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Medical thoracoscopy versus image-guided pleural biopsy for diagnosing pleural diseases
Emad Ibrahima, Rasha Daabisa, Alaa Abdallaha, Amr Abdelkerimb, Mervat A. Ismaila Departments of aChest Diseases, bDiagnostic Radiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt Correspondence to Rasha Daabis, MD, Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, 2152, Egypt. Tel: +20 122 458 2538; e-mails;
[email protected],
[email protected] Received 10 November 2017 Accepted 10 November 2017 The Egyptian Journal of Chest Diseases and Tuberculosis 2018, 67:79–86
Background The diagnostic role of medical thoracoscopy and image-guided pleural biopsy in patients with undiagnosed exudative pleural effusion has increased over the last few years. Objective The aim was to compare the efficacy and safety of medical thoracoscopy versus image-guided [ultrasound (US) and computed tomography] pleural biopsy in the diagnosis of pleural lesions. Patients and methods A total of 40 patients with undiagnosed pleural lesions were divided into two groups. After full investigations, pleural biopsies were taken by medical thoracoscopy and the image-guided technique in groups I and II, respectively. Results In group I, the results of 19 (95%) patients yielded a positive diagnosis, whereas in group II, the results of 17 (85%) patients yielded a positive diagnosis (where results were positive in 80% of US-guided biopsies and 90% in computed tomographyguided biopsies), with no significant difference in the diagnostic yield of the two groups. The US-guided biopsy showed significantly the least duration (P=0.001). Complications were significantly fewer in the image-guided biopsy group (P=0.008). The mean duration of hospital stay was significantly less in the image-guided group than in the medical thoracoscopy group (P=0.001). In conclusion, the overall diagnostic yield is comparably high for medical thoracoscopy and image-guided pleural biopsies, and both are complementary techniques used in different clinical situations. Each diagnostic procedure has its own advantages and disadvantages. Image-guided biopsy is less invasive and can be carried out as an outpatient procedure, whereas medical thoracoscopy provides diagnostic and therapeutic capabilities in one setting. Keywords: computed tomography of chest, image-guided biopsies, medical thoracoscopy, pleural diseases, pleural effusion, thoracic ultrasound Egypt J Chest Dis Tuberc 67:79–86 © 2018 The Egyptian Journal of Chest Diseases and Tuberculosis 2090-9950
Introduction Pleural diseases, whether of inflammatory or malignant etiology, commonly result in pleural effusions. However, around 20% of exudative pleural effusions remain undiagnosed even after thoracentesis and chemical, bacteriological, or cytological analysis [1–3]. An undiagnosed exudative pleural effusion is a common diagnostic dilemma and pleural biopsy is essential for the definite determination of the underlying etiology [4,5]. Multiple biopsy techniques are available for diagnosing pleural diseases. They range from older techniques, including blind or closed pleural biopsy, to newer techniques such as image-guided and thoracoscopic biopsy [6–8]. Indications for pleural biopsy include recurrent pleural effusion of unknown etiology as well as pleural mass or
thickening. Ultrasonography (US) or computed tomography (CT) guidance has increasingly been used to increase the procedural yield of pleural biopsy owing to the ability to visualize abnormal pleural areas and precisely target the biopsy. US has the advantage of assessing loculated pleural effusions and providing a real-time approach to the biopsy with no risk of radiation. CT guidance enables better visualization of the extent of focal pleural masses, besides a clearer delineation of parenchymal pathology [9–12]. The advantage of thoracoscopy instrumentation is that it has the ability to directly visualize the pleural space This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
© 2018 The Egyptian Journal of Chest Diseases and Tuberculosis | Published by Wolters Kluwer - Medknow
DOI: 10.4103/ejcdt.ejcdt_13_17
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and a therapeutic intervention can be performed in the same session, in addition to enabling the diagnostic biopsy of the pleura [13–23]. Aim The aim of this study was to evaluate the diagnostic yield of thoracoscopic compared with image-guided pleural biopsies. Patients and methods Study population
All subjects were enrolled in the study after a written informed consent according to a protocol approved by the Ethics Committee of the Hospital. The patients were divided randomly into two groups as follows: (1) Group I: medical thoracoscopy biopsies were obtained from the suspicious pleural lesions for histopathological examination. (2) Group II: image-guided biopsies were obtained from the suspicious pleural lesions for histopathological examination. Ten of them were obtained by US guidance and the other ten were obtained by CT guidance. Clinical assessment
All the patients included were subjected to a full assessment of history, full clinical examination including general and local chest examination, and routine laboratory and radiological evaluations. In case of pleural effusion, thoracentesis and pleural fluid analysis were carried out. Medical thoracoscopy
Medical thoracoscopy was performed in group I using a rigid thoracoscope (Fig. 1) under local anesthesia with moderate sedation, which was quite well tolerated by the patients. In a few cases, general anesthesia was administered by an anesthesiologist through a
laryngeal mask when patients refused local anesthesia and moderate sedation. Biopsy specimens were obtained from abnormal areas of the parietal pleura. After fixation in formalin, they were sent for histopathological analysis and bacteriologic investigation. Image-guided biopsies
Image-guided biopsies in group II were performed mainly in the intervention suite of the radiology department. USguided biopsy in the current study was performed under local anesthesia for all cases. CT-guided biopsy in the current study was performed under local anesthesia with moderate sedation. An area of pleural abnormality was identified using US or CT imaging. The Automated cutting needle devices were used, and three or more samples were obtained to ensure adequate pleural tissue for histopathological diagnosis (Figs 2–5). Results Diagnostic yield
In group I, the results of 19 (95%) patients were positive and only one result was negative (5%). In group II, the results of 17 (85%) patients were positive and three (15%) results were negative (Table 1). According to the results of the histopathological examination of pleural biopsies obtained through medical thoracoscopy or imageguided pleural biopsy, metastatic adenocarcinoma and malignant mesothelioma were the most common pathological results among the patients studied. Table 2 shows a comparison between the different studied groups according to the pathological type of each biopsy. The diagnostic yield was high for medical thoracoscopy and image-guided pleural biopsies, with no statistically significant difference. Duration of the procedure
In group I, the mean duration of the procedure was 27.15 min (SD: 3.57), with a minimum of 22.0 and a maximum of 37.0 min (Table 3).
Figure 1
In group II: (1) Group 1 (CT-guided pleural biopsy): the mean duration of the procedure was 50.30 min (SD: 6.57), with a minimum of 40 and a maximum of 60 min. (2) Group 2 (US-guided pleural biopsy): the mean duration of the procedure was 10.60 (SD: 4.01), with a minimum of 6 and a maximum of 18 min.
Rigid medical thoracoscopy.
The US-guided biopsy showed significantly the least duration followed by medical thoracoscopy (P=0.001).
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Figure 2
Pleural biopsy steps.
Figure 3
Figure 4
Computed tomography-guided pleural biopsy steps.
Ultrasound-guided pleural biopsy steps.
Complications
tube removal after thoracoscopy was 2 days for uncomplicated cases and the maximum was 15 days for complicated cases, with a mean duration of 5.85 days (SD: 4.52 days). In group II, the minimum number of days of hospital stay was 1 day; thus, it can be considered an outpatient procedure. The maximum number of days of hospital stay was 8 days for the complicated cases, with a mean duration of 2.25 days (SD: 1.86 days) and a median of 2.0 days.
Table 4 shows a comparison of the groups studied in terms of postprocedural complications. The comparison showed a statistically significant difference, where imageguided biopsy yielded fewer complications (P=0.008). Trapped lung was recorded in four (20%) patients in group I, whereas empyema was found in two (10%) patients and wound infection occurred in one (5%) patient. However, hydropneumothorax was recorded in only two (10%) cases in group II, which required tube drainage. Hospital stay
Table 5 shows a comparison between the different studied groups according to the duration of hospital stay. The comparison showed a statistically significant difference, where image-guided pleural biopsies required lower duration of hospital stay (0.001). In group I, the minimum number of days needed for chest
Discussion Pleural biopsies are often required in the workup of undiagnosed pleural effusions. Various techniques are available for the acquisition of pleural tissues for diagnosis. Traditional techniques included blind or closed pleural biopsy, whereas newer ones included image-guided and thoracoscopic biopsy. The advantage of thoracoscopic instrumentation is direct visualization of
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Figure 5
Computed tomography-guided pleural biopsy steps.
Table 1 Comparison of the different studied groups according to the diagnostic yield Results
Group I: thoracoscopy (n=20) [n (%)]
Group II [n (%)] US guided (n=10)
CT guided (n=10)
Total (n=20)
Negative
1 (5.0)
2 (20.0)
1 (10.0)
5 (15.0)
Positive
19 (95.0)
8 (80.0)
9 (90.0)
17 (85.0)
1.000
0.605
0.251
P1
1.000
P2
CT, computed tomography; P1, P value for comparison between group I and each other group; P2, P value for comparison between USguided and CT-guided biopsy; US, ultrasound. Table 2 Comparison between the different studied groups according to the pathological diagnosis Biopsy
Group I: thoracoscopy (n=20) [n (%)]
Group II [n (%)] US guided (n=10)
CT guided (n=10)
Total (n=20)
Negative biopsy
1 (5.0)
1 (10.0)
2 (20.0)
3 (15.0)
Malignant mesothelioma
4 (20.0)
2 (20.0)
2 (20.0)
4 (20.0)
Metastatic adenocarcinoma
11 (55.0)
4 (40.0)
5 (50.0)
9 (45.0)
Non-Hodgkin’s lymphoma
1 (5.0)
0 (0.0)
0 (0.0)
0 (0.0)
Benign mesothelioma
1 (5.0)
0 (0.0)
0 (0.0)
0 (0.0)
Metastatic sarcomatous tumor Caseating granuloma
0 (0.0) 1 (5.0)
0 (0.0) 2 (20.0)
1 (10.0) 0 (0.0)
1 (5.0) 2 (10.0)
Metastatic clear cell carcinoma
1 (5.0)
0 (0.0)
0 (0.0)
0 (0.0)
Chronic noncaseating granuloma
0 (0.0)
1 (10.0)
0 (0.0)
1 (5.0)
CT, computed tomography; US, ultrasound.
the pleural space and the possibility to perform a therapeutic intervention in the same session [7,10,12,14,16,24]. The current study was prospective in design. It enrolled 40 patients with undiagnosed pleural effusions in the period from November 2015 to October 2016. Medical thoracoscopy was performed in 20 patients and image-guided pleural biopsy was performed in the other 20 patients.
The comparison between the two groups regarding the cost was not possible because all procedures in the current study were carried out in the university main hospital for free as they were considered part of a research. The image-guided sampling usually involves the cost of the coaxial needle. However, scheduled thoracoscopy is a more expensive procedure; it has nearly triple the cost of image-guided techniques in both government and private sectors.
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Table 3 Comparison between the different studied groups according to the duration of procedure (min) Duration of procedure (min)
Group I: thoracoscopy (n=20)
Group II US guided (n=10)
CT guided (n=10)
Total (n=20)
Minimum–maximum
22.0–37.0
6.0–18.0
40.0–60.0
6.0–60.0
Mean±SD Median
27.15±3.57 26.50
10.60±4.01 9.50
50.30±6.57 50.0
30.45±21.04 29.0
