy is 1.0, compared with 0.77 in stage II and 0.75 in
stage III for CT and 0.86 in stage II and 0.83 in stage III
for MRI.23 In addition to staging, PET/CT applications in
MPM include targeting of lesions for biopsy, and the
assessment of prognosis, treatment response, and tumor
recurrence.24 By identifying metabolically active lesions
amenable for tissue sampling, PET/CT adds value in
image guided and surgical biopsy planning. In terms of
future directions, PET/CT parameters that take into
account functional volume as defined by metabolic tumor
volume and total lesion glycolysis show significant associ-
ations with survival in patients with MPM.25-27
An important limitation of PET/CT concerns false positive
findings due to infectious or inflammatory conditions. In
patients with occupational exposure to asbestos, enlarged
FDG avid inflammatory lymph nodes can mimic nodal
546 C.D. Strange et al.

Figure 5 Diaphragmatic microscopic invasion. A 50-year-old man with right malignant pleural mesothelioma undergo-
ing preoperative evaluation. Frontal and lateral chest radiographs (A and B) show diffuse circumferential right pleural
thickening and loculated pleural fluid. Axial contrast enhanced CT (C) shows involvement of the right diaphragmatic
pleura (arrows). T1-weighted coronal MRI (D) shows intact right hemidiaphragm (arrows). Imaging is limited in the
detection of small volume abdominal disease. Laparoscopy showed small nodules along the undersurface of the right
hemidiaphragm and peritoneal lavage confirmed malignant cells. Due to transdiaphragmatic tumor extension, the
patient was precluded from surgery.

metastases (Fig. 6). According to the ASCO guidelines for
MPM, patients being considered for maximal surgical cytore-
duction should have mediastinoscopy and/or endobronchial
ultrasound guided biopsy if enlarged and/or PET-avid medi-
astinal lymph nodes are present.8 Another PET/CT pitfall
concerns MPM patients treated with talc pleurodesis. This
procedure causes an inflammatory reaction in the pleura that
can be associated with intense FDG avidity confounding
both interpretation and the quantification of metabolic tumor
volume. The typical appearance of talc deposits on CT as
high attenuation material in the pleura aids in avoiding this
pitfall (Fig. 7).28
Staging
The eighth edition of the TNM staging system for malignant
pleural mesothelioma has been validated by the International
Mesothelioma Interest Group (Tables 1 and 2).5,29 The T
descriptor is based on tumor site and the degree of invasion,
not on tumor size. In the International Association for the
Study of Lung Cancer staging project for MPM, the T
categories were statistically examined to analyze whether sur-
vival was significantly different between them. Due to lack of
clear separation in both the clinically staged and the patho-
logically staged cases, categories T1a and T1b of the TNM
seventh edition were collapsed into one category T1 in the
TNM eighth edition. T1 tumors involve the ipsilateral parie-
tal pleura (including mediastinal and diaphragmatic) with or
without involvement of the visceral pleura. In the patholog-
ically staged cases, there was clear differentiation of survival
between T3 and T4. It is important to emphasize that T3
tumors are locally advanced and still potentially amenable to
surgical resection. T3 tumors involve all of the ipsilateral
pleural surfaces with at least one of the following features:
invasion of the endothoracic fascia, extension into the medi-
astinal fat, solitary resectable focus of invasion in the chest
wall, or nontransmural involvement of the pericardium. In
contrast, T4 tumors are locally advanced and unresectable.
T4 tumors involve all of the ipsilateral pleural surfaces with
at least one of the following features: diffuse or multifocal
invasion of soft tissues of the chest wall, any rib involvement,
invasion of the peritoneum through the diaphragm, invasion
of any mediastinal organ, direct extension to the contralateral
Imaging of Malignant Pleural Mesothelioma 547

Figure 6 False positive lymph nodes. A 63 year-old male brick layer with right epithelial MPM. Axial PET/CT (A) and
contrast enhanced CT (B) shows nodular right pleural thickening consistent with MPM. The FDG avid contralateral
mediastinal enlarged lymph node in the left paratracheal region (long arrow) is suspicious for N2 nodal metastasis.
Mediastinoscopy was negative for malignancy and patient proceeded to extrapleural pneumonectomy. Reactive lymph
nodes due to infectious and inflammatory conditions are a source of false positive results on PET/CT. Note calcified
left anterior pleural plaque due to prior exposure to asbestos is not FDG avid (short arrow).

Figure 7 Talc pleurodesis. A 63 year-old man with right MPM had undergone talc pleurodesis 2 weeks earlier. Axial
PET/CT (A) and noncontrast enhanced CT (B) show FDG avid nodular circumferential right pleural thickening
with SUV of 5.4 along the lateral aspect consistent with MPM. High attenuation material in the right anterior
and mediastinal pleural surfaces (arrows) show intense increased FDG uptake with SUV of 9.3 consistent with
talc pleurodesis. Talc incites an inflammatory reaction that can accumulate FDG years after the procedure and
confound PET/CT interpretation.

pleura, invasion of the spine or brachial plexus, or transmu- Imaging Pitfalls

ral pericardium (with or without pericardial effusion) or
myocardial involvement.
In terms of nodal metastases (N descriptor), N1 nodes
include ipsilateral bronchopulmonary, hilar, or mediastinal
lymph nodes as well as internal mammary, peridiaphrag-
matic, pericardial, or intercostal lymph nodes. N2 nodes
include contralateral bronchopulmonary, hilar or mediastinal
nodes as well as ipsilateral or contralateral supraclavicular
nodes.
The M descriptor denotes the absence (M0) or presence
(M1) of distant metastasis.
In patients with MPM who undergo surgery (extrapleural
pneumonectomy or pleurectomy and decortication), poten-
tial imaging pitfalls relate to the procedures involving the
hemidiaphragm. The mesh used in diaphragmatic recon-
struction is radiolucent on chest radiographs in the first sev-
eral days postoperatively and should not be mistaken for
pneumothorax or pneumoperitoneum (Fig. 8). Over months,
fibroblastic infiltration and epithelial growth over the mesh
render it radiopaque. In addition to diaphragmatic recon-
struction, some MPM patients undergo diaphragmatic
548
Table 1 TNM 8th Edition Staging System for Malignant Pleural
Mesothelioma
T—Primary Tumor
T1
Tumor involving ipsilateral parietal pleura (including medias-
tinal and diaphragmatic pleura)
with or without involvement of visceral pleura
T2
Tumor involving each ipsilateral pleural surfaces (parietal,
mediastinal, diaphragmatic, and visceral pleura) with at
least one of the following features:
 involvement of diaphragmatic muscle
 confluent visceral pleural tumor (including fissures)
 invasion of lung parenchyma
T3
Tumor involving all of ipsilateral pleural surfaces with at least
one of the following:
 invasion of endothoracic fascia
 extension into mediastinal fat
 solitary, completely resectable focus invading soft tis-
sues of chest wall
 nontransmural involvement of pericardium
T4
Tumor involving all of ipsilateral pleural surfaces with at least
one of the following:
 diffuse or multifocal invasion of soft tissues of the chest
wall
 any rib involvement
 invasion of the peritoneum through the diaphragm
 direct extension to contralateral pleura
 invasion of any mediastinal organ
 invasion of spine or brachial plexus
 transmural invasion of pericardium (with or without
pericardial effusion), or myocardium invasion
N—Lymph Nodes
NX Regional lymph nodes not assessable
N0 No regional lymph node metastases
N1 Metastases in ipsilateral bronchopulmonary or hilar or
mediastinal lymph nodes (including internal mammary,
peridiaphragmatic, pericardial or intercostal lymph nodes)
N2 Metastases in contralateral bronchopulmonary, hilar or
mediastinal lymph nodes, or ipsilateral or contralateral
supraclavicular lymph nodes
M—Metastases
MX Distant metastases not assessable
M0 No distant metastases
M1 Evidence of distant metastases
plication to prevent elevation and paradoxical motion of the
diaphragm and atelectasis of the lower lobe. Awareness of
the CT appearance of the pledgetted sutures used in dia-
phragmatic plication to tether the diaphragm to the intercos-
tal soft tissues is important to avoid misinterpretation as
chest wall tumor recurrence (Fig. 9).
C.D. Strange et al.
Table 2 Stage Grouping of Malignant Pleural Mesothelioma
by TNM Description
Stage Description
1a T1 N0 M0
1b T2-T3 N0 M0
II T1-T2 N1 M0
IIIA T3 N1 M0
IIIB T1-T3 N2 M0
T4 N0-N2 M0
IV Any T Any N M1
In terms of post-therapy surveillance, recurrence and/or
progressive metastatic disease are usually detected on CT.
Patterns of recurrence and/or metastases include a soft tissue
lesion along the resection margin, pericardial effusion/thick-
ening, ascites, peritoneal fat stranding, pulmonary nodules,
and mediastinal adenopathy. PET/CT is useful in the detec-
tion of tumor recurrence and can differentiate tumor, which
shows progressive increase in FDG uptake, from granulation
tissue which shows stable or decrease in FDG uptake over
time (Fig. 10).
Treatment Response
Assessment
The Response Evaluation Criteria in Solid Tumors (RECIST)
guidelines released in 2000 were not suitable in MPM due to
the unconventional growth pattern of the pleural tumor.30
This led to the modified RECIST (mRECIST) guidelines spe-
cifically addressing MPM.13 In the mRECIST, tumor thick-
ness perpendicular to the chest wall is used instead of the
longest unidimensional diameter as this is difficult to mea-
sure and reproduce in MPM. These perpendicular measure-
ments are obtained in 2 positions at three separate levels
with the sum of these six measurements defining the pleural
unidimensional measurements. In 2009 RECIST was
updated to version 1.1 with the revised modified RECIST
(mRECIST 1.1) for MPM released in 2018.31,32 In RECIST
1.1, the total number of summed lesions was decreased to 5,
with no more than 2 per organ and lymph nodes were added
to the measurements. Because growth patterns of MPM limit
evaluation of distinct single anatomic lesions, the mRECIST
1.1 focused on selecting specific measurable sites that can be
reliably and reproducibly measured regardless of how many
distinct anatomic lesions these measurement sites represent.
In addition, the mRECIST 1.1 defined numerous technical
issues about measurable disease, including which lesions are
measurable, measurement sites, nonpleural disease, measur-
able lymph nodes, and accommodation for bilateral pleural
disease.32 The mRECIST 1.1 is used to determine complete
response (the disappearance of all pleural and nonpleural
disease), partial response (decrease of at least 30% in
summed measurements), progressive disease (increase of at
least 20% in summed measurements), or stable disease
(between partial response and progression of disease).32
Imaging of Malignant Pleural Mesothelioma 549

Figure 8 Lucency of reconstructed diaphragm. A 60-year-old man with right malignant pleural mesothelioma treated
with extrapleural pneumonectomy. Frontal chest radiograph (A) on postoperative day 4 shows typical lucency along
the right hemidiaphragm (arrows) of the reconstructed diaphragmatic mesh mimicking pneumothorax. Axial CT with
intravenous contrast (B) 2 months later shows the high attenuation reconstructed right hemidiaphram mesh (arrows).

Figure 9 Diaphragmatic pledgets mimicking tumor recurrence. A 72-year-old man with right epithelial MPM had
undergone pleurectomy and decortication with reconstruction of the right hemidiaphragm and pericardium. Preopera-
tive axial PET/CT (A) shows the FDG avid right MPM. Contrast enhanced CT (B and C) 3 months postoperatively
show focal soft tissue lesions representing pledgetted sutures to secure the diaphragmatic mesh (short arrows) to the
intercostal space posteriorly (long arrow/s). Nonenhanced CT (D and E) 10 months postoperatively shows no change
in the high attenuation diaphragmatic pledgets (arrow/s). Awareness of the CT appearance of the pledgetted sutures
used for diaphragmatic plication is important to avoid misinterpretation as tumor recurrence.
550
Figure 10 PET detection of tumor recurrence. A 58-year-old man with left epithelial MPM had undergone extrapleural
pneumonectomy. Eight months following surgery, tumor recurrence in the anterior aspect of the left pneumonectomy
space adjacent to surgical clips (arrow) is difficult to detect on contrast enhanced CT (A). FDG avid tumor recurrence
detected in the left parasternal region (arrow) on PET/CT (B) was confirmed on biopsy. PET/CT is useful to detect
tumor recurrence and guide biopsy.
Conclusion
Malignant pleural mesothelioma, a rare neoplasm arising
from mesothelial cells of the pleura, is associated with poor
prognosis. Available multimodality treatment regimens com-
bine chemotherapy, radiation therapy, and surgery. Imaging
plays an essential role in the diagnosis, staging, and manage-
ment of patients with malignant pleural mesothelioma.
Knowledge of the pearls and pitfalls in imaging interpretation
of MPM, the TNM staging system, and the roles of CT, MRI,
and PET/CT is important to optimize patient management.
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