Role of Rigid Medical Thoracoscopy in Diagnosing Exudative Pleural Effusions with Low Adenosine Deaminase
DOI:
https://doi.org/10.48165/etz3hk86Keywords:
Rigid thoracoscopy, medical thoracoscopy, pleuroscopy, pleural effusion, ADA, tuberculosis, lung malignancyAbstract
Background: Medical thoracoscopy (MT) performed in the evaluation of undiagnosed exudative pleural effusion (EPE) has a high diagnostic yield. In this study, we describe our experience of rigid MT in the evaluation of undiagnosed exudative pleural effusions (EPE) with low adenosine deaminase (ADA). Subjects and Methods:This is a retrospective analysis of RT pleural biopsies performed between July 2012 and June 2015 for diagnosing EPE. These patients had at least two pleural fluid samples negative for malignant cytology and ADA less than 65 IU/L. Here we report the yield and complications of pleural biopsies with RT. Results: Our yield of thoracoscopic pleural biopsies was 81% with malignancy as the commonest diagnosis in 46% patients. Malignant pleural effusion was caused commonly by adenocarcinoma (67%) followed by squamous cell carcinoma (17%), small cell lung cancer (8%) and lymphoma (8%). There was no case of mesothelioma. Biopsy revealed tuberculosis in 31%, vasculitis in 4%, nonspecific pleuritis (NSP) in 11% and normal pleural tissue in 8% subjects. The presence of nodules on CT scan and those on MT had no significant correlation (P > 0.1). ADA did not significantly differ between various biopsy confirmed diagnostic groups (P > 0.2). Minor complications that settled with conservative management developed in 3 patients (11.5%) and were significantly related to comorbidities (p < 0.05) but not to the biopsy result (P = 0.894). Conclusion: Since majority of the EPE turn out to be either malignancy of tuberculosis, a rigid MT evaluation should be considered in all such patients if the facility is available at the center. Rigid MT has high diagnostic yield and acceptable safety.
References
1. Jacobeus HC. The cauterization of adhesions in artificial pneumothorax treatment of pulmonary tuberculosis under thorascopic control. Proc R Soc Med. 1923;16:45–62.
2. Diacon AH, de Wal BWV, Wyser C, Smedema JP, Bezuiden hout J, Bolliger CT, et al. Diagnostic tools in tubercu lous pleurisy: a direct comparative study: 1. Eur Respir J. 2003;22(4):589–591. Available from: https://dx.doi.org/10. 1183/09031936.03.00017103a.
3. PRAKASH UBS, REIMAN HM. Comparison of Needle Biopsy With Cytologic Analysis for the Evaluation of Pleu ral Effusion: Analysis of 414 Cases. Mayo Clin Proc. 1985;60(3):158–164. Available from: https://dx.doi.org/10. 1016/s0025-6196(12)60212-2.
4. Poe RH, Israel RH, Utell MJ. Sensitivity, specificity, and predictive values of closed pleural biopsy. Arch Intern Med. 1984;144:325–333.
5. Bueno CE, Clemente MG, Castro BC, Martín LM, Ramos SR, Panizo AG, et al. Cytologic and bacteriologic analysis of fluid and pleural biopsy specimens with Cope’s needle. Study of 414 patients. Arch Intern Med. 1990;150(6):1190–1194. Available from: https://doi.org/10.1001/archinte.150.6.1190.
6. Koegelenberg CFN, Diacon AH. Pleural controversy: Closed needle pleural biopsy or thoracoscopy-Which first? Respirology. 2011;16(5):738–746. Available from: https://dx. doi.org/10.1111/j.1440-1843.2011.01973.x.
7. Lee P, HSU A, LO C, COLT HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: Accuracy, safety and outcome. Respirology. 2007;12(6):881– 886. Available from: https://dx.doi.org/10.1111/j.1440-1843. 2007.01144.x.
8. Loddenkemper R. Thoracoscopy - state of the art. Eur Respirat J. 1998;11(1):213–221. Available from: https://dx.doi.org/10. 1183/09031936.98.11010213.
9. Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thora coscopy. Curr Opin Pulm Med. 2009;15(4):313–320. Available from: https://dx.doi.org/10.1097/mcp.0b013e32832b8b2d.
10. Loddenkemper R, Grosser H, Gabler A, Mai J, Presseuler H, Brandt HJ. Prospective evaluation of biopsy methods in diagnosis of malignant pleural effusions: intra patient comparision between pleural fluid cytology, blind needle biopsy and thoracoscopy. Am Rev Respir Dis. 1983;127:114.
11. Kendall SWH, Bryan AJ, Large SR, Wells FC. Pleural effu sions: is thoracoscopy a reliable investigation? A retrospective review. Respir Med. 1992;86(5):437–440. Available from: https://dx.doi.org/10.1016/s0954-6111(06)80012-0.
12. Ng TH, How SH, Kuan YC, Hasmah H, Norra H, Fauzi AR. Medical thoracoscopy: Pahang experience. Med J Malaysia. 2008;63:298–301.
13. Tscheikuna J, Silairatana S, Sangkeaw S, Nana A. Outcome of medical thoracoscopy. J Med Assoc Thai. 2009;92:19–23. 14. Mootha VK, Agarwal R, Singh N, Aggarwal AN, Gupta D, Jindal SK. Medical thoracoscopy for undiagnosed pleural effusions: experience from a tertiary care hospital in north India. Indian J Chest Dis Allied Sci. 2011;53(1):21–24. 15. Depew ZS, Wigle D, Mullon JJ, Nichols FC, Deschamps C, Maldonado F. Feasibility and Safety of Outpatient Medical Th oracoscopy at a Large Tertiary Medical Center. A Collaborative Medical-Surgical Initiative. Chest. 2014;146(2):398–405. Available from: https://doi.org/10.1378/chest.13-2113. 16. Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic tho racoscopy: British Thoracic Society Pleural Disease Guideline. Thorax. 2010;65(2):54–60. Available from: https://doi.org/10. 1136/thx.2010.137018.
17. Shujaat A, Bajwa AA, Usman F, Jones L, Cury JD. Safety and Accuracy of Semirigid Pleuroscopy Performed by Pulmonary Fellows at a Major University Hospital. J Bronchology Interv Pulmonol. 2013;20(3):213–223. Available from: https://dx.doi. org/10.1097/lbr.0b013e31829aeac7.
18. Pereyra MF, San-José E, Ferreiro L, Golpe A, Antúnez J, González-Barcala FJ, et al. Role of Blind Closed Pleural Biopsy in the Management of Pleural Exudates. Can Respir
J. 2013;20(5):362–366. Available from: https://dx.doi.org/10. 1155/2013/731352.
19. Maturu VN, Dhooria S, Bal A, Singh N, Aggarwal AN, Gupta D, et al. Role of Medical Thoracoscopy and Closed-Blind Pleural Biopsy in Undiagnosed Exudative Pleural Effusions. J Bronchology Interv Pulmonol. 2015;22(2):121–129. Available from: https://dx.doi.org/10.1097/lbr.0000000000000145.
20. Metintas M, Ak G, Yildirim H, Danacioglu S, Dundar E, Metintas S. The Safety of Medical Thoracoscopy in a Group at High Risk for Complications. J Bronchology Interv Pulmonol. 2013;20(3):224–231. Available from: https://dx.doi.org/10. 1097/lbr.0b013e31829ebdbb.
