University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.
Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
Respiration. 2022;101(1):46-56. doi: 10.1159/000517910. Epub 2021 Aug 30.
Thoracoscopy is the "gold standard" diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces.
A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen.
In the benign group, inflammation was the predominant finding in 65% (n = 33; costoparietal), 44% (n = 21; visceral), and 42% (n = 15; diaphragmatic). Nodules were detected in 24% (n = 12; costoparietal), 8% (n = 4; visceral), and 8% (n = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (n = 33; costoparietal), 32% (n = 13; visceral) and 48% (n = 17; diaphragmatic). Inflammation was detected in 44% (n = 20; costoparietal), 25% (n = 10; visceral), and 29% (n = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces.
This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in >1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.
胸腔镜检查是疑似胸膜恶性肿瘤的“金标准”诊断方法。有人假设，通过胸膜腔的仔细评估，通过结节、胸膜增厚和淋巴管炎的宏观发现，可能足以表明恶性肿瘤。我们试图通过精确定义客观的宏观标准，根据胸腔内模式和解剖位置，将良性和恶性胸膜疾病区分开来，并探索异常对胸膜表面特定部位的偏好，从而对此进行批判性评估。
对 96 名患者的胸腔镜检查录像进行了 2 名独立评估员的结构化审查。根据每个肋胸膜的壁层和脏层表面的结节、淋巴管炎和炎症，对存在的结节、淋巴管炎和炎症进行了商定的客观标准评分。肋胸膜被分为 6 个水平（肋侧和肋后壁层的顶部、中部和下部表面）。在中期审查后，肋胸膜的前表面被排除在分析之外，因为很少能看到这个表面。
在良性组中，炎症是主要发现，占 65%（n=33；肋胸膜）、44%（n=21；脏层胸膜）和 42%（n=15；膈肌）。结节在 24%（n=12；肋胸膜）、8%（n=4；脏层胸膜）和 8%（n=3；膈肌）中被发现。受炎症影响最严重的表面是肋胸膜的中部外侧（60%）和下部外侧（57.8%）。在恶性组中，根据表面，结节是主要发现，占 73%（n=33；肋胸膜）、32%（n=13；脏层胸膜）和 48%（n=17；膈肌）。炎症在 44%（n=20；肋胸膜）、25%（n=10；脏层胸膜）和 29%（n=10；膈肌）中被发现。结节最常见的表面是肋胸膜的中部外侧（67.4%）和下部外侧（66.7%）。
这是胸腔镜检查中胸膜空间异常的第一个详细的解剖描述。虽然结节是恶性胸腔积液的主要表现，但在 24%的良性诊断中也被发现。在肋胸膜的>1 个区域发现结节有利于恶性诊断。炎症是良性胸腔积液的主要表现。我们的结果表明，恶性诊断中肉眼可见的结节偏向于肋侧胸膜的中部和下部表面。
