Page 47 - World Association of Laparoscopic Surgeons - Journal

Atul Soni et al

thoracentesis percutaneous closed pleural biopsy. ultimately be diagnosed as malignant. 2 Contrary to
Thoracoscopy is often performed because these procedures thoracocentesis and percutaneous CPB, thoracoscopy
6
are nondiagnostic. Cytologic analysis of thoracentesis fluid permits biopsy with direct visualization. Thoracoscopy is
is positive in 45 to 80% of malignant pleural effusions; commonly performed after one or two thoracocenteses and
however, it is positive in as few as 20% of patients with at least one nondiagnostic closed pleural biopsy.
mesothelioma. 2,12-17 Repeated thoracentesis for cytologic Thoracoscopy, using either simple rigid or VATS, has
analysis provides limited increases in yield (17 to 22% very high sensitivity (80 to 100%) for both benign and
additional yield for malignancy). 14,18 Thus, closed pleural malignant pleural disease. 2,9,13,14,23-26 Thoracoscopy
biopsy in addition is advocated by some authors to further increases diagnostic yield for effusions after thoracentesis
increase the diagnostic yield. 18 and closed pleural biopsy specimens are nondiagnostic.
Closed pleural biopsy is reported to be diagnostic for Thoracoscopy also yields few false-negative results. Boutin
pleural malignancy in approximately 50% of cases. 16,17 et al 14 retrospectively analyzed 215 simple rigid
A large retrospective study by Prakash 17 involving 414 thoracoscopies for EUO. Thoracoscopy successfully
patients with pleural effusion found malignant disease in identified 131 of 150 (87%) malignant cases whereas
281 (68%) patients. Fluid cytologic study was positive in repeated pleural cytologic study and closed needle biopsy
163 (58%), closed pleural biopsy positive in 121 (43%), specimens the day before surgery yielded positive results
either positive in 183 (65%). However, in only 20 (7%) of in only 62 of 150 (41%) malignant cases. Thoracoscopy
the 281 patients with malignant effusion, closed biopsy
gave positive results in 63 of 75 (84%) patients with
specimens revealed malignant disease when the fluid
malignancy who had at least two previous negative cytologic
cytologic study was negative. This study is often cited as
specimens and one or more negative closed needle biopsy
an indication not to do initial concurrent thoracentesis and 15 15
specimens. Hariis et al reported thoracoscopy had a
closed pleural biopsy when malignancy is the primary
diagnostic sensitivity of 95% for pleural malignancy and
consideration. If the initial thoracentesis fluid is an exudate,
100% for benign disease. Importantly, malignancy was
with cytologic study negative for malignancy, it seems
demonstrated by thoracoscopy in 24 of 35 (69%) patients
reasonable to then repeat thoracentesis with the addition of
who had two negative preoperative pleural cytologic
a closed pleural biopsy. In contrast, it is recommended that
specimens and in 27 of 41 (66%) patients who had a
thoracentesis and closed pleural biopsy both be performed
preoperative nondiagnostic closed pleural biopsy specimen.
initially if tuberculosis is the primary consideration because
However, limitations in the published literature exist
the combined sensitivity for tuberculosis by thoracentesis
regarding thoracoscopy and its utility in the management
culture and closed pleural biopsy is greater than 80%. 17,19
of pleural disease. First, most of the studies show a selection
Normal findings from thoracentesis and closed pleural
bias toward including patients with known malignancy or a
biopsy, however, give no assurance that malignancy is
high pretest likelihood of malignancy, thereby improving
absent. the sensitivity of thoracoscopy. Several studies report a
3,4
Boutin et al 14 noted three limitations of thoracentesis 2,5
high number of mesothelioma cases. Data obtained from
and closed needle biopsy in evaluating malignant effusions:
such studies may not be applicable to an unselected
(1) False-positive cytologic results range from 0.5 to 1.5%;
population with EUO. Second, in four series reporting a
(2) characterizing the type and origin of the cancer is
diagnostic accuracy of 90 to 100%, follow-up was either
difficult; and (3) the sensitivities depend directly on the 3-6
not stated or lasted less than 6 months. In three series in
stage of the cancer. Moreover, closed needle biopsy is
which a total of 822 patients were followed-up for 1 to
effective in adequately sampling the parietal pleura in only 5 years, accuracy was only 62 to 85%. Third, it is unclear
7-9
19
20
75% of attempts. Rodriguez-Panadaro et al, by studying
if the benefits of an earlier diagnosis and the clinical
191 autopsies, added that the parietal pleura is less
certainty of pleural malignancy warrant the costs of the
frequently involved with metastatic pleural disease than the
procedure and its potential morbidity. Thus, many questions
visceral pleura. Localized and diaphragmatic tumors are
still remain regarding the selection of patients for
often not even accessible by closed needle biopsy. The
thoracoscopy, its timing, and its true impact on the
above limitations account for some of the reduced diagnostic
management and outcome of pleural disease.
efficacy of thoracentesis and closed needle biopsy for
malignancy.
Tuberculous Pleurisy
Despite extensive conventional evaluation, 10 to 27%
of patients with pleural effusions remain without a specific The greater debate is whether thoracoscopy is warranted,
diagnosis. 2,4,17,21,22 One third to half of these effusions may if tuberculosis is high on the list of differential diagnoses.
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