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Background Solitary fibrous tumours of the pleura (SFTP) are rare and account for around 5% of pleural based tumours with rates of malignancy of around 30%. Published data primarily includes histologically proven SFTP, but there is little evidence regarding the outcomes of radiologically diagnosed SFTP. Methods A service evaluation of radiologically diagnosed SFTP was completed in 12 UK centres, searching the local radiology database reports for the terms ‘Pleural fibroma’ OR ‘fibrous tumour of the pleura’ OR ‘SFTP’ between 01/01/2005 and 31/12/2015. Scans were determined to demonstrate a ‘typical’ SFTP, ‘unlikely’ SFTP or SFTP that was ‘within the differential diagnosis’. Data were collected to establish subsequent diagnoses and what follow up was undertaken. Results A total of 246 cases were included, table 1 exhibits the outcomes in each radiological group. Of patients with typical appearances for SFTP, 20/44 were histologically confirmed to represent a fibroma, 19/44 underwent radiological follow up only and 4/44 were confirmed not to represent SFTP. Of the patients who underwent radiological follow-up; there were 9 deaths, none of which were known to be related to SFTP, the median longest diameter was 30 mm (IQR 25–40) and the median follow-up time was 62 months (IQR 17–106). Of the 61 cases histologically confirmed SFTP, 17/61 were malignant, 37/61 benign and 7/61 unknown. A total of 26 patients died, 5 secondary to SFTP, 12 unrelated to SFTP and 9 of unknown cause. Conclusion A large proportion of patients with radiologically typical SFTP features do not undergo biopsy or resection and did not have SFTP related adverse outcomes in this small series. Further analysis is needed to determine whether any radiological features can predict clinical outcomes.

Introduction For decades the management of parapneumonic effusions has relied on pleural fluid pH measurement. However, the eventual requirement for fibrinolytics or surgery is more often dictated by the development of loculations. soluble urokinase Plasminogen Activating Receptor (suPAR) is a novel biomarker released by pleural mesothelial cells in response to infection as part of the fibrinolysis cascade. This study assessed levels of suPAR in the pleural fluid (PF) and serum of patients with parapneumonic effusions. Methods We analysed stored serum and PF from a prospectively collected cohort of patients with effusions due to infection. Cases with frank pus on thoracentesis were excluded. Baseline pleural ultrasounds were performed to assess loculations, with routine bloods and pleural fluid analysis. Clinical outcomes and final diagnoses were confirmed at 12 months by two respiratory consultants. suPAR levels were analysed in duplicate using the suPARnostic® double monoclonal antibody sandwich ELISA assay. Binomial logistic regression was used to compare clinical outcomes to biochemical markers. Mann Whitney test was used to compare suPAR levels between groups. Results Between 2008 and 2016 there were 93 patients with parapneumonic effusions recruited (49 non-loculated and 44 loculated effusions). Median PF suPAR was 88ng/ml (9–614ng/ml). PF suPAR was significantly higher in loculated effusions (median 162ng/ml versus 22ng/ml, p The sensitivity and specificity of PF suPAR >35ng/ml to predict loculations was 100% and 91% respectively. 94% of patients (45/48) with a pf suPAR over 35ng/ml were managed with a chest tube. Using stepwise logistic regression (in a model that included PF pH) PF suPAR was an independent predictor of need for fibrinolytics and surgery (p Conclusion The development of loculations is an important differentiator in the management of parapneumonic effusions. suPAR is a novel biomarker and is part of the fibrinolysis cascade. This is the first study to assess the potential role of suPAR in parapneumonic effusions. PF suPAR was superior to PF pH and serum CRP at predicting loculations as well as requirement for fibrinolytics or surgery. Its true utility needs assessing in a larger prospective study.

Background The BTS pleural disease guidelines recommend all patients with an undiagnosed unilateral pleural undergo computed tomography (CT) of the thorax with contrast.1 However, there is no consensus on whether to include the abdomen and pelvis in the initial examination, with the BTS mesothelioma guidelines recommending this as an area that requires further research.2 Methods We performed a cross-sectional study using prospectively collected data between March 2008 and September 2018 of patients presenting with an undiagnosed pleural effusion. All patients consented for this study, underwent CT thorax, abdomen and pelvis as part of their standard work up and were followed for 12 months or until death, to ensure a robust diagnosis. Results 249 patients were included; mean age 72 (IQR 66–80), 167 (67%) male, WHO PS 0–1 (62%), 2–3 (37%), 190 (76%) out-patients, 147 (59%) right sided, 87 (35%) previous asbestos exposure. The final diagnosis was malignancy in 159 (64%). The CT thorax alone was consistent with the final diagnosis in 171 (69%). There were clinically significant findings below the costophrenic recesses in 59 patients (23.6%). Including the abdomen increased the diagnostic yield of clinically significant findings by 11.6% (n=29). Within the malignant group additional findings were of a primary tumour (6), upstaging of disease (19) and alternative biopsy sites (2). Including the pelvis resulted in 30 additional findings (12%), primary tumours (11), upstaging of disease (13) and alternative biopsy sites (3). 14 (5.6%) had an underlying ovarian cancer – 86% would have been missed if only CT chest and abdomen was performed. In females the pelvic CT revealed additional findings in 18 (22%). Conclusion CT thorax, abdomen and pelvis has a considerably higher diagnostic yield than more limited sequences in the work up of unilateral pleural effusions and this paper lends support to its inclusion for standard of care.

Background Radiological monitoring of malignant pleural mesothelioma (MPM) using modified RECIST criteria is limited by low sensitivity and inter-observer variability. Serial serum mesothelin measurement has shown utility in the assessment of treatment response during chemotherapy but has never been assessed in the longer term follow up of patients. Methods This is a single centre study of consecutive patients diagnosed with MPM who received chemotherapy or best supportive care (BSC). Serum mesothelin measurements with paired 6 monthly CT scans were performed following the completion of chemotherapy, or from baseline in the BSC group. Changes in mesothelin were correlated with radiological progression and overall survival. Results Forty-one patients with MPM were recruited and followed up for a minimum of 12 months (range 12–21 months). The majority of patients (n=23) received chemotherapy with pemetrexed and cisplatin. Across the cohort a 10% rise in serum mesothelin could predict radiological progression with a sensitivity of 96% (IQR; 79–100) and specificity of 74% (IQR; 50–91) (figure 1). Sensitivity fell to 80% in sarcomatoid only disease. Patients with a rising mesothelin at 6 months had significantly worse overall survival (175 days) compared to stable/falling levels (448 days) (p=0.003). Conclusions This is the first study to assess serum mesothelin’s ability to detect progression of MPM following chemotherapy or during BSC. A 10% rise in serum mesothelin level showed excellent sensitivity at predicting progressive disease. Mesothelin measurement has several advantages over serial CT imaging including reducing hospital visits and cost.