Mesothelioma Diagnosis

Cancer specialists utilize a number of diagnostic tools to accurately confirm mesothelioma, including blood tests such as MESOMARK and SOMAmer panel, imaging tests such as MRIs, CT scans, PET scans, X-rays and biopsies to investigate cancerous growth in tissue samples.

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There is no clear path to a mesothelioma diagnosis for every patient. Because the disease is so rare and has such common symptoms, doctors sometimes confuse it for a less-serious illness or a different type of cancer.

The most common presenting symptoms of pleural mesothelioma include chest pain and difficulty breathing. Peritoneal mesothelioma patients typically experience abdominal pain and distension. Anyone with a history of occupational asbestos exposure should remain watchful for these symptoms and report them to a doctor immediately.

Pinpointing the disease involves several procedures, including X-rays, CT scans, MRIs, biopsies and PET scans. Each of these tests is performed by a different medical professional, and most people get their diagnosis within two or three months from the time they notice their symptoms.

Diagnosing the cancer in its earliest stages supports a wider range of treatment possibilities that could extend your life expectancy. So it’s important you start looking for a mesothelioma expert.

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What Steps Lead to a Mesothelioma Diagnosis?

There are three steps to the mesothelioma diagnosis:

  • Checklist Icon

    Symptoms Begin to Show

    Patient detects symptoms, which generally start to appear 20-50 years after exposure. These symptoms often mimic those of other diseases.

  • Doctor Icon

    Patient Consults Primary Care Physician

    The primary care physician discusses symptoms with patient. These doctors perform preliminary tests. If cancer is suspected, they refer patient to an oncologist.

  • Lung Icon

    Oncologist Makes Final Diagnosis

    The oncologist conducts a variety of tests based on the patient's health. Tests may include imaging scans, blood tests and biopsies to confirm a mesothelioma diagnosis.

Karen Selby, RN & Patient Advocate, talks about mesothelioma diagnosis and offers information to patients and loved ones about where to start.

If you find yourself in this situation, doctors will start the diagnostic process by asking about your medical history and by performing some standard physical exams. They should ask if you recall any personal past exposure to asbestos.

Providing your doctor with a comprehensive work history can hasten the diagnostic process. Because mesothelioma is a rare cancer with nonspecific symptoms, doctors are unlikely to suspect the disease unless a patient describes a former job where asbestos exposure may have occurred.

By explaining to their doctor that they worked in a high-risk industry, such as asbestos mining, construction or shipbuilding, patients can backup concerns that their symptoms may be asbestos-related.

Next, doctors will order imaging tests to identify any abnormal growths. If those show a suspicious mass that looks like mesothelioma, doctors will request a biopsy to confirm the diagnosis. They will take fluid and tissue samples during the biopsy.

During this process, you'll see several doctors. Patients usually visit a general practitioner, pulmonologist, radiologist, surgeon, pathologist and an oncologist. If any of these doctors suspect mesothelioma or another asbestos disease, that's a sign for any patient to get a second opinion from a mesothelioma specialist, an expert who has experience staging the cancer and treating people who have it.

The doctors who specialize in mesothelioma have dedicated the time it takes to understand the intricacies of diagnosing and treating this disease. They’ve studied under other mesothelioma experts, conducted clinical research, overseen clinical trials and worked with more mesothelioma patients than the average cancer doctor.

The cancer centers that specialize in mesothelioma staff a team of doctors who are experts in subspecialties of mesothelioma diagnosis and treatment, from pathological and surgical to radiological oncology. The pathologists at these centers have more experience diagnosing mesothelioma than most pathologists throughout the U.S. These doctors learn from each other and work together to provide each patient with individualized treatment.

Timeline for Diagnosing Mesothelioma

Timeline for Diagnosing Mesothelioma

The timeline for diagnosing mesothelioma varies from patient to patient. It's based on the symptoms, doctor's experience with the illness, types of tests required to confirm the disease and wait times for the results of those tests.

Here is a possible, and common, explanation for the lengthy process of diagnosing mesothelioma:

  • Day 1: Initial symptoms such as shortness of breath, fatigue and chest pain are common. It's usually not diagnosed at that time, but the doctor might order X-rays.

  • Day 2: X-rays determines fluid in the lungs could be pneumonia.

  • Day 3-Day 13: Physician prescribes antibiotic to treat pneumonia (10-day treatment) OR drains fluid in pleural cavity. No cancer cells detected in fluid.

  • Day 14: X-rays after treatment show lungs are clear. Doctor orders follow-up X-rays and asks patient to return in 30 days.

  • Day 44: Follow-up X-rays show fluid build-up in pleural cavity again. Doctor either drains fluid, which may again test negative for cancer cells, or treats the pneumonia with antibiotics again (add 10 days). Doctor orders PET scans and CT scans.

  • Day 54: Imaging scans show a possible underlying cause or recurrent pneumonia. Patient is referred to a surgeon for an appointment, which can take up to 15 days.

  • Day 69: Surgeon schedules a biopsy appointment, which can take up to 10 days.

  • Day 79: Surgeon takes biopsy, usually done via VATS and typically requires a three-day hospital stay for the patient. Lab work to confirm mesothelioma can take up to 10 days if surgeon sends biopsy to an outside lab.

  • Day 89 (approximately three months later): Mesothelioma confirmed if biopsy tests positive for the disease.

The First Diagnostic Appointment

Most patients make an appointment with their general physician several months after they first notice something wrong with their health. They might be experiencing abdominal or chest pain. Other times they have an unexplained acute shortness of breath or have trouble catching their breath after light exertion.

To Prepare For Your First Appointment

  • Assemble all necessary documents, including insurance cards and ID.

  • Make a mental note to discuss any asbestos exposure you may have experienced, including length, time and location of exposure.

  • Plan to spend between 30 minutes and one hour at the doctor's office.

This initial consultation often includes:

  • Medical Cross Medical History Review
  • Crane Occupational History Review
  • Stethoscope Basic Physical Exam
  • Checklist Discussion of Symptoms

If you have a history of asbestos exposure and have reason to believe you may have mesothelioma, you will want to bring a summary of your work history and any documentation of your asbestos exposure. This information will help your doctor understand why you may be at risk of an asbestos-related cancer.

It's impossible for someone to receive a mesothelioma diagnosis at their first consultation because of the advanced tissue testing required to detect cancerous mesothelioma cells. It won't be the first disease that comes to mind for a primary care doctor (or even for an oncologist). Some physicians may suggest pulmonary function tests, which measure how well your lungs are working. Chances are the general practitioner will send you to a specialist for more tests: Imaging scans or biopsies.

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Testing for Mesothelioma

Testing for mesothelioma is a long, complex process that typically involves multiple cancer specialists and a series of diagnostic tools. The most widely used tests include imaging scans, biopsies and blood tests.

Imaging scans help doctors visualize abnormal growths on the body’s tissues and organs. Some even show areas with high metabolic activity, which suggest cancer may be present.

The most accurate test for confirming a diagnosis is biopsy, a procedure where doctors remove fluid or tissue samples and study them under a microscope. Researchers also are exploring a variety of blood tests for substances that indicate mesothelioma, but currently none are accurate enough to confirm a diagnosis on their own.

Imaging Tests

Oncologists use imaging tests to check for visible signs of tumors. A mesothelioma diagnosis relies on a series of diagnostic imaging tests, including:

X-Rays

X-Rays

Produce basic images of dense areas within the body (such as tumors)

CT Scans

CT Scans

Use electromagnetic imagery to create detailed images of internal structures

MRI

MRIs

Generate images of highly active internal structures using magnets and radio waves

PET Scans

PET Scans

Highlight areas of the body that have abnormally high, potentially cancerous metabolic activity

CT scans are most doctors' first choice, while the "gold standard" for mesothelioma diagnosis is a combination CT-PET. However, many mesothelioma diagnoses are made incidentally, when doctors use other types of scans to identify an unknown condition.

Most doctors’ first choice when testing for mesothelioma is a CT scan, but the current “gold standard” is a combination PET-CT scan. With results from both tests, doctors can get a detailed look inside the body and see whether suspicious growths are cancerous or noncancerous. Potentially cancerous growths will light up on PET scans, but not on CT scans or MRIs.

Most of the time, doctors discover mesothelioma incidentally when they use other types of scans to identify an unknown condition.

Fast Fact In a study of 31 mesothelioma patients, PET-CT scans correctly diagnosed 20 cases, incorrectly diagnosed nine cases; and could not determine two cases. MRI imaging correctly diagnosed both undetermined cases in a follow-up scan.

If you are scheduled for a diagnostic imaging scan:

  • Assemble the same personal documents you collected for your first diagnostic appointment.

  • Plan for a one- to two-hour appointment.

  • Follow any pre-scan guidelines provided by your doctor (such as fasting from food or water).

  • Research relaxation techniques if you are nervous about being in an enclosed scanning machine.

  • Plan to hear the results from your doctor within one to two weeks of the appointment.

A doctor may order a biopsy to confirm specific information if a scan reveals a mass on parts of the body (pleura, pericardium or peritoneum) where mesothelioma tumors typically develop.

Biopsies

Biopsies are small fluid or tissue samples doctors send to a laboratory for evaluation when testing for mesothelioma. These tests can reveal whether a growth is cancerous, where in the body the cancer originated and what type of cells are involved. The cancer's location and cell type play a major role when it comes to planning treatment.

Doctors can retrieve biopsy samples in several different ways:

Fine-Needle Aspiration

Extracts cells through a thin, hollow needle and a syringe.

Thoracoscopy

Takes samples with a camera-equipped tube that doctors insert through the chest wall.

Mediastinoscopy

Mediastinoscopies are similar to thoracoscopies, except doctors insert the tube through an incision in the neck.

Incisional/Core

Incisional/core biopsies are similar to fine-needle biopsies, but use a wider needle to obtain larger samples.

Excisional

Excisional biopsies remove the whole tumor from the body and test selected samples from the mass.

Thoracoscapy is considered the most accurate diagnostic biopsy for mesothelioma. This method allows doctors to look into the pleural cavity and retrieve high-quality biopsy samples; it can result in accurate diagnosis for up to 98 percent of mesothelioma patients.

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Blood Tests

In recent years, researchers have spent a considerable amount of time developing mesothelioma blood tests. These tests analyze your blood for proteins and other substances (biomarkers) that are present in mesothelioma patients. Early studies suggest these blood tests have the potential to play a role in testing for mesothelioma, but they are not yet reliable enough to confirm a diagnosis on their own.

All of the mesothelioma blood tests are ELISA-based, meaning enzyme-linked immunosorbent assay, and they use enzymes to detect protein antibodies in blood samples.

The FDA-approved MESOMARK test can detect soluble mesothelin-related peptide (SMRP), a protein and mesothelioma biomarker. Extensive research shows that SMRP is helpful to monitoring tumor response to treatment, but it cannot definitively diagnose mesothelioma.

Too many false positives are recorded and some cases of cancer go undetected using MESOMARK. The test’s potential to screen for mesothelioma among people exposed to asbestos is questionable as well; one study found it helpful at identifying persons at risk of mesothelioma and another study did not.

The SOMAmer test can detect more than 1,000 proteins in blood serum, and these proteins may have diagnostic value in identifying mesothelioma. A 2012 study analyzed blood serum samples from 117 malignant mesothelioma cases and 142 people exposed to asbestos. These samples detected 13 protein biomarkers that helped to accurately identify malignant mesothelioma.

The test accurately detected malignant mesothelioma in 90 percent of cases and ruled out the cancer in 95 percent of people without the cancer. The biomarker levels correlated with cancer stage, indicating the test may have value in monitoring the progress of mesothelioma. Continued analysis of more cases of mesothelioma is needed to validate the worth of the SOMAmer test.

The Human MPF test measures a protein called megakaryocyte potentiation factor (MPF), which is produced by a mesothelin precursor protein. MPF levels increase as mesothelioma tumors grow and are detected in about 91 percent of late-stage patients. The test can rule out mesothelioma in 95 percent of people who don’t have the cancer, but it accurately identifies the cancer in only 64 percent of people with mesothelioma. The test isn’t sensitive enough to help with diagnosis, but it could help doctors monitor the cancer’s progression and response to treatment.

Diagnostic Capabilities of Mesothelioma Blood Tests

Test: Sensitivity1 Specificity2
MESOMARK 68% 92%
SOMAmer 90% 95%
Human MPF 64% 95%
  1. The percentage of mesothelioma patients correctly diagnosed by the test.
  2. The percentage of healthy people in which the test correctly ruled out a mesothelioma diagnosis.

As researchers continue to refine these tests for diagnosing mesothelioma, they can still play a role in tracking how mesothelioma is progressing in patients.

Staging Mesothelioma

The diagnostic tools used prior to surgery help doctors to estimate the cancer’s stage of progression, which is called clinical staging. These tools are advanced, but directly examining the body through surgery is the most accurate way to determine a cancer’s stage.

Imaging tests are the most noninvasive tools doctors have for estimating the growth and spread, or stage, of mesothelioma cancer. The images created by the scans give an inside view of the body that shows where tumors are growing. Radiologists use these images to identify how far the cancer has spread and then assign a stage based on what they see.

For example, if the images show little tumor growth in a small area on one lung, the cancer could be in stage I or II. If the image shows extensive tumor spread throughout the lungs, diaphragm and possibly into the abdomen, the cancer is likely in stage IV.

Some minimally invasive diagnostic techniques are used to estimate stage, such as the thoracoscopy or mediastinoscopy, which can help determine if the cancer has spread beyond the pleural lining.

However, surgery is the most accurate way to diagnose mesothelioma. Unfortunately, surgery is an invasive procedure and can’t be performed on patients who are in poor health or have late-stage mesothelioma. Imaging scans work well enough to identify late-stage tumor spread, which precludes patients from surgery because the cancer has grown to the point that surgical removal becomes life-threatening.

A 2012 study that analyzed more than 3,000 pleural mesothelioma cases reported on the discrepancy of staging based on clinical versus surgical staging. It showed clinical staging is most accurate for stage III and IV cases. Around 80 percent of patients with clinical stage I cancer were found to have more advanced disease upon surgery, known as upstaging. About 65 percent of patients with clinical stage II disease were upstaged, but only 20 percent with stage III and none with stage IV were upstaged.

Misdiagnosis

Sometimes mesothelioma is misdiagnosed as a less serious disease or another cancer. The initial symptoms of mesothelioma can resemble other conditions like pneumonia or irritable bowel syndrome, making it common for the cancer to be misdiagnosed as a nonterminal condition.

An initial misdiagnosis is common for people who have mesothelioma. As the cancer progresses and more serious symptoms develop, increasingly advanced testing becomes warranted, which leads to an accurate diagnosis.

However, mesothelioma can also be misdiagnosed as other forms of cancer, most commonly a form of lung cancer that develops in mucus-secreting glands called adenocarcinoma. Pathologists are the professionals who analyze tumor biopsy samples, and if they aren’t experienced with differentiating mesothelioma from other cancers a misdiagnosis can occur.

Working with a cancer center that specializes in mesothelioma can confirm or deny the diagnosis. The professionals working at such cancer centers have the experience that’s necessary to accurately diagnose the disease.

After a Mesothelioma Diagnosis

The next step after a mesothelioma diagnosis for many people is that of seeking a second opinion. Opting for a cancer center that specializes in mesothelioma can confirm the diagnosis and get you access to innovative therapies and clinical trials.

Other steps to take after a mesothelioma diagnosis:

  • Learn about your type of mesothelioma and the therapies that may help you live longer. The more you know, the better prepared you’ll feel.

  • Discuss your treatment plan in great detail with your health care team. Thorough communication will help you feel more comfortable and secure with the plan.

  • Ask about complementary therapies that may help with side effects, such as acupressure for chemotherapy-induced nausea. Divulge any medications or supplements you are taking because they could interfere with treatment.

  • Ask your health care team or a patient advocate about financial assistance options, such as travel grants.

  • Reach out to family, friends and health professionals for support. Building a support network will help you and your loved ones cope with mesothelioma.

Additional Resources


Karen Selby is a registered nurse and a Patient Advocate at The Mesothelioma Center. She worked in several subspecialties within nursing before joining Asbestos.com in 2009.

  1. Coolen, J., Keyzer, F., Nafteux, P. (2012). Malignant pleural disease: Diagnosis by using diffusion-weighted and dynamic contrast-enhanced MR imaging – initial experience. Radiology: 263. Retrieved from http://radiology.rsna.org/content/263/3/884.abstract
  2. American Cancer Society. (2010, March24). Overview of biopsy types. Retrieved from http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/testingbiopsyandcytologyspecimensforcancer/testing-biopsy-and-cytology-specimens-for-cancer-biopsy-types
  3. Boutin, C., Rey, F. (1993). Thoracoscopy in pleural malignant mesothelioma: A prospective study of 188 consecutive patients. Part 1: Diagnosis. Cancer; 72 (2). Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/1097-0142%2819930715%2972:2%3C389::AID-CNCR2820720213%3E3.0.CO;2-V/abstract
  4. Fujirebio Diagnostics. (2005). MESOMARK: A potential test for malignant pleural mesothelioma. Retrieved from http://fdi.com/mesomark/usa/documents/FDI%20MesoAbst2h.pdf
  5. Ostroff, R., Mehan, M., Steward, A., et al. (2012). PLOS ONE: Early detection of malignant pleural mesothelioma in asbestos-exposed individuals with a noninvasive proteomics-based surveillance tool. PLOS One. Retrieved from http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0046091
  6. Robinson, B., Creaney, J., Lake, R., et al. (2003). Mesothelin-family proteins and diagnosis of mesothelioma. The Lancet, 362(9396): 1612-1616. doi: 10.1016/S0140-6736(03)14794-0
  7. Park, E., Sandrini, A., Yates, D., et al. (2008). Soluble mesothelin-related protein in an asbestos-exposed population: the dust diseases board cohort study. Am J Respir Crit Care Med, 178(8): 832-837. doi: 10.1164/rccm.200802-258OC
  8. Ostroff, R., Mehan, M., Stewart, A., et al. (2012). Early detection of malignant pleural mesothelioma in asbestos-exposed individuals with a noninvasive proteomics-based surveillance tool. doi: 10.1371/journal.pone.0046091
  9. Hollevoet, K., Nackaerts, K., Thimpont, J., et al. (2009). Diagnostic performance of soluble mesothelin and megakaryocyte potentiating factor in mesothelioma. American Journal of Respiratory and Critical Care Medicine; 181 (620-625). Retrieved from http://ajrccm.atsjournals.org/content/181/6/620.full.pdf
  10. Rusch, V., Giroux, D. (2012). Do we need a revised staging system for malignant pleural mesothelioma? Analysis of the IASLC database. Ann Cardiothorac Surg, 1(4): 438-448. doi: 10.3978/j.issn.2225-319X.2012.11.10

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