Pleural Disease Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mr Wilson is a 68-year-old former shipyard worker who presents with a 6-week history of progressive exertional dyspnoea, persistent right chest wall pain, and 8 kg of unintentional weight loss. He worked in shipbuilding and demolition from 1972 to 1988 with documented heavy asbestos exposure. He is a 50 pack-year smoker with COPD. [1]

On examination he is cachectic and breathless at rest, with a respiratory rate of 24, oxygen saturation 92% on room air. There is stony dullness to percussion with absent breath sounds and reduced vocal resonance over the lower two-thirds of the right hemithorax. His CXR shows a large right pleural effusion and pleural-based opacity. His CT chest with contrast shows circumferential right pleural thickening with a nodular rind encasing the right lung, a large right pleural effusion, volume loss of the right hemithorax, and calcified pleural plaques bilaterally. There are no distant metastases. [1]

His main problems are:

1. Probable malignant pleural mesothelioma secondary to asbestos exposure — primary diagnosis requiring histological confirmation
2. A large symptomatic right pleural effusion requiring drainage and definitive pleural control
3. Severe chest wall pain requiring a multimodal analgesia plan
4. Cachexia and nutritional decline
5. The need for occupational history documentation, compensation referral, and family counselling regarding prognosis [1]

My plan addresses each in turn." [1]

Examiner probing questions and model answers

Q1: "How would you confirm the diagnosis of mesothelioma?" [1]

"I would obtain histological confirmation with immunohistochemistry. Pleural fluid cytology alone is positive in only approximately 30-50% of mesothelioma, and a negative cytology does not exclude the diagnosis. My preferred approach is medical thoracoscopy under local anaesthesia with a semi-rigid thoracoscope — this allows direct visualisation of the pleura, targeted biopsy of nodular areas, therapeutic drainage of the effusion, and talc poudrage pleurodesis in a single procedure. The diagnostic sensitivity of thoracoscopy for mesothelioma is over 90%. If thoracoscopy is not available or the patient is not fit, I would perform a CT-guided cutting-needle biopsy (Abrams or Tru-cut). [1]

The biopsy must include a panel of immunohistochemical stains to distinguish mesothelioma from metastatic adenocarcinoma. Mesothelioma is calretinin positive, WT-1 positive, D2-40 positive, and CK5/6 positive, and is negative for TTF-1, CEA, and Ber-EP4. Adenocarcinoma shows the opposite pattern — TTF-1 positive if it is a lung primary, CEA positive, Ber-EP4 positive, and negative for calretinin and WT-1. I would also send serum mesothelin as a supportive biomarker." [1]

Q2: "The biopsy confirms epithelioid mesothelioma. How would you manage his pleural effusion?" [1]

"My first step is to perform a therapeutic thoracentesis — limited to 1.5 L to avoid re-expansion pulmonary oedema — for symptom relief and to assess whether the lung re-expands on a post-drainage CT. This determines whether pleurodesis is feasible. [1]

If the lung fully re-expands, I would perform talc pleurodesis — ideally poudrage at the time of medical thoracoscopy, or slurry via a chest tube if he did not have a thoracoscopic procedure. Pleurodesis requires apposition of the visceral and parietal pleura, so a trapped lung precludes success. [1]

If the lung is trapped — which is common in mesothelioma because the visceral pleural tumour prevents re-expansion — I would insert an indwelling pleural catheter, a tunneled PleurX catheter for outpatient drainage. The TIME2 trial by Davies and colleagues in JAMA in 2012 showed that an indwelling pleural catheter and talc pleurodesis produce equivalent dyspnoea relief, but the catheter reduces hospital days. Importantly, the catheter is the only option that works when the lung is trapped. [1]

I would counsel him that the catheter requires home drainage by himself or community nursing, that it can remain in situ indefinitely, and that it carries a small risk of catheter-related cellulitis of approximately 6%." [1]

Q3: "Would you offer him chemotherapy?" [1]

"Yes. If he has good performance status — ECOG 0 to 1 — and adequate organ function, I would refer him to the medical oncology MDT for first-line pemetrexed plus cisplatin. The Vogelzang phase III trial in the Journal of Clinical Oncology in 2003 showed that pemetrexed plus cisplatin improved median survival from 9.3 months with cisplatin alone to 12.1 months, with a response rate of 41% versus 17%. The regimen is pemetrexed 500 mg per square metre plus cisplatin 75 mg per square metre every 21 days for up to 6 cycles. Folic acid and vitamin B12 supplementation are mandatory to reduce the myelosuppression, mucositis, and transaminitis associated with pemetrexed. [1]

If his renal function is impaired or his performance status is borderline, I would substitute carboplatin for cisplatin, which is better tolerated. If he is not fit for platinum-based therapy, the focus shifts to best supportive care and symptom control. [1]

I would be honest about the prognosis: mesothelioma is almost always incurable, median survival is 8 to 12 months from diagnosis, and chemotherapy provides a modest survival benefit and symptom control rather than a cure. The epithelioid subtype, which he has, carries the best prognosis among the histological subtypes." [1]

Q4: "How would you manage his chest wall pain?" [1]

"Pain is one of the most challenging symptoms in mesothelioma and is often neuropathic from intercostal nerve and chest wall invasion. I would use a stepwise, multimodal approach in collaboration with the palliative care and pain teams: [1]

First, regular oral analgesia — paracetamol and a long-acting opioid such as oral morphine or a transdermal fentanyl patch, titrated to effect, with short-acting opioid for breakthrough pain. Second, a co-analgesic for the neuropathic component — a gabapentinoid such as pregabalin or a tricyclic such as nortriptyline. Third, intercostal nerve blocks or a thoracic paravertebral block by the pain service for localised, severe pain. Fourth, palliative radiotherapy to a painful chest wall mass can provide meaningful relief and may also reduce the risk of tract metastasis from the biopsy site. Fifth, if the pain is refractory, I would consider a continuous epidural or intrathecal infusion. [1]

I would review his pain regularly and escalate promptly. Uncontrolled pain destroys quality of life in a disease with a short prognosis, and aggressive pain management is one of the most important things I can offer him." [1]

Q5: "He asks about compensation. What do you tell him?" [1]

"Mesothelioma is compensable in all Australian jurisdictions. I would first meticulously document his occupational asbestos exposure — every employer, every job, the nature and duration of exposure, and any secondary exposure such as washing a partner's contaminated work clothes. This documentation is both a clinical and a legal document. [1]

In New South Wales I would refer him to icare Dust Diseases Care, formerly the Dust Diseases Board, which provides compensation for medical expenses, lost income, and lump sum payments regardless of whether a specific negligent employer can be identified. The equivalent statutory schemes operate in other states. I would also advise him that he may have a common-law claim against negligent employers or asbestos manufacturers, and I would encourage him to consult a specialist asbestos lawyer — these claims can provide significant damages and are typically handled on a no-win no-fee basis. [1]

I would explain that the compensation process does not require him to wait until the end of his illness — lump sum claims are processed based on the diagnosis, and I would facilitate prompt referral given his limited prognosis. I would also notify the relevant dust diseases authority as a public health measure, as this helps track asbestos-related disease epidemiology." [1]

Q6: "What is the role of surgery in mesothelioma?" [1]

"Surgery is not standard of care for mesothelioma outside specialist centres and clinical trials. Two procedures have been studied: extrapleural pneumonectomy (EPP), which removes the pleura, lung, diaphragm, and pericardium en bloc, and pleurectomy and decortication (P/D), which removes the pleura and tumour while sparing the lung. Both are major operations with significant morbidity and mortality. [1]

The MARS trial — a UK randomised controlled trial of EPP versus no EPP — was stopped early because of excess mortality in the EPP arm and concluded that EPP should not be offered as standard treatment. Some centres offer P/D in highly selected, fit patients with resectable epithelioid disease as part of multimodality therapy with chemotherapy and radiotherapy, but this remains investigational. [1]

For Mr Wilson, given his COPD and 50 pack-year smoking history, and the lack of a survival benefit from radical surgery, I would not recommend EPP or radical P/D. If he develops a symptomatic trapped lung with restrictive impairment, a limited pleurectomy or decortication for symptom relief might be considered, but the default is systemic therapy and symptom control." [1]

Q7: "He deteriorates rapidly and is now cachectic and in pain. What is your approach to end-of-life care?" [1]

"My approach shifts to comfort-focused palliative care. I would have an honest, compassionate conversation with him and his family about the trajectory — that mesothelioma is progressive, that cure is not possible, and that the goal now is quality of life and dignity. I would discuss and document advance care directives — his preferences regarding resuscitation, ICU admission, and the location of his death. [1]

Symptom control is paramount. I would optimise his analgesia, possibly converting to a subcutaneous infusion of opioid and antiemetic if he cannot take oral medication. I would treat nausea, breathlessness (with low-dose opioids and fans), and terminal restlessness and secretions if they develop. I would ensure the palliative care team is actively involved and arrange community palliative care or hospice admission if he prefers to die at home. [1]

I would address the emotional and spiritual needs of him and his family — counselling, social work, and chaplaincy as appropriate. The compensation claim should be expedited so that it is resolved during his lifetime, providing practical and psychological benefit to the family." [1]

Short Case Discussion

Scenario: "Examine this patient's respiratory system. He was admitted with a pleural effusion."

Candidate presentation (model): [1]

"I examined Mr Wilson's respiratory system. He is breathless at rest, with a respiratory rate of 24. He is not cyanosed. He is not clubbed. [1]

The trachea is central. Chest wall expansion is reduced on the right side. On percussion, there is stony dullness over the lower two-thirds of the right hemithorax. Tactile vocal fremitus is reduced over this area. On auscultation, breath sounds are absent over the right lower and middle zones, with reduced vocal resonance. At the upper border of the dullness, there is an egophonic e-to-a change. There is no wheeze. The left lung is clear. [1]

In summary, these findings are consistent with a large right pleural effusion." [1]

Examiner: "How does a pleural effusion differ from consolidation on examination?" [1]

"Both conditions produce dullness to percussion, but the auscultatory findings are opposite. In a pleural effusion, the fluid in the pleural space blocks the transmission of sound from the lung to the chest wall. Breath sounds are reduced or absent, tactile vocal fremitus is reduced, and vocal resonance is reduced. The percussion note is characteristically stony dull rather than just dull. [1]

In consolidation, the solidified lung conducts sound better than air-filled lung. Breath sounds become bronchial — hollow, tubular, with an equal inspiratory and expiratory phase. Tactile vocal fremitus and vocal resonance are increased, with whispered pectoriloquy and egophony. The percussion note is dull rather than stony dull. [1]

This single contrast — reduced transmission in effusion versus increased transmission in consolidation, both with a dull percussion note — is the most reliable bedside discriminator and a classic examination question. A useful mnemonic: in consolidation, the lung conducts sound better because fluid conducts better than air; in effusion, the pleural fluid blocks sound because it is outside the lung, between the lung and the chest wall." [1]

Examiner: "What would change if this were a pneumothorax instead?" [1]

"The percussion note would be the key discriminator. A pneumothorax produces a hyperresonant percussion note rather than dullness, because the pleural space contains air rather than fluid. Breath sounds would still be reduced or absent, and vocal resonance reduced, just as in an effusion — but the hyperresonance distinguishes it. If it were a tension pneumothorax, I would also find tracheal deviation away from the affected side, hypotension, tachycardia, and distended neck veins from obstructive shock — and I would decompress immediately without further examination or imaging." [1]

Examiner: "His CT shows pleural plaques. What is their significance?" [1]

"Pleural plaques are the most common manifestation of asbestos exposure. They are benign, localised areas of pleural fibrosis, typically on the parietal pleura along the lower chest wall and diaphragm, and often calcified. They spare the costophrenic angles and the visceral pleura. Pleural plaques indicate past asbestos exposure but are not premalignant in themselves — they do not transform into mesothelioma. However, their presence confirms significant asbestos exposure, which puts the patient at risk of mesothelioma, asbestosis (interstitial fibrosis), and asbestos-related pleural effusion. In this patient, the plaques confirm the exposure history and strengthen the clinical case for mesothelioma as the cause of the pleural thickening and effusion." [1]