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Cover
Title Page
Contributors
CHAPTER 1: Anatomy and Physiology of the Pleura
1. Embryology
2. Macroscopic anatomy
3. Microscopic anatomy
4. Innervation, blood supply and lymphatics
5. Physiology of the pleural space
6. Role of the pleural space
7. Further reading
CHAPTER 2: Radiology of Pleural Disease
1. Plain radiography
2. Ultrasound
3. CT scan
4. PET CT
5. MRI
6. Further reading
CHAPTER 3: Pneumothorax
1. Definition, epidemiology, risk factors and aetiology
2. Presentation
3. Investigations
4. Management
5. Recurrent pneumothorax
6. Further reading
CHAPTER 4: Investigation of Pleural Effusions
1. Clinical presentation
2. History taking
3. Examination
4. Initial imaging
5. Pleural fluid tests
6. Biomarkers and auto‐antibodies
7. Cross‐sectional imaging
8. Metabolic and dynamic imaging
9. Pleural biopsy
10. Diagnostic challenges
11. Further reading
CHAPTER 5: Pleural Pathology
1. Normal anatomy and histology of the pleura
2. Pathological processes involving the pleura
3. Neoplasia (other than diffuse malignant mesothelioma) – primary pleural neoplasms and tumour‐like proliferations
4. Inflammation
5. Further reading
CHAPTER 6: Unusual Causes of Pleural Disease
1. Urinothorax
2. Yellow nail syndrome
3. Ovarian hyperstimulation syndrome
4. Meigs syndrome
5. Dural‐pleural fistula
6. Central venous catheter migration
7. Chylothorax
8. Pseudochylothorax
9. Further reading
CHAPTER 7: Pleural Infection
1. Pathology
2. Bacteriology
3. Natural history
4. Symptoms and signs
5. Diagnosis
6. Medical management
7. Surgery
8. Trapped lung
9. Prognosis and long‐term outcomes
10. Conclusions
11. Further reading
CHAPTER 8: Management of Malignant Pleural Effusions
1. Pathophysiology
2. Symptoms
3. Management – general considerations
4. Simple pleural aspiration
5. Intercostal chest drainage and pleurodesis
6. Thoracoscopy and talc poudrage
7. Indwelling pleural catheters
8. Which procedure is best?
9. The future
10. Conclusions
11. Further reading
CHAPTER 9: Malignant Mesothelioma
1. Epidemiology and aetiology
2. Pathogenesis
3. Clinical presentation and investigation
4. Pathological features
5. Diagnosis
6. Treatment and prognosis
7. Further reading
CHAPTER 10: Pleural Interventions
1. Diagnostic thoracocentesis
2. Therapeutic thoracocentesis
3. Complications of diagnostic and therapeutic thoracocentesis
4. Further reading
Section B: Pleural Interventions
1. Chest drain insertion (Seldinger technique)
2. Drain insertion technique
3. Post drain insertion
4. Drain removal
5. Tips
6. Troubleshooting
7. Further reading
Section C: Insertion of an Indwelling Pleural Catheter
1. A step‐by‐step guide to IPC insertion
CHAPTER 11: Medical Thoracoscopy
1. Role of medical thoracoscopy
2. Who should undergo a thoracoscopy?
3. Types of medical thoracoscopy
4. A step‐by‐step guide to medical thoracoscopy
5. Diagnostic accuracy of medical thoracoscopy
6. Complications and adverse events with medical thoracoscopy
7. Conclusions
8. Further reading
Section B: Medical Thoracoscopy
1. Role of medical thoracoscopy
2. A step‐by‐step guide to semi‐rigid thoracoscopy
3. Advantages of the semi‐rigid thoracoscope
4. Disadvantages of the semi‐rigid thoracoscope
5. Diagnostic accuracy of semi‐rigid thoracoscopy
6. Diagnostic accuracy: rigid thoracoscopy versus semi‐rigid thoracoscopy
7. Complications and adverse events with semi‐rigid thoracoscopy
8. Conclusions
CHAPTER 12: Surgical Management of Pleural Disease
1. Historical developments
2. Thoracic anaesthetic
3. Thoracic surgery
4. Primary and secondary pneumothoraces
5. Malignant pleural effusions
6. Empyema
7. Pleural tumour
8. Trauma
9. Conclusions
10. Further reading
Index
End User License Agreement

List of Tables

Chapter 04
1. Table 4.1 Causes of pleural exudates and transudates.
2. Table 4.2 Biomarkers in the investigation of pleural effusions.
Chapter 05
1. Table 5.1 Classification of benign and malignant neoplasms of the pleura, including tumour‐like conditions.
Chapter 08
1. Table 8.1 Advantages and disadvantages of pleural procedures.
Chapter 09
1. Table 9.1 Causes of benign reactive mesothelial hyperplasia and organising pleuritis and histological features mimicking or indicating malignancy.
Chapter 10
1. Table 10.1 Recommended routine pleural fluid tests after diagnostic pleural aspiration.
Chapter 11
1. Table 11.1 A summary of the indications and contraindications for medical thoracoscopy.

List of Illustrations

Chapter 01
1. Figure 1.1 CT angiogram demonstrating the course and variability of the intercostal arteries posteriorly.
Chapter 02
1. Figure 2.1 Postero‐anterior (PA) chest radiograph (CXR) showing pneumothorax. The white arrow indicates the edge of the visceral pleural.
2. Figure 2.2 PA‐CXR showing pleural plaques in left midzone (white arrows).
3. Figure 2.3 Ultrasound appearance of the normal lung and pleura. Echogenic ‘stripe’ of the two opposing pleural layers (white arrow).
4. Figure 2.4 Ultrasound appearance of a pleural effusion (E) with diaphragm (white arrow) and spleen (S) visible.
5. Figure 2.5 Ultrasound image showing heavily septated pleural effusion.
6. Figure 2.6 Two cross‐sectional computed tomography (CT) images showing nodular thickening (asterisk) and mediastinal involvement (arrow) in the presence of pleural effusion (E).
Chapter 03
1. Figure 3.1 Tension pneumothorax with evidence of early tracheal shift.
2. Figure 3.2 Standard methodology for measurement of pneumothorax size.
3. Figure 3.3 Secondary pneumothorax with evidence of interstitial lung disease.
4. Figure 3.4 British Thoracic Society 2010 guideline algorithm for the management of pneumothorax.
Chapter 04
1. Figure 4.1 Algorithm for the investigation of a pleural effusion.
2. Figure 4.2 Chest X‐rays: (a) meniscus of left pleural effusion; (b) D‐shaped appearance of loculated pleural empyema; (c) asbestos‐related pleural plaques.
3. Figure 4.3 Thoracic ultrasound image of a complex septated pleural effusion.
4. Figure 4.4 Thoracic ultrasound demonstrating large anechoic pleural effusion (a) and nodularity and thickening of the diaphragmatic pleura (b).
5. Figure 4.5 Pleural phase contrast CT scan demonstrating the thick, nodular pleural thickening of pleural malignancy (a). Note extension over the mediastinal surface (b).
6. Figure 4.6 Integrated positron emission tomography with computed tomography (PET‐CT) scan of right malignant pleural mesothelioma demonstrating intense areas of pleural FDG avidity.
Chapter 05
1. Figure 5.1 Solitary fibrous tumour (SFT): variable cellularity and branching vasculature (a) with ‘patternless’ arrangement of bland cells with intervening ‘ropey’ collagen (b).
2. Figure 5.2 SFT: tumour exhibiting myxoid (a) and cellular, vaguely herringbone‐like areas (b).
3. Figure 5.3 Nodular pleural plaque: macroscopic appearance of solid, 10 × 20 mm yellowish nodule (a) mimicking an expansile tumour nodule, but histology (b) reveals dense, hyalinised, ‘basket‐weave’ collagen only.
4. Figure 5.4 Chest CT demonstarting pleural thymoma.
5. Figure 5.5 Histology of acute pleural empyema showing a thick layer of fibrinopurulent exudate overlying congested parietal pleura (a) and containing numerous neutrophils and necrotic inflammatory cells (b).
6. Figure 5.6 Organising fibrinous pleuritis demonstrating fibrosis, dense chronic inflammation and vertically oriented vessels (a) and an example of eosinophilic pleuritis associated with mesothelial hyperplasia (b).
7. Figure 5.7 Granulomatous pleuritis: a discrete aggregate of epithelioid histiocytes forming a granuloma.
Chapter 06
1. Figure 6.1 Dystrophic nail changes in a patient with typical yellow nail syndrome.
2. Figure 6.2 CT of the thorax demonstrating a bland‐looking effusion in a patient with nail changes.
3. Figure 6.3 Thoracentesis of fluid, demonstrating milky pleural fluid.
4. Figure 6.4 CT scan demonstrating a ventriculo‐peritoneal shunt.
Chapter 07
1. Figure 7.1 Thoracic ultrasound showing heavily septated complicated parapneumonic effusion.
2. Figure 7.2 Empyema at the time of video‐assisted thoracic surgery (VATS).
Chapter 08
1. Figure 8.1 Site of primary tumour (%) of 2040 patients with malignant pleural effusions.
2. Figure 8.2 CT scan showing a large left‐sided pleural effusion (arrow A), causing complete compression of the left lung. Two pleurally based soft tissue masses are seen on the left (arrow B) with associated pleural thickening.
3. Figure 8.3 A wide‐bore chest drain and drainage bottle.
4. Figure 8.4 A patient undergoing local anaesthetic thoracoscopy. The monitor screens show pleural biopsies being taken.
5. Figure 8.5 Talc poudrage seen via a thoracoscope. A fine film of talc is seen covering the parietal pleura in the top of the picture, with deflated lung visible inferiorly.
6. Figure 8.6 An indwelling pleural catheter immediately after insertion.
7. Figure 8.7 Chest X‐ray showing a right‐sided hydro‐pneumothorax (arrow A) secondary to trapped lung (arrow B), with an indwelling pleura catheter (IPC) in situ. Arrow C illustrates the IPC entering the pleural space and arrow D shows it coiled up externally against the skin.
8. Figure 8.8 An approach to the management of malignant pleural effusions. CXR, chest X‐ray; IPC, indwelling pleural catheter.
Chapter 09
1. Figure 9.1 Epithelioid malignant mesothelioma (EMM). (a,b) Tubulopapillary pattern: note the relatively bland, uniform appearance of the tumour cells. (c,d) Solid pattern: sheets of large, rounded cells with abundant cytoplasm (c) and nested arrangement (d). (e,f) Lattice‐like strands of bland epithelioid cells ‘floating’ within myxoid stroma (e) and lobular carcinoma‐like growth pattern associated with desmoplastic stroma (f).
2. Figure 9.2 EMM: clear cell change imparting signet ring‐like appearance (a) and cytokeratin immunostain (b) demonstrating tubules and cords of mesothelial cells within fibrous tissue beneath the pleural surface: early invasive mesothelioma or entrapped reactive mesothelium? (b) This case subsequently evolved into biphasic diffuse pleural malignant mesothelioma (re‐biopsied after 6 months).
3. Figure 9.3 Sarcomatoid malignant mesothelioma (SMM). (a) Cellular tumour with fairly bland spindle‐shaped cells arranged in haphazard intersecting fascicles; (b) an example demonstrating more pronounced nuclear pleomorphism; (c) desmoplastic variant demonstrating dense collagenous stroma and a storiform arrangement of hyperchromatic spindle cells; and (d) histiocytoid cells partly obscured by a dense lymphoid infiltrate.
4. Figure 9.4 Biphasic malignant mesothelioma (BMM). Sarcomatoid pattern in upper left field merging with rounded, epithelioid tumour cells on the lower right (a) and biphasic appearance emphasised by cytokeratin immunohistochemistry (b).
Chapter 10
1. Figure 10.1 Local anaesthetic insertion into subcutaneous tissue.
2. Figure 10.2 Local anaesthetic insertion into intercostal muscles and parietal pleura.
3. Figure 10.3 Pleural aspiration with 50 mL syringe.
4. Figure 10.4 Equipment for therapeutic aspiration with 6 Fr aspiration catheter.
5. Figure 10.5 Insertion of aspiration catheter.
6. Figure 10.6 Advancing aspiration catheter.
7. Figure 10.7 Fluid drainage bag collecting pleural fluid.
Chapter 10b
1. Figure 10.8 The patient is sitting up and leaning over a table. The red shaded area is the ‘no fly zone’ for chest drain insertion which should be avoided in most cases. A study showed that intercostal arteries are exposed within the intercostal space in the first 6 cm lateral to the spine.
2. Figure 10.9 Decubitus position; the safety triangle is shaded blue.
3. Figure 10.10 Equipment for insertion of a Seldinger chest drain.
4. Figure 10.11 Step‐by‐step guide to insertion of a Seldinger chest drain.
Chapter 10c
1. Figure 10.12 Infiltration of local anaesthetic at drain insertion site. A mark is visible inferiorly where the drain will exit the skin.
2. Figure 10.13 Aspiration of pleural fluid via the introducer needle.
3. Figure 10.14 Removal of the introducer needle with the guidewire left in situ.
4. Figure 10.15 Indwelling pleural catheter with plastic tunnelling device attached to the proximal end. A polyester cuff is visible halfway along the catheter.
5. Figure 10.16 Catheter tunnelled under the skin with the distal end visible externally (the proximal end is not visible).
6. Figure 10.17 Insertion of a blunt dilator and introducer into the pleural space. The proximal end of the catheter is seen exiting the skin at this point.
7. Figure 10.18 Removal of the guidewire and dilator, leaving the introducer in situ.
8. Figure 10.19 Peeling the introducer away from the catheter.
9. Figure 10.20 Advancing the catheter into the pleural space, as the peel‐away introducer is removed.
10. Figure 10.21 Indwelling pleural catheter running smoothly through the subcutaneous tunnel into the pleural space.
Chapter 11
1. Figure 11.1 Blunt dissection into the pleural cavity.
2. Figure 11.2 Trocar insertion.
3. Figure 11.3 Insertion of suction catheter and pleural fluid drainage.
4. Figure 11.4 Insertion of (a) semi‐rigid scope; (b) rigid scope.
5. Figure 11.5 Inspection of pleural surface using rigid scope: (a) normal pleura; (b) diffuse pleural nodularity seen in malignancy.
6. Figure 11.6 Taking pleural biopsies (rigid approach, single port).
7. Figure 11.7 Talc poudrage. Image from rigid scope approach, post poudrage.
8. Figure 11.8 Talc poudrage: (a) under direct vision using semi‐rigid approach; (b) image taken from rigid scope approach.
9. Figure 11.9 Chest drain insertion.
10. Figure 11.10 End of the procedure.
Chapter 11b
1. Figure 11.11 Blunt dissection into the pleural cavity.
2. Figure 11.12 Trocar insertion.
3. Figure 11.13 Inspection of pleural surface (pleural nodule and thickening seen).
4. Figure 11.14 Biopsy forceps.
5. Figure 11.15 Taking pleural biopsies.
6. Figure 11.16 Taking pleural biopsies under direct visualisation.
7. Figure 11.17 Talc poudrage kit.
8. Figure 11.18 Talc poudrage.
9. Figure 11.19 Talc poudrage.
10. Figure 11.20 Chest drain insertion.
11. Figure 11.21 End of the procedure.
Chapter 12
1. Figure 12.1 Theatre set up for a video‐assisted thoracic surgery (VATS) procedure.
2. Figure 12.2 Diaphragmatic fenestrations (whorles) in a young woman who has multiple episodes of pneumothoraxes.
3. Figure 12.3 VATS images of early empyema at fibrinopurulent stage.
4. Figure 12.4 Decortication of thickened visceral pleura in a chronic organising empyema.

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Library of Congress Cataloging‐in‐Publication Data

Names: Rahman, Najib M., editor. | Hunt, Ian, M.D., editor. | Gleeson, Fergus V., editor. | Maskell, Nick A., editor.
Title: ABC of pleural diseases / edited By Najib M. Rahman, Ian Hunt, Fergus V. Gleeson and Nick A. Maskell.
Description: Hoboken, NJ : Wiley, 2017. | Series: ABC series | Includes bibliographical references and index. |
Identifiers: LCCN 2017043481 (print) | LCCN 2017045215 (ebook) | ISBN 9781118527115 (pdf) | ISBN 9781118527108 (epub) | ISBN 9780470654743 (pbk.)
Subjects: | MESH: Pleural Diseases
Classification: LCC RC751 (ebook) | LCC RC751 (print) | NLM WF 140 | DDC 616.2/5–dc23
LC record available at https://lccn.loc.gov/2017043481