Visceral pleural invasion

Last revised by Yuranga Weerakkody on 17 Jan 2024

Visceral pleural invasion is a feature that can be seen in lung cancers. It is defined as tumor extension beyond the elastic layer of the visceral pleura, and in some cases may result in a cancer crossing a fissure to invade an adjacent lobe of the lung. It is considered an aggressive sign and one of the most important adverse prognostic factors in non-small cell lung cancers 1.

There are three described levels of invasion (based on histology):

  • PL0: represents tumor invading either the subpleural lung parenchyma or superficially the pleural connective tissue beneath the elastic layer

  • PL1: refers to a tumor that invades beyond the elastic layer without being exposed on the pleural surface

  • PL2: refers to a tumor that is exposed on the pleural surface, but it does not involve adjacent anatomic structures

The presence of type 2 pleural tags has been shown to have a moderate association with visceral pleural invasion 7.

Other reported features to be associated with pleural invasions include 8

  • jellyfish sign - multiple linear septations between nodule and pleural mimicking jelly tentacles 9

  • adjacent - pleural thickening

  • increased contact surface area (pleural-attached nodules)

  • multiple tags to different pleural surfaces

According to one study, there was ~20% (range 10-30%) worse 5-year survival in tumors with visceral pleural invasion compared to those without visceral pleural invasion.

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