What is the evaluation and management approach for non-calcified pleural thickening of the lung?

From the Guidelines

Non-calcified pleural thickening requires a systematic evaluation approach beginning with a thorough clinical assessment and imaging studies, prioritizing the identification of potentially serious underlying conditions like malignancy and addressing functional impairment affecting respiratory status. The evaluation should include a complete history focusing on asbestos exposure, prior infections, trauma, or malignancy, followed by high-resolution CT scanning which provides better characterization than plain radiographs 1. PET-CT may be useful to distinguish benign from malignant thickening, with malignant lesions typically showing higher SUV values (>2.5) 1. Laboratory tests should include inflammatory markers, while pulmonary function tests help assess functional impact. When malignancy is suspected, tissue sampling is essential, typically via CT-guided needle biopsy or thoracoscopy 1. Management depends on the underlying cause:

• Observation with serial imaging every 6-12 months for stable, asymptomatic cases
• Antibiotics for infectious causes
• Surgical intervention (decortication) for symptomatic cases causing restrictive lung disease
• Malignant pleural thickening (mesothelioma) requires multidisciplinary oncologic management. The approach is individualized based on etiology, with the primary goals being to identify potentially serious underlying conditions like malignancy and to address any functional impairment affecting the patient's respiratory status. Key considerations include:
• The use of thoracic ultrasound to guide diagnostic procedures and improve safety
• The importance of distinguishing between benign and malignant pleural diseases based on clinical history, radiographic findings, and pathologic results
• The role of image-guided pleural biopsy and thoracoscopic pleural biopsy in establishing a diagnosis of malignancy.

From the Research

Evaluation of Non-Calcified Pleural Thickening of the Lung

The evaluation and management approach for non-calcified pleural thickening of the lung involves several key considerations:

• Imaging Techniques: Computed Tomography (CT) scans are crucial in evaluating pleural thickening, as they can help identify the extent and characteristics of the thickening 2, 3.
• Differential Diagnosis: Non-calcified pleural thickening can be caused by various conditions, including asbestos exposure, tuberculosis, and malignant mesothelioma 2, 3, 4.
• Asbestos Exposure: Pleural plaques are a specific sign of asbestos exposure, but round atelectasis and diffuse pleural thickening can also be associated with asbestos exposure 2, 3.
• Pleural Thickening Patterns: CT scans can help differentiate between diffuse and circumscribed pleural thickening, with crow's feet and rounded atelectasis being helpful in distinguishing between plaques and diffuse thickening 3.
• Malignant Mesothelioma: This condition is strongly associated with previous occupational exposure to asbestos and presents with typical CT findings, including irregular and nodular pleural thickening, pleural effusion, and mediastinal and pulmonary contraction 2.
• Other Causes: Focal pleural thickening can be caused by various conditions, including normal structures, functional pleural thickening, previous tuberculosis, pleural metastasis, silicosis, or other rarer conditions 5.
• Residual Pleural Thickening: This can occur as a complication of tuberculous pleural effusion, with factors such as male sex, older age, and negative pleural liquid culture for M. tuberculosis increasing the risk 4.
• Treatment: The treatment approach depends on the underlying cause of the pleural thickening, with chemotherapy being an option for malignant conditions such as epithelioid hemangioendothelioma 6.

Key Considerations

• A rigorous technical approach and familiarity with loco-regional anatomy are essential for accurate diagnosis 5.
• Correct recognition of pleural plaques is crucial, as they may be an independent risk factor for mortality from lung cancer in asbestos-exposed workers 5.
• Biopsy may be necessary for lesion characterization, especially in cases with atypical appearances on CT images 2.