Which imaging modalities are recommended for the diagnosis and staging of mesothelioma in primary care?

In primary care, the recommended initial imaging modality for suspected mesothelioma is an urgent chest X-ray, especially in patients aged 40 and over with unexplained chest pain, cough, or a history of asbestos exposure. This is to promptly identify any pleural abnormalities suggestive of mesothelioma NICE NG12,NICE NG122.

Following a suspicious chest X-ray, the next step is to perform a contrast-enhanced computed tomography (CT) scan of the chest, including the liver, adrenals, and lower neck, to further characterise the disease and assist in staging. CT is the primary imaging modality for diagnosis and staging of mesothelioma, providing detailed anatomical information about tumour extent and involvement of adjacent structures NICE NG122[Gill 2011].

For more detailed assessment of mediastinal and chest wall invasion, ultrasound may be considered if CT findings are equivocal, and surgical assessment may be necessary if resection is contemplated NICE NG122. Positron emission tomography combined with CT (PET-CT) is recommended before treatment in patients who may be candidates for curative therapy, as it helps in detecting nodal and distant metastases, thus refining staging NICE NG122[Nickell LT Jr et al. 2014].

Magnetic resonance imaging (MRI) is not routinely used for staging but may be employed selectively to assess the extent of disease in specific cases, such as superior sulcus tumours or when further soft tissue characterisation is needed NICE NG122[Eibel et al. 2003].

In summary, primary care should initiate urgent chest X-ray for suspected mesothelioma, followed by referral for contrast-enhanced CT for diagnosis and staging. PET-CT and MRI are used in secondary care for further staging and treatment planning NICE NG122,NICE NG12[Gill 2011; Nickell LT Jr et al. 2014; Eibel et al. 2003].