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Pleural Effusion

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Pleural Effusion in Mesothelioma
Presenting sign in 80%+ of pleural mesothelioma patients[1]
Cytology sensitivity ~33% for mesothelioma (95% CI 11.8–61.6%)[2]
Definitive diagnosis VATS pleural biopsy (>95% sensitivity)[1]
Recurrence risk markers Higher fluid LDH; positive cytology[3]
Management options Therapeutic thoracentesis; indwelling pleural catheter (IPC); chemical pleurodesis[4]
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Executive Summary

Pleural effusion — abnormal fluid accumulation between the lung and the chest wall — is the most common presenting feature of malignant pleural mesothelioma, found in more than 80% of patients at diagnosis.[1] The fluid is typically unilateral and exudative, accompanied by progressive dyspnea, non-pleuritic chest pain, and cough; many patients are referred for evaluation only after the effusion has recurred following an initial drainage.[5] Tumor-driven inflammation, lymphatic obstruction, and VEGF-mediated capillary leak are the dominant mechanisms.[6]

Pleural fluid cytology, although the easiest first test to perform, is the least reliable diagnostic tool in mesothelioma of any malignancy that involves the pleura. A 2023 systematic review and meta-analysis in Thorax found that among thoracic malignancies, cytology sensitivity was lowest for mesothelioma (28.9%, 95% CI 16.2–41.5%) and lung squamous cell carcinoma (24.2%, 95% CI 17.0–31.5%), far lower than other pleural malignancies.[7] A 2022 retrospective cohort study published in the Internal Medicine Journal reported cytology sensitivity of only 33.3% (95% CI 11.8–61.6%) for mesothelioma compared with ~90% for breast cancer and ~79% for lung cancer in the same patient population.[2] Sarcomatoid mesothelioma is particularly resistant to cytologic diagnosis and effectively requires tissue biopsy.[7]

When cytology is negative or equivocal — especially in a patient with a history of asbestos exposure and recurrent unilateral effusion — the diagnostic workup must escalate. Video-assisted thoracoscopic surgery (VATS) pleural biopsy is the gold standard, achieving diagnostic sensitivity above 95%.[1] Combined immunohistochemistry — calretinin, WT-1, cytokeratin 5/6, and D2-40 positivity together with CEA, TTF-1, claudin-4, and BerEP4 negativity — plus BAP1 and CDKN2A/MTAP loss assessment is the current standard for distinguishing malignant mesothelioma from reactive mesothelial proliferations.[8][9]

For families confronting a mesothelioma diagnosis that began as "fluid on the lung," legal compensation pathways include federal asbestos bankruptcy trust funds, civil personal injury and wrongful death lawsuits, and VA disability claims for veterans. Filing deadlines for asbestos claims vary by state and are not always measured from the date of diagnosis, and trust fund claims run on separate deadlines set by each trust, so the applicable deadline should be confirmed with a lawyer.

At-a-Glance

Pleural effusion in mesothelioma at a glance:

  • Most common presenting sign — unilateral pleural effusion is found in over 80% of pleural mesothelioma patients at diagnosis[1]
  • Cytology sensitivity is ~33% — meta-analysis found cytology sensitivity for mesothelioma (28.9%) among the lowest of any thoracic malignancy, with only lung squamous cell carcinoma (24.2%) lower[7][2]
  • Sarcomatoid subtype defies cytology — the sarcomatoid histologic variant is particularly resistant to cytologic diagnosis and generally requires tissue biopsy[7]
  • VATS biopsy is the gold standard — video-assisted thoracoscopic surgery achieves diagnostic sensitivity above 95% when cytology is negative[1]
  • Pleural fluid mesothelin is an adjunctive biomarker — elevated mesothelin in undiagnosed effusion has clinical value alongside cytology[10]
  • Australian cohort yield was 32% — a tertiary-center retrospective reported pleural fluid cytology was diagnostic in only 32% of mesothelioma cases versus 87.9% for other malignancies[11]
  • Recurrence is driven by tumor biology — higher pleural fluid LDH and positive cytology independently increase the hazard of effusion recurrence after drainage[3]
  • IHC requires the full panel — diagnostic confirmation needs calretinin + WT-1 + cytokeratin 5/6 + D2-40 positive with CEA + TTF-1 + claudin-4 + BerEP4 negative, plus BAP1 and CDKN2A/MTAP loss assessment[8][9]
  • Both IPC and pleurodesis are valid recurrence options — indwelling pleural catheter and chemical pleurodesis both control recurrent effusion; choice depends on lung re-expansion, performance status, and patient preference[4]
  • Effusion forms early in the disease course — malignant pleural effusion occurs in 54–90% of pleural mesothelioma cases and develops at an early stage; the fluid is biologically active, shielding tumor cells from chemotherapy and promoting tumor growth[12]

Key Facts

Measure Finding (Source)
Effusion as presenting feature >80% of pleural mesothelioma patients (Bianco et al., J Thorac Dis, 2018)[1]
Cytology sensitivity — mesothelioma 33.3% (95% CI 11.8–61.6%) in a 2022 retrospective cohort study (Pairman et al., Intern Med J, 2022)[2]
Cytology sensitivity — lung cancer (comparator) ~79% in the same Pairman cohort[2]
Cytology sensitivity — breast cancer (comparator) ~90% in the same Pairman cohort[2]
Pooled cytology sensitivity (meta-analysis) Among the lowest for any thoracic malignancy (mesothelioma 28.9%, lung squamous cell 24.2%); Kassirian et al., Thorax, 2023, systematic review and meta-analysis[7]
VATS pleural biopsy sensitivity >95% diagnostic sensitivity (current standard, Bianco et al., 2018)[1]
Australian tertiary-center yield (mesothelioma) 32% versus 87.9% for other malignancies (Loveland et al., Intern Med J, 2018)[11]
Recurrence risk factor 1 Higher pleural fluid LDH at thoracentesis (Grosu et al., Respirology, 2019)[3]
Recurrence risk factor 2 Positive initial cytology (Grosu et al., 2019)[3]
Adjunctive biomarker Pleural fluid mesothelin (Davies et al., Am J Respir Crit Care Med, 2009)[10]
Required IHC positive markers Calretinin, WT-1, cytokeratin 5/6, D2-40 (Nabeshima et al., Pathol Int, 2022)[9]
Required IHC negative markers and loss CEA, TTF-1, claudin-4, BerEP4 negative; BAP1 and CDKN2A/MTAP loss assessed (Mansour et al., Cytopathology, 2023; Nabeshima et al., 2022)[8][9]

Why Does Mesothelioma Cause Pleural Effusion?

Malignant pleural effusion in mesothelioma reflects three overlapping mechanisms acting on the pleural space simultaneously. First, tumor cells line both the visceral and parietal pleura diffusely, producing a chronic inflammatory response that increases the permeability of pleural capillaries. Second, infiltrating tumor obstructs the network of lymphatic stomata along the diaphragmatic and mediastinal parietal pleura that normally drain pleural fluid into the systemic circulation; with that outflow blocked, fluid produced at a normal rate cannot be absorbed. Third, vascular endothelial growth factor (VEGF) produced by mesothelioma cells drives further capillary leakage of plasma proteins into the pleural space.[6]

The resulting fluid is almost always exudative by Light's criteria (high protein and lactate dehydrogenase relative to serum) and almost always unilateral — bilateral effusions early in the disease course point away from mesothelioma and toward heart failure, lymphoma, or a primary lung adenocarcinoma with pleural spread. As tumor burden grows, the effusion becomes more rapid to re-accumulate after drainage and more difficult to control. The clinical experience is progressive shortness of breath, especially on exertion, accompanied by a non-pleuritic chest discomfort that patients often describe as "heaviness" rather than sharp pain.[6][1]

How Is Mesothelioma Pleural Effusion Diagnosed?

The standard workup begins with imaging — chest X-ray and then computed tomography (CT) of the chest — and a diagnostic thoracentesis to obtain fluid for analysis. The fluid is sent for cell count and differential, biochemistry to establish exudative status by Light's criteria, microbiology to exclude empyema, and cytology to look for malignant cells.[1]

The problem with cytology in mesothelioma is well-documented. The 2023 Thorax systematic review and meta-analysis by Kassirian and colleagues — the largest synthesis of this question to date — found that among thoracic malignancies, pleural fluid cytology has the lowest diagnostic sensitivity for mesothelioma (28.9%) and lung squamous cell carcinoma (24.2%), far lower than other pleural malignancies, with sarcomatoid mesothelioma "generally preclud[ing] cytology diagnosis" entirely.[7] A 2022 retrospective single-center cohort by Pairman et al. quantified this gap with a head-to-head comparison: in the same patient population, pleural fluid cytology was diagnostic for breast cancer in roughly 90% of cases and for lung cancer in roughly 79%, but for mesothelioma in only 33.3% (95% CI 11.8–61.6%).[2] A 2018 Australian retrospective cohort at a tertiary referral center reported similar numbers — cytology yield of 32% for mesothelioma versus 87.9% for other malignancies in their effusion database.[11]

When cytology is negative or equivocal, pleural fluid mesothelin — measured by ELISA on the same fluid sample — adds adjunctive diagnostic value. Davies and colleagues demonstrated in 2009 that elevated pleural fluid mesothelin in undiagnosed pleural effusions independently raises the pretest probability of mesothelioma, helping clinicians decide whether to escalate to biopsy.[10] A 2021 review by Eccher et al. in Cancer Cytopathology summarized the diagnostic biomarkers usable on effusion cytology, noting sensitivities in the 30%-plus range for several individual markers and a stronger combined performance when several are run together.[13]

Can Molecular Markers Diagnose Mesothelioma From Effusion Fluid?

A newer approach aims to narrow the cytology gap without immediately resorting to surgery: applying the same molecular markers used on surgical tissue to the cell block prepared from the drained pleural fluid. When fluid is centrifuged, the cellular material can be embedded, sectioned, and stained much like a biopsy — allowing immunohistochemistry for BAP1 and MTAP (a surrogate for CDKN2A deletion) to be read directly on effusion-derived cells. Loss of BAP1 and/or MTAP staining supports a malignant diagnosis by distinguishing mesothelioma from the reactive mesothelial cells that shed into any inflamed effusion.[14]

In a single-institution series spanning 2013–2025, an expanded immunohistochemistry and biomarker panel — including BAP1 and MTAP, which became available after 2017 — improved the cytologic diagnosis of mesothelioma on fluid specimens compared with the limited marker panels used earlier.[14] Even so, fluid-based diagnosis remains insensitive on its own: a 2026 Rush University series found pleural-fluid cytology diagnostic in only 26.9% of confirmed mesothelioma cases, rising to 46.2% when atypical and suspicious results were counted as abnormal.[15] Importantly, these markers are read from the patient's own tumor cells purely as a diagnostic tool — they help confirm that a malignancy is present and that it is mesothelioma. They describe the established tumor and say nothing about why the disease developed. For how the same markers define the mesothelioma subtype once tissue is obtained, see Histological_Subtypes_of_Mesothelioma.

When fluid analysis stays inconclusive, tissue sampling follows. A 2026 network meta-analysis of 8,744 patients found rigid medical thoracoscopy the highest-yield sampling method at 95.0%, with closed (blind) pleural biopsy the lowest at 75.1% — reinforcing thoracoscopy's role when a molecular-supported diagnosis cannot be reached from fluid alone.[16]

When Should Suspicion Escalate to Biopsy?

Clinical context drives escalation. A patient with a documented asbestos exposure history (occupational, military, or take-home household) who presents with a unilateral pleural effusion — especially if accompanied by CT findings of pleural thickening, nodularity, or pleural plaques — should be considered to have mesothelioma until biopsy proves otherwise, regardless of cytology results.[1] Recurrent effusion after an initial therapeutic drainage in such a patient is itself a strong signal that pushes the workup beyond cytology.

The definitive procedure is video-assisted thoracoscopic surgery (VATS) pleural biopsy, which permits direct visualization of the pleural surface and targeted multi-site biopsies. Diagnostic sensitivity is above 95% — effectively a gold standard.[1] Less invasive alternatives include image-guided percutaneous pleural biopsy (CT- or ultrasound-guided cutting-needle biopsy), which performs well when CT identifies a discrete pleural target. The Ceruti et al. 2018 review of endoscopic diagnosis and management catalogs the relative roles of medical thoracoscopy, semi-rigid pleuroscopy, and VATS in modern practice.[4]

Tissue diagnosis enables the full immunohistochemistry panel. The current standard requires calretinin, WT-1, cytokeratin 5/6, and D2-40 positive (markers of mesothelial origin) combined with CEA, TTF-1, claudin-4, and BerEP4 negative (markers that would point instead to adenocarcinoma).[9] Crucially, distinguishing malignant mesothelioma from a reactive mesothelial proliferation — which can look morphologically similar — requires demonstration of BAP1 loss and/or CDKN2A/MTAP loss, both detectable by immunohistochemistry and confirmed by FISH or sequencing in difficult cases.[9][8] Without these molecular markers, a benign-appearing biopsy can be misclassified.

How Is Recurrent Pleural Effusion Managed?

Pleural effusion in mesothelioma almost always recurs after a single drainage. The 2019 Grosu et al. analysis identified two independent risk factors for recurrence: higher pleural fluid LDH at the initial thoracentesis and positive cytology at that same procedure.[3] Recurrence is frequently rapid: in a SEER-Medicare cohort of patients with malignant pleural effusion, 36.9% required a second pleural procedure within 14 days of the first thoracentesis, and those managed with a definitive procedure needed far fewer subsequent interventions — a third procedure was required in only 14–18% of patients treated with an indwelling pleural catheter or thoracoscopy versus roughly 70% of those who underwent repeat thoracentesis.[17] Practical implication: patients with either factor should be planned for definitive control of the effusion rather than serial drainages.

Two definitive control options are widely used:

  1. Indwelling pleural catheter (IPC) — a small tunneled drainage catheter placed under local anesthesia and managed at home, allowing the patient or a caregiver to drain a controlled volume of fluid every few days. IPC is well-tolerated, can be placed at the same encounter as diagnostic thoracoscopy, and may produce spontaneous pleurodesis in 30–50% of patients over weeks to months as pleural surfaces inflame and fuse around the catheter.
  2. Chemical pleurodesis — instillation of a sclerosing agent (most commonly graded talc) into the pleural space, intended to fuse the visceral and parietal pleura and obliterate the space in which fluid can re-accumulate. Pleurodesis is less reliable in mesothelioma than in other malignant effusions: in the TIME1 trial dataset it succeeded in 73.3% of mesothelioma patients versus 84.9% of non-mesothelioma patients (against an overall rate of roughly 81%), and a talc-poudrage series reported a complete response of 61% in mesothelioma versus 77% in breast cancer — the diffuse tumor rind along the pleura blunts the inflammatory fusion the procedure depends on.[18][19] Pleurodesis also requires the lung to be capable of re-expanding to the chest wall — a trapped lung, where the mesothelioma rind prevents re-expansion, is a contraindication and often pushes the choice toward IPC.[4][20]

Choice between IPC and pleurodesis depends on lung re-expansion capacity on post-drainage imaging, patient performance status, expected survival (IPC is well-suited to limited-prognosis patients who prefer to avoid hospitalization), and patient preference around daily care. Both approaches reduce hospital re-admissions for recurrent dyspnea compared with serial therapeutic thoracenteses.[4]

Frequently Asked Questions

Is fluid on the lung always cancer?

No. Pleural effusion has many non-cancerous causes including congestive heart failure (the single most common cause), pneumonia (parapneumonic effusion), pulmonary embolism, cirrhosis, and post-cardiac surgery effusion. What makes mesothelioma-related effusion distinct is the combination of unilateral presentation, exudative biochemistry, progressive recurrence after drainage, and a clinical history of asbestos exposure. When these features cluster together, mesothelioma must be ruled out by biopsy even if cytology is negative.[1]

Why does cytology miss so many mesothelioma cases?

Mesothelioma cells in pleural fluid can look morphologically similar to reactive mesothelial cells, which routinely shed into the pleural space in any inflammatory effusion. Without immunohistochemistry, even an experienced pathologist may report the cytology as "atypical mesothelial cells, suspicious but not diagnostic." Sarcomatoid mesothelioma is even harder — sarcomatoid cells exfoliate poorly into fluid, so the cell-block preparation often contains very few diagnostic cells. The 2023 Thorax meta-analysis found mesothelioma (28.9% sensitivity) and lung squamous cell carcinoma (24.2%) had the lowest pooled cytology sensitivity among pleural malignancies, far lower than other cancer types.[7][2]

Does a negative cytology rule out mesothelioma?

No. A negative pleural fluid cytology in a patient with asbestos exposure history and a recurrent unilateral effusion is not adequate to rule out mesothelioma. The standard of care is to proceed to pleural biopsy — preferably VATS — in this scenario.[1][7]

What is the role of pleural fluid mesothelin?

Pleural fluid mesothelin (measured by ELISA) is an adjunctive biomarker that adds clinical value when cytology is equivocal. Elevated levels independently raise the pretest probability of mesothelioma in an undiagnosed effusion and can inform the decision to escalate to biopsy.[10] It is not a stand-alone diagnostic test — biopsy with full IHC remains required for definitive diagnosis.

Indwelling pleural catheter or pleurodesis — which is better?

Neither is universally better; the choice is clinical. Pleurodesis requires the lung to be able to re-expand and is a one-time procedure intended to permanently obliterate the pleural space. Indwelling pleural catheter (IPC) works even when the lung cannot fully re-expand (a "trapped lung," common in advanced mesothelioma), can be placed at the same time as a diagnostic thoracoscopy, and is managed at home. Patient performance status, lung re-expansion capacity on imaging after drainage, and patient preference around daily home care all factor in.[4]

Quick Statistics

  • >80% — proportion of pleural mesothelioma patients presenting with pleural effusion[1]
  • ~33% — cytology sensitivity for mesothelioma in the 2022 Pairman et al. cohort[2]
  • ~90% — cytology sensitivity for breast cancer in the same cohort (comparator)[2]
  • ~79% — cytology sensitivity for lung cancer in the same cohort (comparator)[2]
  • 32% — Australian tertiary-center cytology yield for mesothelioma in the 2018 Loveland et al. cohort[11]
  • 87.9% — yield for other malignancies in the same Loveland cohort[11]
  • >95% — VATS pleural biopsy diagnostic sensitivity (current standard)[1]
  • Two independent risk factors — higher pleural fluid LDH and positive cytology, for effusion recurrence after drainage[3]

  • Danziger & De Llano — mesothelioma and asbestos-related disease legal resources, covering asbestos bankruptcy trust fund claims, personal injury and wrongful death litigation, and VA disability claims for veterans
  • Mesothelioma Lawyer Center — patient and family resources on diagnosis, treatment, clinical trials, and legal options
  • Mesothelioma.net — information on pleural mesothelioma diagnostic workup, treatment, and prognosis

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 Bianco A, Valente T, De Rimini ML, Sica G, Fiorelli A. Clinical diagnosis of malignant pleural mesothelioma. J Thorac Dis. 2018;10(Suppl 2):S253-S261. PMID 29507793. PubMed
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Pairman L, Beckert LEL, Dagger M, Maze MJ. Evaluation of pleural fluid cytology for the diagnosis of malignant pleural effusion: a retrospective cohort study. Intern Med J. 2022;52(7):1154-1159. PMID 35191191. PubMed
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Grosu HB, Molina S, Casal R, Song J, Li L, Diaz-Mendoza J, Reddy C, Yarmus L, Schiavo D, Simoff M, Johnstun J, Raid AA, Feller-Kopman D, Lee H, Sahetya S, Foley F, Maldonado F, Tian X, Noor L, Miller R, Mudambi L, Saettele T, Vial-Rodriguez M, Eapen GA, Ost DE. Risk factors for pleural effusion recurrence in patients with malignancy. Respirology. 2019;24(1):76-82. PMID 29966171. PubMed
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Ceruti P, Lonni S, Baglivo F, Marchetti G. Endoscopic diagnosis and management of pleural effusion in malignant pleural mesothelioma. J Thorac Dis. 2018;10(Suppl 2):S269-S275. PMID 29507795. PubMed
  5. ↑ Sterman DH, Albelda SM. Advances in the diagnosis, evaluation, and management of malignant pleural mesothelioma. Respirology. 2005;10(3):266-283. PMID 15955137. PubMed
  6. ↑ 6.0 6.1 6.2 Musso V, Diotti C, Palleschi A, Tosi D, Aiolfi A, Mendogni P. Management of Pleural Effusion Secondary to Malignant Mesothelioma. J Clin Med. 2021;10(18):4247. PMID 34575358. PubMed
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Kassirian S, Hinton SN, Cuninghame S, Chaudhary R, Iansavitchene A, Amjadi K, Dhaliwal I, Zeman-Pocrnich C, Mitchell MA. Diagnostic sensitivity of pleural fluid cytology in malignant pleural effusions: systematic review and meta-analysis. Thorax. 2023;78(1):32-40. PMID 35110369. PubMed
  8. ↑ 8.0 8.1 8.2 8.3 Mansour MSI, Huseinzade A, Seidal T, Hejny K, Maty A, Taheri-Eilagh F, Mager U, Dejmek A, Dobra K, Brunnström H. Comparison of immunohistochemical mesothelial biomarkers in paired biopsies and effusion cytology cell blocks from pleural mesothelioma. Cytopathology. 2023;34(5):456-465. PMID 37337638. PubMed
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Nabeshima K, Hamasaki M, Kinoshita Y, Matsumoto S, Sa-Ngiamwibool P. Update of pathological diagnosis of pleural mesothelioma using genomic-based morphological techniques, for both histological and cytological investigations. Pathol Int. 2022;72(8):389-401. PMID 35596704. PubMed
  10. ↑ 10.0 10.1 10.2 10.3 Davies HE, Sadler RS, Bielsa S, Maskell NA, Rahman NM, Davies RJ, Ferry BL, Lee YC. Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions. Am J Respir Crit Care Med. 2009;180(5):437-444. PMID 19299498. PubMed
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Loveland P, Christie M, Hammerschlag G, Irving L, Steinfort D. Diagnostic yield of pleural fluid cytology in malignant effusions: an Australian tertiary centre experience. Intern Med J. 2018;48(11):1318-1324. PMID 29869427. PubMed
  12. ↑ Skok K, Hladnik G, Grm A, Crnjac A. Malignant Pleural Effusion and Its Current Management: A Review. Medicina (Kaunas). 2019;55(8):490. PMID 31443309. PubMed
  13. ↑ Eccher A, Girolami I, Lucenteforte E, Troncone G, Scarpa A, Pantanowitz L. Diagnostic mesothelioma biomarkers in effusion cytology. Cancer Cytopathol. 2021;129(7):506-516. PMID 33465294. PubMed
  14. ↑ 14.0 14.1 Selvaggi SM. The Diagnostic Value of Immunohistochemistry and Biomarkers in the Diagnosis of Mesothelioma in Pleural/Peritoneal Effusions. Diagn Cytopathol. 2026. PMID 42163521. PubMed
  15. ↑ Findley J, Demetrious M, Yan L, et al. Pleural Fluid Cytology-Histology Correlation in Patients With Malignant Pleural Mesothelioma: A Series of 26 Cases. Cytopathology. 2026;37(4):382-394. PMID 41721215. PubMed
  16. ↑ Lyu S, Zheng Z, Liao L, et al. Diagnostic performance and safety of image-guided pleural biopsy and medical thoracoscopy for undiagnosed exudative pleural effusion: a systematic review and network meta-analysis. Eur Respir Rev. 2026;35(180). PMID 42270119. PubMed
  17. ↑ Ost DE, Goldblatt C, Jung M, Weiss M, Xu S, Taneja A, et al. The Clinical and Economic Implications of Different Treatment Pathways for Patients With Rapidly Recurrent Malignant Pleural Effusion. Chest. 2024;166(4):867-881. PMID 38838953. PubMed
  18. ↑ Mercer RM, Macready J, Jeffries H, Speck N, Kanellakis NI, Maskell NA, et al. Clinically important associations of pleurodesis success in malignant pleural effusion: Analysis of the TIME1 data set. Respirology. 2020;25(7):750-755. PMID 31846131. PubMed
  19. ↑ Bielsa S, Hernández P, Rodriguez-Panadero F, Taberner T, Salud A, Porcel JM. Tumor type influences the effectiveness of pleurodesis in malignant effusions. Lung. 2011;189(2):151-5. PMID 21331598. PubMed
  20. ↑ Matthews C, Freeman C, Sharples LD, Fox-Rushby J, Tod A, Maskell NA, et al. MesoTRAP: a feasibility study that includes a pilot clinical trial comparing video-assisted thoracoscopic partial pleurectomy decortication with indwelling pleural catheter in patients with trapped lung due to malignant pleural mesothelioma designed to address recruitment and randomisation uncertainties and sample size requirements for a phase III trial. BMJ Open Respir Res. 2019;6(1):e000368. PMID 30687504. PubMed
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