Pleural controversy: Closed needle pleural biopsy or thoracoscopy—Which first?

Abstract

The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91-95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy.

Thoracic Ultrasound-Assisted Selection for Pleural Biopsy With Abrams Needle

“…The Abrams needle is indicated in pleural effusion without pleural thickening or nodularity. 4 Metintas et al found no significant differences in the sensitivities of medical thoracoscopy and CT-guided Abrams pleural needle biopsy in subjects with malignant pleural effusion. 6 The diagnostic sensitivities were 94% and 87%, respectively.…”

“…1,2,[16][17][18] The optimal method for obtaining pleural tissue and a diagnosis in subjects with exudative pleural effusion of unknown etiology is controversial. 4 An important benefit of thoracoscopy is the ability to obtain a diagnosis, drain the effusion, and perform a pleurodesis during the same procedure. 17 However, thoracoscopy is more expensive and time consuming than other procedures.…”

“…1,2 Another factor that might influence the diagnostic yield of CPB is that pleural malignant deposits tend to predominate close to the midline and diaphragm, which are areas that are best avoided when performing CPB. 4 Based on its low diagnostic sensitivity, the utility of CPB in the investigation of exudative pleural effusion has been questioned. 4,5 Thoracoscopy is the gold standard for the diagnosis of malignant pleural effusion.…”

“…4 Based on its low diagnostic sensitivity, the utility of CPB in the investigation of exudative pleural effusion has been questioned. 4,5 Thoracoscopy is the gold standard for the diagnosis of malignant pleural effusion. 2,3 Nevertheless, some studies have proposed that CPB guided by imaging can obtain a diagnostic yield similar to that of thoracoscopy.…”

“…1,2 Some controversy exists about the ideal procedure that should be used to perform a pleural biopsy. 4 The pleural biopsy can be a closed pleural biopsy (CPB), pleural biopsy guided by imaging, or thoracoscopy. 1,2 The diagnostic yield of CPB with respect to malignant pleural effusion is lower than that of cytology, with the reported sensitivities ranging from 48%-56% for CPB.…”