This article will help you read and understand your pathology report for mesothelioma.
by Katherina Baranova MD and Matt Cecchini MD FRCPC, updated December 30, 2020
Your lungs are located within your chest in a space known as the pleural cavity or pleural space. The surface of your lungs and chest wall are covered by a thin type of tissue called the pleurae (singular pleura). The pleura that covers the lung is called the visceral pleura and the pleura that covers the chest wall is known as the parietal pleura. The two layers of pleurae can be understood as a balloon within a balloon. The inner (visceral) pleura and outer (parietal) pleura are separated by a thin space called the pleural cavity.
Pathologists call the pleural cavity a potential space because it is not usually filled with air. In normal conditions there is a thin layer of fluid between the two layers of pleura. Under the microscope the pleura is made up of a layer of cells called mesothelial cells. These cells are small, flat to cuboidal cells, with well-defined cell borders . The part of the cell that holds the genetic material of the cell, the nucleus, is usually found in the center of the cell.
Mesothelioma is a type of cancer that starts from the mesothelial cells that line the pleura. Mesothelioma can start in any location where mesothelial cells are normally found, although the most common location is in the parietal pleura. Another name for mesothelioma is malignant mesothelioma.
Mesothelioma is associated with asbestos exposure in most, but not all cases. Many patients exposed to asbestos will also have areas where their pleura has become abnormally thick. These areas are called pleural plaques and they can usually be seen on imaging of the lungs (x-ray or CT scan). When examined under the microscope, pleural plaques are made up of dense collagen layers that can have a basket weave appearance.
The diagnosis of mesothelioma is usually made after a small sample of tissue is removed in a procedure called a biopsy. In some cases additional surgery may be performed. The diagnosis of mesothelioma can be challenging because non-cancerous conditions such as infection or pleural effusions can lead to changes in the mesothelial cells that can look similar to cancer under the microscope. In order to diagnose mesothelioma your pathologist needs to see mesothelial cells making a tumor, or spreading outside of the pleura into the surrounding tissue or the lungs. The movement of mesothelial cells into surrounding tissues is called invasion.
When examined under the microscope, other types of cancer can look very similar to mesothelioma. Most pathologists will perform a test called immunohistochemistry to help them decide if the abnormal cells are mesothelial cells or cells from another part of the body.
When immunohistochemistry is performed, mesothelial cells will typically show the following results:
Pathologists usually require a combination of immunohistochemical tests to help them decide if the abnormal cells are mesothelial cells or if they are from another part of the body.
In order distinguish between mesothelioma and other conditions, some pathologists may use other immunohistochemistry tests including BAP1 and mTAP. Normal cells in your body will make these proteins. However, these proteins are not produced in many cases of mesothelioma. If these proteins are not detected in the immunohistochemistry test this may help your pathologist make the diagnosis of mesothelioma.
You may see the name of the surgical procedure in your pathology report. The name of the procedure will depend on the amount of tissue removed.
Types of procedure include:
There are three types of mesothelioma based on how the cells look when examined under the microscope. Pathologists decide the type by looking at the size and shape of the cells and the way the cells stick together.
Desmoplastic mesothelioma is another type of mesothelioma that is related to the sarcomatoid type. Desmoplastic mesothelioma can be challenging for the pathologist to diagnose. The tumor is made up of dense fibrous tissue with abnormal spindle cells.
The histologic type is important because patients with the epithelioid type will typically have the best prognosis followed by biphasic then sarcomatoid. The histologic subtype may influence what surgical procedures or therapies are used to treat your specific type of mesothelioma.
Most mesotheliomas grow as a single large tumour that covers both the parietal and visceral pleura. It is often difficult to determine where the tumour stops and the normal, healthy pleural begins. Some mesotheliomas, however, grow as a smaller tumour that is easy to separate from the surrounding normal, healthy pleura. Pathologists describe these tumours as localized mesothelioma.
Patients with localized mesothelioma have a better prognosis and may be able to undergo successful resection of the tumor.
A margin is the normal tissue that surrounds a tumour and is removed with the tumour at the time of surgery. If you underwent a complete resection with an extrapleural pneumonectomy, your pathologist will look for tumor cells at the cut edge of the tissue.
If no tumour cells are seen at the cut edge of the tissue the margin is called negative. If tumour cells are seen at the very edge of the cut tissue, the margin is called positive. A positive margin is important because it is associated with a greater risk that the tumour will come back in the same location (local recurrence) after treatment.
Some patients will receive chemotherapy or radiation therapy prior to the tumour being removed surgically. If you received either chemotherapy or radiation therapy prior to surgery your pathologist will examine the tumour under the microscope to see how much of the tumour is still alive (viable). This is called the treatment effect.
To determine the treatment effect, your pathologist will measure the amount of living (viable) tumour and divide that number by the amount of the total tumour. The treatment effect is usually described as greater or less than 50% of residual viable tumor.
The amount that your tumor responded to therapy may help your oncologist understand how well the tumor is treated by chemotherapy and may be used to help guide further treatment.
Lymph nodes are small immune organs located throughout the body. Cancer cells can travel from the tumour to a lymph node through lymphatic channels located in and around the tumour. The movement of cancer cells from the tumour to a lymph node is called a lymph node metastasis.
Lymph nodes from the neck, chest, and lungs may be removed at the same time as the tumour. Your pathology report will describe the number of lymph nodes examined. Your pathologist will carefully examine each lymph node for cancer cells. Lymph nodes that contain cancer cells are called positive while those that do not contain any cancer cells are called negative.
Finding cancer cells in a lymph node increases the nodal stage (see Pathologic stage below) and is associated with worse prognosis. The nodal stage will depend on where the lymph node with cancer cells was located.
This system uses information about the primary tumour (T), lymph nodes (N), and distant metastatic disease (M) to determine the complete pathologic stage (pTNM). Your pathologist will examine the tissue submitted and give each part a number. In general, a higher number means more advanced disease and worse prognosis.
Tumour stage (pT) for mesothelioma
Mesothelioma is given a tumour stage between 1 and 4 based on invasion by the tumor into other structures and the resectability of the tumor.
Nodal stage (pN) for mesothelioma
Mesothelioma is given a nodal stage between 0 and 2 based on the presence or absence of cancer cells in a lymph node and the location of the lymph nodes that contain cancer cells.
Metastatic stage (pM) for mesothelioma
Mesothelioma is given a metastatic stage of 0 or 1 based on the presence of cancer at a distant body site (for example, the brain).
The metastatic stage can only be determined if tissue from a distant site is sent for pathological examination. Because this tissue is rarely present, the metastatic stage cannot be determined and is listed as pMX.