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We would like to thank Drs Medford and Entwistle for their letter in response to our recent Thorax publication.1 We entirely agree that pleural CT is the gold standard not only in terms of malignant pleural disease but also for intraparenchymal, mediastinal and distant disease. We would suggest that the priority in the “real world” is prompt diagnosis and subsequent management of the pleural effusion, with CT as currently the most useful technique. However, the widespread use of thoracic ultrasound may mean that it is readily available (eg, in the outpatient respiratory clinic) and, given the high diagnostic yield of thoracic ultrasound for malignant pleural disease, may allow patients with clear-cut evidence of malignancy (eg, gross pleural nodularity) to be triaged directly to thoracoscopy or image-guided biopsy. The high proportion of mesothelioma and malignant pleural disease seen in our study is indeed a result of the tertiary nature of our practice, and this will influence the sensitivity and specificity of the test. It is for this reason that we recommended that the diagnostic use of ultrasound for malignant pleural effusion should be assessed in a non-tertiary centre for the results to be more widely applied to practice. The prevalence of tuberculosis (TB) in our area of practice is also low, and ultrasound should be evaluated in this context in a higher prevalence area.
We agree with the authors of the letter that the skill of the operator is an important issue. The results of our study are not intended to apply to level 1 Royal College of Radiology (RCR)-trained chest physicians,2 for whom ultrasound is a valuable technique to diagnose the presence of effusion and aid intervention. However, physicians with increasing experience (eg, level 2) may be able to achieve a reasonable diagnostic sensitivity for malignant pleural effusion using ultrasound—this requires prospective testing and will be an interesting question for future studies. In addition, although we agree that measurements of pleural thickening, diaphragm assessment, etc. are not currently routinely conducted by sublevel 3 RCR operators, this may change with increasing subspecialisation and experience of respiratory physicians with an interest in pleural disease. In these circumstances, our study suggests criteria which may be used for the diagnosis of malignant pleural disease.1
Once again, we would like to thank the authors of the letter for their interest in our study.
Competing interests None.
Provenance and Peer review Not commissioned; not externally peer reviewed.