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Distinction between fibrous pleuritis and desmoplastic mesothelioma

This distinction represents one of the most challenging areas in mesothelioma diagnosis.

Cytology

Effusion cytology has a minimal role in the differential diagnosis between fibrous pleuritis and desmoplastic mesothelioma. This reflects the minimal shedding of malig- nant cells from these fibrous lesions into effusions. In rare cases atypical spindle cells may be recognised in effusion fluids, although this recognition is often retrospective following diagnosis by another modality, such as core or open biopsy.
There may be an absence of mesothelial cells and lymphocytosis in the effusions associated with sarcomatoid/desmoplastic mesothelioma.

Histology

In biopsy material, the desmoplastic variant of mesothelioma may have large areas that are composed of paucicellular collagenous tissue containing bland spindle cells, which mimic either a pleural plaque or reactive process. Conversely, reactive processes may be highly cellular and mitotically active.
Mangano et al. described useful light microscopic features in distinguish- ing desmoplastic mesothelioma from fibrous pleuritis. These features include storiform regions or a ‘patternless pattern’, plus one or more of the following:

· invasion of chest wall tissues;
· foci of bland necrosis (with storiform/micronodular architecture);
· frankly sarcomatoid foci; and
· distant metastasis.

Another useful feature characteristic of a reactive process is that most cellular areas tend to be orientated toward the luminal side of the pleura, whereas the deeper tissues tend to be less cellular; the reverse pattern is seen in malignant cases. Perpendicularly orientated capillaries, almost completely traversing the thickened pleura, favour a reactive process.
In desmoplastic mesothelioma the collagen occurs as interweaving bands that may be branched, whorled, micronodular or storiform, usually different from the laminar or ‘basket-weave’ pattern of benign plaques, or the orderly stratified zonal pattern of organising pleuritis.

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