Incidence of mesothelioma

Mesothelioma is a malignant tumor that originates in the pleura, peritoneum, pericardium and tunica vaginalis, all locations where a lining of normal mesothelial cell is present. According to the official data of Ministry of Health, Labor and Welfare in Japan, the number of death due to mesothelioma was 500 in 1995, increasing gradually to 953 in 2004. This increase appears to parallel the increase of the amount of asbestos imported into Japan between 1960 and 1975, given that the latent period from the beginning of exposure to asbestos and an initial diagnosis of mesothelioma is approximately 40 years.

More detailed examination of the 878 patients who officially died from mesothelioma in 2003 reveals that the male:female ratio was almost 3:1 and that the peak of age of patients was 60+ in males and 70+ in females. The location of the mesothelioma was in the pleura in 84% of the cases, in the peritoneum in 12% and in the pericardium in 1%; there were not cases of mesothelioma in the tunica vaginalis. A larger proportion of females had mesothelioma in the peritoneum and pericardium than in the pleura [1].

General findings on mesothelioma

Mesothelioma can be roughly classified into localized and diffuse types, with the incidence of the latter being much higher than that of the former [2]. The localized form of mesothelioma was more frequently diagnosed in the past; however, most of the localized forms are currently diagnosed as a solitary fibrous tumor [3], which is a separate entity from mesothelioma based on immunohistochemical phenotyping (positive for CD34, a marker of primitive endothelial cell) and has no relation to asbestos exposure [4].

At the early stage of pleural mesothelioma, small nodules are found in the parietal pleura (not in the visceral pleura) that eventually extend along the pleural surface. Eventually, parietal and visceral pleurae show adhesion, and the tumor encloses the entire lung parenchyma. Very few cases of peritoneal mesothelioma have been reported at the early stage and, consequently, little is known in terms of pathology and disease progression during the early stage [5]. Most of peritoneal mesothelioma is found as a diffusely extensive tumor involving intestinal serosa or a large tumor located at the omentum or mesentery.

Following the initial diagnosis of mesothelioma, it is important to confirm the location of the tumor and its gross findings before histological examination. In the case of a pleural mesothelioma, a tumor in the lung parenchyma suggests lung cancer with a pleural extension. In females with peritoneal extension, the ovary should be carefully examined as the primary site of the tumor because the differential diagnosis between ovarian cancer and peritoneal mesothelioma is difficult and can only be made on the basis of histological analyses.

Histology of mesothelioma

Histological classification of mesothelioma is shown in Table 1 [6]. There are three major types—epithelioid type, sarcomatoid type and biphasic type—and the proportion of each is approximately 60, 20 and 20%, respectively (Figs. 1, 2, 3) [7]. The desmoplastic type is rare (probably 1–2%) (Fig. 4), and special variants only appear sporadically (several percentages). However, the proportion of each histological type varies among the reports because of the large variety of histological analyses used [8–11].

Table 1 Histological classification of mesothelioma [6]
Full size table
Fig. 1
figure 1

Microphotograph of epithelioid mesothelioma (H&E stain). Papillo-tubular structure is prominent

Full size image
Fig. 2
figure 2

Microphotograph of sarcomatoid mesothelioma (H&E stain). Proliferation of spindle cells mimies true sarcoma

Full size image
Fig. 3
figure 3

Microphotograph of biphasic mesothelioma (H&E stain). The features of epithelioid mesothelioma and that of sarcomatoid mesothelioma are mixed within one tumor

Full size image
Fig. 4
figure 4

Microphotograph of desmoplastic mesothelioma (H&E stain). The feature of granulation or fibrous pleuritis are dominant

Full size image

Differential diagnosis

It is important to remember that there are many diseases to be differentiated when making a pathological diagnosis and that the tissue to be differentiated varies in terms of histological type (Table 2). Epithelioid types must be differentiated from lung adenocarcinoma for pleural mesothelioma [12], ovarian serous papillary adenocarcinoma or peritoneal serous carcinoma for peritoneal mesothelioma [13]. In terms of sarcomatoid types, sarcoma originating in the chest wall, lung, pleura, abdominal wall, peritoneum and intestine must be excluded. Sarcomatoid carcinoma (spindle cell sarcoma or pleomorphic carcinoma) of the lung is very difficult to differentiate from sarcomatoid pleural mesothelioma [14]. In terms of the biphasic type, carcinosarcoma or pulmonary blastoma of the lung, biphasic synovial sarcoma [15] of the pleural mesothelioma and carcinosarcoma of the female genital organs must be differentiated from their peritoneal counterpart. The desmoplastic type has a similar histology to fibrous pleuritis [16], and the differential diagnosis is very difficult, particularly if only a small biopsy specimen is available. Reactive mesothelial hyperplasia associated with pleuritis or other lung or pleural disease must be differentiated from early-stage epithelioid mesothelioma [17].

Table 2 Differential diagnosis of mesothelioma
Full size table

Usefulness of immunohistochemistry in an accurate diagnosis

The histochemical staining of hyarulonic acid and electron microscopic studies have been widely used in the past for making a differential diagnosis between mesothelioma and other tumors. However, immunohistochemical stains are currently the method of choice because of the simplicity and ease of these techniques. Many antibodies have been detected for use in immunohistochemical staining techniques aimed at diagnosing mesothelioma, but as yet there is no antibody that is completely specific for mesothelioma and on which a pathological diagnosis of mesothelioma can be singly based. Therefore, the combination of a number of antibodies as positive or negative markers is important, and an assessment of the results in a comprehensive manner is necessary (Table 3).

Table 3 Antibodies used in the immunohistochemical staining for differential diagnosis
Full size table

In the case of epithelioid mesothelioma, calretinin, WT1, thrombomodulin, mesothelin and D2-40 can be applied as a mesothelial cell marker [18–22]. CEA, TTF-1, Napsin A and surfactant apoprotein are used as markers for lung adenocarcinoma. In the case of ovarian serous papillary adenocarcinoma, we recommend CEA, Ber-EP4, MOC-31 and ER (estrogen receptor) as positive markers [23].

The antibodies chosen for sarcomatoid mesothelioma are very different from those used for epithelioid mesothelioma. In the case of sarcomatoid mesothelioma, cytokeratin (AE1/AE3 or CAM5.2 as antibodies) exhibits a high specificity and is the most useful [24]. On the other hand, because the diagnosis for true sarcoma is based on the specific differentiation of tumor cells, mesothelioma is eliminated by making its differentiation clear. For example, the following antibodies are known to be useful: MyoD1, desmin and myoglobin for rhabdomyosarcoma; desmin, α-SMA and h-caldesmon for leiomyosarcoma; S-100p for malignant nerve sheath tumor; KP-1 for malignant fibrous histiocytoma [25].

The most difficult tumor to be differentiated from sarcomatoid mesothelioma of pleura is sarcomatoid carcinoma (spindle cell carcinoma, pleomorphic carcinoma) of the lung. When immunohistochemical stainings are used, both respond positively to cytokeratin [24]. In this case, therefore, the gross finding or the clinical diagnosis by imaging is very important, as already mentioned.

Immunohistochemical stains may be useful in differentiating between fibrous pleuritis and desmoplastic mesothelioma. Desmin is positive for spindle cells of the fibrous pleuritis, while desmin is negative for tumor cells of the sarcomatoid mesothelioma [26]. The combination of EMA, desmin and p53 is useful for differentiating between reactive mesothelial hyperplasia and early-stage epithelioid mesothelioma. Reactive mesothelial cells are positive for desmin and negative for EMA and p53 [27].

Compensation or relief of patients

In the compensation system for occupational exposures to asbestos and in the new law for non-occupational exposure to asbestos, if the diagnosis of mesothelioma is certain, it can almost always be presumed to be related to asbestos exposure and the patients can receive compensation or relief. Therefore, the accuracy of the pathological diagnosis as mesothelioma is very important. However, a rough estimate is that approximately 10–15% of mesothelioma patients receive an inadequate diagnosis. In the committee for the judgement of patients’ relief, 30% of applicants are judged as not having mesothelioma or the decision is deferred until additional evidence is provided. It is therefore essential that Japanese clinicians and pathologists make an effort to improve the accuracy of the diagnosis as mesothelioma. In particular, the pathologists must improve the accuracy of the pathological diagnosis using adequate immunohistochemical stains.