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== Introduction ==
== Introduction ==
Mesothelioma is a form of [[Oncology|cancer]] that appears in the epithelial layer called mesoderm that lines the pleurae, peritoneum, and pericardium.  Mesothelioma affects mostly older individuals who have been occupationally exposed to asbestos. Mesothelioma has been described as an insidious neoplasm because of its long latency period—up to 40 years in some series—after exposure to asbestos. It arises in the mesothelial surfaces of tissues in the pleura but can also occur in the peritoneum and the tunica vaginalis. Peak incidence occurs in the 5th and 6th decades of life.<ref>Mott FE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307510/ Mesothelioma: a review.] Ochsner Journal. 2012 Mar 20;12(1):70-9.</ref>  
[[File:Mesotheliomia.jpeg|right|frameless]]
Mesothelioma, also known as malignant mesothelioma, is an aggressive malignant tumour of the mesothelium, with most tumours arise from the pleura<ref name=":3">radiopedia [https://radiopaedia.org/articles/mesothelioma Mesothelioma] Available from:https://radiopaedia.org/articles/mesothelioma (accessed 11.5.2021)</ref>. The subtypes of asbestos strongly associated with malignant mesothelioma are the amosite and crocidolite asbestos<ref name=":2">Jain SV, Wallen JM. Cancer, malignant mesothelioma.2018 Available from: https://www.ncbi.nlm.nih.gov/books/NBK519530/<nowiki/>(accessed 11.5.2021)</ref>.


It is not genetically transferred rather caused by long-duration exposure to asbestos and other carcinogenic fibers. 400 different mineral fibers are present in nature and among them, these 6 fibers (amphiboles fibers [crocidolite, actinolite, tremolite, anthophyllite, and amosite] and serpentine fibers [chrysotile])  collectively known as asbestos for regulatory purpose. These 6 fibers were banned to use commercially after 1980s.<ref name=":0">Carbone M, Adusumilli PS, Alexander Jr HR, Baas P, Bardelli F, Bononi A, Bueno R, Felley‐Bosco E, Galateau‐Salle F, Jablons D, Mansfield AS. [https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21572 Mesothelioma: scientific clues for prevention, diagnosis, and therapy.] CA: a cancer journal for clinicians. 2019 Sep;69(5):402-29.</ref>
Mesothelioma  


Malignant pleural mesothelioma (MPM) is an aggressive cancer of the pleural surface. It is associated with previous asbestos exposure, with a latency period of ∼40 years between fibre exposure and disease presentation.  
* Affects mostly [[Older People - An Introduction|older individuals]] who have been occupationally exposed to asbestos.
* Described as an insidious [[Oncology|neoplasm]] because of its long latency period—up to 40 years in some series—after exposure to asbestos.
* [[File:Pleural normal.jpeg|right|frameless]]Peak incidence occurs in the 5th and 6th decades of life.<ref>Mott FE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307510/ Mesothelioma: a review.] Ochsner Journal. 2012 Mar 20;12(1):70-9.</ref>
* Not [[Genetic Conditions and Inheritance|genetically]] transferred <ref name=":0">Carbone M, Adusumilli PS, Alexander Jr HR, Baas P, Bardelli F, Bononi A, Bueno R, Felley‐Bosco E, Galateau‐Salle F, Jablons D, Mansfield AS. [https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21572 Mesothelioma: scientific clues for prevention, diagnosis, and therapy.] CA: a cancer journal for clinicians. 2019 Sep;69(5):402-29.</ref>
The disease is on the rise, probably due to the spread of asbestos use over past decades. The disease burden is still predominantly borne by the developed world. However, since asbestos use has recently increased in developing countries, a corresponding shift in disease occurrence is anticipated. Global mortality pattern suggests that there are early indications of this shift and lends support to the call by international organizations to eliminate asbestos-related diseases and discontinue the use of asbestos throughout the world.<ref>Delgermaa V, Takahashi K, Park EK, Le GV, Hara T, Sorahan T. [https://www.who.int/bulletin/volumes/89/10/11-086678/en/ Global mesothelioma deaths reported to the World Health Organization between 1994 and 2008. Bulletin of the World Health Organization.] 2011;89:716-24.Available:https://www.who.int/bulletin/volumes/89/10/11-086678/en/ (accessed 11.5.2021) </ref>
 
== Etiology ==
[[File:Asbestos Kitchen Goods (1901) (ADVERT 299).jpeg|right|frameless|499x499px]]
Malignant pleural mesothelioma is primarily linked to asbestos exposure.
 
Image 3: During and after the Industrial Revolution, asbestos was widely used as an insulating material in the United States and Canada. Scientists have linked certain types of asbestos to three fatal diseases: lung cancer, asbestosis, and mesothelioma.
 
* Some studies suggest that asbestos inhalation causes repeated pleural inflammation, interference with mitosis, activation of proto-oncogenes, and free radical production.
* Other reports indicate associations with ionizing [[Radiation Side Effects and Syndromes|radiation]] or a germline mutation of BRCA 1 Associated Protein (BAP1).
* [[Smoking Cessation and Brief Intervention|Smoking]] is not linked with malignant pleural mesothelioma, though smoking and asbestos exposure significantly increase the risk of [[Lung Cancer|lung cancer.]]
 
Professions associated with exposure to asbestos include:
 
* Shipbuilding
* Mining
* Ceramics
* Cement manufacturer with asbestos
* Auto parts manufacturer, especially that of brake lining
* Paper mill worker
* Insulation work
* Railroad repair
 
There is no evidence that alcohol, tobacco, or dietary intake is involved in malignant pleural mesothelioma<ref name=":2" />.


== Epidemiology ==
== Epidemiology ==
Approximately 3000 incident cases of mesothelioma are registered each year in the United States. The incidence rate varies between less than 1 case per 100,000 persons in states with no asbestos industry to 2 to 3 cases per 100,000 persons in states with an asbestos industry. The mean age of death from mesothelioma in the United States was 72.8 years, with a male‐to‐female (M: F) mortality ratio of 4.2:1, as men were traditionally more likely to be employed in trades involving asbestos exposure.<ref name=":0" />  
Mesothelioma is uncommon and accounts for 5-28% of all malignancies that involve the pleura.  
 
* There is a strong association with exposure to asbestos fibres (~10% risk during lifetime; 40-80% of patients have a history of asbestos exposure) with risk associated with duration and breadth of exposure. Paraoccupational exposure (e.g. household members of asbestos-exposed workers) can also occur.
* Not all types of asbestos are strongly implicated, with crocidolite being the main causative fibre type. Given the sources of asbestos exposure being predominantly mining, construction, lagging and machinery mechanics, 60-80% of cases are encountered in males, in general, 20 to 35 years after exposure. Some areas of the world have very regional hotspots, such as Belfast in Northern Ireland, due to the historic shipbuilding industry.
* There is also increased risk for those with household exposure (e.g. family of exposed workers).
* There has been no convincing evidence for an association with smoking<ref name=":3" />
{{#ev:youtube|qUl18OGWGAo}}<ref>Imperial Medicine. What is mesothelioma? Available from: https://www.youtube.com/watch?v=qUl18OGWGAo [last accessed 3/8/2020]</ref>
== Pathophysiology ==
[[File:Mesotheliomia pm.png|right|frameless|350x350px]]
Mesothelial cells are much more susceptible than other cell types to asbestos cytotoxicity. When asbestos and other fibers reach the pleura and peritoneum through lymphatics, they remain in place for months or years, triggering a [[Inflammation Acute and Chronic|chronic inflammatory]] process that helps in the production of mutagenic oxygen radicals induced by asbestos are responsible for asbestos pathogenesis and carcinogenesis.<ref name=":0" />


Between 1994 and 2008, age‐adjusted mesothelioma mortality rates increased by 5.37% per year worldwide<ref name=":0" />.  In a meta-analysis, a significantly increased risk of pleural mesothelioma was reported for both household exposure and neighborhood exposure. Different strengths of association were observed according to fiber type, with the strongest associations noted when amphibole was present and the weakest when chrysotile was present. Therefore, the types of fibers to which residents are exposed to influence mesothelioma rates. Crocidolite and amosite fibers are considered the main cause of mesothelioma among occupationally exposed individuals (mining, road construction, off‐road driving, etc).<ref name=":0" /> 
The three types of mesothelioma are epithelioid, sarcomatoid, and mixed (epithelioid type is associated with better outcomes).  


== Pathogenesis ==
* The tumor is often multifocal, forming multiple nodules starting with the parietal pleura.
Mesothelial cells are much more susceptible than other cell types to asbestos cytotoxicity. When asbestos and other fibers reach the pleura and peritoneum through lymphatics, they remain in place for months or years, triggering a chronic inflammatory process that helps in the production of mutagenic oxygen radicals induced by asbestos are responsible for asbestos pathogenesis and carcinogenesis.<ref name=":0" />
* Spread occurs locally in the visceral pleura before extending to the chest wall, diaphragm, or mediastinum.  
* Regional lymph node spread begins with the bronchopulmonary or hilar lymph nodes before moving to the carinal, internal mammary or peridiaphragmatic nodes.


Asbestos fibres are inhaled and migrate to the pleura. Within the pleural space, fibres cause irritation and a repeated cycle of tissue damage and repair is established. The presence of oxygen free radicals, released by asbestos fibres when phagocytosed by macrophages, causes intra-cellular DNA damage and abnormal repair. Asbestos fibres also penetrate mesothelial cells, where they interfere with mitosis, generate mutations in DNA and alter chromosome structure. Asbestos-exposed mesothelial cells release inflammatory cytokines, including tumour growth factor-β, platelet-derived growth factor and vascular endothelial growth factor (VEGF). This creates a favourable microenvironment for tumour growth. Finally, asbestos induces the phosphorylation of various protein kinases (mitogen-activated protein and extracellular signal-regulated kinases 1 and 2), leading to increased expression of proto-oncogenes and further promotion of abnormal cellular proliferation.<ref name=":1">Bibby AC, Tsim S, Kanellakis N, Ball H, Talbot DC, Blyth KG, Maskell NA, Psallidas I. [https://err.ersjournals.com/content/25/142/472 Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment.] European Respiratory Review. 2016 Dec 1;25(142):472-86.</ref>
The pattern of nodal metastases is different from that seen in lung cancer. With malignant pleural mesothelioma, there is a direct local invasion of the lymph nodes. Overall, the involvement of lymph nodes in malignant pleural mesothelioma is not common<ref name=":2" />.


== Signs and Symptoms ==
== Signs and Symptoms ==
Common signs and symptoms of Pleural mesothelioma are:
[[File:Dyspnea 01.png|right|frameless]]
*Chest wall pain
Malignant pleural mesothelioma usually presents with chest pain and [[Dyspnoea|dyspnea]]. Dyspnea suggests the presence of pleural effusion, the most common initial finding, seen in about 90% of patients. Nonspecific symptoms such as unintentional weight loss, appetite loss, cough, fatigue, and chest wall mass may also occur.<ref name=":2" />
*Pleural effusion, or fluid surrounding the lung
*Shortness of breath
*Fatigue
*Wheezing, hoarseness
*Blood in the sputum (fluid) coughed up (hemoptysis)
*Dry cough  
*Weight loss<ref name=":0" />  
 
== Diagnosis ==
== Diagnosis ==
Diagnosis of mesothelioma is difficult to make. Radiological imaging (X-ray, ultrasound, Ct scan, positron-emission technology (PET)-CT or magnetic resonance imaging (MRI) ) can provide valuable diagnostic and staging information.<ref name=":1" />
Diagnosis of mesothelioma is difficult to make.  


Histology is a reliable prognostic marker. 
* Radiological imaging (X-ray, ultrasound, Ct scan, positron-emission technology (PET)-CT or magnetic resonance imaging (MRI) ) can provide valuable diagnostic and staging information.<ref name=":1">Bibby AC, Tsim S, Kanellakis N, Ball H, Talbot DC, Blyth KG, Maskell NA, Psallidas I. [https://err.ersjournals.com/content/25/142/472 Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment.] European Respiratory Review. 2016 Dec 1;25(142):472-86.</ref>
* Histology is a reliable prognostic marker. 


== Prognosis ==
== Treatment and Prognosis ==
The Mesothelioma prognosis remains disappointing, although there have been some modest improvements in prognosis from newer chemotherapies and multimodality treatments.
Treatment continues to be challenging and the long-term survival is poor. Single modality treatment ([[Surgery and General Anaesthetic|surgery]], radiotherapy, [[Chemotherapy Side Effects and Syndromes|chemotherapy]], [[immunotherapy]] and even photodynamic therapy) have not been shown to improve survival. More recently multi-modality treatment has had some impact on favourable subgroups (early disease, and epithelioid histology). Treatment includes:


== Treatment  ==
* extrapleural pneumonectomy
The role of surgery in pleural mesothelioma is controversial as it is difficult to predict who will benefit from aggressive management, even when local therapies are added to existing or novel systemic treatments. Treatment outcomes are improving, however, for peritoneal mesothelioma. Multidisciplinary international collaboration will be necessary to improve prevention, early detection, and treatment.<ref name=":0" />
* adjuvant chemotherapy
* radiotherapy


There is various medical management for mesothelioma. Chemotherapy is the only treatment modality that has been shown to improve survival in MPM. targeted therapy has recently shown a positive impact.<ref name=":1" /> Radiotherapy is used in two main settings in MPM: as a palliative measure to treat symptoms or an adjuvant to surgery and chemotherapy in the context of trimodality treatment. The benefit of surgery in MPM is much debated, and there is a need for robust randomised trial data to elucidate its efficacy and clarify its role in management. Some surgical procedures are extrapleural pneumonectomy (EPP),extended pleurectomy with decortication, and partial pleurectomy ''via'' VATS.<ref name=":1" />
The prognosis is poor for all tumour types with a median overall survival without treatment of 4-12 months. In favourable patient subgroups up to 45% 5-year survival may be achievable, however even with aggressive multi-modality therapy overall 5-year survival remains poor (3-18%) 3 with a median survival time of approximately 18 months<ref name=":3" />.


== Physiotherapy management ==
== Physiotherapy management ==
Physiotherapy is an important part in Mesothelioma treatment.<br>All patients who suffer from mesothelioma are required to undergo physical therapy, even if you have already undergone surgery, chemo, and/or radiation. There is a valid reason for this. All three types of treatment are exceptionally difficult on your body. With their many negative side effects, your body needs physical therapy to regain the strength it once had. Without physical therapy, these treatment options are less successful. Your body needs all the strength it can get to successfully respond to all treatment options. This therapy will occur with a physical therapist as scheduled by your medical professional. Mesothelioma treatments are designed to help patients feel more comfortable and hopefully extend your quality of life. While there is no cure for mesothelioma at this time, these three treatment options are your best bet. Of course, your doctor might have other suggestions as far as using a combination of these treatments and other medications to help you live as comfortably as possible. Each case of mesothelioma is unique, meaning your treatment method will differ from others.<br>
[[File:The Active Cycle of Breathing Technique..png|right|frameless]]
Patients are encouraged to enter a rehab program to recover functionality after treatment. A good [[Nutrition|diet]] should be encouraged as most patients are [[Introduction to Frailty|frail]] and emaciated. [[Oxygen Therapy at Home|Home oxygen]]  and breathing education (see '''Image''' 6 [[Active Cycle of Breathing Technique|ACBT]]) are often required<ref name=":2" />.
 
[[Breast Cancer|Physiotherapy]] is an integral part of the multidisciplinary approach treatment for patients with cancer.<ref>Hemingway RD. [https://link.springer.com/chapter/10.1007/978-3-319-96244-3_10 Mesothelioma and Physical Therapy.] InCaring for Patients with Mesothelioma: Principles and Guidelines 2019 (pp. 99-119). Springer, Cham.</ref><br>All patients who suffer from mesothelioma are required to undergo physical therapy, even if they have already undergone surgery, chemo, and/or radiation. The reasons for this include:
 
* All three types of treatment are exceptionally difficult on the body. With their many negative side effects, the body needs physical therapy to regain the strength it once had.  
* Without physical therapy, these treatment options are less successful. The body needs all the strength it can get to successfully respond to all treatment options.  
* Therapy with a physical therapist is usually scheduled by the medical professional.  
 
Mesothelioma treatments are designed to help patients feel more comfortable and hopefully extend their [[Quality of Life|quality of life]]. While there is no cure for mesothelioma at this time, these three treatment options are the best bet. Of course, the doctor might have other suggestions as far as using a combination of these treatments and other medications to help client live as comfortably as possible. Each case of mesothelioma is unique, meaning each treatment method will differ from others.
 
Goals include: Respiratory care; [[Pain Mechanisms|pain management]]; improve the patient level of [[Myalgic Encephalomyelitis or Chronic Fatigue Syndrome|fatigue]]; improve bodily muscular and [[Cardiovascular Considerations in the Older Patient|cardiovascular]] endurance.
 
== Resources ==
 
* [https://www.mesothelioma.com/ Patient resources]<br>


== References ==
== References ==

Latest revision as of 09:00, 4 January 2022

Original Editor - Raj Rindani
Top Contributors - Lucinda hampton, Kim Jackson, Manisha Shrestha, Vidya Acharya, Raj Rindani, Rucha Gadgil and Adam Vallely Farrell

Introduction[edit | edit source]

Mesotheliomia.jpeg

Mesothelioma, also known as malignant mesothelioma, is an aggressive malignant tumour of the mesothelium, with most tumours arise from the pleura[1]. The subtypes of asbestos strongly associated with malignant mesothelioma are the amosite and crocidolite asbestos[2].

Mesothelioma

  • Affects mostly older individuals who have been occupationally exposed to asbestos.
  • Described as an insidious neoplasm because of its long latency period—up to 40 years in some series—after exposure to asbestos.
  • Pleural normal.jpeg
    Peak incidence occurs in the 5th and 6th decades of life.[3]
  • Not genetically transferred [4]

The disease is on the rise, probably due to the spread of asbestos use over past decades. The disease burden is still predominantly borne by the developed world. However, since asbestos use has recently increased in developing countries, a corresponding shift in disease occurrence is anticipated. Global mortality pattern suggests that there are early indications of this shift and lends support to the call by international organizations to eliminate asbestos-related diseases and discontinue the use of asbestos throughout the world.[5]

Etiology[edit | edit source]

Asbestos Kitchen Goods (1901) (ADVERT 299).jpeg

Malignant pleural mesothelioma is primarily linked to asbestos exposure.

Image 3: During and after the Industrial Revolution, asbestos was widely used as an insulating material in the United States and Canada. Scientists have linked certain types of asbestos to three fatal diseases: lung cancer, asbestosis, and mesothelioma.

  • Some studies suggest that asbestos inhalation causes repeated pleural inflammation, interference with mitosis, activation of proto-oncogenes, and free radical production.
  • Other reports indicate associations with ionizing radiation or a germline mutation of BRCA 1 Associated Protein (BAP1).
  • Smoking is not linked with malignant pleural mesothelioma, though smoking and asbestos exposure significantly increase the risk of lung cancer.

Professions associated with exposure to asbestos include:

  • Shipbuilding
  • Mining
  • Ceramics
  • Cement manufacturer with asbestos
  • Auto parts manufacturer, especially that of brake lining
  • Paper mill worker
  • Insulation work
  • Railroad repair

There is no evidence that alcohol, tobacco, or dietary intake is involved in malignant pleural mesothelioma[2].

Epidemiology[edit | edit source]

Mesothelioma is uncommon and accounts for 5-28% of all malignancies that involve the pleura.

  • There is a strong association with exposure to asbestos fibres (~10% risk during lifetime; 40-80% of patients have a history of asbestos exposure) with risk associated with duration and breadth of exposure. Paraoccupational exposure (e.g. household members of asbestos-exposed workers) can also occur.
  • Not all types of asbestos are strongly implicated, with crocidolite being the main causative fibre type. Given the sources of asbestos exposure being predominantly mining, construction, lagging and machinery mechanics, 60-80% of cases are encountered in males, in general, 20 to 35 years after exposure. Some areas of the world have very regional hotspots, such as Belfast in Northern Ireland, due to the historic shipbuilding industry.
  • There is also increased risk for those with household exposure (e.g. family of exposed workers).
  • There has been no convincing evidence for an association with smoking[1]

[6]

Pathophysiology[edit | edit source]

Mesotheliomia pm.png

Mesothelial cells are much more susceptible than other cell types to asbestos cytotoxicity. When asbestos and other fibers reach the pleura and peritoneum through lymphatics, they remain in place for months or years, triggering a chronic inflammatory process that helps in the production of mutagenic oxygen radicals induced by asbestos are responsible for asbestos pathogenesis and carcinogenesis.[4]

The three types of mesothelioma are epithelioid, sarcomatoid, and mixed (epithelioid type is associated with better outcomes).

  • The tumor is often multifocal, forming multiple nodules starting with the parietal pleura.
  • Spread occurs locally in the visceral pleura before extending to the chest wall, diaphragm, or mediastinum.
  • Regional lymph node spread begins with the bronchopulmonary or hilar lymph nodes before moving to the carinal, internal mammary or peridiaphragmatic nodes.

The pattern of nodal metastases is different from that seen in lung cancer. With malignant pleural mesothelioma, there is a direct local invasion of the lymph nodes. Overall, the involvement of lymph nodes in malignant pleural mesothelioma is not common[2].

Signs and Symptoms[edit | edit source]

Dyspnea 01.png

Malignant pleural mesothelioma usually presents with chest pain and dyspnea. Dyspnea suggests the presence of pleural effusion, the most common initial finding, seen in about 90% of patients. Nonspecific symptoms such as unintentional weight loss, appetite loss, cough, fatigue, and chest wall mass may also occur.[2]

Diagnosis[edit | edit source]

Diagnosis of mesothelioma is difficult to make.

  • Radiological imaging (X-ray, ultrasound, Ct scan, positron-emission technology (PET)-CT or magnetic resonance imaging (MRI) ) can provide valuable diagnostic and staging information.[7]
  • Histology is a reliable prognostic marker. 

Treatment and Prognosis[edit | edit source]

Treatment continues to be challenging and the long-term survival is poor. Single modality treatment (surgery, radiotherapy, chemotherapy, immunotherapy and even photodynamic therapy) have not been shown to improve survival. More recently multi-modality treatment has had some impact on favourable subgroups (early disease, and epithelioid histology). Treatment includes:

  • extrapleural pneumonectomy
  • adjuvant chemotherapy
  • radiotherapy

The prognosis is poor for all tumour types with a median overall survival without treatment of 4-12 months. In favourable patient subgroups up to 45% 5-year survival may be achievable, however even with aggressive multi-modality therapy overall 5-year survival remains poor (3-18%) 3 with a median survival time of approximately 18 months[1].

Physiotherapy management[edit | edit source]

The Active Cycle of Breathing Technique..png

Patients are encouraged to enter a rehab program to recover functionality after treatment. A good diet should be encouraged as most patients are frail and emaciated. Home oxygen and breathing education (see Image 6 ACBT) are often required[2].

Physiotherapy is an integral part of the multidisciplinary approach treatment for patients with cancer.[8]
All patients who suffer from mesothelioma are required to undergo physical therapy, even if they have already undergone surgery, chemo, and/or radiation. The reasons for this include:

  • All three types of treatment are exceptionally difficult on the body. With their many negative side effects, the body needs physical therapy to regain the strength it once had.
  • Without physical therapy, these treatment options are less successful. The body needs all the strength it can get to successfully respond to all treatment options.
  • Therapy with a physical therapist is usually scheduled by the medical professional.

Mesothelioma treatments are designed to help patients feel more comfortable and hopefully extend their quality of life. While there is no cure for mesothelioma at this time, these three treatment options are the best bet. Of course, the doctor might have other suggestions as far as using a combination of these treatments and other medications to help client live as comfortably as possible. Each case of mesothelioma is unique, meaning each treatment method will differ from others.

Goals include: Respiratory care; pain management; improve the patient level of fatigue; improve bodily muscular and cardiovascular endurance.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 radiopedia Mesothelioma Available from:https://radiopaedia.org/articles/mesothelioma (accessed 11.5.2021)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Jain SV, Wallen JM. Cancer, malignant mesothelioma.2018 Available from: https://www.ncbi.nlm.nih.gov/books/NBK519530/(accessed 11.5.2021)
  3. ↑ Mott FE. Mesothelioma: a review. Ochsner Journal. 2012 Mar 20;12(1):70-9.
  4. ↑ 4.0 4.1 Carbone M, Adusumilli PS, Alexander Jr HR, Baas P, Bardelli F, Bononi A, Bueno R, Felley‐Bosco E, Galateau‐Salle F, Jablons D, Mansfield AS. Mesothelioma: scientific clues for prevention, diagnosis, and therapy. CA: a cancer journal for clinicians. 2019 Sep;69(5):402-29.
  5. ↑ Delgermaa V, Takahashi K, Park EK, Le GV, Hara T, Sorahan T. Global mesothelioma deaths reported to the World Health Organization between 1994 and 2008. Bulletin of the World Health Organization. 2011;89:716-24.Available:https://www.who.int/bulletin/volumes/89/10/11-086678/en/ (accessed 11.5.2021)
  6. ↑ Imperial Medicine. What is mesothelioma? Available from: https://www.youtube.com/watch?v=qUl18OGWGAo [last accessed 3/8/2020]
  7. ↑ Bibby AC, Tsim S, Kanellakis N, Ball H, Talbot DC, Blyth KG, Maskell NA, Psallidas I. Malignant pleural mesothelioma: an update on investigation, diagnosis and treatment. European Respiratory Review. 2016 Dec 1;25(142):472-86.
  8. ↑ Hemingway RD. Mesothelioma and Physical Therapy. InCaring for Patients with Mesothelioma: Principles and Guidelines 2019 (pp. 99-119). Springer, Cham.
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