Pleural Disease

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Pleural Disease

• By Michael Shackcloth

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Pleural effusion

• Definition - increase in fluid in the pleural
  space
• Shows on CXR if gt300ml
• Detected clinically if gt500ml
• Exudates - protein content lt 30g/l
• Blood stained effusions usually malignant
• 50 of malignant effusions are serous

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Pleural effusion - Clinical features

• Shortness of breath
• Decreased chest wall movement
• Tracheal central
• Stony dull to percussion
• Reduced or absent breath sounds
• Signs of underlying cause

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Pleural effusion

• Exudate
• Pneumonia
• Carinoma of the lung
• Pulmonary embolus
• Tuberculosis
• Connective tissue disease
• Post MI
• Mesothelioma
• Acute pancreatitis
• Sarcoidosis
• Yellow nail syndrome

• Transudate
• heart failure
• hypoprotienaemia
• constrictive pericarditis
• hypotyroidism
• ovarian tumours (Meigs syndrome)

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Pleural plaques and Calcification

• Discrete areas of thickened parietal pleura
• Often bilateral
• More common on lower half of thorax
• Do not occur at apex of chest
• Do not occur at apex of chest
• Do not cause adhesions
• Appear smooth and ivory white (may be nodular and
  greyish brown)

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Pleural plaques and Calcification

• Histologically uniformly arranged, densely
  laminated collagen
• Relationship with mesothelioma uncertain
• Common finding on CXR
• Differential diagnosis - any pleural tumour

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Pleural Tumours

• Benign
• Lipoma
• Endotheliomas
• Angiomas
• Cysts

• Malignant
• Metastatic
• Mesothelioma

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Pleural Cysts

• Most common at pleuropericardial angle
• 70 on right
• Unilocular, up to 10cm in diameter
• Typical water density on CXR
• Slow growing
• Rarely symptomatic
• Removed for diagnostic purposes

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Mesothelioma

• Primary tumour usually kills patient
• Caused by asbestos exposure
• 5-7 of all individuals exposed to asbestos
• latent period 20-40 years
• 50 of patients no history of asbestos exposure
• Asbestos cigarettes increases lung Ca risk

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Clinical Presentation

• Symptoms
• Pain
• Shortness of breath
• Hypertrophic pulmonary osteoartropathy

• Signs
• Pleural effusion
• Finger clubbing
• Dullness at site
• Atrial fibrillation

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Investigations

• CXR
• CT scan
• Pleural aspiration
• Bronchoscopy
• Pleural biopsy
• closed
• open
• VATS

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Staging

• I Confined to ipsilateral pleura
• II Involves chest wall, mediastinum,
  pericardium or contralateral pleura
• III Involves both thorax and abdomen or lymph
  nodes outside thorax
• IV Distant metastasis

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Management

• Surgical
• Brachytherapy
• External radiotherapy
• Intracavity radiotherapy
• Chemotherapy
• Combination therapy
• All are usually considered palliative