G.L.MEENA, senior professor & Head, dept of radio diagnosis, sardar patel medical college, bikaner, Rajasthan-334003. E-mail:
Material & Methods: Thirteen patients were included, with a mean age of 64.8 years, with a diagnosis of malignant pulmonary neoplasia with pleural contact, who did not present with costal infiltration in the Computed Tomography (CT) scan. It was decided to include only those patients in whom the CT was not conclusive of invasion of the chest wall since the reason for the present study was to demonstrate the usefulness of ultrasound in doubtful cases with conventional imaging techniques.
Conclusion: Thoracic ultrasound is a useful technique in the assessment of the degree of infiltration of the visceral and parietal pleura, with values of sensitivity and specificity of 100% in our study. Ultrasonographic examination of peripheral pulmonary neoplasms may allow a more precise staging in those patients receiving non-surgical treatments and, in addition, allows a better planning of the surgery, indicating en bloc resections in patients with parietal pleura infiltration.
Keywords: Pleural; Imaging; Ultrasound; Malignancy; Surgery.
A high percentage of patients with lung neoplasms cannot be operated on due to comorbidities, so the staging will be mostly clinical and the anatomopathological assessment of the tumor and its possible pleural infiltration will not be available . Hence the importance of having imaging techniques that allow proper staging .
The new classification TNM v72-4 proposes that the T increase according to the degree of pleural infiltration. Thus, invasion of the visceral pleura is considered to be T2 and the involvement of the parietal layer will be classified as T34.
Regarding surgical resection, many published studies advocate en bloc resection involving the thoracic wall in those cases diagnosed with invasion of the parietal pleura (T3) [5,16]. Although it is a more aggressive surgery, it allows a correct resection of the tumor [10-12].
Thoracic ultrasound was performed using a linear and concave probe . The concave probe was used to identify the pleural masses and the linear probe is used to assess the actual pleural infiltration . It was considered that the tumor did not infiltrate the pleura when the pleuro-pulmonary movement was in agreement with that of the adjacent healthy lung and if the lesion disappeared during the exploration [13,19]. The degree of pleural infiltration was assessed according to the pleuro-pulmonary movement and the morphology of the lesion-pleura interface [5-7]. Criteria for visceral pleura invasion were considered: the decrease (not disappearance) of the movement of the tumor with respect to the surrounding healthy lung parenchyma, the protrusion of neoplastic tissue above the pleuro-pulmonary line and the introduction of the pleuro-pulmonary line inside the tumor [18,24]. Therefore, diagnostic criteria for invasion of the parietal pleura were considered: the absence of movement of the tumor during respiration and the invasion of extra pleural fat .
In all histological specimens, elastic stains were made that allow to determine with greater precision the degree of pleural infiltration  (Figure 1).
• PL0: The tumor is found in the lung parenchyma or infiltrating the pleural connective tissue superficially but does not exceed the elastic layer of the visceral pleura.
• PL1: the tumor overpasses the elastic layer of the visceral pleura.
• PL2: the tumor infiltrates the entire surface of the visceral pleura.
• PL3: the tumor infiltrates the parietal pleura or elements of the chest wall.
The remaining 4 patients were excluded from the study because they corresponded to unrespectable neoplasms because they were stage IV (3 patients) or because they were inoperable patients (1 patient).
After the histological study, pleural infiltration was demonstrated in 8/9 cases, of parietal and visceral pleural leaves in 4/8 and 4/8 only of the visceral pleura. In one case, indemnity was found for the pleural blades.
Regarding the different sonographic signs, it was found that the four cases with absence of tumor movement presented infiltration of the parietal pleura (Figure 2).
The tumor that did not present pleural infiltration showed a correct movement during the ultrasound examination, which was consistent with that of the adjacent healthy lung, and even disappeared from the acquisition plane (Figures 3,4).
The remaining case, with infiltration of visceral pleura, presented a discrete adjacent pleural effusion that probably allowed the normal movement of the lesion (Figure 6).
In only one case infiltration of extra pleural fat was observed, this being punctuate, confirming this fact in the histological piece (Figures 7,8).
The overall results of the study, following the proposed diagnostic schemes ,were 100% sensitive and specific.
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