Clinical Investigations

Chest X-ray - to detect pleural effusions and calcified pleural plaques.

CT scan - may identify an effusion undetectable by conventional radiography. It will show pleural thickening and calcification due to asbestos exposure. It is important in detecting invasion of chest wall, ribs and mediastinum by malignant mesothelioma. Ultrasound - used to localize pleural effusions during thoracentesis.

Thoracentesis - aspiration of pleural fluid using a sterile technique. Fifty to 100 ml are sufficient for diagnosis but more may be removed if the thoracentesis is therapeutic.

Pleural fluid analysis - cytology, biochemistry - total protein, lactate dehydrogenase, amylase, glucose, pH, lipids, complement and antibodies, Gram stain and culture.

Pleural needle biopsy - percutaneous closed needle biopsy with thoracentesis. A diagnosis of malignancy is achieved in 40-70% of cases.

Thoracoscopy and pleural biopsy - thoracoscopy, especially if guided by CT findings, should improve the diagnostic yield to over 95%. Minimally invasive approaches such as video-assisted thoracoscopy (VATS) lead to earlier diagnosis.

Open pleural biopsy (with or without decortication) - occasionally rigid (open tube) pleu-roscopy or even minithoracotomy are required to obtain an adequate pleural biopsy.

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