Review Articles
Guidelines for Pathologic Diagnosis
of Malignant Mesothelioma
2012 Update of the Consensus Statement from the International
Mesothelioma Interest Group
Aliya N. Husain, MD; Thomas Colby, MD; Nelson Ordonez, MD; Thomas Krausz, MD; Richard Attanoos, MB, BS;
Mary Beth Beasley, MD; Alain C. Borczuk, MD; Kelly Butnor, MD; Philip T. Cagle, MD; Lucian R. Chirieac, MD;
Andrew Churg, MD; Sanja Dacic, MD, PhD; Armando Fraire, MD; Francoise Galateau-Salle, MD; Allen Gibbs, MD;
Allen Gown, MD; Samuel Hammar, MD; Leslie Litzky, MD; Alberto M. Marchevsky, MD; Andrew G. Nicholson, DM;
Victor Roggli, MD; William D. Travis, MD; Mark Wick, MD
Accepted for publication June 13, 2012.
Published as an Early Online Release August 28, 2012.
From the Department of Pathology, University of Chicago, Chicago,
Illinois (Drs Husain and Krausz); the Department of Pathology, Mayo
Clinic Arizona, Scottsdale (Dr Colby); the Department of Pathology,
MD Anderson Cancer Center, Houston, Texas (Dr Ordonez); the
Department of Cellular Pathology, University Hospital Llandough,
Cardiff, United Kingdom (Mr Attanoos); the Department of Pathology,
Mount Sinai Hospital, New York, New York (Dr Beasley); the
Department of Pathology, Columbia University Medical Center,
New York, New York (Dr Borczuk); the Department of Pathology,
University of Vermont College of Medicine, Burlington (Dr Butnor);
the Department of Pathology & Genomic Medicine, The Methodist
Hospital, Houston, Texas (Dr Cagle); the Department of Pathology,
Brigham and Women’s Hospital, Boston, Massachusetts (Dr Chirieac);
the Department of Pathology, University of British Columbia,
Vancouver, Canada (Dr Churg); the Department of Pathology,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
(Dr Dacic); the Department of Pathology, University of Massachusetts,
Worcester (Dr Fraire); Laboratoire d’Anatomie Pathologique, Caen-
Cedex, France (Dr Galateau-Salle); the Department of Histopathology,
Llandough Hospital, Penarth, South Glamorgan, United Kingdom (Dr
Gibbs); PhenoPath Laboratories, Seattle, Washington (Dr Gown);
Diagnostic Specialties Laboratory, Bremerton, Washington (Dr Ham-
mar); the Department of Pathology & Laboratory Medicine, University
of Pennsylvania Medical Center, Philadelphia (Dr Litzky); the
Department of Pathology, Cedars-Sinai Medical Center, Los Angeles,
California (Dr Marchevsky); the Department of Histopathology, Royal
Brompton Hospital, London, United Kingdom (Mr Nicholson); the
Department of Pathology, Duke University Medical Center, Durham,
North Carolina (Dr Roggli); the Department of Pathology, Memorial
Sloan-Kettering Cancer Center, New York, New York (Dr Travis); and
the Department of Pathology, University of Virginia Medical Center,
Charlottesville (Dr Wick).
Dr Churg serves as a consultant to law firms in asbestos litigations.
Dr Gibbs undertakes medicolegal work related to mesothelioma. Dr
Roggli testifies as an expert witness in asbestos litigations. The other
authors have no relevant financial interest in the products or
companies described in this article.
Presented at the Pulmonary Pathology Society companion meeting
in conjunction with the United States and Canadian Academy of
Pathology annual meeting; March 17, 2012; Vancouver, British
Columbia, Canada.
Reprints: Aliya N. Husain, MD, Department of Pathology,
MC6101, University of Chicago Medical Center, 5841 S Maryland
Ave, Room S-627, Chicago, IL 60637 (e-mail: aliya.husain@
uchospitals.edu.
Arch Pathol Lab Med—Vol 137, May 2013
 Context.—Malignant mesothelioma (MM) is an uncom-
mon tumor that can be difficult to diagnose.
Objective.—To provide updated practical guidelines for
the pathologic diagnosis of MM.
Data Sources.—Pathologists involved in the Internation-
al Mesothelioma Interest Group and others with an interest
in the field contributed to this update. Reference material
includes peer-reviewed publications and textbooks.
Conclusions.—There was consensus opinion regarding (1)
distinction of benign from malignant mesothelial prolifera-
tions (both epithelioid and spindle cell lesions), (2) cytologic
diagnosis of MM, (3) key histologic features of pleural and
peritoneal MM, (4) use of histochemical and immunohisto-
chemical stains in the diagnosis and differential diagnosis of
MM, (5) differentiation of epithelioid MM from various
carcinomas (lung, breast, ovarian, and colonic adenocarci-
nomas, and squamous cell and renal cell carcinomas), (6)
diagnosis of sarcomatoid mesothelioma, (7) use of molecular
markers in the diagnosis of MM, (8) electron microscopy in
the diagnosis of MM, and (9) some caveats and pitfalls in the
diagnosis of MM. Immunohistochemical panels are integral
to the diagnosis of MM, but the exact makeup of panels used
is dependent on the differential diagnosis and on the
antibodies available in a given laboratory. Immunohisto-
chemical panels should contain both positive and negative
markers. It is recommended that immunohistochemical
markers have either sensitivity or specificity greater than
80% for the lesions in question. Interpretation of positivity
generally should take into account the localization of the
stain (eg, nuclear versus cytoplasmic) and the percentage of
cells staining (.10% is suggested for cytoplasmic membra-
nous markers). These guidelines are meant to be a practical
reference for the pathologist.
(Arch Pathol Lab Med. 2013;137:647–667; doi: 10.5858/
arpa.2012-0214-OA)
A s part of the International Mesothelioma Interest Group
(IMIG) biennial meeting held in Chicago (October
2006), there was a pathology half-day workshop that
Malignant Mesothelioma Diagnosis—Husain et al 647
included invited lecturers and an open forum on the
pathologic diagnosis of malignant mesothelioma (MM).
The discussion focused on practical diagnostic guidelines
meant to be a reference for the pathologist, rather than a
mandate or review of the literature. With input from other
pathologists who could not attend the meeting, an article
titled ‘‘Guidelines for Pathologic Diagnosis of Malignant
Mesothelioma’’ was published in 2009.1 This article repre-
sents an update by the original contributors and includes
contributions from additional pathologists with expertise in
this area.
GENERAL RECOMMENDATIONS
The diagnosis of MM should always be based on the
results obtained from an adequate biopsy (less commonly
cytology, exfoliative and fine-needle aspiration) in the
context of appropriate clinical, radiologic, and surgical
findings. A history of asbestos exposure should not be
taken into consideration by the pathologist when diagnos-
ing MM. Location of the tumor (pleural versus peritoneal) as
well as the sex of the patient will affect the differential
diagnosis as discussed below. The histologic diagnosis of
MM is based not only on the appropriate morphology but
also on the appropriate immunohistochemistry. Specific
information on antibody clones and their source should be
obtained from the current literature, since this is an evolving
area and is outside of the scope of this article. Molecular
testing is now more widely available and is helpful in
selected cases.
BENIGN VERSUS MALIGNANT MESOTHELIAL
CELL PROLIFERATIONS
Separating benign from malignant mesothelial prolifera-
tions presupposes first that the process has been recognized
as mesothelial. The diagnostic approach used when distin-
guishing reactive mesothelial hyperplasia from epithelioid
mesothelioma is different from that used when distinguish-
ing fibrous pleuritis from desmoplastic mesothelioma.2 The
major problem areas are discussed below.
Reactive Mesothelial Hyperplasia Versus Epithelioid MM
It is well known that reactive mesothelial proliferations
may mimic mesothelioma (or metastatic carcinoma). Some
of the causes of reactive mesothelial hyperplasia in the
pleural space include infections, collagen vascular diseases,
pulmonary infarcts, drug reactions, pneumothorax, sub-
pleural lung carcinomas, surgery, trauma, and nonspecific
inflammation. Exuberant mesothelial reactions also are
encountered in the peritoneum and pericardium, and the
latter may be particularly worrisome.
The specific features of a reactive mesothelial proliferation
that may mimic a neoplasm include high cellularity, the
presence of numerous mitotic figures and cytologic atypia,
the presence of necrosis, the formation of papillary groups,
and entrapment of mesothelial cells within fibrosis mim-
icking invasion (Figure 1). Features distinguishing reactive
mesothelial hyperplasia from mesothelioma are summa-
rized in Table 1.
Demonstration of stromal or fat invasion is a key feature
in the diagnosis of MM (Figure 2). Invasion may be into
visceral or parietal pleura (or beyond) and this can be
highlighted with immunostains such as pancytokeratin or
calretinin. Invasion into the peripheral lung is also a useful
feature in cases involving visceral pleura. Invasion by
648 Arch Pathol Lab Med—Vol 137, May 2013
mesothelioma is often subtle and may be into only a few
layers of collagenous tissue below the mesothelial space.
Invasive mesothelial cells may also be deceptively bland in
appearance and completely lack a desmoplastic reaction.
However, it is emphasized that when a substantial amount
of solid malignant tumor with histologic features of MM (ie,
a tumor mass) is identified, the presence of invasion is not
required for diagnosis.
Reactive mesothelial proliferations tend to show a
uniformity of growth and this may be highlighted with
pancytokeratin staining, which shows regular sheets and
sweeping fascicles of bland spindle cells that respect
mesothelial boundaries in contrast to the disorganized
growth and haphazardly intersecting proliferations seen in
mesothelioma. The use of pancytokeratin staining to assess
the overall architecture of a mesothelial proliferation cannot
be overemphasized.
While certain immunohistochemical stains are more likely
to show positivity in benign proliferations and others in
malignant proliferations, they should not be solely relied on
for diagnosis in individual cases (Table 2). The most helpful
of these include epithelial membrane antigen (EMA), p53,
desmin, glucose transporter 1 (GLUT-1), and insulin-like
growth factor II messenger RNA–binding protein 3 (IMP3),
which can be applied as a panel.3–6 When GLUT-1 staining
is positive, it may be a helpful marker for MM, both
epithelial and sarcomatoid (Figure 3, A through D) but is
not helpful when negative. It is more likely to be positive in
pleural than in peritoneal MM. Overall sensitivity and
specificity are reported to be 54% and 98%, respectively.7
Oncofetal protein IMP3 was recently shown to be positive in
33 of 45 MMs (73%; Figure 4) and negative in all 64 reactive
mesothelial lesions tested.8
Markers that have been studied in the literature and that
are not considered useful in the diagnosis of mesothelioma
versus mesothelial hyperplasia include minichromosome
maintenance 2 protein, telomerase transcriptase expression
(which needs to be studied further), Ki-67, transforming
growth factor, epidermal growth factor receptor, Bcl-2, and
argyrophilic nucleolar organizer region.9
Most recent published studies show that the presence of
homozygous deletion of p16 (as discussed below) rules out a
reactive lesion.
Fibrous Pleurisy Versus Desmoplastic Variant
of Sarcomatoid Mesothelioma
The identification of features of malignancy in a desmo-
plastic mesothelioma requires adequate tissue, and the
amount of tissue in a closed pleural biopsy is often
insufficient. Large surgical biopsy specimens are generally
needed. High-grade sarcomas presenting in the pleura
generally do not enter into the differential diagnosis of
fibrous pleurisy versus desmoplastic mesothelioma. Features
to separate the latter two are shown in Table 3.
The distinction of fibrous pleurisy from desmoplastic
mesothelioma can be made by identifying one or more of
the following features in a spindle cell proliferation of the
pleura: invasive growth, bland necrosis, frankly sarcomatoid
areas, and metastatic disease.10 Stromal invasion is often
more difficult to recognize in spindle cell proliferations of
the pleura than in epithelioid proliferations. The invasive
malignant cells are often deceptively bland, resembling
fibroblasts, and pancytokeratin staining is invaluable in
highlighting the presence of cytokeratin-positive malignant
cells in regions where they should not normally be present:
Malignant Mesothelioma Diagnosis—Husain et al
Figure 1. Reactive mesothelial hyperplasia within fibrous tissue, mimicking invasion (hematoxylin-eosin, original magnification 3100).
Figure 2. Epithelioid malignant mesothelioma invading fat ((hematoxylin-eosin, original magnification 3100).
Figure 3. A through D, Glucose transporter 1 (GLUT-1) staining of mesothelial lesions. A, Malignant mesothelioma with strong immunoreactivity for
GLUT-1. B, Mesothelial hyperplasia negative for GLUT-1. As expected, staining for red blood cells is strongly positive. C, Well-differentiated papillary
mesothelioma is negative for GLUT-1. D, Sarcomatoid mesothelioma with positive staining for GLUT-1 (original magnifications 3400 [A and D];
original magnifications 3200 [B and C]).

Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al 649
 Table 1. Reactive Mesothelial Hyperplasia Versus Mesothelioma
Mesothelial Hyperplasia Mesothelioma
Absence of stromal invasion Stromal invasion usually apparent
(beware of entrapment and en face cuts) (highlight with pancytokeratin staining)
Cellularity may be prominent but is confined to the Dense cellularity including cells surrounded by stroma
mesothelial surface/pleural space and not in the stroma
Simple papillae; single cell layers Complex papillae; tubules, cellular stratification
Loose sheets of cells without stroma Cells surrounded by stroma (‘‘bulky tumor’’ may involve the mesothelial
space without obvious invasion)
Necrosis rare Necrosis present (occasionally)
Inflammation common Inflammation usually minimal
Uniformity of growth Expansile nodules; disorganized growth
(highlighted with cytokeratin staining) (highlighted with cytokeratin staining)
EMA, p53, GLUT-1, and IMP3 usually stain negatively EMA, p53, GLUT-1, and IMP3 often stain positively
Desmin often stains positively Desmin often stains negatively
Usually Not Useful
Mitotic activity
Cytologic atypia
Abbreviations: EMA, epithelial membrane antigen; GLUT-1, glucose transporter 1; IMP3, insulin-like growth factor II messenger RNA–binding
protein 3.

in the connective tissue, adipose tissue, or skeletal muscle laminin, and collagen IV usually show positivity in true
deep to the parietal pleura, or invading the visceral pleura adipose tissue and can help in distinguishing it from fake
and lung tissue (or other extrapleural structures present in fat, which is negative for all three (Figure 8, A through F).
the sample) (Figure 5, A and B). Bland necrosis of Uniformity of growth and thickness of the pleural process,
paucicellular fibrous tissue may be subtle and one may be surface atypia with deep maturation, and perpendicular
reluctant to base a diagnosis of malignancy solely on its thin-walled vessels are all typical of reactive fibrous pleuritis
presence. Fortunately, most cases that show bland necrosis (Figure 9, A and B), in contrast to the disorganized growth
also show invasive growth.10 Similarly, the presence of pattern and variable thickness of desmoplastic mesothelio-
‘‘frankly sarcomatoid foci’’ is a distinctly subjective deter- mas. A helpful clue in desmoplastic mesotheliomas is the
mination and one would be reluctant to base a diagnosis of presence of expansile nodules of varying sizes with abrupt
malignancy on its presence alone, since reactive processes changes in cellularity between nodules and their surround-
may show marked cytologic atypia, albeit typically at the ing tissue.
surface of the process.
While identification of invasion into adjacent tissues is CYTOLOGIC DIAGNOSIS OF MALIGNANT
often straightforward with the aid of pancytokeratin MESOTHELIOMA
staining, Churg et al11 have recently pointed out that fatlike Mesotheliomas often present with recurrent serous
spaces (‘‘fake fat’’) may be encountered in some cases of effusions, which are submitted for cytologic evaluation.
organizing pleuritis, probably as a result of artifactual Even though the cytologic features of MM were described
changes in the dense fibrous connective tissue (Figure 6, A more than 50 years ago and have been further refined in
and B). In these regions, horizontally oriented cytokeratin- numerous subsequent articles, there is still doubt as to the
positive cells may be encountered around the fatlike spaces ability of the cytopathologic modality to establish a
(Figure 7). Awareness of this phenomenon, and looking for definitive diagnosis of malignant mesothelioma.12,13 The
vertically oriented cytokeratin-positive cells invading into published sensitivity of cytologic diagnosis of mesothelioma
readily identifiable adipose tissue (Figure 5, B), should help ranges between 32% and 76%. This broad range of
one avoid misinterpreting this phenomenon. Also, S100, sensitivity (high false-negative rate) is probably related to
sampling rather than interpretation, though one has to
accept that there is a broad morphologic overlap between
reactive mesothelial cells and malignant cells of mesothe-
Table 2. Immunohistochemistry to Separate
lioma. The absence of one of the key histologic diagnostic
Reactive Mesothelial Proliferations
from Mesotheliomaa
features of malignant mesothelioma, invasion of preexisting
tissue (not granulation tissue), is not a characteristic of
Reactive Mesothelium, Mesothelioma, exfoliative cytology specimens.
Antibody No. (% Positive) No. (% Positive) To achieve correct cytologic diagnosis it is important to
Desmin 34/40 (85) 6/60 (10) obtain an adequate amount of well-preserved fluid, which
EMA 8/40 (20) 48/60 (80) has to be prepared to ensure satisfactory cell concentration
p53 0/40 (0) 27/60 (45)
GLUT-1 5/150 (3) 103/153 (67)
suitable for making quality smears (direct, cytospin, thin-
IMP3 0/64 (0) 33/45 (73) layer) and cell blocks. Similar to histologic specimens (as
discussed in other sections of this article), application of
Abbreviations: EMA, epithelial membrane antigen; GLUT-1, glucose
transporter 1; IMP3, insulin-like growth factor II messenger RNA– immunocytochemical and molecular techniques, either on
binding protein 3. smears or on cell blocks, enhances greatly the possibility to
a
Data derived from Kato et al,5 Acurio et al,6 Shi et al,8 Monaco et al,20 reach a correct diagnosis.8,14–17 Molecular techniques, such
and Attanoos et al.78 as fluorescence in situ hybridization (FISH) in demonstrat-
650 Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al
Figure 4. Epithelioid malignant mesothelioma with strong cytoplasmic staining for insulin-like growth factor II messenger RNA–binding protein 3
(IMP3) (original magnification 3400).
Figure 5. A and B, Desmoplastic mesothelioma. A, Proliferation of bland-appearing spindle cells with haphazard growth pattern. B, Keratin staining
highlights infiltration into fat (hematoxylin-eosin, original magnification 3200 [A]; original magnification 3200 [B]).
Figure 6. A and B, Fake fat in a pleural biopsy sample from a patient with effusion and fibrosis (hematoxylin-eosin, original magnifications 340 [A]
and 3100 [B]).
Figure 7. Staining for keratin AE1/AE3 showing horizontal keratin-positive reactive spindle cells around fake fat (see Figure 5, B, for comparison
with adipose tissue) (original magnification 3100).

Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al 651
 Table 3. Fibrous Pleurisy Versus Desmoplastic Mesothelioma
Fibrous Pleurisy
Storiform pattern not prominent
Absence of stromal invasion
Necrosis, if present, is at the surface (where there is
often associated acute inflammation)
Uniform thickness of the process
Hypercellularity at the surface with maturation and
decrease in cellularity with depth (so-called zonation)
Perpendicularly oriented vessels
Usually Not Useful
Atypia (unless severe)
Mitotic activity unless numerous atypical mitotic figures
ing homozygous deletion of the p16 gene in about 70% of
mesothelial proliferations, are particularly promising, as
reported specificity is 100%.18–20 However, emerging data
indicate that subtyping of epithelioid mesothelioma accord-
ing to morphologic features and nuclear grade21 is important
to predict survival, hence a cytologic diagnosis of ‘‘malig-
nant mesothelioma epithelioid type’’ might not be sufficient
in the future. Apart from diagnostic difficulties, the frequent
practice of litigation in cases of mesotheliomas makes
pathologists reluctant to diagnose mesothelioma without
histologic confirmatory evidence.
One also has to recognize that not all mesotheliomas yield
effusions and the sarcomatoid mesotheliomas are virtually
never diagnosed on effusion cytology. In such cases, fine-
needle aspiration, combined with core biopsy (or larger
tissue samples), are necessary to establish the diagnosis.
Many of the cytologic features (scalloped borders of cell
clumps, intercellular windows, with lighter dense cytoplasm
edges, and low nuclear/cytoplasmic ratios) are shared
between reactive and malignant epithelioid mesothelial
cells. Usually, the malignant cells in sarcomatoid MM are
not shed into the effusion fluid, which may contain the
overlying reactive epithelioid mesothelial cells that may
mislead the pathologist.
The most useful cytologic features of epithelioid MMs are
as follows (Figure 10, A through D):
 The presence of numerous relatively large (.50 cells) balls of
cells with berrylike external contours is characteristic of MM.
Most cells are much larger than the average mesothelial cells.
This includes enlargement of cytoplasm, nucleus, and nucleo-
lus.22
 The presence of macronucleoli. However, prominent nucleoli
can be present in reactive mesothelial cells and not all MM cells
have macronucleoli.
 Nuclear atypia, if present.
Key cytologic features of adenocarcinoma are as follows:
 Clumps of cells usually have smooth rather than berrylike
borders.
 The nuclear to cytoplasmic ratio is usually higher than in MM
 Nuclear variability in shape and size is much more common.
 Cytoplasmic vacuoles often contain epithelial mucin in contrast
to mesothelial cells, which contain hyaluronic acid.
 Cytoplasm is less dense than in mesothelial cells, and
‘‘windows’’ are rarely present.
652 Arch Pathol Lab Med—Vol 137, May 2013
Desmoplastic Mesothelioma
Storiform pattern often prominent
Stromal invasion present (highlight with pancytokeratin staining)
Bland necrosis of paucicellular collagenized tissue
Disorganized growth with uneven thickness, expansile nodules, and abrupt
changes in cellularity
Lack of maturation from the surface to depths of the process
Paucity of vessels, without orientation
Cellularity
 Psammoma bodies (when present) are more likely to be a
feature of adenocarcinoma than MM, but they do occur in MM
rarely.
The differential diagnosis, and use of immunohistochem-
istry and molecular markers in cytologic specimens, is
similar to that in tissue sections (see below).
HISTOLOGIC FEATURES OF MM
Most MMs are readily identified or strongly suspected on
routine hematoxylin-eosin staining where they exhibit a
variety of histologic subtypes, broadly divided into epithe-
lioid, sarcomatoid, or mixed (biphasic) categories. Multiple
patterns of each of these subtypes have been described,
some of which are now being shown to have prognostic
importance (see below). Also, the recognition of the various
patterns is helpful for the pathologist diagnostically and will
guide the differential diagnosis and selection of appropriate
markers. However, most mesotheliomas have several
patterns and on a biopsy sample it may not be possible to
further subclassify the tumor. Thus the pattern may be
included as a comment or in the microscopic description
(Table 4). Although histologic grading has not traditionally
been performed, a recent study of resected epithelioid MM23
showed that a 3-tiered nuclear grading score based on
mitotic activity and nuclear atypia is strongly predictive of
survival. It will be interesting to see if these results are
corroborated in future studies.
Epithelioid MMs are composed of polygonal, oval, or
cuboidal cells that often mimic nonneoplastic reactive
mesothelial cells. Sarcomatoid MMs usually consist of
spindle cells but can be composed of lymphohistiocytoid
cells and/or may also contain heterologous rhabdomyosar-
comatous, osteosarcomatous, or chondrosarcomatous ele-
ments.24,25 Mixed or biphasic MMs contain both epithelioid
and sarcomatoid areas within the same tumor.26–32 In
general, the differential diagnosis for MM depends on its
basic histologic category: the differential diagnosis for
epithelioid MM includes carcinomas and epithelioid can-
cers; the differential diagnosis for sarcomatoid MM includes
sarcomas and other spindle cell neoplasms; and the
differential diagnosis of mixed MM includes mixed or
biphasic tumors such as synovial sarcoma and metastatic
pleomorphic carcinoma of lung. Desmoplastic mesothelio-
mas may mimic fibrous pleuritis. Since each broad histologic
category has its own distinctive differential diagnosis, the
Malignant Mesothelioma Diagnosis—Husain et al
Figure 8. A through F, S100, laminin, and collagen IV staining is negative in fake fat (A through C) and positive in true fat (D through F) (original
magnifications 3200 [A through F]).

immunostains selected for further workup of an MM are
dictated by the histologic category into which it falls.33
The most frequent histologic type of MM is epithelioid.
The common secondary growth patterns of epithelioid MM
Arch Pathol Lab Med—Vol 137, May 2013
are readily recognized by most pathologists: tubulopapillary,
acinar (glandular), adenomatoid (also termed microglandu-
lar), and solid. Some epithelioid MMs have a distinctive
feature consisting of clusters of tumor cells floating in pools
Malignant Mesothelioma Diagnosis—Husain et al 653
Figure 9. A and B, Reactive fibrous pleuritis. A, There is uniformity of growth and thickness of the reactive process. B, Perpendicular, uniformly
spaced thin-walled vessels with fibrin on one surface and progressive maturation of fibrous tissue in deeper part (hematoxylin-eosin, original
magnifications 340 [A] and 3100 [B]).
Figure 10. A through D, Cytologic features of malignant mesothelioma (MM). A, Numerous large clumps of cells are present in effusion of MM. B,
The clumps have a berrylike external contour. C, Multiple binucleated cells are seen. D, Cell block also shows frequent clumps and can be very useful
in performing special stains (Papanicolaou, original magnifications 340 [A], 3200 [B], and 3400 [C]; hematoxylin-eosin, original magnification 3200
[D]).

654 Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al
 Table 4. Histologic Subtypes and Patternsa
of Malignant Mesothelioma
Epithelioid mesothelioma
Tubulopapillary
Micropapillary
Trabecular
Acinar
Adenomatoid
Solid
Clear cell
Deciduoid
Adenoid cystic
Signet ring cell
Small cell
Rhabdoid
Pleomorphic
Sarcomatoid mesothelioma
Conventional, spindle cell
Desmoplastic
Heterologous differentiation (osteosarcomatous,
chondrosarcomatous, etc)
Lymphohistiocytoid (may also be classified as epithelioid)
Biphasic/mixed
a
Subtype must be given in the diagnosis, but histologic pattern,
epithelioid or sarcomatous, may be described in a comment or
microscopic description.
of hyaluronic acid. Less commonly, tumor cells may be
clear, deciduoid, signet ring, small cell, or rhabdoid or may
have an adenoid cystic pattern.26,27,29–32,34
The tubulopapillary pattern consists of a mixture of
papillary structures lined by bland flat, cuboidal, or polygonal
cells with fibrovascular cores and glandlike tubules. Of note,
a micropapillary pattern (without central fibrovascular core)
should be classified as different from tubulopapillary, as the
former correlates with a higher incidence of lymphatic
invasion.21 The acinar pattern consists of elongated or
branching glandlike lumina lined by relatively bland cuboidal
cells. The adenomatoid pattern consists of bland, flat to
cuboidal cells lining small glandlike structures.35
The solid epithelioid MM consists of nests, cords, or sheets
of round, oval, or polygonal cells with abundant eosinophilic
cytoplasm and round, vesicular nuclei with prominent
nucleoli. These cells resemble nonneoplastic, reactive meso-
thelial cells and the differential diagnosis may include reactive
mesothelial hyperplasia, solid adenocarcinoma, and even
squamous cell carcinoma owing to the abundant pink
cytoplasm. The solid, poorly differentiated pattern consists
of sheets and nests of relatively discohesive polygonal to
round cells, with uniform nuclei. Lymphomas and poorly
differentiated carcinomas enter into the differential diagnosis
of solid, poorly differentiated MM. Recently, epithelioid
mesotheliomas with marked nuclear pleomorphism in
greater than 10% of the tumor have been shown to behave
in similar fashion to sarcomatoid and biphasic variants, with
a proposal that a ‘‘pleomorphic’’ variant be recognized as an
adversely prognostic epithelioid pattern.21,36
The clear cell MM is composed of mesothelial cells with
clear cytoplasm, which should be differentiated from clear
cell renal cell carcinomas, clear cell carcinomas of the lung,
clear cell melanoma, and other clear cell tumors that can
metastasize to the pleura.37–40
The deciduoid MM is composed of sheets of large, round
to polygonal cells with sharp cell borders, abundant glassy
eosinophilic cytoplasm, and round vesicular nuclei with
prominent nucleoli.
Arch Pathol Lab Med—Vol 137, May 2013
The adenoid cystic pattern consists of cribriform and
tubular patterns separated by fibrous stroma, and the
differential diagnosis includes adenoid cystic carcinoma in
addition to adenocarcinoma. The signet ring and lipid-rich
MMs consist of clusters or sheets of cells that contain
cytoplasmic vacuoles; these rare tumors should be differ-
entiated from metastatic signet ring cell adenocarcinoma
and renal cell carcinoma, respectively.41 The extremely rare
small cell MM consists of uniform small, round cells with
bland nuclei and a high nuclear to cytoplasmic ratio.42 The
rhabdoid pattern is characterized by the presence of
discohesive cells having abundant eosinophilic cytoplasm,
an eccentric nucleus with a prominent nucleolus, and a
rounded, eosinophilic cytoplasmic inclusion that sometimes
causes nuclear indentation. The proportion of the rhabdoid
component in these tumors ranges from 15% to 75%.43
Secondary patterns of sarcomatoid MM may demonstrate
anaplastic and giant cells with a differential diagnosis of
high-grade sarcoma, osteosarcomatous areas with a differ-
ential diagnosis of osteosarcoma, or chondrosarcomatous
areas with differential diagnosis of chondrosarcoma.44–46
The lymphohistiocytoid pattern (which may be better
regarded as epithelioid subtype rather than sarcomatoid,
since its prognosis is more like the former) consists of
discohesive, atypical histiocytoid-appearing MM cells within
an intense lymphoplasmacytic infiltrate. The differential
diagnosis includes nonneoplastic inflammatory process,
non-Hodgkin lymphoma, and Hodgkin lymphoma.47,48
Most desmoplastic MMs are sarcomatoid MMs, although
occasional epithelioid desmoplastic MMs can occur. A
paucicellular distribution of bland neoplastic spindle cells
between bands of dense collagenous stroma that resemble
pleural plaque is the distinguishing feature of desmoplastic
MM. This type of MM may not be suspected unless frankly
sarcomatoid areas of the tumor are found. This pattern is
discussed further below. When prominent neoplastic giant
cells or anaplastic cells are present (pleomorphic MM),
pleomorphic carcinoma and other high-grade, poorly
differentiated neoplasms metastatic to the pleura should
be excluded.
Heterologous differentiation within a mesothelioma is a
rare but well-established feature that occurs more frequently
in sarcomatoid variants, although it can also be seen with
biphasic and epithelioid morphologies. This most common-
ly takes the form of osteosarcomatous or chondrosarcoma-
tous elements, although rarely, rhabdomyosarcomatous
elements may be present.49 One case showing angiosar-
comatous differentiation has also recently been reported.50
These elements are morphologically indistinguishable from
the sarcomas themselves, and diagnosis is made on the
basis of identifying the combined mesothelial elements,
which usually predominate. In rare cases, mesothelial
elements are in the minority and thorough sampling of
any potential primary pleural sarcoma is recommended to
exclude heterologous differentiation.
MORPHOLOGIC FEATURES RELATED
TO PERITONEAL MM
The morphology of peritoneal malignant mesothelioma
(PMM) is similar to that of pleural MM in that there are
epithelioid and sarcomatous types, with the former includ-
ing the common tubulopapillary/papillary and solid histo-
logic features. In the peritoneum, however, several site-
specific issues are recognized.
Malignant Mesothelioma Diagnosis—Husain et al 655
 While epithelioid and sarcomatous types can be seen in
PMM, the incidence of biphasic tumors is lower than in
pleural disease, and pure sarcomatous tumors are very
rare.51,52 As in pleural MM, the biphasic and sarcomatoid
subgroups have a significantly poorer prognosis and are less
amenable to treatment overall.53,54 While definitions of
pleural MM have proposed a minimum of 10% spindled
growth for a biphasic designation, the less common
occurrence of biphasic histologic appearance and the
distinctly poorer prognosis of this group in PMM may
make a minimum value less practical. It remains unclear
whether identification of any component of malignant
spindled histology portends a poor prognosis in PMM.55
Multiple mesothelial-lined cysts, also known as benign
multicystic mesothelioma, represent a rare but well-
described entity that may enter the differential diagnosis
of mesothelial neoplasia. This lesion is nearly always
encountered in the peritoneum, although rare cases with
pleural involvement have been described. These cystic
proliferations are lined by bland mesothelial cells and lack
stratification, papillation, or atypia. If defined in this fashion,
this process does not metastasize but can recur.56
Well-differentiated papillary mesothelioma (WDPM) is
also an important subgroup much more frequently encoun-
tered in the peritoneum than in the pleura. These generally
noninvasive papillary neoplasms are lined by bland meso-
thelial cells with low-grade nuclei. These nuclei are small,
smoothly contoured, and do not contain nucleoli. Mitoses
are rarely present. The combination of more-than-bland
low-grade nuclei, architectural complexity or solid pattern,
or overt invasion should be used to exclude WDPM in favor
of papillary epithelioid malignant mesothelioma. In a recent
series of WDPM in women,57 1 of 26 patients had recurrent
disease and none died of disease-related causes. No
association with asbestos exposure was identified. The
largest tumor in this series was 2.0 cm. Many cases had
multifocality, however. Setting a size limit to the use of this
diagnosis was proposed by these authors; it is clear,
however, that bona fide cases can have a tumor size that
exceeds 2.0 cm. It is acknowledged that bulky disease is one
feature against WDPM. A discussion of size criteria remains
an important open question, as the major concern in a larger
or multifocal tumor is the undersampling or misclassifica-
tion of a papillary epithelioid malignant mesothelioma as a
WDPM. In summary, when narrowly defined by morpho-
logic criteria, WDPM has an excellent prognosis, although
recurrent disease can be problematic. Since the natural
history of this subgroup is distinct from PMM, it is an
important morphologic distinction from architecturally
similar but more aggressive papillary epithelioid malignant
mesotheliomas.58,59
HISTOCHEMICAL STAINING IN MM
The cytoplasmic vacuoles in adenocarcinomas frequently
contain epithelial mucin highlighted by periodic acid–Schiff
after digestion (PAS-D) and mucicarmine stains. Epithelial
mucin can also be positive by Alcian blue but it is not
digested by hyaluronidase. While it has been generally
accepted that MMs do not show PAS-D–positive vacuoles,
as seen in adenocarcinomas, there are rare published
examples of epithelioid MM that show PAS-D positivity.60
Mesothelial cells may have vacuoles containing hyaluronic
acid, positive by Alcian blue and digestible by hyaluroni-
dase. Mucicarmine may also stain hyaluronic acid in MM;
656 Arch Pathol Lab Med—Vol 137, May 2013
thus, mucicarmine stain is not recommended for distin-
guishing MM from adenocarcinoma.
IMMUNOHISTOCHEMICAL STAINING IN MM
A definitive diagnosis of malignant mesothelioma re-
quires a workup including immunohistochemistry and in
some cases, histochemical stains for mucin. The role of
immunohistochemistry varies depending on the histologic
type of mesothelioma (epithelioid versus sarcomatoid), the
location of the tumor (pleural versus peritoneal), and the
type of tumor being considered in the differential diagnosis
(adenocarcinoma, squamous cell carcinoma, malignant
melanoma, epithelioid hemangioendothelioma). The im-
munohistochemical approach is also different depending on
whether the tumor is sarcomatoid or epithelioid. Since
biphasic mesotheliomas have an epithelioid component, the
differential diagnosis is similar to that of epithelioid
mesotheliomas.
Immunohistochemical staining for pancytokeratin is
useful in the diagnosis of mesothelioma since virtually all
epithelioid MMs and most sarcomatoid MMs will be
positive. In a recent study,61 93% of sarcomatoid mesothe-
liomas exhibited immunoreactivity for cytokeratin (CK); this
percentage may be even higher if a cocktail of keratins is
used. Sarcomatoid MM with osteosarcomatous or chondro-
sarcomatous differentiation may be keratin negative. If an
epithelioid malignant neoplasm causing diffuse pleural
thickening is keratin negative with pancytokeratin immu-
nostaining (using multiple keratins including AE1/AE3,
CAM 5.2, and CK5/6), one should consider other possible
differential diagnoses such as malignant melanoma, epithe-
lioid hemangioendothelioma, or angiosarcoma (although
some of these can be keratin positive), and malignant
lymphoma. In this circumstance, it is recommended that a
screening panel be performed to address these possibilities.
Such a panel might include CD45, CD20, CD3, or CD30 for
large cell lymphomas; S100 and HMB-45 for melanoma;
and CD31 and CD34 for angiosarcoma and epithelioid
hemangioendothelioma. Since D2-40 will stain epithelioid
vascular tumors, it is not a good marker for this differential
diagnosis. Further confirmatory staining may be useful if
one or more of these screening markers show positivity.
Ultrastructural studies may be of benefit in particularly
difficult cases.
On occasion, a tumor may not stain with any marker. This
lack of staining can be caused by a variety of reasons,
including overfixation in formalin. Negative immunoreac-
tivity may also occur in alcohol-fixed tissues if antigen
retrieval is used; therefore, some knowledge about the
fixative is important. If needed, vimentin may be used to
assess immunoreactivity.
As the role of immunohistochemistry has evolved, it has
become a standard to use panels of positive and negative
antibodies that vary depending on the differential diagnosis.
Since there is variability of staining between different
antibody clones and between separate laboratories, no
specific panel of antibodies is recommended. It is best for
each laboratory to test staining conditions for the antibodies
of choice with appropriate controls. If possible, one should
choose antibodies with a sensitivity or specificity of at least
80%.
There is no absolute number of antibodies that can be
recommended for the diagnosis of malignant mesothelioma.
Workup can be done in stages. An initial workup could use
Malignant Mesothelioma Diagnosis—Husain et al
 Table 5. Immunohistochemical Markers Used in the Differential Diagnosis Between Epithelioid Pleural Mesothelioma
and Lung Adenocarcinoma
Marker Current Value/Comments
Epithelioid mesothelioma (positive mesothelioma markers)
Calretinin Very useful. It can be demonstrated in nearly all epithelioid mesotheliomas when antibodies to human
recombinant calretinin are used. The staining is often strong and diffuse, and both nuclear and
cytoplasmic. Five percent to 10% of lung adenocarcinomas are positive, but the staining is usually focal.
Cytokeratin 5 or 5/6 Very useful. It is expressed in 75% to 100% of the mesotheliomas. Approximately 2% to 20% of lung
adenocarcinomas can be focally positive.
WT-1 Very useful. Approximately 70% to 95% of the mesotheliomas show nuclear positivity. Lung
adenocarcinomas are negative.
D2-40 (podoplanin) Very useful. Approximately 90% to 100% of mesotheliomas show positivity along the cell membranes. Up
to 15% of lung adenocarcinomas are focally positive.
Lung adenocarcinoma (positive carcinoma markers)
MOC-31 Very useful. Approximately 95% to 100% of lung adenocarcinomas are positive. Two percent to 10% of
mesotheliomas show focal staining.
Y
BG8 (Lewis ) Very useful. Approximately 90% to 100% of lung adenocarcinomas are positive. Three percent to 7% of
mesotheliomas show focal reactivity.
CEA (monoclonal) Very useful. Approximately 80% to 100% of lung adenocarcinomas are positive. Fewer than 5% of
mesotheliomas are focally positive.
B72.3 Very useful. Seventy-five percent to 85% of lung adenocarcinomas are positive. Very few mesotheliomas
are positive.
Ber-EP4 Very useful. Ninety-five percent to 100% of lung adenocarcinomas are strongly positive. Up to 20% of
mesotheliomas are focally positive.
TTF-1 Very useful. Seventy-five percent to 85% of lung adenocarcinomas show nuclear positivity. It is not
expressed in mesotheliomas.
Napsin A Very useful. Eighty percent to 90% of lung adenocarcinomas show cytoplasmic staining. It is not expressed
in mesotheliomas.
Abbreviations: BG8, blood group 8; CEA, carcinoembryonic antigen; TTF-1, thyroid transcription factor-1; WT-1, Wilms tumor 1.

2 mesothelial markers and 2 markers for the other tumor
under consideration on the basis of morphology (adeno-
carcinoma, squamous cell carcinoma). If the results are
concordant, the diagnosis may be considered established. If
they are discordant, a second stage, expanding the panel of
antibodies, may be needed. The pattern of immunohisto-
chemical staining is important with certain antibodies, such
as calretinin, where both cytoplasmic and nuclear staining is
required to support a diagnosis of mesothelioma, and Wilms
tumor 1 (WT-1), which should be only nuclear. There is no
standard for the percentage of tumor cells that should be
positive, but some have used a 10% cutoff for membranous
and cytoplasmic staining.
Pleural Epithelioid Mesothelioma Versus Carcinoma
The differential diagnosis of epithelioid pleural mesothe-
lioma is greatly facilitated by the use of immunohistochem-
istry. A relatively large number of markers that can assist in
distinguishing epithelioid pleural mesothelioma from met-
astatic carcinoma originating either in the lung or in distant
organs, such as the kidney, breast, or ovary, are currently
available. Tables 5 and 6, respectively, list the markers that
are currently useful in distinguishing epithelioid pleural

Table 6. Immunohistochemical Markers Used in the Differential Diagnosis Between Epithelioid Pleural Mesothelioma
and Squamous Carcinoma of the Lung
Marker Current Value/Comments
Epithelioid mesothelioma (positive mesothelioma markers)
WT-1 Very useful. Up to 95% of mesotheliomas show nuclear positivity. Lung squamous carcinomas are negative.
Calretinin Somewhat useful. Virtually all mesotheliomas are positive, often strongly and diffusely, with nuclear and
cytoplasmic staining. Approximately 40% of lung squamous carcinomas are positive, but the staining is
often focal.
D2-40 (podoplanin) Not useful. Approximately 80% to 100% of mesotheliomas are positive. Fifty percent of lung squamous
carcinomas also stain.
Cytokeratin 5 or 5/6 Not useful. It is expressed in 75% to 100% of mesotheliomas and 100% of lung squamous carcinomas.
Lung squamous carcinoma (positive carcinoma markers)
p63 or p40 Very useful. One hundred percent of lung squamous carcinomas show strong and diffuse nuclear positivity.
Seven percent of mesotheliomas react, often focally.
MOC-31 Very useful. Ninety-seven percent to 100% of lung squamous carcinomas are positive. Two percent to 10%
of mesotheliomas show focal staining
BG8 (LewisY) Very useful. Eighty percent of lung squamous carcinomas are positive. Three percent to 7% of
mesotheliomas show focal staining.
Ber-EP4 Useful. Approximately 85% to 100% of lung squamous carcinomas are positive. Up to 20% of
mesotheliomas are focally positive.
Cytokeratin 5 or 5/6 Not useful. One hundred percent of lung squamous carcinomas and 75% to 100% of mesotheliomas are
positive.
Abbreviations: BG8, blood group 8; WT-1, Wilms tumor 1.
Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al 657
Figure 11. A and B, Calretinin staining. A, Malignant mesothelioma has diffuse strong nuclear and cytoplasmic positivity. B, Adenocarcinoma is
usually negative but may show focal positivity as shown here (original magnifications 3200 [A] and 3400 [B]).
Figure 12. A and B, cytokeratin 5/6 staining. A, Malignant mesothelioma with strong reactivity. B, Large cell carcinoma with only focal reactivity
(original magnifications 3400 [A and B]).

mesotheliomas from lung adenocarcinomas, and those that
discriminate between epithelioid mesotheliomas and squa-
mous cell carcinomas. Since none of these markers are
100% specific, the IMIG recommends that at least 2
mesothelial and 2 carcinomas markers, in addition to
cytokeratin (using a broad-spectrum anti-cytokeratin anti-
body), be included in any panel.1 Based on their sensitivity
and specificity, calretinin (Figure 11, A and B), CK5 or CK5/6
(Figure 12, A and B), WT-1 (Figure 13, A through C), and
D2-40 (podoplanin) (Figure 14, A and B) are the best
positive mesothelioma markers; and MOC-31 (Figure 15, A
through C), Ber-EP4, carcinoembryonic antigen (CEA), and
Lewis(y) antigen blood group 8 (BG8) are the best overall
carcinoma markers.62–64 Because of their high specificity for
lung adenocarcinomas, thyroid transcription factor-1 (TTF-
1) (Figure 16) and napsin A have an advantage over the
other markers in that they can be used to confirm the
pulmonary origin of an adenocarcinoma. MOC-31, Ber-EP4,
CEA, BG8 (Figure 17), and p63 are regarded as the best
positive carcinoma markers for differentiating between
epithelioid mesotheliomas and squamous cell carcinomas
because they are commonly expressed in the latter and are
658 Arch Pathol Lab Med—Vol 137, May 2013
usually absent in the former.65 p63 has an advantage over
the other 4 markers in that, in addition to being strongly and
invariably expressed in squamous cell carcinomas, while it is
absent in mesotheliomas, it may also assist in distinguishing
squamous cell carcinomas from pulmonary adenocarcino-
mas. Because WT-1 is expressed in most epithelioid
mesotheliomas, but absent in squamous cell carcinomas, it
is the best positive mesothelioma marker for discriminating
between these malignancies. Calretinin is not as useful in
this scenario since it often shows positivity in squamous cell
carcinomas.
Other carcinomas that metastasize to the pleura, and
which can potentially be confused with mesothelioma, are
those that originate in the ovary and fallopian tube
(discussed later), breast, kidney, and gastrointestinal tract.
Since most breast carcinomas express estrogen receptor,
gross cystic disease fluid protein-15, or mammaglobin,
immunostaining for these markers can be very useful in
distinguishing mesothelioma from a metastatic breast
carcinoma. Markers useful in differentiating mesothelioma
from metastatic renal cell carcinoma are given in Table 7.
Because of their sensitivity and specificity, calretinin, D2-40
Malignant Mesothelioma Diagnosis—Husain et al

Figure 13. A through C, Wilms tumor 1 (WT-1) staining. A, Strong
nuclear staining in malignant mesothelioma invading fat. Note that
endothelial cells show cytoplasmic staining only. B, Strong granular
cytoplasmic staining in large cell carcinoma. C, Cytoplasmic staining in
adenocarcinoma of lung (original magnifications 3200 [A] and 3400 [B
and C]).
(podoplanin), and cytokeratin 5/6 are the best positive
mesothelioma markers.66 Among the carcinoma markers,
PAX8 or PAX2 are the most useful as they are expressed in
most renal cell carcinomas (Figure 18),67 but not in
Arch Pathol Lab Med—Vol 137, May 2013
mesotheliomas.68 Renal cell carcinoma marker and CD15
can also be useful, but the sensitivity and specificity of these
markers for renal cell carcinomas is significantly lower than
those of PAX8 or PAX2.
Immunohistochemical Issues in Peritoneal Mesothelioma
Diffuse malignancies of the peritoneum include PMM and
secondary peritoneal carcinomatosis in the clinical, imaging,
and gross pathologic differential diagnosis in many cases. In
pleural disease, pseudomesotheliomatous carcinoma (de-
fined as a carcinoma that grows along pleura encasing the
lung) is most often from an adenocarcinoma of pulmonary
origin, while peritoneal carcinomatosis can be of ovarian,
fallopian tube (previously considered as primary peritoneal
carcinomas), gastric, pancreatic, colonic, and more rarely,
breast origin.51,69 Therefore, immunohistochemistry panels
have to be adjusted accordingly.
Most studies have focused on differentiating PMM from
papillary serous carcinoma (PSC) and these are summarized
in Table 8. There have been fewer data directly comparing
the profile of PMM to pancreatic, gastric, and colon
carcinoma. The markers useful in female patients include
calretinin, and possibly D2-40 (which can also be positive in
some cases of PSC), for positive markers in PMM; and
MOC-31, BG8, and with less specificity, Ber-EP4, for
positive adenocarcinoma markers. While specific, B72.3
staining may be too focal in many PSC cases, although a
positive result is very useful. The high frequency of reactivity
for the mesothelioma markers CK5/6 and WT-1 in PSC and
the less frequent staining for CEA in PSC limits the ability of
those markers to discriminate between these entities.
Carcinoembryonic antigen may also be useful in the setting
when PSC is not in the differential diagnosis. Although h-
caldesmon has been reported to be highly useful as a
mesothelial marker,70 other studies68 have not shown this. A
strongly positive result for estrogen receptor may be helpful
in difficult cases, as would a positive result for progesterone
receptor. A very useful marker to address the problem of
tumors of müllerian origin in women and tumors of renal
origin in all patients is PAX8.68,71 PAX8 is a transcription
factor involved in the development of thyroid, kidney, and
müllerian system. While focal or weak staining can be seen
in a small number of mesotheliomas, a high percentage of
ovarian, tubal, endometrial, and renal tumors show
immunoreactivity that is frequently diffuse and intense.
This marker is very promising when added to a panel to
differentiate abdominal malignant mesothelioma from
carcinoma.
In male patients, WT-1 (nuclear staining) and D2-40 are
useful markers in addition to calretinin for MM, and for
nonserous adenocarcinoma, B72.3, MOC31, BG8, and Ber-
EP4 all have high sensitivity and specificity.
Sarcomatoid Mesothelioma
The criteria for distinguishing reactive fibrous pleurisy
from sarcomatoid mesothelioma have been well character-
ized and are summarized above.
An immunohistochemical panel that can be useful for the
initial evaluation of a sarcomatoid tumor involving the
pleura should include cytokeratins, calretinin, and D2-40.
Multiple cytokeratin antibodies including AE1/3, CAM 5.2
(or CK18), and CK7 should be used, as cytokeratin
expression can be focal, weak, and/or variable.72,73 Other
positive markers that are used in the evaluation of
epithelioid mesothelioma, such as WT-1 and CK5/6, as
Malignant Mesothelioma Diagnosis—Husain et al 659
Figure 14. A and B, D2-40 staining. A, Strong membranous staining in malignant mesothelioma. B, Focal staining in squamous cell carcinoma
(original magnifications 3200 [A] and 3400 [B]).
Figure 15. A through C, MOC31 staining. A, Large cell carcinoma with membranous staining. B, Papillary adenocarcinoma of lung with strong
staining. C, Focal staining in malignant mesothelioma (original magnifications 3400 [A and B] and 3200 [C]).
Figure 16. Thyroid transcription factor-1 (TTF-1) shows strong nuclear staining in lung adenocarcinoma (original magnification 3400).

660 Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al
Figure 17. Blood group 8 (BG8) shows strong membranous staining in large cell carcinoma (original magnification 3400).
Figure 18. PAX8 shows strong nuclear staining in this case of metastatic clear cell carcinoma from kidney (original magnification 3200).
Figure 19. A, Fluorescence in situ hybridization (FISH)–negative results for p16 deletion: 2 green signals (9p centromere) and 2 red signals (p16);
B, FISH-positive results for p16 deletion: only 2 green signals (9p centromere) and no red signals (p16) (original magnifications 31000 [A and B]).

well as adenocarcinoma markers, such as Ber-EP4, CEA,
and MOC-31, do not provide much added utility in
sarcomatoid tumors. D2-40 and calretinin have been the 2
positive mesothelial markers most consistently expressed in
sarcomatoid mesotheliomas in a variable percentage of
cases.74,75 False positives can occur by the misinterpretation
of positive D2-40 reactivity within benign entrapped
lymphatics or reactive mesothelial elements. A recent
study61 reported the presence of usually focal calretinin
immunoreactivity labeling fewer than 10% of tumor cells in
31% of sarcomatoid mesotheliomas.
A histologically malignant sarcomatoid tumor that is
strongly and diffusely cytokeratin positive usually limits the
differential diagnosis to sarcomatoid mesothelioma, sarco-
matoid carcinoma, and, on occasion, synovial sarcoma or
metastatic sarcomatoid renal cell carcinoma. Although
synovial sarcomas of the pleura (or primary pulmonary
synovial sarcomas involving the pleura) usually present as
localized solid tumors, they can present with diffuse pleural
thickening that is similar to malignant mesothelioma. The
diagnosis of synovial sarcoma should be considered when
there is a highly cellular neoplasm with very little cytoplasm
Arch Pathol Lab Med—Vol 137, May 2013
in tumor cells, resulting in overlapping nuclei with the
presence of focal hemangiopericytoma-like blood vessels
and limited keratin expression. The diagnosis can be
confirmed by molecular testing for its distinctive X:18
translocation in formalin-fixed, paraffin-embedded tissue.
Unless there is convincing calretinin and D2-40 positivity, it
is difficult to separate out the spindled cell component of a
partially sampled sarcomatoid carcinoma from sarcomatoid
mesothelioma. Heterologous elements may be present in
both tumors. A possible distinguishing feature is when the
tumor has areas where the malignant cells are infiltrating
through densely collagenized fibrosis (as is characteristic of
desmoplastic mesothelioma). This pattern is quite typical of
malignant mesothelioma and favors that diagnosis, al-
though ultimately, in this instance, the diagnosis may have
to incorporate other gross and clinical features. In some
cases, especially with limited biopsy material, it may be
difficult to distinguish metastatic sarcomatoid carcinoma
from sarcomatoid mesothelioma. Carcinoma markers such
as CEA and TTF-1 (for lung) can be tried. Sarcomatoid renal
cell carcinoma can metastasize to the pleura and grow like a
mesothelioma, producing a pseudomesotheliomatous sar-
Malignant Mesothelioma Diagnosis—Husain et al 661
 Table 7. Immunohistochemical Markers Used in the Differential Diagnosis Between Epithelioid Pleural Mesothelioma
and Renal Cell Carcinomas
Marker Current Value/Comments
Epithelioid mesothelioma (positive mesothelioma markers)
Cytokeratin 5 or 5/6 Very useful. Seventy-five percent to 100% of mesotheliomas are positive. Renal cell carcinomas are
negative.
Mesothelin Very useful. One-hundred percent of mesotheliomas are positive. Renal cell carcinomas are negative.
Calretinin Very useful. Virtually all mesotheliomas are positive and the staining is often strong and diffuse with
nuclear and cytoplasmic staining. Four percent to 10% of renal cell carcinomas are focally positive.
D2-40 (podoplanin) Very useful. Approximately 80% to 100% of mesotheliomas show positivity along the cell membrane.
Renal cell carcinomas are negative.
WT-1 Useful. Approximately 70% to 93% of mesotheliomas show nuclear positivity. Four percent of renal cell
carcinomas are positive.
Renal cell carcinoma (positive carcinoma markers)
PAX8 or PAX2 Very useful. Eighty-five percent to 100% of renal carcinomas are positive. Mesotheliomas are negative.
CD15 (Leu-M1) Useful. Approximately 65% of renal cell carcinomas are positive. Mesotheliomas only rarely show focal
positivity. Can stain any necrotic tissue.
RCC Ma Somewhat useful. Fifty percent to 70% of renal cell carcinomas are positive. Eight percent to 26% of
mesotheliomas are focally positive.
MOC-31 Limited utility. Fifty percent of renal cell carcinomas are positive. Two percent to 10% of mesotheliomas
show focal staining.
Ber-EP4 Not useful. Approximately 40% of renal cell carcinomas are positive. Up to 20% of mesotheliomas are
focally positive.
CD10 Not useful. Eighty percent of renal cell carcinomas are positive. Approximately 50% of mesotheliomas are
positive.
BG8 (LewisY) Not useful. Four percent of renal cell carcinomas and 3% to 7% of mesotheliomas are positive.
Abbreviations: BG8, blood group 8; WT-1, Wilms tumor 1.

Table 8. Peritoneal Malignant Mesothelioma (PMM) Versus Papillary Serous Carcinoma (PSC)
and Nongynecologic Adenocarcinoma (AdCa)
Positive mesothelioma markers
Calretinin Useful. Positivity in 85% to 100% of PMM cases, but reactivity in 0% to 38% of PSCs limits its use as a
single marker.
D2-40 Potentially useful. Positivity in 93% to 96% of PMM cases, but wide spectrum of positivity in PSCs from
13% to 65%; requires more data in this context.
CK5/6 Not useful. Positivity in 53% to 100% of PMM cases, and positivity in 22% to 35% of PSC cases.
WT-1 Not useful. Positivity in 43% to 93% of PMM cases, but 89% to 93% of PSCs are positive.
PSC markers
MOC31 Very useful. Positivity in 98% of PSCs and 5% of PMM cases.
PAX 8 Very useful. Positivity in most müllerian carcinomas; negativity in PMM.
BG8 Very useful. Positivity in 73% of PSCs and 3% to 9% of PMM cases.
Ber-EP4 Useful. Positivity in 83% to 100% of PSCs and 9% to 13% of PMM cases.
B72.3 Limited utility. Positivity in 65% to 100% of PSCs and 0% to 3% of PMM cases, but many cases show only
trace/focal staining.
CEA Not useful. Zero percent to 45% of PSCs (average, 20%) and 0% of PMM cases, but sensitivity in PSC is
too low compared to other choices.
ER Useful. Sixty percent to 93% in PSCs, and negativity or very low positive rate (0%–8%) in PMM cases.
PR Limited utility. Lower sensitivity than ER, but uniformly negative staining in PMM. May be valuable if shows
positivity.
PMM versus nongynecologic AdCa (biliary, pancreatic, gastric, colonic)
Calretinin Very useful. Positivity in 85% to 100% of PMM cases but also positivity in 10% of pancreatic AdCas, so
limited as a single marker.
WT-1 Very useful. Positivity in 43% to 93% of PMM cases, 3% of gastric AdCas, negativity in pancreatic AdCa.
D2-40 Potentially useful. Positivity in 93% to 96% of PMM cases, negativity in pancreatic and gastric AdCa (but
limited data).
CK5/6 Not useful. Positivity in 53% to100% of PMM cases, but 38% of pancreatic AdCas are positive.
MOC31 Very useful. Positivity in 5% of PMM cases and 87% of AdCas.
BG8 Very useful. Positivity in 3% to 9% of PMM cases and 89% of AdCas.
CEA Very useful. Positivity in 81% of AdCas, negativity in PMM.
B72.3 Very useful. Positivity in 84% of pancreas, 89% of bile duct, 98% of colon AdCas; 0% to 3% of PMM
cases.
Ber-EP4 Useful. Positivity in .98% of pancreatic and gastric AdCas, 9% to13% of PMM cases.
CDX2 Useful. Ninety percent to 100% of colon, 80% of small intestine, and 70% of gastric carcinomas are
positive; negativity in PMM.
Abbreviations: BG8, blood group 8; CEA, carcinoembryonic antigen; CK5/6, cytokeratin 5/6; ER, estrogen receptor; PR, progesterone receptor; WT-
1, Wilms tumor 1.
662 Arch Pathol Lab Med—Vol 137, May 2013 Malignant Mesothelioma Diagnosis—Husain et al
comatoid-type pattern. Differential cytokeratin positivity
profiles, other than CK5/6, have not been reported to date in
the differential diagnosis of these 2 tumors. CK5/6 shows
negativity in sarcomatoid renal cell carcinomas, but the low
sensitivity of CK5/6 as a marker in sarcomatoid mesothe-
lioma greatly limits its utility.66 Calretinin and D2-40
positivity have not been extensively studied in sarcomatoid
renal cell carcinomas. One series reported calretinin
negativity in all four sarcomatoid renal cell carcinomas
tested but at this point, it would be prudent to incorporate
additional gross and clinical correlation.66
A histologically malignant sarcomatoid tumor that is
either focally cytokeratin positive or cytokeratin negative
should be cautiously interpreted, and a diagnosis of
mesothelioma very carefully considered. Focal cytokeratin
positivity has been reported in many different types of
sarcomas. It is also possible that the focal cytokeratin
positivity represents entrapment of benign pleural elements.
If the results from the initial round of cytokeratins prove to
be negative or there is only focal cytokeratin positivity,
additional blocks should be selected and stained, and
cytokeratin antigen retrieval techniques, as well as antibody
source and dilutions, should be reviewed. A vimentin stain
is useful in assessing the general antigenic integrity of the
tissue. Particularly in the absence of convincing cytokeratin
positivity, calretinin and/or D2-40 positivity alone should
not be interpreted as evidence of mesothelial differentiation.
These markers show variable positivity in many different
types of sarcomas, and other immunohistochemical markers
should be added at this point. The expanded differential
diagnosis might include other sarcomas (epithelioid he-
mangioendothelioma/angiosarcoma, synovial sarcoma, li-
posarcoma, myogenic or neurogenic tumors), malignant
solitary fibrous tumor, melanoma, and lymphoma. The
marker panel should be expanded accordingly to include
antibodies such as CD31, CD34, desmin, myoglobin, S100,
and CD45. It should be noted that some muscle markers are
often positive, at least focally, and on occasion more
diffusely, in sarcomatoid mesotheliomas.76 These markers
include muscle-specific actin and a smooth muscle actin. In
contrast to reactive mesothelial cells, desmin positivity in
pure sarcomatoid mesotheliomas is quite rare.76,77 After
extensive workup and with appropriate clinical and radio-
logic features, cytokeratin-negative sarcomatoid mesotheli-
omas have been published as a diagnosis of exclusion.72,78,79
MOLECULAR MARKERS IN MM
Key molecular alterations in pathogenesis of malignant
mesothelioma have been known for decades, but their
potential diagnostic and prognostic implications have only
recently been more extensively investigated.80 One of the
most common genetic alterations in mesothelioma is the
homozygous deletion of the 9p21 locus within a cluster of
genes that includes cyclin-dependent kinase inhibitor 2A
(CDKN2A), CDKN2B, and methylthioadenosine phosphor-
ylase (MTAP).81–85 Several cytogenetic and molecular studies
have reported p16/CDKN2A deletions in up to 80% of
primary pleural mesotheliomas, depending on the histologic
subtype (90%–100% of sarcomatoid mesothelioma, 70% of
epithelioid and mixed types). In contrast, this deletion
occurs in approximately 25% of peritoneal mesothelio-
mas.18,85,86 Besides homozygous deletion, point mutations
and DNA methylation occur less frequently at the same
genetic locus.83 P16/CDKN2A is present in all normal cells
Arch Pathol Lab Med—Vol 137, May 2013
and is essential for normal cell cycle control, and therefore
its loss may be a helpful marker of malignancy. It has been
demonstrated that deletions of p16/CDKN2A occur in
malignant mesotheliomas only, whereas point mutations
and DNA methylation may occur in benign mesothelial cells
as well.87 Therefore, the detection of deletion can be a useful
approach for distinguishing benign from malignant meso-
thelial proliferations. It should be emphasized that this
technique is not useful for distinguishing malignant
mesothelioma from adenocarcinoma (as discussed below).
Various methods, including polymerase chain reaction–
based techniques and FISH, have been used in detection of
deletions. The FISH assay can be performed by using a
commercially available dual-color FISH probe (Abbott
Molecular, Des Plaines, Illinois). It can be reliably performed
on archival paraffin-embedded tissue and is relatively less
expensive than other molecular assays. Another advantage
of this technique over polymerase chain reaction–based
assays is the ability to identify homozygous and hemizygous
deletions. Furthermore, different tumor areas can be
simultaneously analyzed and visualized. The FISH tech-
nique for detection of 9p21 deletions has been shown to be
a very powerful technique for confirming the diagnosis of
malignant mesothelioma in effusion and formalin-fixed,
paraffin-embedded tissue specimens (Figure 19, A and
B).19,20,86,88,89
The diagnosis of atypical mesothelial proliferation is more
common in cytologic specimens than in surgical specimens
because the diagnosis of mesothelioma can be more
challenging in cytologic specimens because of the inability
to evaluate for tissue invasion and of the numerous
cytomorphologic mimics of mesothelioma, including reac-
tive mesothelial proliferations. In the diagnosis of MM in
effusion cytology across all cytologic categories, studies
showed an overall sensitivity of p16 FISH between 56% and
79% with a positive predictive value of 100%. FISH p16 also
showed better sensitivity and specificity than GLUT-1
immunohistochemical marker in cytology specimens.20
The main challenge in the assessment of p16 deletion by
FISH in cytology specimens when cell block is available is
the presence of admixed reactive mesothelial cells that could
be morphologically indistinguishable from malignant me-
sothelial cells and could potentially lead to false-negative
FISH results.
Although studies showed statistically proven good corre-
lation between p16 deletion and lack of p16 protein
expression, there is a subset of cases where p16 protein
expression would be maintained despite the presence of p16
gene deletion and vice versa. This could be explained by the
type of antibody, assay conditions, preanalytic variables, and
interpretation criteria. Therefore, immunohistochemical
assessment for loss of p16 protein expression would be
unreliable and should not be used as a surrogate method for
detection of p16 deletion.86
Homozygous deletion of the p16 gene can be used not
only as diagnostic, but also as a prognostic marker. It has
been demonstrated that the presence of p16 homozygous
deletion correlates with a shorter survival in patients with
malignant mesotheliomas.85,90,91 There is also a correlation
between p16 protein loss, as demonstrated by immunohis-
tochemistry, and a poor prognosis with increased risk of
death in peritoneal mesothelioma, but the association is not
as strong.55,90 There are no molecular markers to help
distinguish malignant mesotheliomas from carcinomas or
sarcomas on formalin-fixed, paraffin embedded tissue.
Malignant Mesothelioma Diagnosis—Husain et al 663
Genetic alterations of 9p are one of the most frequent events
in other tumor types including non–small cell carcinomas of
the lung, melanoma, and sarcomas; therefore, deletion
cannot be used to differentiate these neoplasms from
malignant mesotheliomas.92–94 However, detecting t(X:18)
is most useful in the differential diagnosis of synovial
sarcoma. Begueret et al95 have confirmed the presence of
this translocation in 90% of purely sarcomatoid primary
synovial sarcomas of the pleura, while this translocation has
never been detected in malignant mesothelioma.96
DNA methylation profiles, microRNA dysregulation, and
BAP1 mutations are being studied, which are likely to yield
important results in understanding pathogenesis and
developing targeted therapy for MM, but are currently not
used for diagnosis.
ELECTRON MICROSCOPY OF MM
The electron microscopic features of malignant mesothe-
lioma are well described.30,97 There is no single ultrastruc-
tural feature that is diagnostic of mesothelioma, but rather, a
combination of several features may be diagnostically
useful. For epithelioid mesotheliomas these include very
long, thin apical microvilli that do not have a glycocalyx, as
opposed to the generally shorter microvilli of adenocarci-
nomas that usually do have a glycocalyx; perinuclear
tonofilament bundles; the presence of basal lamina; and
long desmosomes.
It should be emphasized that the role of electron
microscopy in this setting is very restricted because most
tumors that show the ultrastructural features described
above are epithelial mesotheliomas for which light micros-
copy with immunohistochemistry is vastly faster and often
cheaper (and more widely available) in establishing the
correct diagnosis. Sarcomatous mesotheliomas for the most
part do not show specific ultrastructural features, and
tumors that are poorly differentiated by light microscopy
and do not demonstrate a typical pattern of immunohisto-
chemical staining usually lack specific features by electron
microscopy as well.98,99 Occasionally, electron microscopy is
useful in establishing the correct diagnosis when the
immunohistochemical results are equivocal or further
support of a diagnosis of either MM or serous carcinoma
is needed.65 Formalin-fixed material retrieved from a
paraffin block may be satisfactory, since microvilli and
tonofilament bundles tend to be preserved.
FEATURES NOT USEFUL IN MAKING THE DIAGNOSIS
OF MM
History of Asbestos Exposure
Because there is an association of asbestos exposure and
the development of malignant mesothelioma, many pathol-
ogists may adopt the position that a history of asbestos
exposure makes a tumor more likely to be a mesothelioma,
and, conversely, in the absence of such a history, they are
reluctant to diagnose mesothelioma. However, the history
of exposure to asbestos or the absence of such a history is
not useful to the pathologist in making a diagnosis of
mesothelioma. The situation is analogous to that of lung
cancer: although most lung cancers occur in cigarette
smokers, no one would hesitate to diagnose a lung cancer
if told that the patient was a nonsmoker. For mesothelioma
a similar scenario applies: the diagnosis is based on clinical,
radiologic, and, ultimately, pathologic features, and the
664 Arch Pathol Lab Med—Vol 137, May 2013
issue of asbestos exposure is irrelevant. Attribution of cause
is a separate issue.
Presence of Psammoma Bodies
Like many tumors with a papillary architecture, meso-
theliomas may occasionally contain psammoma bodies.
While the presence of psammoma bodies might suggest
certain carcinomas (such as papillary carcinoma in the
thyroid and serous papillary tumors of the female genital
tract), their presence is not a diagnostic aid in either
confirming or excluding a diagnosis of mesothelioma.
Positivity of Mucin Stains
While the presence of mucin has been classically used to
support a diagnosis of adenocarcinoma over mesothelioma,
mucin positivity may be encountered in mesotheliomas.
With Alcian blue and colloidal iron staining, mesotheliomas
that may contain hyaluronate droplets show a positive
reaction; this material is removed with hyaluronidase
pretreatment. The spaces containing the positive material
tend to be quite large and not typical of the intracellular
mucin droplets seen in adenocarcinoma. Because hyaluron-
idase-sensitive material may be encountered in mesotheli-
omas, PAS-D stains have been recommended for neutral
(‘‘epithelial’’) mucins, since this finding is almost entirely
restricted to adenocarcinoma. Rarely, otherwise typical
mesotheliomas may contain mucicarmine-positive, PAS-
D–positive, and Alcian blue–positive droplets that are
resistant to hyaluronidase. Ultrastructural evaluation in the
small series reported by Hammar60 suggested that this
positivity was related to crystallized proteoglycans.
Faint mucicarmine positivity is common in the vacuoles of
mesotheliomas and should not be considered a feature
diagnostic of adenocarcinoma.
Simian Virus 40 Exposure
Simian virus 40 has been proposed by some as an
etiologic agent in some mesotheliomas. While this proposal
remains controversial it is clear that the presence or absence
of exposure to simian virus 40 is not a criterion in
confirming or excluding the diagnosis of mesothelioma.30
PITFALLS IN THE DIAGNOSIS OF MM
The first ‘‘port of call’’ for the histologic diagnosis of
malignant mesothelioma is the morphology. Immunohisto-
chemical stains are important for confirmation of the
diagnosis, but they should not be used to force a tumor
into the diagnosis of mesothelioma when it does not look
like a mesothelioma on hematoxylin-eosin; neither should
they be performed automatically or blindly without consid-
ering several factors. As stated previously, the major
determinants of which panel to use are (1) the location of
the tumor—it will vary as to whether it is pleural, peritoneal,
or another serosal surface; (2) the phenotypic problem—
benign versus malignant, epithelioid, spindle, biphasic,
small cell, pleomorphic, and (3) the experience of the
laboratory. A laboratory using immunohistochemical stains
should be performing them frequently, have well-estab-
lished protocols, and should have an appreciation of their
sensitivities and specificities with respect to the various
morphologic problems. There is no single utopian immu-
nohistochemical panel to cover all diagnostic ‘‘mesothelial’’
problems.
Malignant Mesothelioma Diagnosis—Husain et al
 One of the problems in comparing the results of particular
antibodies from different studies is a lack of standardization
of immunohistochemical procedures. This can result in
conflicting results for sensitivity and specificity for various
antibodies. The study of King et al4 (2006) tabulates the data
for antibody clone, manufacturer, dilution, and antigen
retrieval methods for 5 antibodies used in separating benign
and malignant mesothelial proliferations in 13 studies. It
illustrates the wide variability between the various studies.
Before using an antibody for diagnosis, a laboratory should
have carried out an extensive workup to find the ideal
conditions for routine use.4
The type of pathologic sample may affect results. For
example, tiny needle biopsy samples may show crush
artifact and false-positive immunostaining with various
antibodies. Also, the edges of biopsy specimens may show
artifactual positive immunostaining. There may also be
variation in interpretation of what is positive, illustrated by
the fact that some laboratories will only consider calretinin
as showing positivity when there is nuclear staining,
whereas a minority will consider cytoplasmic staining as
showing positivity. This can significantly affect sensitivity
and specificity.
Another problem associated with immunohistochemistry
may be putting too much emphasis on focal immunoposi-
tivity. We would suggest that weak or focal staining of fewer
than 10% of the cells should be considered as being
negative when interpreting a panel of stains. Also, one can
observe positive immunostaining with mesothelial markers
in reactive proliferations of submesothelial fibroblasts in the
vicinity of nonmesothelial tumors and inflammatory pleural
diseases—it is important not to diagnose these as meso-
theliomas. In contrast, mesotheliomas may invade the
underlying lung, and entrapped pulmonary epithelial cells
may show positive immunostaining with epithelial markers.
Careful correlation with the hematoxylin-eosin sections is
necessary to avoid misinterpretation.
It is also important to know the full range of cell types an
individual marker may stain. For example, WT-1 and D2-40
(podoplanin) show positivity in endothelial cells, which
should not be misinterpreted as positive tumor staining in
small, crushed biopsy samples in particular. Similarly,
‘‘mesothelial markers’’ may show positivity in tumors other
than mesothelioma. For example, WT-1 may show positivity
in ovarian serous tumors and melanoma, calretinin in
synovial sarcoma and some germ cell tumors, and CK 5/6 in
squamous carcinomas. As such, the significance of positive
staining in a single marker should be interpreted within the
context of the totality of immunohistochemical, morpho-
logic, and clinical findings.
Another pitfall leading to misdiagnosis may result from
‘‘false’’ invasion, which can apply to the pleura or chest wall
fat. Inflammatory pleural processes may result in mesothe-
lial cells lying quite deeply within the pleura (as a result of
entrapment in granulation tissue), but these are usually
parallel with the pleural surface. Sometimes one sees
tubular collections of reactive mesothelial cells, which are
lined up parallel to the pleural surface. These do not connote
malignancy. Sometimes a section taken parallel to the
pleural surface may give a false impression of a full-
thickness mesothelial proliferation. Organizing pleuritis
may result in a ‘‘fake fat’’ phenomenon whereby a greatly
thickened fibrotic paucicellular pleura is associated with
circular fatlike spaces and with cytokeratin-positive spindle
cells running between these fatlike spaces (Figure 7).
Arch Pathol Lab Med—Vol 137, May 2013
However, they are parallel to the pleural surface and
vimentin stain shows that there is no cellular lining to the
spaces. On the other hand, desmoplastic mesothelioma
usually shows a downward rather than horizontal growth
pattern of the keratin-positive spindle cells (Figure 5, B).11
MESOTHELIOMA REVIEW PANELS
Mesothelioma review panels have been functioning since
the 1960s. These panels have served as a referral source for
pathologists facing diagnostic problems and, more recently,
to confirm diagnoses for treatment trials. In North America
there is the US and Canadian Mesothelioma Panel
(overseen by A. C.) and there are several in Europe, with
the best known and most productive being the French
Mesopanel (overseen by F. G.-S.). The diagnosis of
mesothelioma has been considered to be difficult, although
the application of immunohistochemical staining has made
the diagnosis more reliable. In a 1991 report from the US
and Canadian Mesothelioma Panel, only 70.5% of 200 cases
had a three-fourths majority agreement from the panel. It
should be emphasized that these represented referral cases
and by their nature were already difficult. In a more recent
report from the same panel,28 agreement among panel
members as to benign versus malignant was 78% for a
group of 217 cases.
SUMMARY
This article gives broad guidelines for making the
diagnosis of MM, which although a rare tumor, has a grave
prognosis and invariably has medicolegal implications. The
salient recommendations are use of histologic features and
immunohistochemical panel in distinguishing benign from
malignant mesothelial proliferations and the use of molec-
ular assays, such as homozygous p16 deletion, in challeng-
ing cases; on biopsy, subtyping should be done, but
assigning a further pattern is often not possible; there is
limited usefulness of cytology, histochemical stains, and
electron microscopy; panels of antibodies need to be used
according to the differential diagnosis in each case; in the
typical case in which all features are concordant, 2
mesothelioma markers and 2 carcinoma markers may be
adequate to make a diagnosis, but when there are
discordant findings, additional markers should be used.
The pathologist should always take the clinical, radiologic,
and pathologic features into consideration and get expert
second opinion in difficult cases, as necessary.
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