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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 525-528  

Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural effusions


1 Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardio- Thoracic Sciences [AICTS], Pune, Maharashtra, India
2 Department of Pulmonary Medicine, ILBS, New Delhi, India
3 Department of Respiratory and Sleep Medicine, Artemis Hospital, Gurugram, Haryana, India
4 Department of Pathology, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Submission03-Oct-2019
Date of Decision14-Nov-2019
Date of Acceptance06-Jan-2020
Date of Web Publication7-Sep-2020

Correspondence Address:
Vikas Marwah
Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardio- Thoracic Sciences (AICTS), Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_277_19

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  Abstract 


Background: Medical thoracoscopy is a minimally invasive technique to inspect the pleural space and to perform biopsy of pleural lesions under direct vision. In this study, the diagnostic utility of thoracoscopy for undiagnosed exudative lymphocytic pleural effusions from a tertiary care respiratory center will be discussed. Materials and Methods: In a retrospective analysis of thoracoscopic procedures, we performed between September 2017 and August 2019, the yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed exudative lymphocytic pleural effusions was evaluated. Undiagnosed exudative pleural effusions were defined as pleural effusions where an etiologic diagnosis could not be ascertained by initial pleural fluid biochemical and microbiological analysis, including protein, sugar, lactate dehydrogenase, Gram and acid-fast bacilli stains and Mycobacterium tuberculosis culture, pleural fluid adenosine deaminase levels, and at least two pleural fluid cytologies negative for malignant cells or other definite causes. We analyzed the clinical, radiological, cytological, and histopathological data of the patients and also the complications of thoracoscopy. Results: We performed thoracoscopy in 68 cases of undiagnosed exudative pleural effusions using the rigid thoracoscope. The overall diagnostic yield of thoracoscopic pleural biopsy was 95.6% in patients with undiagnosed exudative pleural effusions. Malignant pleural effusion was diagnosed in 67.6% of patients, while tuberculosis was diagnosed with pleural biopsy in 25% of patients. Three cases of subcutaneous emphysema, 2 cases of postprocedure fever were observed, and one patient had prolonged air leak. Conclusion: Medical thoracoscopy has a good diagnostic yield in patients with undiagnosed exudative lymphocytic pleural effusions and is a safe procedure as well.

Keywords: Exudative pleural effusion, thoracoscopic pleural biopsy, thoracoscopy


How to cite this article:
Marwah V, Bhattacharyya D, Ali MF, Rajput AK, Sengupta P, Bhati G. Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural effusions. Med J DY Patil Vidyapeeth 2020;13:525-8

How to cite this URL:
Marwah V, Bhattacharyya D, Ali MF, Rajput AK, Sengupta P, Bhati G. Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural effusions. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 30];13:525-8. Available from: http://www.mjdrdypv.org/text.asp?2020/13/5/525/294358




  Introduction Top


Medical thoracoscopy is a simplified video-assisted thoracoscopic surgery, which is done under local anesthesia and conscious sedation by trained pulmonologists. Thoracoscopy is the gold standard for the diagnosis of pleural effusions nowadays[1] with diagnostic yield in malignant pleural disease reaching 90%.[2],[3],[4]

Complication rates are low (2%–5%) and are typically minor (subcutaneous emphysema, bleeding, infection), with mortality rates <.1%.[2] In trained hands, medical thoracoscopy is a safe and well-tolerated procedure with good diagnostic yield and therapeutic efficacy. In spite of this, many patients in our country are diagnosed to have tuberculosis on radiologic basis[5] and treated with ATT empirically, leading to a delay in diagnosis of malignancy. In our study, we analyzed the diagnostic efficacy of medical thoracoscopy in patients with undiagnosed exudative lymphocytic pleural effusions and also looked at its safety.


  Materials and Methods Top


This is a retrospective study conducted at our center to analyze the diagnostic utility of thoracoscopy in undiagnosed exudative lymphocytic pleural effusions. All the cases which remain undiagnosed after initial and repeated biochemical and cytological analysis of the pleural fluid undergo medical thoracoscopy at our institution.

The following records of all patients were reviewed: age, sex, symptoms and signs, chest X-ray, computed tomography (CT) scan and ultrasonography of the thorax, and fiberoptic bronchoscopy (FOB) (where carried out). The CT thorax and FOB were not performed in all patients but at the discretion of the attending physician. The decision to perform medical thoracoscopy was made by the respiratory physician when etiologic diagnosis could not be ascertained by initial pleural fluid biochemical and microbiological analysis, including protein, sugar, lactate dehydrogenase, Gram and acid-fast bacilli (AFB) stains and Mycobacterium tuberculosis culture, pleural fluid adenosine deaminase (ADA) levels, and at least two pleural fluid cytologies negative for malignant cells or other definite causes.

The major contraindication to thoracoscopy was the lack of a pleural space due to pleural adhesions. Medical thoracoscopy was performed in all patients who were included in the present study. All cases were admitted at least 1 day before the procedure and were kept nil by mouth for 6 h before the procedure. All procedures were done under local anesthesia by a respiratory physician under conscious sedation in a spontaneously breathing patient. Written informed consent was obtained. Patients were then made to lie in lateral decubitus position with affected side facing upward. Bedside ultrasound was conducted to localize the pleural effusion and site marked for trocar insertion. Patients underwent the procedure in the bronchoscopy suite equipped with patient monitoring devices. Vital parameters such as electrocardiogram, blood pressure, and oxygenation were monitored throughout the procedure.

After skin sterilization, a single Puncture was given in the mid-axillary line into the fifth or sixth intercostal space. Blunt dissection was done to enter the pleural space. A trocar with cannula was then inserted into the pleural cavity, and pleural fluid was drained completely. Then, the rigid thoracoscope (Richard Wolf) was inserted and the pleural cavity was inspected systematically. Optical biopsy forceps were used from the same port to obtain 4–6 pleural biopsies by lateral “lift and peel” technique under direct visual control from all suspected areas. A 28 F chest tube was inserted for drainage with underwater seal. A chest X-ray was performed 2 h after the procedure. The chest tube was removed after the daily pleural fluid drainage was ʊ ml. The findings, outcome, and complications of thoracoscopy procedures were recorded in all cases.


  Results Top


During the study period, 68 patients (50 males and 18 females) underwent medical thoracoscopy for undiagnosed exudative pleural effusion. The mean age of patients was 43.5 years (range: 19–78 years). The most common respiratory symptom was dyspnea in 42 patients (61.8%), followed by cough in 38 (55.9%) and fever in 16 (23.5%). Thirty-five patients (51.5%) were smokers. Thirty-eight patients had right-sided pleural effusion (55.9%), 23 patients were left-sided (33.8%), and bilateral effusions were present in 7 cases (10.3%) in the study population [Table 1].
Table 1: Baseline characteristics of the study participants

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Thoracoscopic appearance of tuberculosis cases was usually that of extensive grayish-white micronodules involving the parietal pleura [Figure 1]. Significant adhesions were also noted. Nodular lesions were seen in most cases with malignancy [Figure 2]. Histopathological examination of thoracoscopic pleural biopsy revealed: malignancy in 46 (67.6%) cases, tuberculosis in 17 (25.0%) cases, and empyema in two (2.9%) patients. In the cases diagnosed with empyema, the histopathological examination of the thoracoscopic pleural biopsy showed acute neutrophilic pleuritis in one patient and acute inflammation with bacterial colonies in the other. All cases of tuberculosis had evidence of caseating granuloma and Ziehl–Neelsen stain was positive for AFB in five cases. There was evidence of chronic nonspecific inflammation in three (4.4%) cases. The diagnostic efficacy of medical thoracoscopy was found to be 95.6%.
Figure 1: Thoracoscopic image shows diffuse micronodules on the parietal pleura in tuberculous pleural effusion

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Figure 2: Thoracoscopic image of shows multiple nodules on the parietal pleura in malignant pleural effusion

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Adenocarcinoma (24 cases) was found to be the most common (52.2%) form of malignancy [Table 2]. This was followed by squamous cell carcinoma– 11 (23.9%), malignant mesothelioma in 4 (8.7%), small-cell carcinoma – 3 (6.5%), poorly differentiated carcinoma – 3 (6.5%), and non-Hodgkin's lymphoma – 2 (4.3%) cases.
Table 2: Histopathological diagnosis and frequency

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There was no major complication in the present study. Minor complications encountered during the perioperative period were self-limiting subcutaneous emphysema in three (4.4%), postoperative fever in two (2.9%) cases, and air leak in one patient. The symptoms of fever and subcutaneous emphysema abated in 3–5 days, while the air leak resolved spontaneously in 5–6 days. There was no death or any severe complication in any of the 68 patients included in the present study.


  Discussion Top


Algorithms for investigating exudative pleural effusions of unknown etiology begin with thoracentesis. However, cytological examination of pleural fluid is diagnostic in only 60%–80% of patients with metastatic pleural involvement[6] and ɬ% of patients with mesothelioma.[7] Thoracentesis with percutaneous closed-needle biopsy may be diagnostic in 60% of malignant pleural effusions,[8] but we stopped doing closed-needle biopsies at our institution since 2015 in view of much higher yield with thoracoscopy. Medical thoracoscopy has the advantage that it can be performed under local anesthesia or conscious sedation, in an endoscopy suite, and using nondisposable rigid instruments. Thus, it is considerably less invasive and less expensive than video-assisted thoracoscopic surgery.

The value of medical thoracoscopy for patients with undiagnosed exudative pleural effusion was retrospectively determined in the present study. Thoracoscopy made a definite diagnosis in 65 of 68 patients, giving a positivity rate of 95.6%. Bergqvist and Nordenstam observed a 96% diagnostic accuracy for thoracoscopy, with a sensitivity of 91% and specificity of 100%.[9] There are several reasons why thoracoscopy may be successful when thoracentesis and percutaneous needle biopsy fail to establish the diagnosis. Malignant pleural disease is not always accessible to the needle biopsy of the parietal pleura. Boutin et al. described 84% of pleural lesions in 203 patients undergoing thoracoscopy were in the lower hemithorax, partially or totally inaccessible to needle biopsy.[10]

In the present study, malignancy was detected in 67.6% cases, tuberculosis in 25.0%, and empyema in 2.93% cases. In a series of 215 patients with pleural effusions of unknown etiology despite repeated thoracentesis and percutaneous needle biopsy of the pleura, thoracoscopy resulted in a diagnosis of malignancy in 150 (70.0%) of the patients.[11] Similar levels of diagnostic accuracy have been reported by Page et al.[12] Similarly, a retrospective study of 138 patients reported an overall diagnostic efficacy of 97%, including 93% for carcinoma, 100% for mesothelioma, and 94% for tuberculosis.[13] Thoracoscopy is not required to be done in a routine case of tuberculous pleural effusion. However, thoracoscopy may be useful in the following circumstances: (a) in difficult diagnostic situations, (b) when lysis of adhesion is necessary, and (c) when larger amounts of tissue are necessary for the determination of drug resistance.[12]

The most common histological diagnosis in our study was pleural malignancy (n = 46, 67.6%). Hucker et al.[13] reported malignancy in 59% of cases, and Hansen et al.[14] reported malignancy in 62% of their study population. Malignant effusions were slightly more in our study as compared to other similar studies probably due to referral bias as we had done thoracoscopy in undiagnosed cases referred to as a tertiary care center. Among the malignancy cases, adenocarcinoma (52.2%) was found to be the most common, followed by squamous cell carcinoma (23.9%) and malignant mesothelioma (8.7%) while small-cell carcinoma (6.5%) was found to be less common. This is consistent with another published study from China.[15] In this study, malignant pleural effusion was much more likely as ADA was low, but 25% of patients still had pleural tuberculosis.

In our series, thoracoscopy was demonstrated to be a safe and well-tolerated procedure with minor complications of self-limiting subcutaneous emphysema (4.4%) and postoperative fever (2.9%). In spite of this, medical thoracoscopy is not frequently performed and there are fewer studies on its role in undiagnosed exudative pleural effusions from our country.[16],[17] The scarcity of thoracoscopy being used as a routine diagnostic modality may highly be due to the unavailability of equipment and physicians' lack of experience in carrying out the procedure.


  Conclusion Top


In patients with undiagnosed exudative pleural effusion, thoracoscopic pleural biopsy under local anesthesia should be performed because the technique has a high diagnostic rate, and can be easily and safely carried out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Froudarakis ME. New challenges in medical thoracoscopy. Respiration 2011;82:197-200.  Back to cited text no. 1
    
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Metintas M, Ak G, Dundar E, Yildirim H, Ozkan R, Kurt E, et al. Medical thoracoscopy vs. CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: A randomized, controlled trial. Chest 2010;137:1362-8.  Back to cited text no. 3
    
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Rodríguez-Panadero F. Medical thoracoscopy. Respiration 2008;76:363-72.  Back to cited text no. 4
    
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Marwah V, Barthwal MS, Rajput AK. Are pulmonary opacities a marker of pulmonary tuberculosis? Med J Armed Forces India 2014;70:22-5.  Back to cited text no. 5
    
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Ryan CJ, Rodgers RF, Unni KK, Hepper NG. The outcome of patients with pleural effusion of indeterminate cause at thoracotomy. Mayo Clin Proc 1981;56:145-9.  Back to cited text no. 6
    
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Pugatch RD, Faling LJ, Robbins AH, Snider GL. Differentiation of pleural and pulmonary lesions using computed tomography. J Comput Assist Tomogr 1978;2:601-6.  Back to cited text no. 7
    
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Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: General overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006;28:409-22.  Back to cited text no. 8
    
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Bergqvist S, Nordenstam H. Thoracoscopy and pleural biopsy in the diagnosis of pleurisy. Scand J Respir Dis 1962;47:64-73.  Back to cited text no. 9
    
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Boutin C, Viallat JR, Cargnino P, Rey F. Thoracoscopic lung biopsy. Experimental and clinical preliminary study. Chest 1982;82:44-8.  Back to cited text no. 10
    
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Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in Malignant Pleural Effusions. Am Rev Respir Dis 1981;124:588-92.  Back to cited text no. 11
    
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Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: A review of 121 consecutive surgical procedures. Ann Thorac Surg 1989;48:66-8.  Back to cited text no. 12
    
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Hucker J, Bhatnagar NK, al-Jilaihawi AN, Forrester-Wood CP. Thoracoscopy in the diagnosis and management of recurrent pleural effusions. Ann Thorac Surg 1991;52:1145-7.  Back to cited text no. 13
    
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Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: A retrospective study. Respir Med 1998;92:228-32.  Back to cited text no. 14
    
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Wang Z, Tong ZH, Li HJ, Zhao TT, Li XY, Xu LL, et al. Semi-rigid thoracoscopy for undiagnosed exudative pleural effusions: A comparative study. Chin Med J (Engl) 2008;121:1384-9.  Back to cited text no. 15
    
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Prabhu VG, Narasimhan R. The role of pleuroscopy in undiagnosed exudative pleural effusion. Lung India 2012;29:128-30.  Back to cited text no. 16
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Patil CB, Dixit R, Gupta R, Gupta N, Indushekar V. Thoracoscopic evaluation of 129 cases having undiagnosed exudative pleural effusions. Lung India 2016;33:502-6.  Back to cited text no. 17
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