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.
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