Uniportal VATS pleural biopsy in the diagnosis of exudative pleural effusion: awake or intubated?

Malignant pleural effusion diagnosis and therapy

Malignant pleural effusion (MPE) is a serious complication of advanced tumor, with relatively high morbidity and mortality rates, and can severely affect the quality of life and survival of patients. The mechanisms of MPE development are not well defined, but much research has been conducted to gain a deeper understanding of this process. In recent decades, although great progress has been made in the management of MPE, the diagnosis and treatment of MPE are still major challenges for clinicians. In this article, we provide a review of the research advances in the mechanisms of MPE development, diagnosis and treatment approaches. We aim to offer clinicians an overview of the latest evidence on the management of MPE, which should be individualized to provide comprehensive interventions for patients in accordance with their wishes, health status, prognosis and other factors.

Diagnostic role of video-assisted thoracoscopy in the management of indeterminate pleural effusion

BACKGROUND

The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients.

AIM

To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center.

PATIENTS AND METHODS

Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed.

RESULTS

Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis.

CONCLUSION

Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.

Clinical Value of Pleural Effusion and Serum MMP-3 and CYFRA21-1 Combined with ADA in Differential Diagnosis of Pleural Exudative Effusion

Objective

The aim of the study is to investigate the clinical value of matrix metalloproteinases-3 (MMP-3) and cytokeratin 19 fragment antigen 21-1 (CYFRA21-1) combined with adenosine deaminase (ADA) in pleural effusion and serum in benign and malignant pleural exudative effusion (PEE).

Methods

A total of 119 adult patients with PEE admitted in our hospital from May 2018 to October 2021 were selected. According to the patient's condition, the patients were divided into the benign group (n = 75) and the malignant group (n = 44). The levels of MMP-3, CYFRA21-1, and ADA in pleural effusion and serum were detected. The receiver operating characteristic (ROC) curve was used to analyze the individual and combined predictive value of MMP-3, CYFRA21-1, and ADA levels.

Results

In the malignant group, the pleural effusion and serum MMP-3 and CYFRA21-1 levels were higher than those in the benign group and the ADA levels were lower than those in the benign group (P < 0.05). In the malignant group, the positive detection rate of pleural effusion and serum MMP-3 and CYFRA21-1 was higher than that in the benign group and the positive detection rate of pleural effusion and serum ADA were lower than that in the benign group (P < 0.05). The AUC of pleural effusion MMP-3, serum MMP-3 and the combination of them in the diagnosis of PEE were 0.764, 0.722 and 0.810, respectively. The AUC of pleural effusion CYFRA21-1 and serum CYFRA21-1 and combination of them in the diagnosis of PEE were 0.776, 0.748 and 0.822, respectively. The AUC of pleural effusion ADA, serum ADA and their combination in differential diagnosis of PEE were 0.762, 0.737 and 0.836, respectively. The AUC of pleural effusion and serum of MMP-3 and CYFRA21-1 combined with ADA for differential diagnosis of PEE was 0.923.

Conclusions

The diagnostic efficacy of MMP-3 combined with CYFRA21-1 and ADA in pleural effusion and serum for benign and malignant PEE are better than single index, which has certain clinical values for the selection of early intervention scheme for PEE patients.

Malignant pleural disease: a pragmatic guide to diagnosis

PURPOSE OF REVIEW

The diagnosis of malignant pleural disease is important in the care of patients with cancer. However, a one-size-fits-all approach to diagnosis may lead to delays in care as the sensitivity of each biopsy modality varies and can be dependent on the tumor type. We review current literature on pleural biopsy techniques and propose a diagnostic algorithm for suspected malignant pleural disease.

RECENT FINDINGS

Recent literature has shown that the sensitivity of pleural fluid cytology varies based on tumor type resulting in a limited value of repeated thoracenteses in many cases. Furthermore, the ability to test for molecular biomarkers on pleural fluid samples has contributed to the recommendations to send large volumes of pleural fluid for analysis. Studies have also supported the consideration of medical thoracoscopy earlier in the diagnostic work-up of malignant pleural disease.

SUMMARY

The decision to repeat a diagnostic thoracentesis when suspecting malignant pleural effusions should take into account the primary tumor type. Open pleural biopsy with medical thoracoscopy has been shown to be a relatively safe diagnostic modality with high sensitivity and should be considered in patients with a nondiagnostic thoracentesis.