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21: Benign and Malignant Pleural Tumors

Siva Raja; Carol F. Farver; Sudish C. Murthy; David Mason

Key Concepts

  • Epidemiology

    • Pleural tumors are a small but significant subset of thoracic malignancies. The majority of pleural tumors tend to be malignant and mesothelioma is the most common diagnosis. Most patients have had environmental exposure to asbestos.

  • Pathophysiology

    • Pleural tumors are generally characterized as benign or malignant. Benign tumors are usually slow growing and do not cause symptoms until they exert mass effect, or in the case of MPM, when they cause pain by tumor invasion or dyspnea secondary to pleural effusion.

  • Diagnosis/clinical features

    • Many pleural-based tumors are diagnosed incidentally on imaging performed for unrelated reasons. The primary radiographic evaluation consists of CXR and CT scan. Once the pleural-based lesions have been identified, tissue diagnosis is obtained via image-guided core-needle biopsy or through thoracoscopic biopsy. When symptoms are present, they are most commonly chest wall pain from tumor invasion or dyspnea from restriction or cough.

  • Treatment

    • Benign tumors of the pleura are followed with serial imaging or resected. Treatment options for MPM are varied and range from palliation of symptoms to radical surgery within a multimodality regimen.

  • Prognosis

    • The prognosis for benign lesions of the pleura is excellent and recurrences are rare after complete resection. MPM, however, is often advanced at presentation and prognosis is poor. However, early-stage patients with epithelioid histology and negative resection margins have promising long-term survival.

Introduction

The diagnosis and treatment of pleural diseases was a formidable task for practitioners of ancient and medieval medicine as most maladies of the thoracic cavity proved to be rapidly and universally fatal. The development of general anesthesia, thoracic imaging, and closed suction drains has greatly facilitated the diagnosis and treatment of pleural disease, including primary tumors of the pleura.

Pleural Anatomy

The pleura refers to a continuous mesothelial tissue layer of mesenchymal origin that lines the chest cavity and blankets thoracic structures.1,2 Standard nomenclature differentiates the parietal pleura, which covers the chest wall, mediastinum, and diaphragm, from the visceral pleura, which invests the lung parenchyma. The hilum of the lung and the inferior pulmonary ligament serve as the anatomic interfaces between these two layers. Blood supply and lymphatic drainage follow that of structures—parietal pleura supplied by intercostal, internal mammary, superior phrenic, and anterior mediastinal arcades. Lymphatics drain to intercostal, mediastinal, and phrenic lymph nodes. Communications across the diaphragm and chest apex link the thorax to the peritoneal cavity and ipsilateral axillary lymph nodes respectively. The visceral pleura contain both a pulmonary and a bronchial blood supply but drains solely into the pulmonary venous circulation. Visceral pleural lymphatics drain to mediastinal lymph nodes. Autonomic and somatic fibers innervate the pleura. The visceral pleura carry autonomic fibers only. Pain, carried through somatic routes, is generated from parietal pleural inflammation, such as by direct tumor invasion or local irritation.

Evaluation of Pleural-Based Abnormality

The evaluation of ...

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