Closed pleural needle biopsy: predicting diagnostic yield by examining pleural fluid parameters

Comparison between closed pleural biopsy and medical thoracoscopy for the diagnosis of undiagnosed exudative pleural effusions: a systematic review and meta-analysis

Background

Exudative pleural effusion (EPE) is a common diagnostic challenge. The utility of medical thoracoscopy (MT) and closed pleural biopsy (CPB) to aid in the diagnosis of EPE has been reported in many published studies. Herein, we perform a systematic review and meta-analysis to compare the diagnostic yield and safety of CPB and MT in EPE.

Methods

Four databases were searched for studies reporting the diagnostic yield of CPB and MT for EPE. The quality of the included studies was evaluated according to the quality assessment of diagnostic accuracy studies (QUADAS) tool. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and complication risks were compared between the two groups.

Results

Ten studies dealing with CPB and twenty-three studies dealing with MT for the diagnosis of EPE were included in this meta-analysis. Pooled sensitivity, specificity, PLR, NLR and DOR of CPB group was 77%, 99%, 32.55, 0.22, 165.71, respectively, while pooled sensitivity, specificity, PLR, NLR and DOR of MT group was 93%, 100%, 10.82, 0.08, 162.81, respectively. The area under the summary receiver operating characteristic (SROC) curve of CPB and MT were both 0.97. The ability of CPB to diagnose non-malignant diseases was like MT (69% vs. 68%), while the ability was lower than that of MT to diagnose malignant diseases (72% vs. 92%). The pooled diagnostic accuracy of CPB and MT for mesothelioma was 26% (95% CI, 14–38%) and 42% (95% CI, 22–62%) (P<0.001), respectively. The rate of complications with CBP was lower than that reported for MT.

Conclusions

CBP is a relatively accurate tool with a lower complication rate compared to MT in the diagnosis of EPE, especially in diagnosing non-malignant diseases. We confirm the utility of MT in the diagnostic workup of malignancy (especially mesothelioma); however, in selected cases, CPB could be used as the first diagnostic approach with a favorable safety profile.

Is There a Role for a Needle Thoracoscopic Pleural Biopsy under Local Anesthesia for Pleural Effusions?

Background

A closed pleural biopsy is commonly performed for diagnosing patients exhibiting pleural effusion if prior thoracentesis is not diagnostic. However, the diagnostic yield of such biopsies is unsatisfactory. Instead, a thoracoscopic pleural biopsy is more useful and less painful.

Methods

We compared the diagnostic yield of needle thoracoscopic pleural biopsy performed under local anesthesia with that of closed pleural biopsy. Sixty-seven patients with pleural effusion were randomized into groups A and B. Group A patients were subjected to closed pleural biopsies, and group B patients were subjected to pleural biopsies performed using needle thoracoscopy under local anesthesia.

Results

The diagnostic yields and complication rates of the two groups were compared. The diagnostic yield was 55.6% in group A and 93.5% in group B (p<0.05). Procedure-related complications developed in seven group A patients but not in any group B patients. Of the seven complications, five were pneumothorax and two were vasovagal syncope.

Conclusion

Needle thoracoscopic pleural biopsy under local anesthesia is a simple and safe procedure that has a high diagnostic yield. This procedure is recommended as a useful diagnostic modality if prior thoracentesis is non-diagnostic.

Trends in pleural biopsies between 1996 and 2006 at a tertiary medical center

INTRODUCTION

To determine the cause of an exudative pleural effusion, clinicians may choose one of the three types of pleural biopsies--blind, image-guided, or surgical biopsies--depending on the extent of pleural involvement and the available expertise and technology. The purpose of this study was to examine the trends in the type of pleural biopsies performed between 1996 and 2006 and to assess the diagnostic sensitivity of the 3 aforementioned types of pleural biopsy.

METHODS

This was a retrospective study of all patients who underwent a pleural biopsy at a large teaching hospital between January 1, 1996, and December 31, 2006. Patients were identified by reviewing databases for surgical pathology and hospital discharge. The final diagnosis was determined by conducting a detailed chart review. We examined the trend in pleural biopsies from 1996 and 2006. We also compared the disease-specific sensitivity of blind, image-guided and surgical biopsies.

RESULTS

Of the 174 pleural biopsy specimens identified, 103 (59.1%) were blind, 38 (21.8%) were image guided (ultrasound and computed tomography), and 33 (18.9%) were surgical (video-assisted thoracoscopic surgery and open surgical). The proportion of blind pleural biopsies performed declined from 77.7% in 1996 to 26.6% in 2006 (P < 0.0001). During the same period, the proportion of image-guided biopsy rose from 7.4% to 53.3% (P < 0.001). The sensitivity of blind, image-guided and surgical biopsy was 42%, 78.7%, and 92.8%, respectively.

CONCLUSIONS

The number of blind pleural biopsies performed by pulmonary fellows declined substantially between 1996 and 2006, with an increasing trend toward image-guided biopsy.