Pleural effusions and pneumothorax: Beyond simple plumbing: Expert opinions on knowledge gaps and essential next steps

Our plain-English summary of Pleural effusions and pneumothorax: Beyond simple plumbing: Expert opinions on knowledge gaps and essential next steps, by R. Thomas, N.M. Rahman, N.A. Maskell, et al (Respirology, 2020).

The study

• Authors: R. Thomas, N.M. Rahman, N.A. Maskell, Y.C.G. Lee
• Journal: Respirology
• Published: 2020;25(9):963-971
• Type of article: Review
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence-based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.

© 2020 Asian Pacific Society of Respirology.

In plain English

This invited review collected expert opinions on knowledge gaps in pleural infection, malignant pleural mesothelioma, malignant pleural effusion and spontaneous pneumothorax, and reported no new data. The authors argued that recent research had focused mainly on drainage rather than the underlying diseases. Median survival in mesothelioma, they wrote, remained 12 months. They said the tumour's hidden location in the pleural cavity makes early detection very difficult. Without a tissue biopsy, cases appearing as diffuse pleural thickening can be hard to distinguish on imaging from benign pleural plaques. They described mesothelin as the only marker showing some promise for predicting the disease, but said its sensitivity is low and raised levels occasionally point to other cancers that have spread to the pleura. They noted that asbestos is still widely mined and used in developing countries. Where it was banned decades ago, mesothelioma incidence had only plateaued. They suggested one explanation: longer lifespans mean more elderly people exposed decades earlier develop the disease. The authors concluded that pleural research must ultimately aim to stop effusions or pneumothorax developing in the first place.

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: Invited narrative review collecting expert opinions; no original data
• Who was studied: No study population. The review covered malignant pleural effusion, mesothelioma, pleural infection and pneumothorax.
• Exposure: No exposure was studied. The review discusses asbestos as the cause of mesothelioma; no fiber types are named.
• Main results:
  • The authors stated that most recent pleural studies have focused on draining fluid or air ('pleural plumbing').
  • The authors stated that, for malignant pleural mesothelioma, no treatment advance has made a realistic impact on survival, which they gave as a median of 12 months.
  • The authors wrote that mesothelioma develops in the hidden pleural cavity, which makes early detection extremely difficult.
  • The authors wrote that some mesotheliomas develop as diffuse pleural thickening. Without a tissue biopsy, these are difficult to distinguish on imaging alone from benign pleural plaques and non-asbestos causes of pleural fibrosis.
  • The authors described mesothelin as the only marker that has shown some promise in predicting the development of mesothelioma.
  • The authors wrote that a raised mesothelin level points towards pleural malignancies, most commonly mesothelioma and occasionally other metastatic carcinomas, but that its sensitivity is low.
  • The authors cited the MARS randomized trial (another study) as finding that extra-pleural pneumonectomy for mesothelioma was harmful and shortened survival by 5.5 months.
  • The authors noted that asbestos continues to be widely mined and used, especially in developing countries.
  • The authors stated that in the developed world, where asbestos use was banned decades ago, mesothelioma incidence has only plateaued.
  • As one possible explanation for this plateau, the authors suggested that longer lifespans mean more elderly people exposed decades earlier will develop mesothelioma.
• The authors' conclusion: The authors concluded that the ultimate goal of pleural research must be to stop effusions or pneumothorax from developing in the first place. They said research should move beyond drainage to understanding the underlying diseases.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Pneumothorax, Clinical Trial.

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• Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage — P. Lange, J. Mortensen, et al. (1988)
• A simple "expert system" for morphometric evaluation of cells in pleural effusions — M. Oberholzer, G. Feichter, et al. (1989)
• Recurrent pneumothorax following abdominal paracentesis — P.J. Stafford (1990)
• Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial — S. Muruganandan, M. Azzopardi, et al. (2018)
• Profile of soluble factors in pleural effusions predict prognosis in mesothelioma — I.M. Dick, Y.C.G. Lee, et al. (2022)

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