Pleural malignant mesothelioma (MM), which is an aggressive neoplasm with a high mortality, frequently manifests initially as pleural effusions. The sensitivity of cytologic examination for its diagnosis varies widely in literature and most of the figures are from earlier studies with conventional cytologic preparations. The objective of this study was to provide the current evidence on the role and sensitivity of cytologic examination of pleural fluid in the diagnosis of MM. We reviewed the cytologic findings in pleural effusions of a large series of histologically proven MM (234 cases) diagnosed in our institution between 2001 and 2008. Of all cases, 154 (66%) had cytologic material examined. A specific diagnosis of MM was rendered or suspected in 53% (79 patients). The lowest sensitivity (20%) was noticed in sarcomatoid MM cases. MM was favored over adenocarcinoma in 97% of patients with positive cytologic findings that have been confirmed with immunohistochemistry. In this series, five cases were inadequate and five cases were initially reported as atypical, whereas 65 cases (44%) were reported as negative for malignancy. On review of the cytology slides, only four cases were upgraded from benign to suspicious compared to four cases downgraded from suspicious to atypical but no significant improvement to the diagnosis could be made on revision. These data suggested that a cytologic diagnosis contributed useful information in patients with epithelioid and biphasic pleural MM. Limitations of the cytologic examination of MM should also be acknowledged.