Malignant pleural disease

Last revised by Liz Silverstone on 21 Mar 2023

Malignant pleural disease usually heralds a poor prognosis, whether it represents a primary pleural malignancy or metastatic involvement

Clinical presentation is variable. Patients may be asymptomatic or have pleuritic pain. If associated with a sizable pleural effusion, then respiratory compromise may be evident. If a tumor is from the chest wall, then musculoskeletal pain or even a palpable mass may be present.

The pleura can be involved by malignancy by three main mechanisms:

  1. direct extension from an adjacent tumor, e.g. bronchogenic carcinoma

  2. a primary tumor, e.g. mesothelioma, primary pleural lymphoma

  3. pleural metastases

In each of these, the manifestation can be either solid disease or a malignant pleural effusion, or a combination of both. The relative etiology is 1,6

Conventional imaging is in general highly specific for the diagnosis of pleural malignancy but unfortunately lacks sensitivity 3

Plain films in the setting of malignant pleural effusion are insensitive at distinguishing it from a benign effusion. 

In cases where multiple nodular regions or pleural thickening are present the diagnosis may be evident, especially if a primary tumor or other metastatic deposits are visible.

CT is the work-horse of pleural imaging, able to achieve specificities of close to 100% 3. The portal-venous phase (also known as the pleural phase in the chest) is optimal for demonstrating pleural enhancement, rather than arterial phase imaging used routine thoracic CT. A number of features are recognized in differentiating benign from malignant, including 1,3,8:

Diffuse pleural calcification overlying this region generally suggests a benign process

In many cases the primary malignancy will be visible (e.g. breast cancer, bronchogenic cancer) and/or evidence of pulmonary or bony metastases will be visible. 

FDG-PET is far more sensitive than conventional imaging in diagnosing malignant pleural disease and distinguishing them from benign processes 3. Hypermetabolism can be seen in either the pleura or pleural effusion. Although both benign and malignant processes, benign processes rarely increase the SUV over 2.0 3

MRI findings of high signal intensity on T2 in relation to intercostal muscles and/or contrast-enhanced on T1 images together with CT morphology has a 100% and a specificity of 93% in the detection of pleural malignancy 5.

Both treatment and prognosis are dependent on the underlying type of malignancy. In the case of primary malignancies of the pleura (e.g. mesothelioma) resection may be a possibility in highly selected cases.

Thoracentesis of malignant pleural effusions has limited effect with reaccumulation occurring, on average, at four days. 

In general, and certainly in the case of diffuse pleural metastatic disease, systemic therapies or radiotherapy are the only options. These are discussed separately as part of articles pertaining to individual malignancies:

Differential diagnosis depends on the predominant form the pleural disease takes:

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