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In a study of 90 patients with MPM, Adams et al (31) found that the most common symptoms at initial presentation were chest wall pain (62%) and shortness of breath (53%) (2,7). The chest pain is usually insidious in onset and is most often nonpleuritic (56% of patients). Only a small percentage of patients present initially with pleuritic chest pain (6%). Pain may be referred to the shoulder or upper abdomen. The shortness of breath or dyspnea is usually progressive and may be associated with fevers, chills, and sweats (30% of cases). Approximately 30% of patients present with weakness, fatigue, or malaise (30%). Cough (24% of cases), weight loss (22%), and anorexia (10%) are less frequent presenting symptoms. A sensation of fullness or heaviness in the chest, hoarseness, early satiety, myalgias, and other symptoms each occurred in less than 5% of patients (31). Most patients have symptoms for 4-6 months before diagnosis (32). Rarely, MPM is incidentally discovered because of an abnormal radiograph in asymptomatic patients.
The most common findings at initial physical examination are signs of pleural effusion (79% of cases), such as dullness to percussion or decreased breath sounds in the affected side. Decreased chest excursion (15% of cases), palpable lymph nodes (12%), palpable liver (9%), and chest tenderness (9%) are the next most common findings. Secondary hypertrophic osteoarthropathy occurs in less than 10% of patients but is more characteristic of localized fibrous tumor of the pleura, which is typically a benign neoplasm (32). Clubbing, pleural or pericardial rub, cachexia, and ascites each occur in less than 5% of patients (31). Disseminated intravascular coagulation, thrombophlebitis, and pulmonary emboli may also accompany MPM (7,33).
Laboratory analysis may reveal thrombocytosis (more than 400,000 platelets per cubic millimeter [400 X 1010/L]), which occurs in 34%-41% of patients (34). Intermittent hypoglycemia is found in less than 10% of patients; it has also been reported to occur with localized fibrous tumor of the pleura (32). Hemolytic anemia may also be present (33).
Late in the course of the disease, as MPM invades adjacent structures, patients may develop dysphagia, chest pain, cord compression, neural syndromes, Horner syndrome, or superior vena cava syndrome secondary to tumor invasion of the esophagus, ribs, vertebrae, nerves, and superior vena cava (33).
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