The first pleural biopsy was diagnostic of malignancy or granulomatous pleuritis in 32 (48 percent) of the 66 patients who were ultimately diagnosed to have either of these disorders. Eighty-seven patients had an initial pleural biopsy consistent with nonspecific pleuritis. Pleural tissue was identified in each of these biopsy specimens. Forty-five of the 87 patients underwent another closed pleural biopsy; 20 of these patients were ultimately diagnosed as having either malignant or granulomatous pleuritis, and this second procedure indicated a specific etiology in 11 (55 percent) of the 20 patients. In three of the 11 patients, the pleural biopsy was nondiagnostic, but the pleural fluid cytologic findings were positive.
Two patients had pleural malignancy diagnosed by a third pleural biopsy, while one patient underwent four procedures before his diagnosis was confirmed. Overall morphologic evidence of malignancy or granulomas was demonstrated in 43 pleural biopsy specimens. The pleural biopsy was the only diagnostic specimen obtained in 22 patients with granulomatous pleuritis and 12 patients with malignant pleural disease. Six patients with nondiagnostic tissue specimens had either a positive tissue culture (n = 3) or pleural fluid cytologic findings (n = 3). In 17 patients, the malignant etiology of the pleural disease was established by the bronchoscopic demonstration of malignancy in the ipsilateral lung (n = 14) or by open biopsy (n = 3).
The clinical characteristics of the patients with malignant effusions, granulomatous pleuritis, and nonspecific pleuritis are presented in Table 2. The age of the patients and proportion of women in each of the three groups was similar. The male preponderance is due to the fact that 72 of the 119 patients were from the VA Medical Center. Forty percent of the patients from LSU Medical Center were women. The patients with malignant pleural disease were symptomatic longer than the patients with granulomatous disease (p<0.5). The duration of symptoms in the patients with nonspecific pleuritis was intermediate and not significantly different from either of the other two groups.
Pleuritic chest pain and other respiratory symptoms such as dyspnea and cough were common in all three groups. Weight loss exceeding 4.5 kg (10 lbs) was observed in a majority of the patients with granulomatous and malignant pleural disease and was the only symptom which was significantly more common than in patients with nonspecific pleuritis (p<0.001). A majority of the patients with granulomatous pleuritis were febrile, a finding which was uncommon in the other two groups (p<0.001). Examination of the chest, heart, and abdomen revealed a similar frequency of abnormalities in each group. The results of routine laboratory tests which included a CBC, SMA-18, and urinalysis were not helpful in distinguishing between the three groups.
Table 2—Patient Characteristics
|Malignancy (n = 41)||Granulomatous Pleuritis (n = 25)||Nonspecific Pleuritis (n = 53)|
|Age, yrs||64 (±2)||56 (±4)||58 (±2)|
|Duration of symptoms, wks||8.5 (±1.7)||3.5 (±1.0)||5.5 (±1.0)|
|Pleuritic pain, n||22||11||23|
|Respiratory Sxs, n||18||11||15|
|Weight loss, n||32||15||9t|
|Fever >38°C, n||4||17*||4|
|Abnormal exam, n|
|Abnormal routine lab, n||36||23||44|
|+ PPD, no. + /no. tested||3/28||20/24*||5/42|
|WBCs(xl03 cells/mm)||3.3 (±0.9)||2.6 (±0.6)||3.8 (±0.8)|
|% lymphs in pleural||70 (±5)||84 (±4)||63 (±5)|
|>95% lymphs, n||12||16||6t|
|Chest x-ray film, n|
|Follow-up, mo||5.3 (±1.1)||37.5 (±2.5)||32.4 (±2.9)|
Category: Nonspecific Pleuritis
Tags: malignant granulomatous, nonspecific pleuritis, pleural disease