Background: Transthoracic ultrasound (US) is an important instrument to identify pleural effusions and safely conduct invasive procedures. It also allows systematic scanning of the pleural surface, though its value remains uncertain for differentiation between malignant (MPE) and nonmalignant pleural effusion (non-MPE) in routine clinical practice. Objectives: To evaluate the utility of US features to predict malignancy in undiagnosed pleural effusions in a real-life clinical setting. Methods: The US features of 154 consecutive patients with a pleural effusion were prospectively assessed. Anonymous images were recorded by an operator blinded to the clinical and radiological results. The US findings were classified by independent reviewers and compared to the final diagnosis. Results: A total of 133 patients were included (age 67 ± 16 years; BMI 25.1 ± 4.6; 54.1% females). The final diagnosis was MPE in 66 cases and non-MPE in 67 cases. US had an overall sensitivity of 80.3%, a specificity of 83.6%, and positive and negative predictive values of 82.8 and 81.2%, respectively, for the detection of malignancy. US accuracy was 81.9%. The presence of pleural/diaphragmatic nodules, pleural/diaphragmatic thickness >10 mm, and a swirling sign was significantly different between both groups (p < 0.001). Lung air bronchogram sign and a septated US pattern were more common in non-MPE patients (p < 0.01). The existence of nodularity and the absence of air bronchograms were more likely to indicate malignancy (OR 29.0, 95% CI 7.65-110.08 and OR 10.4, 95% CI 1.65-65.752, respectively). Conclusions: In the presence of an undiagnosed pleural effusion, US morphological characteristics can aid in differentiating MPE from non-MPE. Pleural/diaphragmatic nodularity was the most relevant feature although no finding was pathognomonic of MPE.

Keywords:
Ultrasound, Thorax, Pleural effusion, Diagnosis, Lung cancer, Neoplasia
1.
Villena V, López Encuentra A, Echave-Sustaeta J, Alvarez Martínez C, Martín Escribano P: Prospective study of 1,000 consecutive patients with pleural effusion: etiology of the effusion and characteristics of the patients. Arch Bronconeumol 2002;38:21-26.
2.
Postmus PE, Brambilla E, Chansky K, Crowley J, Goldstraw P, Patz EF, Yokomise H, International Association for the Study of Lung Cancer International Staging Committee, Cancer Research and Biostatistics, Observers to the Committee, Participating Institutions: The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol 2007;2:686-693.
3.
Rivera MP, Mehta AC, Wahidi MM: Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed - American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e142S-e165S.
4.
Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Group: Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(suppl 2):ii4-ii17.
5.
Abramowitz Y, Simanovsky N, Goldstein MS, Hiller N: Pleural effusion: characterization with CT attenuation values and CT appearance. AJR Am J Roentgenol 2009;192:618-623.
6.
Arenas-Jiménez J, Alonso-Charterina S, Sánchez-Payá J, Fernández-Latorre F, Gil-Sánchez S, Lloret-Llorens M: Evaluation of CT findings for diagnosis of pleural effusions. Eur Radiol 2000;10:681-690.
7.
Koegelenberg CF, von Groote-Bidlingmaier F, Bolliger CT: Transthoracic ultrasonography for the respiratory physician. Respiration 2012;84:337-350.
8.
Diacon AH, Schuurmans MM, Theron J, Schubert PT, Wright CA, Bolliger CT: Safety and yield of ultrasound-assisted transthoracic biopsy performed by pulmonologists. Respiration 2004;71:519-522.
9.
Koegelenberg CF, Diacon AH: Image-guided pleural biopsy. Curr Opin Pulm Med 2013;19:368-373.
10.
Botana-Rial M, Leiro-Fernández V, Represas-Represas C, González Piñeiro A, Tilve-Gómez A, Fernández-Villar A: Thoracic ultrasound-assisted selection for pleural biopsy with abrams needle. Respir Care 2013;58:1949-1954.
11.
Qureshi NR, Rahman NM, Gleeson FV: Thoracic ultrasound in the diagnosis of malignant pleural effusion. Thorax 2009;64:139-143.
12.
The Royal College of Radiologists: Ultrasound Training Recommendations for Medical and Surgical Specialties, ed 2. London, The Royal College of Radiologists, 2012.
13.
Bugalho A, Semedo J, Alpendre J, Cepeda Ribeiro J, Carreiro L: Ultrasound in chest disease. Rev Port Pneumol 2010;16:589-606.
14.
Yang PC, Luh KT, Chang DB, Wu HD, Yu CJ, Kuo SH: Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol 1992;159:29-33.
15.
Salyer WR, Eggleston JC, Erozan YS: Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Chest 1975;67:536-539.
16.
Garcia LW, Ducatman BS, Wang HH: The value of multiple fluid specimens in the cytological diagnosis of malignancy. Mod Pathol 1994;7:665-668.
17.
Nance KV, Shermer RW, Askin FB: Diagnostic efficacy of pleural biopsy as compared with that of pleural fluid examination. Mod Pathol 1991;4:320-324.
18.
Prakash UB, Reiman HM: Comparison of needle biopsy with cytologic analysis for the evaluation of pleural effusion: analysis of 414 cases. Mayo Clin Proc 1985;60:158-164.
19.
Venekamp LN, Velkeniers B, Noppen M: Does ‘idiopathic pleuritis' exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy. Respiration 2005;72:74-78.
20.
Leung AN, Müller NL, Miller RR: CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol 1990;154:487-492.
21.
Görg C, Restrepo I, Schwerk WB: Sonography of malignant pleural effusion. Eur Radiol 1997;7:1195-1198.
22.
Chen HJ, Hsu WH, Tu CY, Yu YH, Chiu KL, Hang LW, Hsia TC, Shih CM: Sonographic septation in lymphocyte-rich exudative pleural effusions: a useful diagnostic predictor for tuberculosis. J Ultrasound Med 2006;25:857-863.
23.
Chian CF, Su WL, Soh LH, Yan HC, Perng WC, Wu CP: Echogenic swirling pattern as a predictor of malignant pleural effusions in patients with malignancies. Chest 2004;126:129-134.
24.
Reissig A, Kroegel C: Sonographic diagnosis and follow-up of pneumonia: a prospective study. Respiration 2007;74:537-547.
25.
Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, Aliberti S, Neumann R, Kroegel C, Hoyer H: Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest 2012;142:965-972.
26.
Kuo CH, Lin SM, Chen HC, Chou CL, Yu CT, Kuo HP: Diagnosis of peripheral lung cancer with three echoic features via endobronchial ultrasound. Chest 2007;132:922-929.
27.
Yang PC, Luh KT, Wu HD, Chang DB, Lee LN, Kuo SH, Yang SP: Lung tumors associated with obstructive pneumonitis: US studies. Radiology 1990;174:717-720.
28.
Suzuki N, Saitoh T, Kitamura S: Tumor invasion of the chest wall in lung cancer: diagnosis with US. Radiology 1993;187:39-42.
29.
Bandi V, Lunn W, Ernst A, Eberhardt R, Hoffmann H, Herth FJ: Ultrasound versus CT in detecting chest wall invasion by tumor: a prospective study. Chest 2008;133:881-886.
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2014
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