A multidisciplinary approach for the diagnosis of benign asbestos pleural effusion: a single-center experience

Our plain-English summary of A multidisciplinary approach for the diagnosis of benign asbestos pleural effusion: a single-center experience, by W. Luo, Y. Zeng, P. Shen, et al (Journal of Thoracic Disease, 2020).

The study

• Authors: W. Luo, Y. Zeng, P. Shen, X. Wu, J. Wang, X. Zhang
• Journal: Journal of Thoracic Disease
• Published: 2020;12(8):4338-4346
• Cited by: 3 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: There is little detailed information regarding benign asbestos pleural effusion (BAPE). It is frequently misdiagnosed because of lack of a standardized diagnostic approach and criteria. The present study aimed to better characterize BAPE and outline a diagnostic approach for this disease.

Methods: Complete clinical data of 11 consecutive patients with BAPE were prospectively collected and analysed. A multidisciplinary team (MDT) was involved in discussing the suspected cases of BAPE. The team was comprised of thoracic physicians, radiologists and pathologists. A multidisciplinary practical diagnostic approach for BAPE was introduced.

Results: Six patients had respiratory symptoms, but another 5 were asymptomatic. All the patients had an asbestos exposure and the median duration was 23.9 years (rang, 12-36 years). The median level of lactate dehydrogenase (LDH), adenosine deaminase (ADA), proteins and carcinoembryonic antigen (CEA) in the pleural fluid (PF) were 221.4 U/L (range, 189.8-11,325 U/L), 21 U/L (rang, 14-247 U/L), 48.3 g/dL (range, 35.2-53.2 g/dL) and 3.46 mg/mL (range, 0.84-4.54 mg/mL), respectively. Five patients had pleural plaques, 2 had diffuse pleural thickening (DPT), 1 had asbestosis, and 1 had round atelectasis. The pleural biopsy specimens showed a benign fibrotic pleura in all case. The symptoms and pleural pulmonary radiologic findings remained stable during the follow-up.

Conclusions: BAPE is diagnosed by exclusion. A suspected diagnosis of BAPE with an asbestos exposure should be considered, especially with the presence of pleural plaques, and/or DPT, and rounded atelectasis. The MDT-based diagnostic approach may reduce misdiagnosis.

2020 Journal of Thoracic Disease. All rights reserved.

In plain English

This single-center study from Guangzhou, China, described 11 patients diagnosed with benign asbestos pleural effusion (BAPE), a non-cancerous build-up of fluid around the lungs, and presented a team-based way of diagnosing it. Of 21 suspected cases among patients treated between January 2013 and January 2018, the 11 with complete clinical information were included. All were men with occupational asbestos exposure, most often construction work, lasting a median of 24 years. The article does not name fiber types. A team of respiratory physicians, radiologists and pathologists discussed each suspected case, using test results to rule out other causes such as cancer and tuberculosis. Five patients had no symptoms. All 11 had first been given another diagnosis, six of them tuberculous effusion. Pleural biopsies showed no cancer or tuberculosis, and no asbestos bodies or fibers were found. All patients stayed stable over at least 24 months of follow-up. The authors concluded that BAPE should be suspected in unexplained pleural fluid, especially with pleural plaques, diffuse pleural thickening and rounded atelectasis. They also said the team approach may reduce misdiagnosis. They named the small, single-center sample as a limitation.

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: Prospective case series from a single hospital, describing patients with benign asbestos pleural effusion and proposing a multidisciplinary team diagnostic approach
• Who was studied: 11 patients (all men, ages 51 to 77) with benign asbestos pleural effusion at the First Affiliated Hospital of Guangzhou Medical University, China, treated between January 2013 and January 2018. Of 21 suspected cases identified, only the 11 with complete clinical information were included.
• Exposure: Occupational asbestos exposure in jobs including construction (3 patients), paper mill, copper wire plant, chemical plant, steel production, plumbing, petrochemical work, electrical work and glasswork. Median exposure duration was 24 years (range 12 to 36 years). Median interval from exposure to presentation was 12 years (range 8 to 30 years). Fiber types are not reported.
• Main results:
  • Respiratory physicians, radiologists and pathologists discussed each suspected case until they reached consensus. When a pathologist found pleural fibrosis, other conditions were excluded by discussing the clinical characteristics with all clinicians. Other pleural diseases had been excluded after pleural biopsy, pleuroscopy, cytology and laboratory testing.
  • Six of the 11 patients had respiratory symptoms; the other 5 (5/11, 45.5%) had none.
  • All 11 patients were initially given a different diagnosis: 6 as tubercular pleural effusion, 4 as parapneumonic pleural effusion and 1 as malignant pleural effusion.
  • The effusion was on one side in 9 patients (81.8%) and on both sides in the remaining 2 (18.2%). All effusions were exudates by Light's criteria.
  • According to the text, chest CT showed pleural plaques in 5 patients, diffuse pleural thickening in 2, asbestosis in 1 and round atelectasis in 1.
  • In the pleural fluid of the 11 patients, the median LDH was 221.4 U/L (range 189.8 to 11,325 U/L), as printed. The article printed median ADA 21 U/L (range 14 to 247 U/L), proteins 48.3 g/dL (range 35.2 to 53.2 g/dL) and CEA 3.46 mg/mL (range 0.84 to 4.54 mg/mL).
  • Pleural biopsies showed fibrosis of the pleura, mesothelial cells and lymphocytes. No asbestos bodies or asbestos fibers were found, and there was no evidence of tuberculosis or malignancy.
  • Follow-up lasted at least 24 months (mean 31.9 months, range 24 to 48 months). All patients stayed stable without additional therapy, and in one patient the pleural fluid regressed.
• The authors' conclusion: The authors concluded that BAPE is diagnosed by exclusion and should be suspected in patients with unexplained pleural fluid, especially with pleural plaques, diffuse pleural thickening and rounded atelectasis. They said the multidisciplinary team approach may reduce misdiagnosis.
• Limitations the authors state:
  • Single-center study with a small number of patients, so the characteristics of BAPE were not fully addressed; the authors said a large multicenter prospective study is needed.
  • The diagnostic value of specific pleural fluid measurements remains to be tested in larger prospective studies.

Topics

Medical terms in this study, explained in our Lexicon: Multidisciplinary Team, Benign Asbestos Pleural Effusion, Asbestos Exposure, Lactate Dehydrogenase (LDH), Carcinoembryonic Antigen (CEA), Pleural Plaques, Diffuse Pleural Thickening, Atelectasis.

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