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Suspected malignant pleural mesothelioma — RCPSC IM MCQ

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HardRespirologySuspected malignant pleural mesotheliomaRCPSC IM

A 70-year-old with an exudative lymphocyte-predominant pleural effusion has nodular pleural thickening, asbestos exposure and negative fluid cytology. What is the best next investigation?

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Correct answer: A — Obtain image-guided or thoracoscopic pleural biopsy

The best answer is “Obtain image-guided or thoracoscopic pleural biopsy”. Pleural malignancy remains likely despite negative cytology, particularly with nodular thickening and asbestos exposure. Tissue biopsy is required; delay or unrelated tests risk missing mesothelioma or metastatic disease. Negative pleural-fluid cytology has imperfect sensitivity, particularly for mesothelioma, so suspicious pleural morphology still requires histologic sampling.

Reference: Canadian Thoracic Society, 2023 COPD pharmacotherapy guideline: https://cts-sct.ca/guideline-library/