Pleural mesothelioma — SCE Respiratory MCQ

Correct answer: B — Medical thoracoscopy with pleural biopsy

This presentation is highly suspicious for malignant pleural mesothelioma: previous asbestos exposure, progressive dyspnoea, recurrent unilateral exudative pleural effusion, nodular pleural thickening and diaphragmatic pleural involvement. Negative pleural cytology does not exclude pleural malignancy, particularly mesothelioma, and repeated cytology after adequate samples has lower yield and risks delaying diagnosis. The next investigation should obtain pleural tissue. In UK practice, after clinical assessment, CT and non-diagnostic aspiration, pleural biopsy is recommended; where available, medical thoracoscopy allows direct visualisation of abnormal pleura and targeted biopsies, with the option of same-procedure talc poudrage if appropriate. Blind Abrams biopsy has lower diagnostic yield than image-guided or thoracoscopic biopsy and is not preferred when CT shows focal pleural disease. Serum mesothelin is not a diagnostic substitute for histology, and empirical pleurodesis without tissue diagnosis is inappropriate when malignancy/mesothelioma is suspected. Therefore the most appropriate investigation is medical thoracoscopy with pleural biopsy.

Reference: British Thoracic Society Guideline for Pleural Disease 2023. Thorax 2023;78(Suppl 3):s1–s42. https://thorax.bmj.com/content/78/Suppl_3/s1