CHEST
Volume 146, Issue 4, October 2014, Pages 1001-1006
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Original Research: Disorders of the Pleura
Physician-Based Ultrasound-Guided Biopsy for Diagnosing Pleural Disease

https://doi.org/10.1378/chest.14-0299Get rights and content

BACKGROUND

Definitive diagnosis of pleural disease (particularly malignancy) depends upon histologic proof obtained via pleural biopsy or positive pleural fluid cytology. Image-guided sampling is now standard practice. Local anesthetic thoracoscopy has a high diagnostic yield for malignant and nonmalignant disease, but is not always possible in frail patients, if pleural fluid is heavily loculated, or where the lung is adherent to the chest wall. Such cases can be converted during the same procedure as attempted thoracoscopy to cutting-needle biopsy. This study aimed to determine the diagnostic yield of a physician-led service in both planned biopsies and cases of failed thoracoscopy.

METHODS

This study was a retrospective review of all ultrasound-guided, cutting-needle biopsies performed at the Oxford Centre for Respiratory Medicine between January 2010 and July 2013. Histologic results were assessed for the yield of pleural tissue, final diagnosis, and clinical follow-up in nonmalignant cases.

RESULTS

Fifty ultrasound-guided biopsies were undertaken. Overall, 47 (94.0%) successfully obtained sufficient tissue for histologic diagnosis. Of the 50 biopsy procedures, 13 were conducted after failed thoracoscopy (5.2% of 252 attempted thoracoscopies over the same time period); of these 13, 11 (84.6%) obtained sufficient tissue. Thirteen of 50 biopsy specimens (26.0%) demonstrated pleural malignancy on histology (despite previous negative pleural fluid cytology), while 34 specimens (68.0%) were diagnosed as benign. Of the benign cases, 10 were pleural TB, two were sarcoidosis, and 22 were benign pleural thickening. There was one “false negative” of mesothelioma (median follow-up, 16 months).

CONCLUSIONS

Within this population, physician-based, ultrasound-guided, cutting-needle pleural biopsy obtained pleural tissue successfully in a high proportion of cases, including those of failed thoracoscopy.

Section snippets

Materials and Methods

A retrospective review was undertaken of all thoracoscopies and pleural biopsies performed at the Oxford Centre for Respiratory Medicine between January 2010 and July 2013. All the patients with planned pleural biopsies and those patients in whom thoracoscopy could not be performed (“failed” thoracoscopy), and so converted to ultrasound-guided biopsy, were further assessed. The histologic results were analyzed to determine the yield of pleural tissue. The patients were followed up in a

Patients

Over the 3-year period, a total of 252 thoracoscopies were attempted. Of these, 13 (5.2%) were not successful and, hence, were converted on table to image-guided, cutting-needle biopsy. An additional 37 preplanned, ultrasound-guided biopsies were also conducted. These planned biopsies were undertaken in cases in which either there was a small or heavily septated effusion, adhered lung (visualized as a lack of pleural sliding on thoracic ultrasound), or patient frailty. Therefore, a total of 50

Discussion

We have demonstrated that real-time, ultrasound-guided pleural biopsies conducted by respiratory physicians have a high diagnostic yield for both planned biopsies and on-table conversion to biopsy after attempted thoracoscopy. The 94.0% yield for planned biopsy is comparable to the high yield described by radiologists for ultrasound- and CT image-guided biopsies.11

The yield for the 13 patients who were converted to ultrasound-guided biopsy after failed thoracoscopy was 84.6%. This is a

Acknowledgments

Author contributions: R. J. H. and N. M. R. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. R. J. H., J. P. C., A. M., and N. M. R. contributed to the study concept; R. J. H., J. P. C., M. N., M. M., I. P., A. M., and N. M. R. contributed to data analysis; M. N., H. R., N. H., and I. P. contributed to data collection; A. A. and F. V. G. contributed to analysis of CT images; and R. J. H., J. P. C., A.

References (11)

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FUNDING/SUPPORT: This research was supported by the National Institute for Health Research Oxford Biomedical Research Centre, The Oxford University Hospitals Trust, University of Oxford.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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