An Electrocautery Pleural Biopsy for the Diagnosis of Desmoplastic Malignant Mesothelioma During Semirigid Thoracoscopy

Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician

INTRODUCTION

Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics.

AREAS COVERED

Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years.

EXPERT OPINION

As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.

Pleural Cryobiopsy versus Flexible Forceps Biopsy in Subjects with Undiagnosed Exudative Pleural Effusions Undergoing Semirigid Thoracoscopy: A Crossover Randomized Trial (COFFEE Trial)

BACKGROUND

There is no randomized study comparing pleural cryobiopsy (CB) and flexible forceps biopsy (FFB) in subjects undergoing medical thoracoscopy for the diagnosis of pleural effusions.

OBJECTIVE

In this crossover study, we compared the diagnostic yield of CB versus FFB in subjects undergoing semirigid thoracoscopy.

METHODS

Subjects undergoing semirigid thoracoscopy for undiagnosed pleural effusions were subjected to both CB and FFB, with the order of performing the biopsy randomized in a 1:1 ratio. The primary outcome was the diagnostic yield obtained with CB versus FFB. The secondary outcomes included the biopsy size, depth, histologic interpretability, artefacts, the difficulty of performing biopsy on an operator-rated visual analog scale, the severity of bleeding observed at the time of the biopsy, and the duration of the procedure.

RESULTS

Of the 201 subjects screened, 50 (mean age 52.4 years; 18 women) were included. The diagnostic yield of CB (78.0%) was not different from FFB (76.0%, p = 1.00). CB yielded a larger specimen than FFB (median size 7.0 vs. 4.0 mm; p < 0.001), and a greater depth of specimens (up to the pleural fat or deeper, CB vs. FFB 65.2 vs. 40.8%; p = 0.02). The CB procedure was quicker than FFB (median duration 10 vs. 15 min; p < 0.001). There were no significant differences in the difficulty of performing the biopsy, the severity of bleeding, histologic interpretability, or artefacts in the specimens between the CB and FFB groups.

CONCLUSION

The diagnostic yield of pleural CB was comparable to FFB during semirigid thoracoscopy.