The Role of Abrams Percutaneous Pleural Biopsy in the Investigation of Exudative Pleural Effusions

Diagnosis and Pattern Identification of Intrathoracic Malignant Melanoma Metastasis: A Retrospective Single Center Analysis

The lung is a frequent site of secondary malignancies. Melanoma is a malignant tumor originating from melanocytes, that accounts for the majority of death related to skin cancers. In advanced stages, it can also present with intrathoracic metastasis, particularly in the lungs, but infrequent intrathoracic manifestations are possible. A retrospective analysis of the cases referred to the pulmonary endoscopy unit of the hospital of Reggio Emilia in the last 10 years (since December 2012) was carried out, discovering 17 cases of melanoma metastasis with thoracic localizations, either with or without a diagnosis of primary melanoma. Four repetitive patterns of clinical-radiological presentation have been identified and described through the same number of paradigmatic clinical cases: nodal involvement (35%), lung mass(es) (41%), diffuse pulmonary involvement (12%), and pleural involvement (12%). These different presentations imply the use of different diagnostic techniques, with an overall high diagnostic yield (87.5%). Finally, a brief analysis of survival based on the pattern of presentation has been performed, finding no statistically significant differences between the four groups at metastasis diagnosis (p-value = 0.06, median survival of respectively 54, 8, 9, and 26 months from metastasis diagnosis), while there is a significant difference considering patients with lung involvement versus nodal/pleural involvement (p = 0.01).

Cytological Diagnostic Procedures in Malignant Mesothelioma

Malignant mesotheliomas (MM) are rare tumors with high mortality rates, whose incidence varies regionally and nationally, and the diagnosis is difficult. Histology-based diagnosis is considered the gold standard despite its low sensitivity of 57-84%. However, recent advances in cytological analysis offer promise for diagnostic advancements. In this study, we reappraised the current cytological guidelines for the MM diagnosis and concluded on their practicability and reliability. The study included 5731 consecutive specimens of pleural effusions from 4552 patients (3026 males of the average age of 67.5 years and 1526 females of the average age of 65.4 years) between December 2017 and January 2000. Out of these patients, 444 (9.8%) were diagnosed with MM. The effusions were examined by immunocytochemistry using routine Giemsa staining. Additionally, hyaluronic acid (HA) was assessed. Cytological findings confirmed 223 out of the 444 MM. The additional 88 cases with negative cytology were corroborated by supplemental assessments of HA above 30 mg/L. Cytological evaluation accomplished the sensitivity of 0.50, specificity of 0.99, and a positive predictive value (PPV) of 0.97 for MM diagnosis. The use of HA determination raised the sensitivity to 0.70 without affecting the specificity or PPV. We conclude that cytological evaluation of effusions aided by the assessment of HA demonstrates the diagnostic sensitivity and specificity for MM no less than the hitherto standard histological evaluation. The cytology-based MM diagnosis may thus be routinely considered when MM is suspected and may offer confirmatory advantages in difficult or doubtful diagnostic cases.

Malignant Pleural Effusions

Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.

Diagnostic yield and safety of closed needle pleural biopsy in exudative pleural effusion

BACKGROUND

Closed pleural biopsy was previously considered a procedure of choice in cases of undiagnosed pleural effusion with good efficacy. Currently, the closed pleural biopsy has been replaced by thoracoscopic biopsy but not easily available in resource-limited setups.

OBJECTIVE

The objective of this study was to analyze the diagnostic yield and safety of closed needle pleural biopsy in exudative pleural effusion and assessment of patients' characteristics with the yield of pleural biopsy.

DESIGN

This was a cross-sectional study.

SETTINGS

This study was conducted at Institute of Respiratory Diseases, SMS Medical College, Jaipur, a tertiary care center of West India.

PATIENTS AND METHODS

A total of 250 cases of pleural effusion were evaluated with complete pleural fluid biochemical, microbiological, and cytological examination. Out of these 250 patients, 59 were excluded from the study as the diagnosis could be established on initial pleural fluid examination. The remaining (191) patients were considered for closed pleural biopsy with Abrams pleural biopsy needle.

MAIN OUTCOME MEASURES

The main outcome measure was diagnostic yield in the form of confirming diagnosis.

RESULTS

Out of the 191 patients with exudative lymphocytic pleural effusion, 123 (64.40%) were diagnosed on the first pleural biopsy. Among the remaining 68 patients, 22 patients had repeat pleural biopsy with a diagnostic yield of 59.9%. The overall pleural biopsy could establish the diagnosis in 136 (71.20%) patients with pleural effusion. The most common diagnosis on pleural biopsy was malignancy followed by tuberculosis.

CONCLUSIONS

Closed pleural biopsy provides diagnostic yield nearly comparative to thoracoscopy in properly selected patients of pleural effusions. In view of good yield, low cost, easy availability, and very low complication rate, it should be used routinely in all cases of undiagnosed exudative lymphocytic pleural effusion.

LIMITATIONS

There was no comparison with a similar group undergoing thoracoscopic pleural biopsy.

The diagnostic yield of closed needle pleural biopsy in exudative pleural effusion: a retrospective 10-year study

Background

Pleural effusion is a common presentation in clinical practice. About 40% of exudative pleural effusion is unable to be diagnosed through thoracentesis, and closed pleural biopsy (CPB) is needed. This study was designed to investigate the diagnostic yield of CPB in exudative pleural effusion.

Methods

This was a retrospective 10-year study of patients with unexplained exudative pleural effusion who underwent CPB in two centers. Malignant pleural effusion (MPE) was diagnosed when there was histopathological evidence of pleural tissue, pulmonary tissue, or pleural fluid. Tuberculous pleural effusion (TPE) was confirmed when granuloma or coagulative necrosis was observed in pleural tissue, Ziehl-Neelsen acid-fast staining was positive, or adenosine deaminase (ADA) in pleural effusion was higher than 35IU with clinical symptoms of TB orγ-interferon increased with symptoms of TB.

Results

A total of 644 patients were enrolled, of which 479 were specifically diagnosed (217 patients with TPE and 262 patients with MPE). The sensitivity of CPB in the diagnosis of MPE was 51.5%. Among the pathological types of MPE, lung adenocarcinoma accounted for 77.9% (204/262) of cases, making up the largest proportion. The sensitivity of CPB for diagnosing TPE was 68.7%.

Conclusions

CPB has a relatively high sensitivity in the diagnosis of exudative pleural fluid, especially in relation to tuberculous lesions. CPB could provide an alternative technique in clinical practice, especially for basic hospital units without thoracoscopy.

Application of Narrow-Band Imaging thoracoscopy in diagnosis of pleural diseases

BACKGROUND

Patients with undiagnostic pleural effusions are routinely examined by conventional medical thoracoscopy under the white light (WL). The endoscopic appearance of pleural diseases under WL could be misleading. Narrow-Band Imaging (NBI) has been applied as an interesting and effective diagnostic tool for endoscopy. However, there is also controversy about its value in the application of thoracoscopy.

OBJECTIVE

The objective of this study was to investigate the diagnostic value of NBI technology during thoracoscopy.

METHODS

Patients with undiagnosed pleural effusions admitted to our hospital between September 2017 and September 2019 were enrolled. During the thoracoscopy, we performed WL mode first and then NBI. Pictures of endoscopic real-time lesions were recorded under two modes, and at least five pieces of tissue were taken, respectively, on pleura lesions. Biopsy specimens were respectively taken for pathologic analysis. Diagnostic sensitivity, specificity were calculated to compare with pathologic results.

RESULTS

100 eligible patients were enrolled, including 63 with malignancy, 23 with tuberculous pleurisy, 3 with systemic disease and 11 with the negative condition. Compared with pathological results, the sensitivity of WL was 91.01%, and NBI 84.27%; while the specificity of WL was 27.27%, and NBI 81.82%. Compared NBI with WL, the former's specificity is superior to the latter's, which is statistically significant (P < 0.05).

CONCLUSIONS

The advantage of NBI lies in its high specificity. It's useful to diagnose unknown pleural effusions in clinical practice. With better visualization of blood vessels, we can enhance the accuracy of biopsy and reduce the risk of unexpected bleeding arose from the biopsy.

Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview

Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.

Accuracy of closed pleural biopsy in the diagnosis of malignant pleural effusion

OBJECTIVE

Previous studies have demonstrated that closed pleural biopsy (CPB) has a sensitivity of less than 60% for diagnosing malignancy. Therefore, controversy has recently emerged regarding the value of CPB as a diagnostic test. Our objective was to assess the accuracy of CPB in diagnosing malignancy in patients with pleural effusion.

METHODS

This was a prospective 8-year study of individuals who underwent CPB to establish the etiology of pleural effusion. Information on each patient was obtained from anatomopathological reports and medical records. When CPB findings showed malignancy or tuberculosis, the biopsy was considered diagnostic, and that was the definitive diagnosis. In cases in which biopsy histopathological findings were nonspecific, a definitive diagnosis was established on the basis of other diagnostic procedures, such as thoracoscopy, thoracotomy, fiberoptic bronchoscopy, biochemical and cellular measurements in pleural fluid, and/or microbiological tests. The accuracy of CPB was determined with 2 × 2 contingency tables.

RESULTS

A total of 1034 biopsies from patients with pleural effusion were studied. Of those, 171 (16.54%) were excluded from the accuracy analysis either because of inadequate samples or insufficient information. The results of the accuracy analysis were as follows: sensitivity, 77%; specificity, 98%; positive predictive value, 99%; negative predictive value, 66%; positive likelihood ratio, 38.5; negative likelihood ratio, 0.23; pre-test probability, 2.13; and post-test probability, 82.

CONCLUSIONS

CPB is useful in clinical practice as a diagnostic test, because there is an important change from pre-test to post-test probability.

Diagnostic value of medical thoracoscopy in malignant pleural effusion

Background

Medical thoracoscopy has been shown to be an efficacious procedure in diagnosing unexplained exudative pleural effusions with excellent safety. This study aimed to assess the diagnostic significance of thoracoscopy in the management of patients with malignant pleural effusion (MPE).

Methods

Consecutive patients with malignant pleural effusion were retrospectively reviewed, and their demographic, radiographic, thoracoscopic and histological data were collected.

Results

Between July 2005 and June 2014, 342 of 833 patients undergoing thoracoscopy were finally confirmed to suffer from MPE. The top three frequent causes of MPE were metastatic carcinoma (79.5%), malignant mesothelioma (10.2%), and lymphoma (2.9%). Among metastatic malignancies, the most common cancer was lung cancer (85.2%), followed by breast cancer (4.4%), ovarian cancer (2.2%), pancreatic cancer (1.8%), etc. No serious adverse events associated with thoracoscopy were recorded.

Conclusions

Medical thoracoscopy is a valuable and safe tool in diagnosing malignant pleural effusion with minimal complication rates.

Novel systemic therapy against malignant pleural mesothelioma

Malignant pleural mesothelioma is an aggressive tumor of the pleura with an overall poor prognosis. Even with surgical resection, for which only a subset of patients are eligible, long term disease free survival is rare. Standard first-line systemic treatment consists of a platinum analog, an anti-metabolite, and sometimes anti-angiogenic therapy, but there is currently no well-established standard therapy for refractory or relapsed disease. This review focuses on efforts to develop improved systemic therapy for the treatment of malignant pleural mesothelioma (MPM) including cytotoxic systemic therapy, a variety of tyrosine kinase inhibitors and their downstream effector pathways, pharmacologic targeting of the epigenome, novel approaches to target proteins expressed on mesothelioma cells (such as mesothelin), arginine depletion therapy, and the emerging role of immunotherapy. Overall, these studies demonstrate the challenges of improving systemic therapy for MPM and highlight the need to develop therapeutic strategies to control this disease.

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

Background

The most efficient approach to diagnose malignant pleural effusions (MPEs) is still controversial and uncertain. This study aimed to evaluate the utility of a combined approach using ultrasound (US)-guided cutting-needle biopsy (CNB) and standard pleural biopsy (SPB) for diagnosing MPE.

Methods

Pleural effusions were collected from 172 patients for biochemical and microbiological analyses. US-guided CNB and SPB were performed in the same operation sequentially to obtain specimens for histological analysis.

Results

US-guided CNB and SPB procedures provided adequate material for histological analysis in 90.7 and 93.0% of cases, respectively, while a combination of the 2 techniques was in 96.5% of cases. The sensitivity, specificity, positive-predictive value (PPV), negative-predictive value (NPV) and diagnostic accuracy of US-guided CNB versus SPB were: 51.2 vs 63.4%, 100 vs 100%, 100 vs 100%, 64.9 vs 72.2% and 74.4 vs 81.3%, respectively. When CNB was combined with SPB, the corresponding values were 88.6, 100, 100, 88.6 and 93.9%, respectively. Whereas sensitivity, NPV and diagnostic accuracy were not significantly different between CNB and SPB, the combination of CNB and SPB significantly improved the sensitivity, NPV and diagnostic accuracy versus each technique alone (p < 0.05). Significant pain (eight patients), moderate haemoptysis (two patients) and chest wall haematomas (two patients) were observed following CNB, while syncope (four patients) and a slight pneumothorax (four patients) were observed following SPB.

Conclusions

Use of a combination of US-guided CNB and SPB afforded a high sensitivity to diagnose MPEs, it is a convenient and safe approach.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0318-x) contains supplementary material, which is available to authorized users.

Ultrasound-Guided Abrams Pleural Biopsy vs CT-Guided Tru-Cut Pleural Biopsy in Malignant Pleural Disease, a 3-Year Follow-up Study

Purpose

Conventional Abrams biopsy shows low sensitivity in suspected malignant pleural disease. There are limited data on the improvement in sensitivity by adding in image guidance. This retrospective study compares the diagnostic sensitivity of Abrams biopsy using ultrasound guidance with CT-guided Tru-Cut biopsy in suspected malignant pleural disease.

Methods

Data were collected from 2006 to 2012 of patients who underwent image-guided biopsies for suspected non-tuberculous pleural disease. Data were collected on the result of the initial biopsy and final patient diagnosis as of June 2015.

Results

Sixty-three patients underwent image-guided Abrams biopsy and 29 underwent CT-guided Tru-Cut biopsies. The sensitivity of Abrams was 71.43 % compared to 75 % in the CT-guided Tru-Cut group. Specificity was 100 % in both groups.

Conclusions

Image-guided Abrams biopsies demonstrate comparable diagnostic sensitivity in malignant pleural disease to CT-guided Tru-Cut biopsy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00408-016-9933-9) contains supplementary material, which is available to authorized users.

A potential role for VEGF in the diagnostic approach of pleural effusions

BACKGROUND

Vascular endothelial growth factor (VEGF) may play a role in pleural fluid formation, as it represents a potent inducer of capillary permeability. We aimed to investigate the diagnostic utility of VEGF levels in pleural fluid and serum in patients with pleural effusions with initially negative diagnostic work up.

METHODS

Seventy-one patients with exudative lymphocytic pleural effusions undiagnosed after initial diagnostic work up were enrolled in this prospective study and their clinical course was followed up to 24 months. VEGF levels were measured in serum and pleural fluid by using immunoenzymometric assay.

RESULTS

During the follow up period, in 43 patients the pleural effusion was eventually attributed to malignancy while in the rest 28 patients it was due to non-malignant causes (benign and unknown origin). Patients with malignancy had significantly higher VEGF levels in pleural fluid compared to patients with non-malignant effusions (1,506 vs. 588 pg/dL, P=0.0001), while no statistically significant difference was found in the VEGF serum levels between the two groups.

CONCLUSIONS

Pleural VEGF levels may be helpful in identifying malignant pleural effusion (MPE) in patients with negative diagnostic work up at the initial assessment and help in selecting patients for more invasive procedures.

Yield of closed pleural biopsy and cytology in exudative pleural effusion

Objective:

To determine diagnostic yield of Closed Pleural Biopsy (CPB) and Cytology in Exudative Pleural Effusion (PE).

Methods:

This prospective comparative study was conducted at Chest Unit-II & Medical Unit-IV of Dow University of Health Sciences, Karachi Pakistan from January 2011 till December 2014.

Results:

Ninety-four patients with exudative PE were finally included. The mean age (SD) was 44.0 (13.8) years. Overall Specific Diagnosis was reached in 76/94 patients; 46 Tuberculosis PE (TPE) & 30 Malignant PE (MPE). CPB diagnosed all TPE patients alone and 28/30 of MPE. Cytology diagnosed only 10/30 patients of MPE with 8 patients having both CPB & Cytology positive for malignancy whereas in the remaining two cases only Cytology positive. The sensitivity of CPB in detecting TPE and MPE was 93.9% and 82.4% respectively whereas specificity for both was 100%. The diagnostic yield of cytology in detecting MPE is only (33.3%). The diagnostic yield of CPB for TPE and MPE is 100% and 93.3% respectively. The overall specific diagnostic yield of CPB is 78.7%.

Conclusion:

CPB is better than pleural fluid cytology alone with the later adding little to diagnostic yield when both combined in distinguishing TPE from MPE, the two main differential of exudative PE in a TB-Endemic country.

Modern management of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a deadly disease that produces a significant worldwide health care burden. The majority of cases are associated with prior asbestos exposure, but recent studies have identified a possible genetic predisposition in a minority of patients. Historically, obtaining a pathologic diagnosis of MPM was challenging, but with current pathological techniques, a secure diagnosis is possible in the majority of patients. Curative therapy for MPM remains elusive, and the primary treatment option for fit patients is platinum-based chemotherapy. Encouraging recent reports suggest that there may be a benefit to the addition of bevacizumab to standard chemotherapy as well as with the use of immune checkpoint inhibitors in MPM. Selected patients may be considered for aggressive surgical approaches, but there is considerable controversy regarding the true benefit of surgery and multimodality therapy in this disease.

Outpatient thoracoscopy: safety and practical considerations

PURPOSE OF REVIEW

Medical thoracoscopy, also known as pleuroscopy, has been utilized by chest physicians for more than a century. Despite this, it has only recently re-emerged as an important tool for interventional pulmonologists to diagnose and treat pleural diseases. The purpose of this review is to critically assess the recent literature related to medical thoracoscopy, specifically as it pertains to its safety and feasibility as an outpatient procedure.

RECENT FINDINGS

Recent data have reaffirmed the clinical utility of medical thoracoscopy and suggest that it can be safely performed in an outpatient setting. A single-center study of 51 patients published in the past year described both the feasibility and safety of outpatient medical thoracoscopy. This study highlights the notion that the majority of patients do not require hospital admission after a routine diagnostic thoracoscopy in the absence of talc poudrage. Another study this year described the successful use of chest physician-directed ultrasound-guided cutting needle biopsy when medical thoracoscopy was not technically possible.

SUMMARY

The contribution of medical thoracoscopy in the diagnosis and management of pleural diseases is increasingly recognized. Evidence supports the routine practice of medical thoracoscopy on an outpatient basis in experienced centers.

Diagnostic value of thyroid transcription factor-1 for pleural or other serous metastases of pulmonary adenocarcinoma: a meta-analysis

The role of thyroid transcription factor 1 (TTF-1) in the diagnosis of metastatic pulmonary adenocarcinomas in pleural, pericardial, and peritoneal effusions has not been defined. This study aimed to assess the overall diagnostic accuracy of TTF-1 for metastatic pulmonary adenocarcinomas in pleural or other effusions. Literature search was conducted in PubMed, EMBASE, and other databases to find eligible publications. Quality was assessed according to standardized QUADAS-2 criteria. Sensitivity, specificity, positive/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR) were pooled. Summary receiver operating characteristic (SROC) curves were used to assess overall performance of the TTF-1 assay. A systematic search revealed 20 studies comprising a total of 1,213 subjects in this meta-analysis. The summary estimates were listed as follows: sensitivity, 0.74 (95% CI: 0.69–0.79); specificity, 0.99 (95% CI: 0.97–1.00); PLR, 78.16 (95% CI: 27.15–225.05); NLR, 0.26 (95% CI: 0.22–0.32); and diagnostic odds ratio, 297.75 (95% CI: 104.16–851.19). Estimated positive and negative post-probability values for metastatic pulmonary adenocarcinomas prevalence of 20% were 95% and 6%, respectively. The area under the SROC curve was 0.96. TTF-1 shows significant potential as a diagnostic marker to differentiate metastatic pulmonary from non-pulmonary adenocarcinomas in pleural or other effusions. These results justify larger, more rigorous studies to confirm such a diagnostic role.

An Autopsied Case of Malignant Sarcomatoid Pleural Mesothelioma in Which Chest Pain Developed Several Months Earlier without Abnormality on Imaging

The patient experienced chest pain for about 7 months, but a diagnosis could not be made until after death. He was diagnosed with malignant sarcomatoid pleural mesothelioma on autopsy. In this case report, difficult aspects of the diagnosis are discussed. The 70-year-old Japanese man was a driver who transported ceramic-related products. Right chest pain developed in July 2013, but no abnormality was detected on a chest computed tomography (CT) performed in September 2013, and the pain was managed as right intercostal neuralgia. A chest CT performed in late October 2013 revealed a right pleural effusion, and the patient was referred to our hospital in early November 2013. Thoracentesis was performed, but the cytology was negative, and no diagnosis could be made. Close examination was postponed because the patient developed a subarachnoid hemorrhage. He underwent ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) after discharge from the neurosurgery department, and extensive right pleural thickening and ¹⁸F-FDG accumulation in this region were observed. Based on these findings, malignant pleural mesothelioma was suspected, and a thoracoscopy was performed under local anesthesia in early December 2013, but no definite diagnosis could be made. The patient selected best supportive care and died about 7 months after the initial development of right chest pain. The disease was definitively diagnosed as malignant sarcomatoid pleural mesothelioma by a pathological autopsy. When chronic chest pain of unknown cause is observed and past exposure to asbestos is suspected, actions to prevent delay in diagnosis should be taken, including testing for suspicion of malignant pleural mesothelioma.

Delayed onset of benign pleural effusion following concurrent chemoradiotherapy for inoperable non-small-cell lung cancer

Chronic benign pleural effusion (BPE) is a rare complication of concurrent chemoradiotherapy (CRT) for inoperable stage IIIA non-small-cell lung cancer (NSCLC). This report presents three cases of BPE, the workup to differentiate this benign condition from recurrence of cancer and recommends a pleural biopsy as part of the diagnostic process. These inflammatory exudates often remain indolent, and may not require drainage or surgical intervention. In the absence of clinical, radiological and pathological evidence of recurrent disease, we recommend clinicians manage these patients expectantly, using regular clinical assessment and imaging.

A pilot study of autofluorescence in the diagnosis of pleural disease

BACKGROUND

Conventional medical thoracoscopy (MT), routinely performed in patients with pleural disease, does not always lead to a conclusive diagnosis. The endoscopic appearance of pleural diseases under white light could be misleading. Autofluorescence has been shown to be an interesting and effective diagnostic tool. The objective of this study was to evaluate the diagnostic value of autofluorescence imaging during MT.

METHODS

Patients with undiagnosed pleural effusion admitted to our clinical center between August 2013 and February 2014 were enrolled. MT was performed first with white light and then by autofluorescence. Endoscopic results of different diseases were recorded, and biopsy specimens were obtained for pathologic analysis. We calculated the diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the two methods by comparing them with the pathologic results.

RESULTS

Thirty-seven eligible patients were studied, including 21 with malignancy, nine with tuberculous pleurisy, three with infective pleurisy, and four with no diagnosed condition. Autofluorescence revealed additional malignant lesions, which were missed under white light in five patients. The diagnostic sensitivity and NPV of autofluorescence were 100% (95% CI, 98.5%-100%) and 100% (95% CI, 93.9%-100%), respectively. Autofluorescence was superior to white light, with a sensitivity of 92.8% (95% CI, 89.3%-95.3%) and NPV of 76.8% (95% CI, 67.0%-84.4%). For the specificity and PPV, no significant difference was found.

CONCLUSIONS

The advantage of autofluorescence is its high sensitivity and NPV. It is useful to detect microlesions and delineate the pathologic margins. Autofluorescence can benefit patients with its better visualization.

Transcutaneous pleural biopsy with a retrograde forceps: a novel approach

PURPOSE

Pleural biopsies are commonly performed to investigate the cause of exudative pleural effusion. Biopsy needles (e.g. Abrams needle, Cope needle) are traditionally used to perform the biopsy. However, certain complications such as pneumothorax and haemothorax have been described. We present a technique utilizing a novel retrograde forceps, which could improve the simplicity and lower the complication rate of performing closed pleural biopsies.

DESCRIPTION

A retrograde forceps (Retroforceps, Karl Storz, Tuttlingen, Germany) was used to perform 20 transcutaneous pleural biopsies in a cadaver thorax under thoracoscopical control. Video documentation of the procedure from outside and inside the thorax was performed. The surgeon performing the biopsy was blinded to the thoracoscopical view. After the removal of the forceps, it was checked whether biopsy material was retrieved. The video material was retrospectively used to confirm whether the biopsy was taken from the pleura parietalis.

EVALUATION

Biopsy material was retrieved in 19 out of 20 biopsy attempts. Video material confirmed that the biopsy was taken from the pleura parietalis in all cases.

CONCLUSIONS

Using a retrograde biopsy forceps is a simple and practicable procedure suitable for clinical application. This technique could potentially reduce the incidence of pneumothorax.

Pleural fluid adenosine deaminase (pfADA) in the diagnosis of tuberculous effusions in a low incidence population

INTRODUCTION

Previous studies have assessed the diagnostic ability of pleural fluid adenosine deaminase (pfADA) in detecting tuberculous pleural effusions, with good specificity and sensitivity reported. However, in North Western Europe pfADA is not routinely used in the investigation of a patient with an undiagnosed pleural effusion, mainly due to a lack of evidence as to its utility in populations with low mycobacterium tuberculosis (mTB) incidence.

METHODS

Patients presenting with an undiagnosed pleural effusion to a tertiary pleural centre in South-West England over a 3 year period, were prospectively recruited to a pleural biomarker study. Pleural fluid from consecutive patients with robust 12-month follow up data and confirmed diagnosis were sent for pfADA analysis.

RESULTS

Of 338 patients enrolled, 7 had confirmed tuberculous pleural effusion (2%). All mTB effusions were lymphocyte predominant with a median pfADA of 72.0 IU/L (range- 26.7 to 91.5) compared to a population median of 12.0 IU/L (range- 0.3 to 568.4). The optimal pfADA cut off was 35 IU/L, which had a negative predictive value (NPV) of 99.7% (95% CI; 98.2-99.9%) for the exclusion of mTB, and sensitivity of 85.7% (95% CI; 42.2-97.6%) with an area under the curve of 0.88 (95% CI; 0.732-1.000).

DISCUSSION

This is the first study examining the diagnostic utility of pfADA in a low mTB incidence area. The chance of an effusion with a pfADA under 35 IU/L being of tuberculous aetiology was negligible. A pfADA of over 35 IU/L in lymphocyte-predominant pleural fluid gives a strong suspicion of mTB.

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.

Role of blind closed pleural biopsy in the managment of pleural exudates

INTRODUCTION

The performance of blind closed pleural biopsy (BCPB) in the study of pleural exudates is controversial.

OBJECTIVE

To assess the diagnostic yield of BCPB in clinical practice and its role in the study of pleural exudates.

METHODS

Data were retrospectively collected on all patients who underwent BCPB performed between January 1999 and December 2011.

RESULTS

A total of 658 BCPBs were performed on 575 patients. Pleural tissue was obtained in 590 (89.7%) of the biopsies. A malignant pleural effusion was found in 35% of patients. The cytology and the BCPB were positive in 69.2% and 59.2% of the patients, respectively. Of the patients with negative cytology, 21 had a positive BCPB (diagnostic improvement, 15%), which would have avoided one pleuroscopy for every seven BCPBs that were performed. Of the 113 patients with a tuberculous effusion, granulomas were observed in 87 and the Lowenstein culture was positive in an additional 17 (sensitivity 92%). The overall sensitivity was 33.9%, with a specificity and positive predictive value of 100%, and a negative predictive value of 71%. Complications were recorded in 14.4% of patients (pneumothorax 9.4%; chest pain 5.6%; vasovagal reaction, 4.1%; biopsy of another organ 0.5%).

CONCLUSIONS

BCPB still has a significant role in the study of a pleural exudate. If an image-guided technique is unavailable, it seems reasonable to perform BCPB before resorting to a pleuroscopy. These results support BCPB as a relatively safe technique.

Clinical characteristics, treatment and survival outcomes in malignant mesothelioma: eighteen years' experience in Turkey

BACKGROUND

Malignant mesothelioma (MM) is an insidious tumor with poor prognosis, arising from mesothelial surfaces such as pleura, peritoneum and pericardium. We here aimed to evaluate the demographic, clinical, and radiological features of patients with MM followed in our center as well as their survival.

METHODS

The study included 228 patients (131 male, 97 female) who were followed up in our institution between 1993 and 2010 with the diagnosis of MM.

RESULTS

The mean age was 59.1 years in men and 58.7 years in women and the sex ratio was 1.4:1 in favor of males. Environmental asbestos exposure was present in 86% of the patients for a mean duration of 40±20 years (range: 3-70). Pleural effusion and thoracic/abdominal pain were the most common presenting signs and symptoms (70.2% and 57.8%, respectively). One hundred-thirteen (66%) patients were treated with platinum-based combination chemotherapy (PBCT) plus supportive care (SC) and 67 (34%) patients received SC alone. The median follow-up time was 10.0 months. The median overall survival was significantly improved with PBCT plus SC compared to SC alone (11.4 vs. 5.1 months; p=0.005). The 6, 12, 18, and 24-month survival rates were significantly improved with PBCT plus SC compared to SC alone (72%, 43%, 19%, and 2% vs. 49%, 31%, 11%, and 1%).

CONCLUSION

The survival of patients with MM improved in patients treated with PBCT. The survival advantage continued 12- and 24-month after the initial time of combination chemotherapy.

Pleural effusion: diagnosis, treatment, and management

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.

Fluorescence thoracoscopy in the detection of pleural malignancy

OBJECTIVE

Conventional thoracoscopy, routinely performed in patients with pleural diseases, is not always conclusive in staging of pleural spread. Fluorescence diagnosis (FD) with 5-aminolaevulinic acid (5-ALA) has been used in the diagnostic purpose for various malignancies. The impact of fluorescence thoracoscopy on diagnosis and staging of pleural malignancies was examined.

METHODS

A total of 23 patients with non-conclusive pleural effusions were enrolled in the prospective single-institution trial. Eligible patients were administered 25 mg/kg of 5-ALA ('Alasense', Niopik, Russian Federation) per os 3 h before video-assisted thoracoscopy. After conventional inspection with white light, thorough fluorescence investigation of the visceral and parietal pleura was performed (D-LIGHT Auto Fluorescent System, Karl Storz, Germany). Biopsy specimens of both normal and abnormal sites, as determined from white-light and FD inspection, were obtained for histological examination.

RESULTS

There was no morbidity or mortality due to the procedure. A definitive diagnosis was obtained in all cases: malignant mesothelioma in 13 cases, other malignancies (pleural metastases) in 8 cases and non-specific inflammation in 3 patients. A total of 118 biopsy specimens were available for histological examination. In 20 patients, all pleural deposits (n = 60) detected by white-light thoracoscopy had bright red fluorescence during FD and were proved to be malignant. Upstaging occurred in 12 patients (57.2%) (unsuspected 21 tumour deposits) due to FD examination. Micrometastases of macroscopically normal pleura were detected, only by FD, in one patient. Comparing the results of histological examination of specimens detected by conventional thoracoscopy with that by fluorescence thoracoscopy, we obtained 82 true positive, 10 false-negative, 23 true negative, 3 false-positive results with a specificity of 88.4%, sensitivity of 89.1% and diagnostic accuracy of 88.9%.

CONCLUSIONS

FD using 5-ALA in the pleural cavity is a feasible diagnostic tool when used in addition to white-light thoracoscopy. It improves visualization of additional lesions or even micrometastases in patients with pleural malignancy.

Diagnostic molecular biomarkers for malignant pleural effusions

Malignant pleural effusions (MPEs) are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive tests is important because the median survival after diagnosis is only 4–9 months. Pleural fluid cytology is pivotal to current MPE diagnostic algorithms but has limited sensitivity (30–60%). Consequently, many patients need to undergo invasive diagnostic tests such as thoracoscopic pleural biopsy. Recent genomic, transcriptomic, methylation and proteomic studies on cells within pleural effusions have identified novel molecular diagnostic biomarkers that demonstrate potential in complementing cytology in the diagnosis of MPEs. Several challenges will need to be addressed prior to the incorporation of these molecular tests into routine clinical diagnosis, including validation of molecular diagnostic markers in well-designed prospective, comparative and cost–effectiveness studies. Ultimately, minimally invasive diagnostic tests that can be performed quickly will enable clinicians to provide the most effective therapies for patients with MPEs in a timely fashion.

Diagnosis of pleural effusion: a systematic approach

In most diseases related to pleural effusion, the fluid analysis yields important diagnostic information, and in certain cases, fluid analysis alone is enough for diagnosis. The many important characteristics of pleural fluid are described, as are other complementary investigations that can assist with the diagnosis of common and rare pleural effusions. For a systematic review of pleural effusion, a literature search for articles on the practical investigation and diagnosis of pleural effusion was done. Articles included guidelines, expert opinion, experimental and nonexperimental studies, literature reviews, and systematic reviews published from May 2003 through June 2009. The search yielded 1 guideline, 2 meta-analyses, 9 literature reviews, 1 randomized control trial, and 9 clinical studies. On the basis of class IIa or class I evidence from these articles, a step by step approach is recommended for investigating a pleural effusion, beginning with assessment of the medical history, clinical examination, radiology, pleural fluid evaluation, and finally, if no diagnosis is forthcoming, a pleural biopsy under image guidance or thoracoscopy.

Biopsy techniques for the diagnosis of mesothelioma

The incidence of mesothelioma continues to increase in the Western world and is likely to do so until 2011-2015. It commonly presents with breathlessness secondary to a pleural effusion, and whilst guidelines still advise thoracocentesis as the first line investigation, the sensitivity of this is low and a tissue diagnosis is usually required. Abrams needle biopsy also has a low diagnostic yield and high complication rate and is not recommended in guidelines on the investigation of mesothelioma. Computed tomography-guided biopsy or thoracoscopy both have a comparable sensitivity and low complication rates. Local anaesthetic thoracoscopy is increasingly used by respiratory physicians and has a comparable diagnostic sensitivity to Video-Assisted Thoracoscopic Surgery (VATS) without the need for a general anaesthetic. The requirement for prophylactic radiotherapy after pleural procedures in cases of mesothelioma is contentious, as the results from early trials suggesting it reduces tract seeding have been disputed by more recent trials.

[Ultrasound in chest disease]

In the past few years transthoracic ultrasound has been recognized as an important tool for chest physicians. At present, ultrasound devices are practical, portable, easy to use and reliable, which makes them suited for diagnostic investigations as well as for therapeutic procedures guidance. Basic ultrasound technical expertise is required to assess pleural effusions and perform ultrasound -guided thoracentesis. More complex procedures can be done with specific training and include assistance to chest drain insertion and identification with potential biopsy of thoracic lesions. The authors aim to review, in a practical approach, the technique and recent developments in this field. Clinical cases are presented in order to illustrate and guide the beginner in chest ultrasound.

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.

Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial

BACKGROUND

In cases of pleural effusion, tissue samples can be obtained through Abrams needle pleural biopsy (ANPB), thoracoscopy, or cutting-needle pleural biopsy under the guidance of CT scan (CT-CNPB) for histopathologic analysis. This study aimed to compare the diagnostic efficiency and reliability of ANPB under CT scan guidance (CT-ANPB) with that of medical thoracoscopy in patients with pleural effusion.

METHODS

Between January 2006 and January 2008, 124 patients with exudative pleural effusion that could not be diagnosed by cytologic analysis were included in the study. All patients were randomized after the CT scan was performed. Patients either underwent CT-ANPB or thoracoscopy. The two groups were compared in terms of diagnostic sensitivity and complications associated with the methods used.

RESULTS

Of the 124 patients, malignant mesothelioma was diagnosed in 33, metastatic pleural disease in 47, benign pleural disease in 42, and two were of indeterminate origin. In the CT-ANPB group, the diagnostic sensitivity was 87.5%, as compared with 94.1% in the thoracoscopy group; the difference was not statistically significant (P = .252). No difference was identified between the sensitivities of the two methods based on the cause, the CT scan findings, and the degree of pleural thickening. Complication rates were low and acceptable.

CONCLUSION

We recommend the use of CT-ANPB as the primary method of diagnosis in patients with pleural thickening or lesions observed by CT scan. In patients with only pleural fluid appearance on CT scan and in those who may have benign pleural pathologies other than TB, the primary method of diagnosis should be medical thoracoscopy.

TRIAL REGISTRATION

clinicaltrials.gov; Identifier: NCT00720954.

Pneumothorax, pneumomediastinum and subcutaneous emphysema following closed percutaneous pleural biopsy: a case report

Minimally invasive investigations, such as pleural fluid cytological assessment and closed percutaneous pleural biopsy, are often performed first in the investigation of suspected malignant pleural effusions. Malignant pleural effusions can be diagnosed with pleural fluid cytology alone in most cases; however, closed pleural biopsy is performed to increase the diagnostic yield when pleural fluid cytology is negative. This additional yield is at the expense of increased complication rates. We report a 64-year old man with a negative pleural fluid cytology but suspected malignant pleural effusion who underwent a closed pleural biopsy, which was complicated by pneumothorax, pneumomediastinum and severe subcutaneous emphysema. Pulmonary laceration by the pleural biopsy needle is the most likely aetiology of these complications. Our case report highlights an infrequent but significant complication of closed percutaneous pleural biopsy.

Clinical Quiz 2 A Young Male with Fever and Abdominal Chest X-Ray

A 28- year old male from Nepal presented with history of fever, right-sided chest pain for the last four weeks. During admission some investigations were carried out.

Diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.