Biopsy Techniques for the Diagnosis of Mesothelioma

Abstract

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.

Challenges and controversies in the diagnosis of mesothelioma: Part 1. Cytology-only diagnosis, biopsies, immunohistochemistry, discrimination between mesothelioma and reactive mesothelial hyperplasia, and biomarkers

“…Although a cytology-only diagnosis of MM based on effusion fluid can be made at a high order of specificity in some cases, the main problem is one of low sensitivity, reported to be in the range of about 30–75%,11 22 and as low as 16% for a ‘positive’ diagnosis after the exclusion of ‘suspicious’ findings 23. In a study of 162 cases of MM, effusion fluid cytology showed high specificity (∼99%) when all criteria for diagnosis were fulfilled 17.…”

“…Biopsy techniques for MM diagnosis have been reviewed by Walters and Maskell 23. In general, the confidence index for a biopsy diagnosis of MM is proportional to the volume of tumour sampled: Attanoos and Gibbs32 found that diagnosis of MM was attained in 75% of biopsies measuring over 10 mm in size, but only 8% when the biopsy was less than 10 mm in diameter.…”

“…Flexible thoracoscopy under local analgesia or neurolept anaesthesia is used increasingly by respiratory physicians, with a diagnostic yield comparable to ‘standard’ VAT 38. In a review of seven post-2000 studies, Walters and Maskell23 found that local anaesthetic thoracoscopy gave a diagnosis of MM in 87.5–100% of cases.…”

Sensitivity of Initial Thoracentesis for Malignant Pleural Effusion Stratified by Tumor Type in Patients with Strong Evidence of Metastatic Disease

“…This has indeed proven to be the case for mesothelioma [14]. The sensitivity of thoracentesis in patients with mesothelioma is between 16 and 30.8%, since it is difficult to differentiate between reactive mesothelial cells secondary to inflammation and malignant cells [5,15]. The diagnostic sensitivity of thoracentesis may also differ between lung cancer sub-types, with metastatic adenocarcinoma having a greater sensitivity than squamous cell carcinoma [5,7].…”

Diagnóstico y tratamiento del mesotelioma pleural maligno

“…1). La video-assisted thoracoscopic surgery (VATS) permite una mejor estadificación del tumor (especialmente en el área mediastínica) e incluso hacer pleurectomía/decorticación, pero requiere más recursos, incluyendo anestesia general e intubación traqueal 35 . El rendimiento de la pleuroscopia (también llamada «toracoscopia médica») es subóp-timo en el mesotelioma con componente sarcomatoso 36 , y entonces es preferible obtener muestras más representativas mediante VATS o minitoracotomía 37 .…”