Introduction and Objectives Local anaesthetic thoracoscopy has a high diagnostic yield in undiagnosed pleural effusion, but cannot be performed in cases with heavily loculated pleural fluid or where lung is adherent to the chest wall. On table, ultrasound-guided trans-thoracic cutting needle biopsy provides a potential route to obtain tissue for histological analysis in such cases. There is currently a paucity of data addressing the diagnostic yield of this procedure when conducted by chest physicians in response to a failed thoracoscopic procedure. The present study was conducted to determine whether this method is able to obtain pleural tissue in cases of failed thoracoscopy, and whether the results correlated with the computed tomography (CT) scan results obtained before attempted thoracoscopy.
Methods Retrospective review of cases of unsuccessful thoracoscopy, which were converted to real-time ultrasound-guided cutting needle biopsy in the Pleural Unit between January 2010 and April 2012. The available histological results were assessed for the yield of pleural tissue, of definitive pleural diagnosis and compared to the pre-thoracoscopy CT scan results.
Results Of 147 attempted thoracoscopies, 11 (7.5%) were not successful and were converted on table (using the same anaesthetised tract used to attempt to introduce the thoracoscope ports) to real-time image-guided trans-thoracic cutting needle biopsy. Of these, 1/11 (9.1%) demonstrated pleural malignancy on histology (despite negative cytology), while in 8/11 (72.7%) of cases, a benign pleural diagnosis was made. Pre-procedure CT scans were performed on 8 of the 9 patients for which a histological diagnosis was made, and were reported as likely malignant effusion in 4 (50%) cases. 2/11 (18.2%) biopsies failed to obtain sufficient tissue for histological diagnosis.
Conclusion Around 7.5% of attempted thoracoscopies are unsuccessful, and in these cases, real-time ultrasound guided cutting needle pleural biopsy obtains pleural tissue successfully in a high proportion. This approach offers the advantage of obtaining pleural tissue in a single procedure where thoracoscopy has failed. The true sensitivity and specificity of this technique now requires further assessment, including comparison to long term outcomes of patients with benign pleural histology obtained using this technique.
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