Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies

Our plain-English summary of Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies, by H.E. Davies, J.E. Nicholson, N.M. Rahman, et al (European Journal of Cardio-thoracic Surgery, 2010).

The study

• Authors: H.E. Davies, J.E. Nicholson, N.M. Rahman, E.M. Wilkinson, R.J. Davies, Y.C. Lee
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2010;38(4):472-7
• Cited by: 95 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: Medical thoracoscopy is recommended in the investigation of patients with exudative pleural effusions, especially when pleural fluid analysis is uninformative. The histological finding of 'nonspecific pleuritis/fibrosis' is common in thoracoscopic biopsies and presents a great uncertainty for clinicians and patients as the long-term outcome of these patients is unclear, and anxieties about undiagnosed malignancy persist.

Method: A retrospective case-note study of 142 patients who underwent medical thoracoscopy over a 58-month period in a tertiary referral centre with a high incidence of mesothelioma. Patients with 'nonspecific pleuritis/fibrosis' were followed up until death or for a mean (±SD) period of 21.3 (±12.0) months.

Results: A definitive histological diagnosis was achieved in 98 (69%) patients. A total of 44 (31%) patients had 'nonspecific pleuritis/fibrosis'. Five (12%) were subsequently diagnosed with malignant pleural disease after a mean interval of 9.8 (±4.6) months. All five patients had histologically confirmed mesothelioma. In 26 patients with 'nonspecific pleuritis/fibrosis', no cause for the pleural effusion was discovered. The false-negative rate of thoracoscopic biopsy for the detection of pleural malignancy was 5%, with a diagnostic sensitivity of 95% and negative predictive value of 90%. Pleural effusion recurrence was more frequently associated with a false-negative pleural biopsy result. However, there was no correlation with other patient characteristics or the thoracoscopist's prediction based on macroscopic appearances.

Conclusion: Thoracoscopic pleural biopsy is valuable in the diagnosis of pleural malignancies. Patients with 'nonspecific pleuritis/fibrosis' require follow-up as a malignant diagnosis (especially mesothelioma) may eventually be established in approximately 12% of cases.

Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

In plain English

This retrospective case-note review covered 142 patients who had medical thoracoscopy, a camera examination of the chest lining with biopsies. They were treated over 58 months from January 2000 at an Oxford pleural unit with, the authors said, a high incidence of mesothelioma. Biopsies gave a definite diagnosis in 98 patients (69%). In 44 (31%) they showed only 'nonspecific pleuritis/fibrosis': inflammation or scarring with no sign of cancer or another specific cause. Of the 42 of these with complete follow-up, five (12%, 95% confidence interval 4.5 to 26.4%) were later diagnosed with malignant mesothelioma on repeat biopsy or at autopsy. One table marks all five as having known asbestos exposure, but another gives 80% for this group, so the article is inconsistent. That second table gives 45% for patients whose disease stayed benign, a difference that was not statistically significant (p value 0.34). The authors reported that the missed cases could not have been predicted from clinical or imaging features or from appearances seen during the procedure. They concluded that patients with this biopsy finding need follow-up.

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 case-note study of patients who underwent medical thoracoscopy
• Who was studied: 142 patients (102 male, mean age 64.6 years) who had local anaesthetic thoracoscopy over 58 months from January 2000 at a tertiary referral pleural unit in Oxford, UK. Of these, 44 had 'nonspecific pleuritis/fibrosis', and complete data were available for 42 of the 44.
• Exposure: The study assessed thoracoscopic pleural biopsy as a diagnostic test. Previous asbestos exposure was recorded as one clinical variable. No fiber types, jobs or doses were given.
• Main results:
  • Thoracoscopic biopsies gave a definitive histological diagnosis in 98 of the 142 patients (69%).
  • Complete data were available for 42 of the 44 patients with 'nonspecific pleuritis/fibrosis'.
  • Of these patients, five (12%, 95% CI 4.5 to 26.4%) were ultimately found to have pleural malignancy on follow-up. The percentage corresponds to five of the 42 with complete data: Table 3 compares 37 benign-course patients with 5 false-negative patients.
  • In all five of these patients, malignant mesothelioma was diagnosed on repeat pleural biopsy or at autopsy.
  • Table 2, which lists the five false-negative patients individually, marks all five as having known asbestos exposure. Table 3 reports known asbestos exposure in 80% of this group, so the article is internally inconsistent on this point.
  • Table 3 reports known asbestos exposure in 45% of patients with a benign disease course and in 80% of patients with a false-negative result (p value 0.34). The authors saw no association between pleural malignancy and a history of asbestos exposure.
  • The false-negative rate of thoracoscopic pleural biopsy for detecting pleural malignancy was 5/94 (5%, 95% CI 2.3 to 12.5%). Diagnostic sensitivity was 95% (95% CI 87.5 to 98.0%) and negative predictive value was 90% (95% CI 77.8 to 96.3%).
  • Four patients with benign asbestos-related pleural effusion (BAPE) showed no pleural malignancy after a mean follow-up of 26.0 months.
  • 26 patients with 'nonspecific pleuritis/fibrosis' had no cause found for their effusion after extensive investigation and follow-up.
  • Pleural effusion recurred in 7 patients (17%): in 2 of 4 patients with pleural malignancy and in 5 of 34 patients with benign disease (p value 0.15; the study counted p less than 0.05 as significant).
  • All five false-negative results occurred in patients with a high pre-thoracoscopy clinical suspicion of malignancy. There were none among low-suspicion cases (p value 0.14).
  • In Table 3, current smoking was recorded in 13% of the benign-course group and in 80% of the false-negative group (p value 0.04).
  • The thoracoscopist's impression of the pleura during the procedure was not reliable for telling benign from malignant disease. Sensitivity was 100% (95% CI 39.6 to 100%) and specificity was 21% (95% CI 9.6 to 39.4%).
• The authors' conclusion: The authors concluded that thoracoscopic pleural biopsy is valuable in diagnosing pleural malignancies. They stated that patients with 'nonspecific pleuritis/fibrosis' require follow-up, because a malignant diagnosis, especially mesothelioma, may eventually be made in about 12% of cases. They also stated that the false-negative cases could not have been predicted from clinical or radiological parameters or from what was seen at thoracoscopy.
• Limitations the authors state:
  • The authors noted that mesothelioma incidence varies widely around the world. They said the threshold for further surgical biopsy should reflect the local incidence.
  • The authors stated that further large prospective studies are needed of patients with a benign pleural biopsy result, in populations with differing mesothelioma incidence.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Fibrosis, Medical Thoracoscopy, Pleural Effusion, Mesothelioma, Thoracoscopy, Pleural Biopsy.

Related studies

• Outcome of patients with nonspecific pleuritis at thoracoscopy — J.M. Wrightson, H.E. Davies (2011)
• Chronic follicular pleuritis: a B cell-rich form of nonspecific pleuritis/fibrosis — S.A. Yousem (2019)
• Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy — M. Metintas, G. Ak, et al. (2012)
• What is the significance of non-specific pleuritis? A trick question — J. Janssen, F. Maldonado, et al. (2018)
• Nonspecific pleuritis: optimal duration of follow-up — Z.S. DePew, A. Verma, et al. (2014)
• Investigation and outcomes in patients with nonspecific pleuritis: results from the International Collaborative Effusion database — A. Sundaralingam, A. Aujayeb, et al. (2023)

Browse more research in European Journal of Cardio-thoracic Surgery, or return to medical research.