Combined ultrasound-guided cutting-needle biopsy and standard pleural biopsy for diagnosis of malignant pleural effusions

Ultrasonic Elastography-guided Pleural Biopsy for the Diagnosis of Pleural Effusion: A Multicenter Prospective Study of Diagnostic Test Performance

Rationale: The diagnostic yield of traditional ultrasound-guided pleural biopsy remains unsatisfactory, particularly when the pleural thickness is ⩽5 mm and/or no pleural nodules are detected. Pleural ultrasound elastography (UE) has a better diagnostic yield than traditional ultrasound for malignant pleural effusion (MPE). However, studies on UE-guided pleural biopsies are lacking. Objectives: To evaluate the feasibility and safety of UE-guided pleural biopsy. Methods: In this multicenter prospective single-arm trial, patients with pleural effusion whose pleural thickness was ⩽5 mm with no pleural nodules were enrolled between July 2019 and August 2021. The diagnostic yield of UE-guided pleural biopsy for pleural effusion and its sensitivity for detecting MPE were evaluated. Results: Ninety-eight patients (mean age, 62.4 ± 13.2 yr; 65 men) were prospectively enrolled. The diagnostic yield of UE-guided pleural biopsy for making any diagnosis was 92.9% (91/98), and its sensitivity for MPE was 88.7% (55/62). In addition, its sensitivity for pleural tuberculosis was 69.6% (16/23). The rate of postoperative chest pain was acceptable, and there was no pneumothorax. Conclusions: UE-guided pleural biopsy is a novel technique for diagnosing MPE with good diagnostic yield and sensitivity. Clinical trial registered with https://www.chictr.org.cn (ChiCTR2000033572).

Thoracic ultrasound-guided real-time pleural biopsy in the diagnosis of pleural diseases: a systematic review and meta-analysis

BACKGROUND

Real-time thoracic ultrasound-guided pleural biopsy (TUSPB) is an important diagnostic method for pleural diseases. Traditional two-dimensional thoracic ultrasound, as well as newly developed contrast-enhanced ultrasound (CEUS) and ultrasound elastography (UE), are all used as guidance tools for pleural biopsies. Herein, we aimed to determine the diagnostic yield of real-time TUSPB for pleural diseases to better inform the decision-making process.

METHODS

A literature search of the MEDLINE/PubMed, Embase, and Cochrane Library databases was performed up to June 2023. A binary random-effects model was applied to determine the pooled diagnostic yield.

RESULTS

Fifteen studies comprising 1553 patients with pleural diseases were included and analyzed. The overall diagnostic yield of TUSPB for pleural diseases was 85.58% (95% confidence interval [CI]: 81.57-89.58%). The sensitivity was 77.56% for pleural malignancy and 80.13% for tuberculous pleurisy. The sub-analysis result revealed that CEUS-guided pleural biopsy provided a pooled diagnostic yield of 98.24%, which was higher than that of conventional TUSPB (78.97%; p < 0.01). The overall proportion of adverse events for TUSPB was 6.68% (95% CI: 5.31-8.04%).

CONCLUSION

Conventional TUSPB has good pooled diagnostic yields and high safety. CEUS and UE are promising guidance tools for pleural biopsy with the potential to increase diagnostic yield.

Marked safety and high diagnostic yield of freehand ultrasound-guided core-needle biopsies performed by pulmonologists

Background

Adequate tissue sampling is fundamental for establishing a definitive diagnosis, assessing prognosis and tailoring therapy. Each of the methods for obtaining tissue (e.g., endoscopic, image guidance and surgical biopsies) results in a different diagnostic yield and complication rate profile.

Objectives

Present feasibility, and assess safety and efficacy of freehand transthoracic ultrasound‐guided core‐needle biopsies (USGNB) of thoracic lesions performed by pulmonologist.

Methods

A retrospective analysis study of ultrasound‐guided core‐needle biopsies of thoracic lesions performed at the Pulmonary Institute of Rabin Medical Center was conducted from September 2020 to October 2021. All core‐needle biopsies were performed under local anesthesia with guidance of Mindray TE7 2019 US system. Procedural variables including complications and pathological diagnostic yield were the primary end point. IRB 0671‐21‐RMC.

Results

In total 91 biopsy procedures were analyzed in38 females and 53 males, average age 71.1 years. Twenty‐three (25.3%) cases were lung lesions, 7 (7.7%) – mediastinal, 13 (14.3%) – chest wall, 27 (29.7%) – pleural, and 21 (23.1%) supraclavicular lesions. Average lesion size was 51.6 mm, the largest in the mediastinum and the smallest in supraclavicular locations (97.7mm and 28.0 mm, respectively). Overall pathological diagnostic yield was 90%, highest success in chest wall (100%) and lowest in mediastinal biopsies (71.4%). We had only one complication –hemothorax resolved by chest tube drainage‐ accounting for only 1.1% complication rate.

Conclusion

Safety and efficacy were demonstrated in freehand US‐guided core‐needle biopsy of thoracic lesions performed by pulmonologists. We suggest thoracic ultrasound and USG‐CNB be part of training and clinical practice in interventional pulmonology.

Comparison of Diagnostic Yield and Complications in Ultrasound-Guided Closed Pleural Biopsy Versus Thoracoscopic Pleural Biopsy in Undiagnosed Exudative Pleural Effusion

Introduction

Malignancy, tuberculosis, and non-tubercular pleural infections account for most exudative pleural effusion. Pleural fluid cytology, biochemical tests and even pleural fluid cell block studies may fail to yield a diagnosis in certain cases. Medical thoracoscopy is the gold standard for the diagnosis of unexplained pleural effusions. However, access to medical thoracoscopy may be limited, particularly in developing countries. Also, certain patients may not be fit to undergo the procedure because of medical conditions. An ultrasound-guided pleural biopsy is an option in such conditions. The present study is intended to compare the diagnostic yield and complications of both methods of pleural biopsy in undiagnosed exudative pleural effusion under a randomized controlled trial.

Method

After fulfilling all the inclusion criteria, participants were randomized to either ultrasound-guided closed pleural biopsy or thoracoscopic-guided pleural biopsy groups. The primary outcome was to compare the diagnostic yield of ultrasound-guided Tru-Cut® (Newtech Medical Devices, Faridabad, India) closed pleural biopsy versus thoracoscopic pleural biopsy, and the secondary outcomes were to compare the complications rate, duration of the procedure, and hospital stay in the patients undergoing ultrasound-guided pleural biopsy versus thoracoscopic pleural biopsy, and predictors of a positive biopsy result in both groups.

Result

A total of 118 patients with pleural effusion were screened; 39 of them who were eligible, randomized into the ultrasound group (20 patients) and the thoracoscopic group (19 patients). The median age of participants was 53.5 (50-58) years and 55 (45-64) years in the ultrasound and thoracoscopic groups, respectively. Pleural fluid cell count, protein, adenosine deaminase (ADA), and lactate dehydrogenase (LDH) were similar in both groups, although pleural fluid glucose was low in the ultrasound group. Diagnostic yield was 90% (18/20) and 94.7% (18/19) in the ultrasound and thoracoscopic groups, respectively, which was statistically non-significant (p=0.963). The median duration of hospital stay was 9.5 (5.3-27) days and 15 (12-22) days in ultrasound and thoracoscopic groups respectively. The thoracoscopic group had a more prolonged stay compared to the ultrasound group, but it was statistically non-significant (p=0.09). The duration of the procedure was significantly longer in the thoracoscopic group 90 (85-105) minutes, in comparison to ultrasound 47.5 (41.3-55) minutes (p=0.001). No major complications were seen in both groups. Subcutaneous emphysema was the most common complication in the thoracoscopic group (10%), followed by hemorrhage (5.3%), and respiratory failure (5.3%). Hypotension was the only complication in the ultrasound group (5%). The rate of complications was significantly higher in the thoracoscopic group (p<0.01).

Conclusion

Ultrasound-guided closed pleural biopsy is as good as thoracoscopic pleural biopsy in undiagnosed exudative pleural effusion. It was associated with a shorter procedure duration, a shorter hospital stay, and fewer complications as compared to thoracoscopic biopsy. Both the procedures were safe in experienced hands and a hospital setup, but the thoracoscopic pleural biopsy was associated with complications.

Translational Nanotherapeutics Reprograms Immune Microenvironment in Malignant Pleural Effusion of Lung Adenocarcinoma

Malignant pleural effusion (MPE) remains a treatment bottleneck in advanced lung cancer, due to its complicated microenvironments and "cold" immunity. Therefore, the search for therapeutic drugs to transform MPE to functionally "hot" one could advance the development of effective immunotherapeutic strategy. Herein, translational selenium nanoparticles coated with immune-modulating macromolecule lentinan (SeNPs@LNT) are designed to restore the dysfunctional immune cells in patient-derived MPE microenvironment. Internalization of the SeNPs@LNT can effectively reduce the immunosuppressive status by enhancing the proliferation of CD4⁺ T cells and natural killer cells, and remodeling the tumor associated macrophages into tumoricidal M1 phenotype in MPE derived from patients presenting low Se levels in blood and pleural effusion. Th1, cytotoxic T cell, γδ T, and B cell functions are upregulated, and Th2, Th17, and Treg cells activity is downregulated. Furthermore, SeNPs@LNT can be gradually metabolized into SeCys2 to promote the production of metabolites associated with tumor growth inhibition and immune response activation in MPE microenvironment. In contrast, lung cancer markers and vitamin B6 metabolism are decreased. The translational SeNP-based nanotherapeutic strategy restores functional "cold" MPE to "hot" MPE to activate the immune responses of various immune cells in MPE of lung cancer patients.

A multidisciplinary approach for the diagnosis of benign asbestos pleural effusion: a single-center experience

Background

There is little detailed information regarding benign asbestos pleural effusion (BAPE). It is frequently misdiagnosed because of lack of a standardized diagnostic approach and criteria. The present study aimed to better characterize BAPE and outline a diagnostic approach for this disease.

Methods

Complete clinical data of 11 consecutive patients with BAPE were prospectively collected and analysed. A multidisciplinary team (MDT) was involved in discussing the suspected cases of BAPE. The team was comprised of thoracic physicians, radiologists and pathologists. A multidisciplinary practical diagnostic approach for BAPE was introduced.

Results

Six patients had respiratory symptoms, but another 5 were asymptomatic. All the patients had an asbestos exposure and the median duration was 23.9 years (rang, 12–36 years). The median level of lactate dehydrogenase (LDH), adenosine deaminase (ADA), proteins and carcinoembryonic antigen (CEA) in the pleural fluid (PF) were 221.4 U/L (range, 189.8–11,325 U/L), 21 U/L (rang, 14–247 U/L), 48.3 g/dL (range, 35.2–53.2 g/dL) and 3.46 mg/mL (range, 0.84–4.54 mg/mL), respectively. Five patients had pleural plaques, 2 had diffuse pleural thickening (DPT), 1 had asbestosis, and 1 had round atelectasis. The pleural biopsy specimens showed a benign fibrotic pleura in all case. The symptoms and pleural pulmonary radiologic findings remained stable during the follow-up.

Conclusions

BAPE is diagnosed by exclusion. A suspected diagnosis of BAPE with an asbestos exposure should be considered, especially with the presence of pleural plaques, and/or DPT, and rounded atelectasis. The MDT-based diagnostic approach may reduce misdiagnosis.

Diagnostic value of ultrasound-guided needle biopsy in undiagnosed pleural effusions: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Undiagnosed pleural effusions (UPEs) are a common problem of respiratory medicine, leading to an increased diagnostic burden globally. However, the most efficient and cost-effective approaches to UPEs remain controversial. This study aimed to assess the diagnostic value of ultrasound-guided needle biopsy (UGNB) in UPEs.

METHODS

We conducted a search of PubMed, Embase, the Cochrane Library and reference lists of retrieved studies with no publication data limitation. Articles that investigated the diagnostic accuracy of UGNB in UPEs were included. The quality of eligible studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. The diagnostic value of UGNB was evaluated by calculating the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds rate, and the area under the curve for the summary receiver operating characteristic curve using a random effects model.

RESULTS

Seven studies comprising 165 patients with UPEs met the inclusion criteria. UGNB had a pooled sensitivity of 83% (95% confidence intervals [CI], 75% - 89%), a specificity of 100% (95% CI, 90% - 100%), a positive likelihood ratio of 8.89 (95% CI, 3.29 - 24.02), a negative likelihood ratio of 0.23 (95% CI, 0.16 - 0.33), a diagnostic odds rate of 51.47 (95% CI, 14.70 - 180.16), and an area under the curve of 0.94. Six pneumothorax cases (3.6%), 5 local wound infections (3.0%), and 1 empyema case (less than 1%) were observed. There was no significant heterogeneity or publication bias in this study.

CONCLUSIONS

Based on current evidence, UGNB is a safe and convenient procedure with a high accuracy for diagnosing UPEs. However, physicians should still be cautious in interpreting negative UGNB results.

Diagnostic procedure for idiopathic eosinophilic pleural effusion: a single-center experience

Background

Eosinophilic pleural effusion (EPE) is attributed to several well-recognised causes. However, some patients remain idiopathic, even after thorough clinical work-up. The present study aimed to better characterize idiopathic EPE (IEPE) and to outline the diagnostic procedure for this disease.

Methods

Complete clinical data of 11 consecutive patients with IEPE were prospectively collected and analysed. Preliminary diagnostic procedure of IEPE in our hospital was performed.

Results

All the 11 patients had respiratory symptoms and unilateral pleural effusion (PE) occurred in 4 patients. The mean percentage of eosinophils in PE was 22.4% (range, 12.4–50.5%). Lactate dehydrogenase, adenosine deaminase, proteins and carcinoembryonic antigen in PE were 246.0 U/L (range, 89.8–421.9 U/L), 13.8 U/L (range, 1.8–24.0 U/L), 42.6 g/dl (range, 32.8–52.6 g/dl) and 2.17 mg/mL (range, 0.46–4.31 mg/mL), respectively. Parasite-specific IgG antibody in blood and parasite eggs in stool were both negative. No evidence of tuberculosis or malignancy was observed in pleural biopsy. Symptoms and abnormal pulmonary imaging were eliminated after glucocorticoid use.

Conclusions

IEPE is a diagnosis of exclusion. Patients with EPE without a clear cause should be asked to provided complete medical, surgical and drug-related histories. A thorough work-up is essential. Moreover, we recommend follow-up after the use of glucocorticoid until effusion resolves.

Trial registration

GYFYY. Registration No: GYFYY20150901221. Registered time: 1 September 2015. Date of enrolment of the first participant to the trial: 22 January 2016.

Retrospective study of pleural parasitic infestations: a practical diagnostic approach

BACKGROUND

Pleural parasitic infestation (PPI) is a disease prevalent in certain parts of the world. It is frequently misdiagnosed due to its lack of standardized diagnostic criteria. The purpose of this study was to evaluate the clinical characteristics of PPI patients and develop a practical diagnostic approach for PPI.

METHODS

A retrospective study was conducted by reviewing the medical records of 11 patients with PPI. A practical diagnostic approach was proposed based on the unique laboratory findings.

RESULTS

All patients demonstrated respiratory symptoms, including shortness of breath, cough, fever, chest pain, excessive sputum and hemoptysis. Leukocytosis (> 10,000/μL) and eosinophilia (> 500/μL) of peripheral blood were present in 45.5 and 36.4% patients, respectively. The mean concentrations of pleural effusion lactate dehydrogenase (LDH), adenosine deaminase (ADA), protein and carcinoembryonic antigen (CEA) were 338.2 U/L (range, 61-667 U/L), 11.6 U/L (range, 0.1-28.2 U/L), 43.7 g/dL (range, 21.9-88.1 g/dL), and 1.84 mg/mL (range, 0.28-4.8 mg/mL), respectively. The mean percentage of eosinophils in the pleural effusion was 19.5% (10.5-41%). Blood test was positive for parasite-specific IgG antibody in 9 patients, including 4 for Paragonimus westermani, 3 for Taenia solium, 1 for Clonorchis sinensis and 1 for Echinococcus granulosus. Eggs of Clonorchis sinensis were detected in the stool of two patients. Sparganum was found in the pleural effusion of one patient. Respiratory symptoms and abnormal appearances in pulmonary radiographic examination were disappeared in all patients who received anti-parasitic treatment.

CONCLUSIONS

In patients with unexplained pleural effusion, parasite-specific IgG antibody tests should be performed when pleural fluid testing shows eosinophilic pleural effusion. It is preferable to consider the diagnosis of PPI in clinical practice when serum parasite-specific IgG antibody test is positive.

Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases

BACKGROUND

This study aimed to prospectively evaluate the efficacy and reliability of a diagnostic workup, triaging pleural biopsy method according to baseline computerized tomography (CT) findings in the diagnosis of pleural diseases.

METHODS

Patients with pleural pathology were divided into 3 arms according to findings on CT scan images. Arm A: patients with pleural thickening/lesion in addition to pleural effusion. These patients underwent CT scan-guided Abrams' needle pleural biopsy. Arm B: patients with pleural effusion alone or suspected benign asbestos pleurisy. This group underwent medical thoracoscopy (MT). Arm C: patients with only pleural thickening. This group underwent ultrasonography-guided cutting needle pleural biopsy. MT was planned in patients who did not have a specific diagnosis in the CT scan-guided Abrams' needle pleural biopsy group. When patients with a histopathologic diagnosis of fibrinous pleuritis after MT were assessed in terms of the risk factors for malignant pleural diseases, we offered a further invasive procedure.

RESULTS

A total of 164 patients were enrolled in the study. Diagnostic sensitivity after the initial procedure was 90.2% in Arm A, 93.3% in Arm B, 95.2% in Arm C, and 92.4% in the entire workup. The negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy. Five cases who had a diagnosis of fibrinous pleuritis after MT were detected to have risk factors, 4 of which (80%) indicated malignant disease. Complication rates were low and acceptable.

CONCLUSION

Use of CT scans to triage an appropriate pleural biopsy method is associated with high diagnostic success. We recommend that the proposed diagnostic workup in this study may be used as a diagnostic algorithm for pleural diseases that require a histopathologic analysis. Determination of risk factors predicting malignant disease in patients where fibrinous pleuritis is reported after MT would be useful for clinical practice.

Ultrasound-guided pleural cutting needle biopsy: accuracy and factors influencing diagnostic yield

Background

The aim of this study was to retrospectively investigate the diagnostic accuracy of ultrasound-guided pleural cutting needle biopsy (US-guided PCNB) and the potential factors influencing diagnostic yield.

Methods

From July 2014 to June 2016, a total of 147 percutaneous US-guided PCNBs in 144 patients were retrospectively reviewed. The final diagnosis was confirmed by histopathological analysis and follow-up. We calculated diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and divided all cases into group of correct diagnoses (true-positive and true-negative cases) and group of incorrect diagnoses (false-positive, false-negative, and inconclusive cases). Univariate and multivariate logistic regression analyses were performed to analyze the differences of influencing factors (patient, pleura, and biopsy-associated factors) in the between the two groups.

Results

Seven patients were excluded because of loss to follow-up. A total of 140 cases were ultimately included (105 males and 35 females). There were 105 cases in the correct diagnosis group, and 35 cases in the incorrect diagnosis group. The overall accuracy of US-PCNB was 75.0% and the sensitivity, specificity, PPV, NPV in malignant diagnosis were 58.1%, 99.0%, 96.2%, and 84.2%, respectively. On univariate analysis, variables affecting diagnostic accuracy of US-PCNB were the pleural thickness (<3 mm in thickness 61.0%, ≥3 mm in thickness 85.2%; P=0.001), morphology (non-nodular pleura 71.4%, nodular pleura 95.2%; P=0.026), and needle size (18 G 69.1%, 16 G 87.0%; P=0.022). Finally multivariate logistic regression demonstrated that pleural thickness [odds ratio (OR): 0.278, P=0.003] and needle size (OR: 0.291, P=0.018) independently predicted diagnostic accuracy.

Conclusions

Pleural thickness and the size of the biopsy needle were significantly correlated with the diagnostic yield.

The pleural fluid lactate dehydrogenase/adenosine deaminase ratio differentiates between tuberculous and parapneumonic pleural effusions

Background

Although pleural fluid lactate dehydrogenase (LDH) and adenosine deaminase (ADA) levels are often used to distinguish between tuberculous pleural effusion (TPE) and parapneumonic pleural effusion (PPE), this can be challenging as the LDH level may vary from normal to severely increased in PPE and a significantly elevated ADA is frequently measured in both conditions. In this study, we evaluated use of the pleural fluid LDH/ADA ratio as a new parameter to discriminate TPE from PPE.

Methods

A retrospective study was conducted in patients with pathologically-confirmed TPE (n = 72) and PPE (n = 47) to compare pleural fluid LDH and ADA levels and LDH/ADA ratios between the 2 groups. A receiver operating characteristic (ROC) curve was constructed for identifying TPE.

Results

The median pleural fluid LDH and ADA levels and LDH/ADA ratios in the TPE and PPE groups were: 364.5 U/L vs 4037 U/L (P < .001), 33.5 U/L vs 43.3 U/L (P = .249), and 10.88 vs 66.91 (P < .0001), respectively. An area under the ROC curve of 0.9663 was obtained using the LDH/ADA ratio as the indicator for TPE identification, and the sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were, respectively, 93.62%, 93.06%, 13.48, and 0.068 at a cut-off level of 16.20.

Conclusions

The pleural fluid LDH/ADA ratio, which can be determined from routine biochemical analysis, is highly predictive of TPE at a cut-off level of 16.20. Measurement of this parameter may be helpful for clinicians in distinguishing between TPE and PPE.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0526-z) contains supplementary material, which is available to authorized users.