The clinical presentation of mesothelioma is rather insidious and a very late diagnosis is made in most patients due to the nonspecific nature of complaints [1] [2]. It is established that up to 4 months pass from the onset of symptoms before the tumor is recognized [3], which significantly reduces survival rates. Mesotheliomas are much more likely to occur in men, primarily due to its association with occupational exposure to asbestos and other known carcinogens (the male-to-female ratio is established at 5:1) [2] [4]. The clinical presentation depends on the location of the tumor, with the two main locations being the pleura (the most common) and the peritoneum [1] [2] [3] [4]. In the majority of cases suffering from pleural mesothelioma, a nonproductive cough that is often accompanied by dyspnea, fatigue, diaphoresis, and focal chest pain in some people are notable complaints [1] [2] [5]. Rarely, scoliosis toward the ipsilateral side or splinting may develop due to the expansive nature of the tumor [1]. Conversely, abdominal pain, swelling, anorexia, profound losses in body weight, as well as ascites are manifestations of peritoneal mesothelioma [3]. In some patients, the diagnosis is made incidentally [3].

• Fatigue

  In the majority of cases suffering from pleural mesothelioma, a nonproductive cough that is often accompanied by dyspnea, fatigue, diaphoresis, and focal chest pain in some people are notable complaints. [symptoma.com]

  […] symptoms: Abdominal pain, bowel irregularity, general fatigue, seizures Pericardial Symptoms include: Irregular heartbeat Shortness of breath Chest pain General fatigue Weight loss Diagnosis Many patients are diagnosed with mesothelioma after exhibiting [mesotheliomaguide.com]

  Pericardial mesothelioma symptoms include the following: Heart palpitations, irregular heartbeat Pain in the chest Inexplicable difficulty breathing (dyspnea) Sweating or fever Fatigue Because this form of mesothelioma so rarely affects patients, its [mesotheliomasymptoms.com]

  Temporary side effects include nausea, vomiting, hair loss, and fatigue. The physician may prescribe medication to reduce the nausea and vomiting. [asbestosnetwork.com]

  Early signs of pleural mesothelioma include: Trouble breathing Long-lasting cough Pain under the rib cage or in the abdomen Pain while breathing Weight loss and fatigue Diagnosis Images may be taken of your bodily structures. [uvahealth.com]

• Abdominal Pain

  Conversely, abdominal pain, swelling, anorexia, profound losses in body weight, as well as ascites are manifestations of peritoneal mesothelioma. In some patients, the diagnosis is made incidentally. [symptoma.com]

  Our patient presented with abdominal pain and surgery showed a large subserous mass (12.0   11.4   9.8 cm) combined with a small intramural solid nodule (2.0   1.0   1.0 cm), and multiple minute neoplastic growth on the ovary. [ncbi.nlm.nih.gov]

  A chest wall mass, weight loss, sweating, abdominal pain and ascites (due to peritoneal involvement) are less common presentations. [orpha.net]

• Increased Abdominal Girth

  Symptoms of peritoneal mesothelioma are unspecific, the most frequent being increased abdominal girth, pain and weight loss [ 2 ]; usually diagnosis occurs late. Treatment includes the combination of debulking surgery and i.p. chemotherapy. [web.archive.org]

• Localized Chest Pain

  Typical symptoms are nonspecific, such as a nonproductive cough, dyspnea, and localized chest pain in the case of pleural mesothelioma, whereas abdominal pain, anorexia, weight loss, and swelling of the abdomen are reported with peritoneal tumors. [symptoma.com]

• Vascular Disease

  diseases, surgery and trauma. [doi.org]

• Short Arm

  Deletion mapping of the short arm of chromosome 3 in human malignant mesothelioma. Genes Chromosom. Cancer 9, 76–80 (1994). 14. Murthy, S.S. & Testa, J.R. [nature.com]

• Scrotal Pain

  Most patients with WDPM suffer from scrotal pain or swelling, but hydrocele seems to be the most common presenting symptom. These lesions are usually not aggressive and are accompanied by an indolent clinical behavior. [ncbi.nlm.nih.gov]

• Epididymal Mass

  Left hydrocelectomy was performed and pathological analysis of the epididymal mass revealed a well-differentiated papillary mesothelioma. We discuss the sonographic and pathological findings of this rare neoplasm. [ncbi.nlm.nih.gov]

The diagnostic workup should start with a meticulous clinical assessment. A detailed history must cover the onset of symptoms and their progression, as well as occupational details and whether exposure to asbestos or other harmful chemicals exists. During the physical examination, dullness on percussion due to a pleural effusion or diminished breathing sounds may be detected in the case of pleural mesotheliomas [1], in which case imaging studies need to be employed. Although plain radiography is a useful first-line study for the evaluation of the chest, more advanced studies, such as computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), mediastinoscopy, laparoscopy, and positron emission tomography (PET) are recommended, primarily because they are able to determine the stage and aid in designing the optimal therapeutic strategy [1] [2] [3] [6]. To make a definite diagnosis, however, a sample of the tumor must be obtained for a histopathological examination. Because pleural cytology is not useful in the case of mesothelioma, fine-needle aspiration biopsy (FNAB), often guided by CT, or video-assisted thoracoscopy (which shows superior results compared to FNAB) are viable techniques that are used in practice [1] [2]. Immunohistochemical staining should include calretinin, as it carries a sensitivity rate of 95% and a specificity rate of 87% [2]. Other important markers are cytokeratin, mesothelin, and D2-40 [1] [2] [7].

• Listeria Monocytogenes

  Three agents targeting mesothelin have been tested to date; SS1P, a recombinant immunotoxin targeting mesothelin; MORAb-009, a chimeric anti-mesothelin monoclonal antibody; and CRS-207, a live-attenuated Listeria monocytogenes vector encoding human mesothelin [doi.org]

• Pleural Exudate

  Lung cancer and malignant pleural exudate developed after a long latency cumulative retention time of asbestos fibers. [ncbi.nlm.nih.gov]

1. Mott FE. Mesothelioma: A Review. Ochsner J. 2012;12(1):70-79.
2. Porpodis K, Zarogoulidis P, Boutsikou E, et al. Malignant pleural mesothelioma: current and future perspectives. J Thorac Dis. 2013;5(Suppl 4): S397-S406.
3. Bridda A, Padoan I, Mencarelli R, Frego M. Peritoneal Mesothelioma: A Review. Medscape General Medicine. 2007;9(2):32.
4. Nasreen N, Khodayari N, Mohammed KA. Advances in malignant pleural mesothelioma therapy: targeting EphA2 a novel approach. Am J Cancer Res. 2012;2:222-234.
5. Muers MF, Stephens RJ, Fisher P, et al. Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial. Lancet 2008;371:1685-1694.
6. Pickhardt PJ, Bhalla S. Primary neoplasms of peritoneal and sub-peritoneal origin: CT findings. Radiographics. 2005;25:983–995.
7. Husain AN, Colby TV, Ordóñez NG, et al. Guidelines for pathologic diagnosis of malignant mesothelioma: a consensus statement from the International Mesothelioma Interest Group. Arch Pathol Lab Med. 2009;133(8):1317–1331.