The Impact of Thoracoscopy on the Management of Pleural Disease

doi:10.1378/chest.107.3.845

Chest

Volume 107, Issue 3, March 1995, Pages 845-852

https://doi.org/10.1378/chest.107.3.845 Get rights and content

Study objective

To describe the diagnostic efficacy, morbidity, and patient outcome of thoracoscopy; to quantify the direct impact of thoracoscopy on clinical management; and to determine preoperative variables associated with finding malignancy at thoracoscopy to aid patient selection.

Design

Retrospective chart review of consecutive cases of thoracoscopy for pleural disease.

Setting

Single tertiary medical center.

Patients

One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 through 1992).

Measurements and results

Final diagnoses were 98 (54%) malignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a diagnostic sensitivity of 95% for malignancy and 100% for benign disease. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cytologic specimens. Chart review by preestablished criteria showed information obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least one perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was performed, although none died within 48 h. There was one thoracoscopy-related death. Sixty-two (34%) patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathoracic malignancy present at thoracoscopy died within 6 months. Patients found to have malignant pleural disease by thoracoscopy were more likely to have a preoperative history of a malignancy (p=0.001). Age more than 50 years was associated with finding malignancy at thoracoscopy (p=0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy (p=0.004). Preoperative pleural data showed that idiopathic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions.

Conclusions

(1) Thoracoscopy increases yield for malignant and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management in 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignant pleural disease, thoracoscopy has its greatest diagnostic yield in older patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.

Section snippets

Patient population

We retrospectively reviewed 182 consecutive thoracoscopies performed for pleural disease over a 5-year period at the Cleveland Clinic Foundation. Twelve other charts were unavailable for review. We did not differentiate between rigid pleuroscopy and video-assisted thoracoscopy (only a few cases) in this analysis. All patients in this study were hospitalized.

Prethoracoscopy Assessment

Data for hospital admission and consultants’ history, examinations, and the preoperative testing for intrathoracic disease were reviewed.

Results

Results are summarized in Table 1.

Discussion

The relative ease of access to the pleural space allows for the study of pleural fluid and tissue for diagnostic evaluation. Conventional sampling includes thoracentesis and closed pleural biopsy. Cytologic analysis of pleural fluid by thoracentesis is positive in 45% to 80% of malignant pleural effusions but is positive in as few as 20% of patients with mesothelioma.2, 7, 10, 11 Repeated cytologic analysis can increase the yield for malignancy by an additional 17% to 22%.7, 12 Some advocate

Conclusions

This retrospective study suggests thoracoscopy increases diagnostic yield for both benign and malignant disease when thoracentesis and closed needle biopsy are nondiagnostic. Thoracoscopy directly impacts the management of pleural disease in most patients undergoing this procedure. A significant complication rate can occur in patients undergoing diagnostic and therapeutic thoracoscopy under general anesthesia. Several preoperative clinical variables are associated with finding malignancy by

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Video-thoracoscopy for the evaluation of undiagnosed pleural effusion: Is it possible to optimize its indication?
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Chronic follicular pleuritis: a B cell–rich form of nonspecific pleuritis/fibrosis
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The parietal pleura is often biopsied in patients with idiopathic pleural effusion, and in up to 40% of cases, a diagnosis of nonspecific pleuritis/fibrosis (NSP) is rendered. The histology of this reaction has not been well described including a pattern of B cell lymphoid hyperplasia described as “chronic follicular pleuritis (CFP)”. Thirty-two cases of NSP were studied, of which 13 (41%) corresponded to CFP with the remainder displaying a fibrinous and organizing pleuritis with varying degrees of collagenization. CFP had similar etiologies as NSP with long term follow-up, including cardiac disease, pericarditis, asbestos exposure, and occult malignancy. The importance of recognizing a previously undescribed B cell/plasma cell pleural inflammatory response in reactive pleural disease is discussed.
Efficacy and Cost of Awake Thoracoscopy and Video-Assisted Thoracoscopic Surgery in the Undiagnosed Pleural Effusion
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Citation Excerpt :
A case series described a sensitivity of 98.9% and specificity of 93.3% for VATS [13] in undiagnosed pleural disease. In addition, major and minor complications in our study for both VATS and AT are comparable with other studies, with major complications being infrequent [5, 7–10, 12, 14–17]. Hospital stay was significantly shorter in the AT group and relates to the majority of cases being performed as outpatient procedures.
The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions.
The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared.
Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p < 0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p < 0.001).
Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice.
Detection of Pleural Fluid Biochemistry Changes in Two Consecutive Thoracenteses for Differentiating Malignant from Benign Effusions
2018, Archivos de Bronconeumologia
Evaluar si los cambios en los parámetros bioquímicos del líquido pleural (LP) entre 2 toracocentesis sucesivas permiten predecir derrames pleurales (DP) malignos o benignos.
Estudio retrospectivo de los pacientes con exudado linfocitario y citología negativa para malignidad que se sometieron a una segunda toracocentesis en nuestro centro durante los últimos 15 años (muestra de derivación), y en los que se alcanzó un diagnóstico final. Las diferencias absolutas (Δa) o porcentuales (Δp) de diferentes parámetros bioquímicos del LP capaces de predecir la naturaleza maligna o benigna del DP en la muestra de derivación se evaluaron en una población independiente.
Se incluyeron 214 pacientes con DP (70 malignos y 144 benignos) en la muestra de derivación. Las Δp LDH (lactato deshidrogenasa) > 0%, Δp neutrófilos > –10% (cualquier aumento o bien un descenso inferior al 10%), y Δa proteínas < 0,1 g/dL (cualquier descenso o bien un aumento inferior a 0,1 g/dL) entre la segunda y primera toracocentesis mostraron unas odds ratio de 6,4, 3,9 y 2,1 para discriminar DP maligno de benigno, respectivamente. La presencia de las 3 condiciones conjuntamente se asoció con una likelihood ratio positiva de 5,6, mientras que la ausencia de cualquiera ellas se asoció con una likelihood ratio negativa de 0,04 para predecir malignidad. Los resultados se reprodujeron en la población de validación.
El aumento de LDH y neutrófilos, junto con el descenso de proteínas en una segunda toracocentesis, aumenta la probabilidad de que el origen del DP sea neoplásico, mientras que lo contrario la reduce significativamente.
To assess whether changes in pleural fluid (PF) biochemistries between two consecutive thoracenteses enable clinicians to predict malignant or benign pleural effusions (PE).
Retrospective study of patients with lymphocytic exudates and negative PF cytology, who underwent a second thoracentesis in our center in the last 15 years in whom a final diagnosis was reached (derivation sample). Absolute (Δa) and percentage differences (Δp) in PF biochemistries which predicted a malignant or benign PE in the derivation sample were evaluated in an independent population (validation sample).
The derivation sample included 214 PE patients (70 malignant and 144 benign PE). Δp lactate dehydrogenase (LDH) > 0%, Δp neutrophils > –10% (any increase or less than 10% decrease) and Δa protein < 0.1 g/dL (any increase or less than 0.1 g/dL decrease) between the second and the first thoracentesis had an odds ratio of 6.4, 3.9 and 2.1, respectively, to discriminate malignant from benign PE. The presence of the three conditions together had a positive likelihood ratio of 5.6, whereas the absence of any of the 3 parameters had a likelihood ratio of 0.04 for predicting malignancy. These results were reproduced in the validation sample.
An increase in LDH and neutrophils along with a decrease in protein in a second thoracentesis increase the probability of malignant PE, while the opposite reduces it significantly.
Malignant pleural effusion: current understanding and therapeutic approach
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Chest

Minimally Invasive Techniques: ArticlesThe Impact of Thoracoscopy on the Management of Pleural Disease

Study objective

Design

Setting

Patients

Measurements and results

Conclusions

Section snippets

Patient population

Prethoracoscopy Assessment

Results

Discussion

Conclusions

Ann Thorac Surg

Ann Thorac Surg

Respir Med

Mayo Clin Proc

Am J Surg

Comput Radiol

Ann Thorac Surg

Chest

Lancet

J Thorac Cardiovasc Surg

Mayo Clin Proc

Ueber die Moglichkeit die zystoscopie bei Untersuchung serosen Hohlungen anzuwenden

Munch Med Wochenschr

Thoracoscopy for the diagnosis of pleural disease

Ann Intern Med

Thoracoscopy in the diagnosis of pleural effusion

Thorax

Minimally Invasive Techniques: Articles
The Impact of Thoracoscopy on the Management of Pleural Disease