Practice Rational imaging

Investigating suspected malignant pleural effusion

BMJ 2007; 334 doi: (Published 25 January 2007) Cite this as: BMJ 2007;334:206
  1. N M Rahman, thoracic research fellow1,
  2. R J O Davies, consultant chest physician1,
  3. F V Gleeson, consultant radiologist2
  1. 1Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ
  2. 2Radiology Department, Churchill Hospital
  1. Correspondence to: F V Gleeson fergus.gleeson{at}
  • Accepted 30 November 2006

Learning points

  • Large unilateral pleural effusions are most often caused by malignancy; diagnostic pleural aspiration has a sensitivity of 60% for malignancy

  • If pleural fluid cytology is negative, computed tomography of the chest should be done before the effusion is drained; this has a high sensitivity for malignant pleural disease

  • Pleural fluid should initially be drained only for symptomatic relief; leaving some fluid in the pleural cavity allows the choice of a safe image guided biopsy or thoracoscopy

  • Computed tomography guided biopsy and thoracoscopy (which can be done under conscious sedation by a physician) have high diagnostic yields for malignant pleural disease

  • Computed tomography guided biopsy should be used when pleural thickening is present, with only a small volume of pleural fluid, or when thoracoscopy is not available

  • Thoracoscopy should be used when a substantial amount of pleural fluid remains, if no nodularity is identified on chest computed tomography, and where both a diagnosis and a therapeutic procedure (talc pleurodesis) are needed

The patient

A 77 year old man presented with a three week history of progressive dyspnoea, associated with a cough productive of white sputum and left sided chest pain. He had no medical history of note, although he was an ex-smoker of 40 pack years. He had previously worked as an engineer but had no known …

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