Unilateral Pleural Effusions with More Than One Apparent Etiology. A Prospective Observational Study

Bintcliffe, Oliver; Hooper, Clare; Rider, Iain J.; Finn, R S; Morley, Anna; Zahan-Evans, Natalie; Harvey, John; Skyrme-Jones, A; Maskell, Nick A

doi:10.1513/annalsats.201601-082oc

Cited by 42 publications

(49 citation statements)

References 18 publications

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“…Our findings are in accordance with three of the five above studies (18,19,21). The sensitivity was higher in two studies (86% and 92%, respectively) (11,20).…”

Section: Discussionsupporting

confidence: 92%

“…Furthermore, the sensitivity of a non-guideline supported CT was significantly higher than a guideline-supported CT. The sensitivity of CT for predicting malignancy in pleural effusions have been investigated in five studies, yet none reported data on unilateral effusions in isolation (11,(18)(19)(20)(21).…”

Section: Discussionmentioning

confidence: 99%

“…Two studies found a specificity of 93% and 92%, respectively (19,21). In one of the studies, an advanced score was calculated based on logistic regression findings (21).…”

Section: Discussionmentioning

confidence: 99%

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Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline

Reuter¹,

Lindgaard²,

Laursen³

et al. 2019

J. Thorac. Dis

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Background: The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines' recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods: The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013-2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light's criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results: In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light's criteria not assessed: n=111; 67%). 18 F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guidelinesupported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. Conclusions: Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.

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“…Our findings are in accordance with three of the five above studies (18,19,21). The sensitivity was higher in two studies (86% and 92%, respectively) (11,20).…”

Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline

Reuter¹,

Lindgaard²,

Laursen³

et al. 2019

J. Thorac. Dis

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“…This may indicate that being evaluated for possible malignancy-associated pleural effusion by VATS, i.e., having recurrent pleural effusion is a marker of significant and serious yet non-malignant condition. It is well-known that pleural effusions may in many cases have more than one cause (17). However, there are no long-term prospective studies on possible benefits or risks of follow-up in these patients, yet systematic evaluation for thyroid, renal, hepatic and heart disease increased the number of targetable diagnoses (18).…”

Section: Discussionmentioning

confidence: 99%

Incidence of malignancy and survival in patients with idiopathic pleuritis

Reuter¹,

Clementsen²,

Bødtger³

2019

J. Thorac. Dis.

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Background: The long-term outcome after non-diagnostic thoracoscopy (idiopathic pleuritis) has not been investigated in nationwide studies, and the survival has never been estimated. Therefore, we decided to investigate the three-year incidence of malignancy and survival of patients with idiopathic pleuritis. Methods: Retrospective, register-based, nationwide study of patients undergoing diagnostic video-assisted thoracoscopic surgery (VATS) thoracoscopy ≤30 days after thoracentesis, using The National Patient Registry and The Danish Cancer Registry. Idiopathic pleuritis was defined as; no diagnosis of malignancy within 31 days after VATS. Patients were followed for 36 months after VATS. Results: In total, idiopathic pleuritis were identified in 547 out of 658 patients undergoing VATS (83%), and 29 (5%) were diagnosed with malignancy during the 3 years follow-up period after VATS. Of these, 93% were diagnosed with malignancy within the first year. Numbers-needed-to-follow-up for detecting one case of malignancy was 18 during the first year after VATS and 250 in the two subsequent years. Survival was independent on type of malignancy (MPM vs. other malignancies; P=0.13) and of time from VATS to diagnosis (≤31 days vs. 1-36 months; P=0.15). Median survival in the non-malignant group was 1,095 days. Conclusions: Our study confirms a low incidence of malignancy in idiopathic pleuritis after VATS. Nearly all incident cases of malignancy were diagnosed within 12 months from VATS. No survival disadvantage was observed in patients with incident malignancy. Our data suggest that follow-up of idiopathic pleuritis could safely be limited to 1 year. The optimal follow-up strategy remains to be investigated. Cite this article as:Reuter SB, Clementsen PF, Bodtger U.Incidence of malignancy and survival in patients with idiopathic pleuritis.

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“…Idiopathic pleural effusion was defined as any persistent, exudative pleural effusion that remains undiagnosed after the history and physical examination, biochemical and cytological studies of pleural fluid, radiographic examinations and histopathological analysis of biopsied specimens [4,6]. Diagnosis of idiopathic pleural effusion was made after a minimum of 1-year follow-up (range 5 1-10 years), with detailed exploration including computed tomographic (CT) scanning to exclude other causes of effusion such as malignant pleural mesothelioma and carcinomatous pleuritis, according to previous studies that mainly performed follow-up of 1-2 years [4,7,[33][34][35][36]. In this retrospective study, we accumulated 830 pleural fluid samples at Yamaguchi-Ube Medical Center between 2000 and 2012 and reviewed 35 patients with undiagnosed pleural effusions who underwent thoracoscopy and pleural biopsy, after excluding three patients who had a malignancy during follow-up.…”

Section: Patientsmentioning

confidence: 99%

Association of immunoglobulin G4 and free light chain with idiopathic pleural effusion

Murata

Aoe

Mimura‐Kimura

et al. 2017

Clinical and Experimental Immunology

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The cause of pleural effusion remains uncertain in approximately 15% of patients despite exhaustive evaluation. As recently described immunoglobulin (Ig)G4-related disease is a fibroinflammatory disorder that can affect various organs, including the lungs, we investigate whether idiopathic pleural effusion includes IgG4-associated etiology. Between 2000 and 2012, we collected 830 pleural fluid samples and reviewed 35 patients with pleural effusions undiagnosed after pleural biopsy at Yamaguchi-Ube Medical Center. Importantly, IgG4 immunostaining revealed infiltration of IgG4-positive plasma cells in the pleura of 12 patients (34%, IgG4 group). The median effusion IgG4 level was 41 mg/dl in the IgG4 group and 27 mg/dl in the IgG4 group (P < 0·01). The light and heavy chains of effusion IgG4 antibodies of patients in the IgG4 group were heterogeneous by two-dimensional electrophoresis, indicating the absence of clonality of the IgG4 antibodies. Interestingly, the κ light chains were more heterogeneous than the λ light chains. The measurement of the κ and λ free light chain (FLC) levels in the pleural fluids showed significantly different κ FLC levels (median: 28·0 versus 9·1 mg/dl, P < 0·01) and κ/λ ratios (median: 2·0 versus 1·2, P < 0·001) between the IgG4 and IgG4 groups. Furthermore, the κ/λ ratios were correlated with the IgG4 /IgG plasma cell ratios in the pleura of the IgG4 group. Taken together, these results demonstrate the involvement of IgG4 in certain idiopathic pleural effusions and provide insights into the diagnosis, pathogenesis and therapeutic opportunities of IgG4-associated pleural effusion.

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Unilateral Pleural Effusions with More Than One Apparent Etiology. A Prospective Observational Study

Cited by 42 publications

References 18 publications

Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline

Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline

Incidence of malignancy and survival in patients with idiopathic pleuritis

Association of immunoglobulin G4 and free light chain with idiopathic pleural effusion

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