The Prevalence and Clinical Relevance of Non-expandable Lung in Malignant Pleural Mesothelioma: A Prospective, Single-Center Cohort Study of 229 Patients.

Annals of the American Thoracic Society 2019 June 12 [Link]

Bibby AC, Halford P, De Fonseka D, Morley AJ, Smith S, Maskell NA



Non-expandable lung is a recognised phenomenon that can create management challenges in mesothelioma. Its prevalence and clinical importance are unknown.


The aim of this study was to describe the prevalence of non-expandable lung and to evaluate whether there was any association between non-expandable lung and survival in a clinical cohort of mesothelioma patients.


This was a prospective, observational cohort of mesothelioma patients, seen in a single centre between 01/03/2008 and 03/08/2017. Baseline characteristics were collected at diagnosis. Serial chest radiographs were assessed for the presence of pleural effusions and non-expandable lung (defined as a lack of lung expansion following pleural aspiration or drainage). Patients were followed up until death or censored on 14/03/2019.


Of 229 patients, 192 (82.7%) had a pleural effusion at presentation, with non-expandable lung observed in 64/192 (33.3%). Breathlessness and cough were more frequent with pleural effusions, especially with underlying non-expandable lung, whilst chest pain was more prevalent in patients without effusions. Patients with pleural effusions, both with and without underlying non-expandable lung, were more likely to have epithelioid disease, early stage disease and to receive chemotherapy than patients with no pleural effusion. Non-expandable lung was an independent risk factor for short survival, with a hazard ratio for mortality of 1.80 (95% confidence interval 1.16 to 2.80) compared with patients without non-expandable lung. The presence of a pleural effusion did not appear to be associated with a worse prognosis compared to patients with an effusion (adjusted HR 1.86, 95% confidence interval 0.93 to 3.72).


This is the first study to describe the prevalence and clinical implications of non-expandable lung in mesothelioma. It demonstrated that NEL is a relatively common phenomenon that is associated with significant symptomatology and shorter survival.