ArticlesStandard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial
Introduction
About 40 000 cases of pleural effusion are attributable to cancer every year in the UK, and 175 000 in the USA.1 Incidence of primary pleural malignant disease— mesothelioma—is rapidly rising in the UK, and is predicted to account for about 1% of all deaths in UK men born in the 1940s.2, 3 Cytological examination of pleural fluid for malignant cells establishes a positive diagnosis of malignancy in only 60% of carcinomatous effusions4, 5, 6, 7, 8, 9, 10, 11 and 30% of effusions secondary to mesothelioma.12, 13 Pleural biopsy to enable histological examination is needed for accurate diagnosis in the remainder. Pleural biopsy is therefore an important diagnostic method, which will be of growing relevance during the predicted mesothelioma epidemic of the next 20 years.2, 3
Despite the substantial burden of disease for which pleural biopsy is indicated, to our knowledge, no randomised trials have been done to assess the optimum diagnostic method, and no improvement has been made in the technique, which has been used for over 40 years. The standard technique uses a reverse bevel needle, such as the Abrams' needle,8, 14, 15 with local anaesthetic and without image guidance. This technique is associated with a substantial incidence of complications, including pneumothorax, haemothorax, and empyema, and in rare cases can be fatal.4, 6, 7, 8, 16 Furthermore, yield over pleural fluid cytology alone is increased by only 7–26%,5, 7, 16 and the procedure is painful, especially when done by inexperienced operators.
CT-guided cutting-needle biopsy of pleural tissue associated with a pleural effusion is a relatively new technique compared with Abrams' biopsy.17, 18 Results of observational series suggest this technique might improve diagnostic sensitivity to about 80% for pleural malignancy.17, 18, 19, 20 However, these studies are nonrandomised, tend to include CT-guided and ultrasound-guided procedures, and are mainly done in patients without pleural effusions.19, 20 If CT-guided biopsy is strikingly superior to traditional Abrams' biopsy, this technique would produce better diagnostic information from fewer passes—and by inference fewer complications and greater acceptability to patients. Reduction of the number of pleural procedures in patients with mesothelioma is especially important, because one in three biopsy sites are invaded by this tumour unless the sites are irradiated.21
We therefore did a prospective trial to measure sensitivity for malignant disease with standard Abrams' biopsy and with CT-guided needle biopsy, to assess whether CT-guided biopsy was an improvement over the standard technique.
Section snippets
Study design and setting
This study was a prospective, parallel, randomised trial done in one centre (Oxford Centre for Respiratory Medicine, Oxford, UK). Patients with undiagnosed pleural effusions are referred to the Oxford unit directly from general practitioners (60%), from other local hospital consultants (30%), and occasionally from respiratory consultants in other neighbouring health authorities (10%). The population served by this unit has a low prevalence of asbestos exposure and hence a low frequency of
Results
During the recruitment period, 53 patients who were eligible for the study were identified; 50 consented to enter the study (figure 3). 45 of these presented directly to the Oxford Centre for Respiratory Medicine, the other five were referred from other hospitals in the region. 46 of the patients had one non-diagnostic pleural aspiration before randomisation; the remaining four had two negative aspirations. None had undergone a pleural biopsy procedure before trial entry. Characteristics of
Discussion
We have shown that CT-guided pleural biopsy is more effective than standard Abrams' biopsy in diagnosis of malignant pleural disease. The size of this advantage is considerable. Standard Abrams' biopsy correctly diagnosed malignancy in 47% of patients eventually proved to have pleural malignancy, whereas CT-guided biopsy accurately identified 87%. Thus, undertaking CT-guided biopsy as the initial procedure would avoid doing repeated biopsy in 40% of patients compared with current practice,
References (29)
- et al.
The incidence of pleural effusion in a well-defined region: epidemiologic study in central Bohemia
Chest
(1993) - et al.
Continuing increase in mesothelioma mortality in Britain
Lancet
(1995) - et al.
Comparison of needle biopsy with cytologic analysis for the evaluation of pleural effusion: analysis of 414 cases
Mayo Clin Proc
(1985) - et al.
Pleural biopsy in the diagnosis of pleural effusion: a report of 200 cases
Lancet
(1958) - et al.
The role of cytologic evaluation of pleural fluid in the diagnosis of malignant mesothelioma
Chest
(1997) New inventions: a pleural-biopsy punch
Lancet
(1958)- et al.
Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura
Chest
(1975) - et al.
Percutaneous image-guided cutting needle biopsy of the pleura in the diagnosis of malignant mesothelioma
Chest
(2001) - et al.
Powered cutting needle biopsy of the pleura and chest wall
Clin Radiol
(1990) - et al.
Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy
Chest
(1995)
Diagnostic thoracoscopy
Clin Chest Med
Points to consider when choosing a biopsy method in cases of pleurisy of unknown origin
Chest
Ultrasound-guided pleural biopsy with Tru-Cut needle
Chest
The diagnostic and therapeutic utility of thoracoscopy: a review
Chest
Cited by (305)
Chest Magnetic Resonance Imaging: Advances and Clinical Care
2024, Clinics in Chest MedicineLung cancer: Diagnostic techniques
2023, Lung Cancer: an Evidence-Based Approach to Multidisciplinary ManagementThe role of an interventional pulmonologist in the management of metastatic pleural effusions (MPE)
2022, Revue des Maladies RespiratoiresUpdate on the diagnosis and management of malignant pleural effusions
2022, Respiratory Medicine