Diagnosis of malignant pleural disease: Ultrasound as "a detective probe"

Our plain-English summary of Diagnosis of malignant pleural disease: Ultrasound as "a detective probe", by G. Messina, M. Bove, G. Natale, et al (Thoracic Cancer, 2023).

The study

• Authors: G. Messina, M. Bove, G. Natale, V. Di Filippo, G. Opromolla, A. Rainone, B. Leonardi, M. Martone, A. Fiorelli, G. Vicidomini, M. Santini, A. Ronchi, E. Massimilla, C.M. Della Corte, M. Pirozzi, M. Caterino, F. Ciardiello, M. Fasano
• Journal: Thoracic Cancer
• Published: 2023;14(3):223-230
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pleural mesothelioma (MPM) is an invasive, aggressive pleural tumor with a predominantly local spread. The objective of this study was to assess thoracic ultrasound (TUS) as an imaging modality with high sensitivity for the identification of malignant pleural involvement and in order to guide pleural biopsies.

Methods: In this retrospective single-center study between January 2018 and June 2022, 51 consecutive patients with impassable circumferential pleural thickening underwent TUS at the Thoracic Surgery Unit of the Vanvitelli University of Naples. Pleural biopsies were performed, and then large and multiple samples were sent to the pathological anatomy for histological examination.

Results: In all patients who underwent ultrasound examination, we chose the optimal point of entry to perform pleural biopsies and selected the areas of greater thickening without pleural effusion. No patient had any complications. No drainage tubes were placed after the pleural biopsies and no pneumothorax was present during the following days of hospitalization. The patients were discharged on the second postoperative day.

Conclusion: With TUS the precise pleural thickening localization, local infiltration, mass extent, its nature (solid, cystic or complex) and ultrasound features can be easily defined. Furthermore, ultrasound is more economical than computed tomography and avoids the risks associated with radiation. Thoracic ultrasound is an important component of the diagnostic procedure in detecting a safe entry site for biopsies of MPMs.

© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

In plain English

This was a retrospective study at the Thoracic Surgery Unit of the Vanvitelli University of Naples, Italy. It covered 51 consecutive patients (January 2018 to June 2022) whose pleura, the lung lining, had thickened all around, closing off the pleural space. Of these patients, 41 (80%) had a history of occupational asbestos exposure. Before surgery, ultrasound located the thickest areas and a safe entry point. The authors then took tissue samples through a skin cut of about 2 cm. The authors reported malignant pleural mesothelioma in 43 patients (85%) and a secondary tumor in seven (15%), although 43 plus seven is one short of 51 and one of the seven was inflammatory thickening. Ultrasound sensitivity was reported as 97% and accuracy as 94%. No complications such as bleeding or pneumothorax (collapsed lung) occurred, no drainage tubes were placed, and patients were discharged on the second day after surgery. The authors concluded that chest ultrasound helps locate pleural thickening and guide a safe biopsy entry site. They called the study preliminary, needing more cases. Other numbers in the article also conflict.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective, observational, single-centre study of thoracic ultrasound used to locate malignant pleural disease and guide pleural biopsy
• Who was studied: 51 consecutive patients with impassable circumferential pleural thickening at the Thoracic Surgery Department of the Vanvitelli University of Naples, Italy, January 2018 to June 2022. Mean age was 69 years; 38 were men and 13 were women.
• Exposure: The study examined a diagnostic method (thoracic ultrasound to guide pleural biopsy), not asbestos exposure as such. 41 of the 51 patients (80%) had a history of occupational asbestos exposure. No fiber types or doses are given.
• Main results:
  • The authors reported a final diagnosis of malignant pleural mesothelioma in 43 patients (85%) and a secondary tumor in seven (15%). Added together, 43 plus seven is one fewer than the 51 patients studied.
  • Mesothelioma subtypes among the 43 cases were epithelioid 31 (71%), sarcomatous 7 (16%), mixed 4 (10%) and desmoplastic 1 (3%).
  • Among the seven patients the authors call secondary tumors, the text lists lung cancer in four, breast cancer in one, squamous cell carcinoma of unknown origin in one, and inflammatory thickening (not a tumor) in one. The table lists ovarian cancer instead of inflammatory thickening.
  • For ultrasound, the authors reported 35 true positives, 2 false positives and 1 false negative. They gave sensitivity 97%, positive predictive value 95%, negative predictive value 93% and accuracy 94%.
  • In the study patients, pleural mesothelioma appeared on ultrasound as an irregularly limited, echo-poor, knotty or planar widening along the pleura.
  • Biopsies were taken as incisional biopsies using forceps, through a small skin incision of about 2 cm.
  • No patient had complications such as bleeding, infection or damage to the visceral pleura.
  • No drainage tubes were placed, and no pneumothorax was present during the hospital stay. Patients were discharged on the second day after surgery.
• The authors' conclusion: The authors concluded that chest ultrasound is a supplementary technique in the preoperative evaluation of malignant pleural disease. In their view it allows pleural tumors or thickening to be localized and guides a safe entry site for pleural biopsy. They also called the work a preliminary single-centre study needing further cases.
• Limitations the authors state:
  • Small number of patients
  • Ultrasound results depend on the operator and the patient. An inexperienced operator may not obtain adequate images and can be misled by artifacts.
  • Subcutaneous emphysema or pleural calcifications can block ultrasound, and because of the ribs only 70% of the pleural surface can be explored.
  • Single-centre preliminary study needing further cases

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Ultrasound, Pleural Mesothelioma, Pleural Thickening, Thoracic Surgery, Pleural Effusion, Pneumothorax.

Related studies

• Physician-based ultrasound-guided biopsy for diagnosing pleural disease — R.J. Hallifax, J.P. Corcoran, et al. (2014)
• Convex-probe endobronchial ultrasound-guided cryobiopsy for pleural tumors: three case reports — T. Nakai, Y. Furukawa, et al. (2026)
• Advantages of thoracic ultrasound-guided fine-needle aspiration biopsy in lung cancer and mesothelioma — M. Sperandeo, L. Dimitri, et al. (2014)
• Ultrasound-guided medical thoracoscopy in the absence of pleural effusion — G. Marchetti, A. Valsecchi, et al. (2015)
• First report of probe based confocal laser endomicroscopy during medical thoracoscopy — O. Bonhomme, B. Duysinx, et al. (2019)
• Diagnosis and initial management of nonmalignant diseases related to asbestos — American Thoracic Society (2004)

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