Medical Thoracoscopy vs CT Scan-Guided Abrams Pleural Needle Biopsy for Diagnosis of Patients With Pleural Effusions: A Randomized, Controlled Trial

doi:10.1378/chest.09-0884

Chest

Volume 137, Issue 6, June 2010, Pages 1362-1368

https://doi.org/10.1378/chest.09-0884 Get rights and content

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.

Section snippets

Materials and Methods

This prospective, randomized, parallel study was conducted in the Chest Diseases Department of the Medical Faculty of Eskisehir Osmangazi University from January 2006 to January 2008. The study was approved by the Ethical Committee of Eskisehir Osmangazi University Medical Faculty (2006-06-07 and 2006/387).

Results

The total number of patients included in the study was 124, with 72 men and 52 women; the mean age was 60.9 ± 13.5 years. The distribution of diagnoses for patients included in the study is shown in Table 1.

The randomization diagram-trial profile of patients in the study is shown in Figure 2. Thoracoscopy was performed on 62 patients, 33 (53%) men and 29 (47%) women. The mean age was 61.1 ± 14.3 years (r, 27–85). CT-ANPB was performed on 62 patients, 39 (63%) men and 23 (37%) women. The mean

Discussion

Although CT-CNPB and medical thoracoscopy have a higher diagnostic yield than closed pleural biopsy in malignant disease, both are more expensive and time consuming.16, 18, 19, 20 Image-guided pleural biopsy, on the other hand, can be performed in outpatient conditions9, 10, 19 and can be used in patients without pleural effusion. It requires an experienced radiologist, a disposable cutting biopsy needle, and extra use of CT scanning, and it must be performed in the radiology department. As an

Acknowledgments

Author contributions: Dr M. Metintas: contributed to the idea for and design of the study, performing thoracoscopy, and drafting and editing of the manuscript.

Dr Ak: contributed to the idea for and design of the study and performing thoracoscopy.

Dr Dundar: contributed to performing histopathologic studies on biopsy samples of the patients.

Dr Yildirim: contributed to performing thoracoscopy.

Dr Ozkan: contributed to investigating CT scans of the patients.

Dr Kurt: contributed to managing the

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El mesotelioma es una neoplasia poco frecuente y con mal pronóstico que se relaciona con la exposición al asbesto y cuyo pico de incidencia en Europa se estima a partir del año 2020. Su diagnóstico es complejo, siendo fundamentales las técnicas de imagen y la realización de técnicas invasivas pleurales para la confirmación anatomopatológica. En la bibliografía médica se recogen las distintas rentabilidades diagnósticas de estas técnicas invasivas. El presente trabajo consistió en revisar cómo se llegó al diagnóstico definitivo de casos de mesotelioma de nuestro centro para comprobar si existía concordancia con los datos de la bibliografía.
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Se revisaron 26 casos de mesotelioma (22 hombres y 4 mujeres). Edad media de 74 años. Nueve pacientes tenían antecedentes de exposición al asbesto. El derrame pleural moderado-importante fue el hallazgo radiológico más frecuente (23/26). La sensibilidad de las técnicas invasivas fue del 13% para la citología, del 11% para la biopsia sin guía de imagen, del 93% para la biopsia guiada por técnicas de imagen y del 67% para la biopsia quirúrgica.
En nuestra revisión la biopsia pleural guiada con técnicas de imagen fue la prueba que tuvo mayor rentabilidad diagnóstica, por lo que habría que considerarla como la prueba invasiva inicial para el estudio del mesotelioma.
Mesothelioma is an infrequent neoplasm with a poor prognosis that is related to exposure to asbestos and whose peak incidence in Europe is estimated from 2020. Its diagnosis is complex, imaging techniques and the performance of invasive pleural techniques being essential for pathological confirmation. The different diagnostic yields of these invasive techniques are collected in the medical literature. The present work consisted of reviewing how the definitive diagnosis of mesothelioma cases in our center was reached to check if there was concordance with the data in the bibliography.
Retrospective review of patients with a diagnosis of pleural mesothelioma in the period 2019-2021, analyzing demographic data and exposure to asbestos, the semiology of the radiological findings and the invasive techniques performed to reach the diagnosis.
Twenty-six mesothelioma cases were reviewed (22 men and 4 women). Median age 74 years. Nine patients had a history of asbestos exposure. Moderate-severe pleural effusion was the most frequent radiological finding (23/26). The sensitivity of the invasive techniques was as follows: cytology 13%, biopsy without image guidance 11%, image-guided biopsy 93%, surgical biopsy 67%.
In our review, pleural biopsy performed with image guidance was the test that had the highest diagnostic yield, so it should be considered as the initial invasive test for the study of mesothelioma.
Pleural Malignancy–Challenges in Diagnosis and Multidisciplinary Approach
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El derrame pleural se define como la acumulación de líquido en el espacio pleural. La insuficiencia cardíaca congestiva es su causa más frecuente. Los derrames pleurales pueden clasificarse según sus características bioquímicas en trasudados o exudados, y según su etiología. La clínica más frecuente es el dolor de características pleuríticas de inicio agudo y habitualmente unilateral, y la disnea de esfuerzo. Como signos clínicos puede observarse durante la auscultación una disminución de las vibraciones vocales, la abolición o disminución del murmullo vesicular o percusión mate. Para el diagnóstico etiológico es fundamental una buena historia clínica y exploración física, unido a pruebas de imagen y técnicas invasivas. El abordaje terapéutico variará en función de la etiología para realizar un tratamiento dirigido.
Pleural effusion is defined as the accumulation of fluid in the pleural space. Congestive heart failure is the most common cause. Pleural effusion can be classified according to its biochemical characteristics in transudates or exudates and according to its etiology. The most frequent symptom is pain of pleuritic characteristics that has an acute onset and is usually unilateral as well as dyspnea on exertion. In regard to clinical signs, a decrease in vocal vibrations, an absence or decrease in vesicular breath sounds, or dull percussion can be observed during auscultation. A good medical history and physical examination together with imaging tests and invasive techniques are fundamental for the etiological diagnosis. The treatment approach will vary based on the etiology in order to provide targeted treatment.
The role of an interventional pulmonologist in the management of metastatic pleural effusions (MPE)
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Un épanchement pleural lié à une cause maligne survient chez 20 % de tous les patients atteints de cancer et laisse généralement présager un mauvais pronostic, tout en limitant la qualité de vie du patient. Le diagnostic et la palliation des symptômes est le but de la prise en charge de ces épanchements, tout en minimisant la durée de son hospitalisation pour améliorer sa qualité de vie. Traditionnellement, cela était réalisé par une ponction et/ou une biopsie pleurale suivi d’un drainage thoracique avec l’instillation d’agents sclérosants dans l’espace pleural, en cas de récidive de l’épanchement. Récemment, l’émergence des nouvelles méthodes telles que la biopsie échoguidée, la réalisation de plus en plus courante de la thoracoscopie médicale, ainsi que les cathéters pleureux à demeure ont modifié la prise en charge des pleurésies malignes. L’objectif de cette revue de la littérature est de préciser le rôle du pneumologue interventionnel dans la gestion des pleurésies malignes en se référant aux divers moyens diagnostiques et thérapeutiques qu’il doit posséder actuellement.
An interventional pulmonologist possesses expertise in minimally invasive diagnostic and therapeutic procedures involving the airways, lungs and pleura. A malignant pleural effusion (MPE), which occurs in 20% of cancer patients, can be a daunting diagnostic challenge insofar as the pleural cavity is a closed cavity. In these patients, treatment may consequently be delayed before a precise diagnosis can be given. In the meantime, an interventional pulmonologist is called upon to carry out a wide range of examinations in order to establish the etiological diagnosis and to treat the symptoms of an MPE patient. Classical medical thoracoscopy, also called “pleuroscopy”, is the reference method in MPE diagnosis because it allows visualization of the pleural cavity, pleural biopsy under direct visual control, providing excellent diagnostic yield. Over the past decade, new diagnostic methods have emerged, such as ultrasound-guided biopsy, as well as different interventions, such as indwelling pleural catheters, aimed at improving the quality of life of MPE patients, for whom therapeutic options are limited. The objective of this review of the literature is to point out the role of the interventional pulmonologist in the management of MPE by detailing the various diagnostic and therapeutic methods he possesses at the present time.
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This article summarizes the clinical guidelines for the diagnosis and treatment of malignant pleural effusion (MPE) sponsored by the Spanish Society of Thoracic Surgery (SECT). Ten clinical controversies were elaborated under the methodology of PICO (Patient, Intervention, Comparison, Outcome) questions and the quality of the evidence and grading of the strength of the recommendations was based on the GRADE system. Immunocytochemical and molecular analyses of pleural fluid may avoid further invasive diagnostic procedures. Currently, the definitive control of MPE can be achieved either by pleurodesis (talc poudrage or slurry) or the insertion of a indwelling pleural catheter (IPC). It is likely that the combination of both techniques (i.e., thoracoscopy with talc poudrage and insertion of a IPC, or instillation of talc slurry through a IPC) will have a predominant role in the future therapeutic management.
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Citation Excerpt :
Sensitivity remains high (90.1%) even in patients who first had a nondiagnostic “blind” pleural biopsy.63 When comparing image-guided biopsy (Abrams Needle) versus MT, the sensitivity for MT was increased but not statistically significantly so.64 MT with local anesthetic has a low rate of complication and mortality despite the invasive nature of the procedure.

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Funding/Support: This study has been supported by the Research Fund of Eskisehir Osmangazi University (Project Number: 2007-11.008).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

ORIGINAL RESEARCHPLEURAL DISEASEMedical Thoracoscopy vs CT Scan-Guided Abrams Pleural Needle Biopsy for Diagnosis of Patients With Pleural Effusions: A Randomized, Controlled Trial

Background

Methods

Results

Conclusion

Trial registration

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Chest

Mayo Clin Proc

Lancet

Chest

Lancet

Chest

Clin Radiol

Clin Radiol

Chest

Chest

Eur J Radiol

ORIGINAL RESEARCH
PLEURAL DISEASE
Medical Thoracoscopy vs CT Scan-Guided Abrams Pleural Needle Biopsy for Diagnosis of Patients With Pleural Effusions: A Randomized, Controlled Trial