Clinical feature of diagnostic challenging cases for pleural biopsy in patient with malignant pleural mesothelioma

Our plain-English summary of Clinical feature of diagnostic challenging cases for pleural biopsy in patient with malignant pleural mesothelioma, by M. Hashimoto, A. Sato, A. Kuroda, et al (General Thoracic and Cardiovascular Surgery, 2020).

The study

• Authors: M. Hashimoto, A. Sato, A. Kuroda, A. Nakamura, T. Nakamichi, N. Kondo, M. Yuki, K. Nabeshima, T. Tsujimura, S. Hasegawa
• Journal: General Thoracic and Cardiovascular Surgery
• Published: 2020;68(8):820-827
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: Pleural biopsy through video-assisted thoracic surgery (VATS pleural biopsy) is the most reliable diagnostic procedure for malignant pleural mesothelioma (MPM). However, definitive diagnosis of MPM is occasionally difficult to establish. This study aims to investigate clinicopathological features of MPM patients who failed diagnosis by the first VATS pleural biopsy.

Methods: Four hundred consecutive patients with suspected MPM who received VATS pleural biopsy between March 2004 and July 2017 were enrolled in this retrospective study. Patients, whose histological diagnoses were not definitive in the first VATS pleural biopsy, were followed up as atypical mesothelial proliferation (AMP) or non-specific pleuritis (NSP). Re-examination was performed in cases strongly suspected of having MPM.

Results: Of the 400 patients, 267 (66.8%) were pathologically diagnosed with MPM, 25 with metastatic carcinoma and 6 with benign pleural disease by the first VATS pleural biopsy. Of the remaining 102 patients diagnosed with AMP or NSP, 10 patients (9.8%) were subsequently diagnosed with MPM. Analysis of the clinical course revealed that only insufficient tissue for diagnosis was obtained via VATS pleural biopsy in all cases and that it was caused by very early stage without visible tumour in 4 patients, intrathoracic inflammation in 4 and desmoplastic MPM in 2.

Conclusions: In our review, 9.8% of patients diagnosed with AMP or NSP in first VATS pleural biopsy were subsequently diagnosed with MPM due to insufficient tissue for diagnosis. Definitive diagnosis via VATS pleural biopsy is sometimes challenging in following situation; very early stage, intrathoracic inflammation and desmoplastic MPM.

In plain English

This retrospective study from one hospital in Japan reviewed 400 consecutive patients suspected of having malignant pleural mesothelioma (MPM). All had a surgical pleural biopsy by video-assisted thoracic surgery (VATS) between 2004 and 2017. The first biopsy gave a definite diagnosis of MPM in 267 patients (66.8%), metastatic carcinoma in 25 and benign pleural disease in 6. The other 102 were labelled atypical mesothelial proliferation or non-specific pleuritis. When 11 of them were examined again, 10 (9.8% of the 102) were diagnosed with MPM and 1 with metastatic carcinoma. The median time to re-examination was 5 months. In all 10 MPM cases, the first biopsy had not obtained enough tissue for diagnosis. The causes were a very early stage without visible tumour (4 patients), inflammation inside the chest (4), or desmoplastic MPM (2). The article mentioned asbestos exposure only for two patients, who were followed up because that history raised suspicion of MPM. The authors concluded that VATS biopsy diagnosis is sometimes difficult in these three situations. They noted that their data came from a single institution and covered a period when diagnostic guidelines changed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective study of a historical cohort at a single institution
• Who was studied: 400 consecutive patients suspected of malignant pleural mesothelioma who underwent VATS pleural biopsy at Hyogo College of Medicine Hospital, Japan, between 2004 and 2017; median age 68 years (range 40–85), 83.3% male
• Exposure: The study was about a diagnostic procedure (VATS pleural biopsy). It does not report a systematic or quantitative assessment of asbestos exposure. The article mentions asbestos only for two patients (patients 7 and 8), who were followed up because their history of asbestos exposure raised suspicion of MPM.
• Main results:
  • At the first VATS pleural biopsy of the 400 patients, 267 (66.8%) were diagnosed with MPM, 25 with metastatic carcinoma and 6 with benign pleural disease
  • Of the 102 patients whose first biopsy showed atypical mesothelial proliferation (AMP) or non-specific pleuritis (NSP), 10 (9.8%) were later diagnosed with MPM
  • Of all 400 patients with suspected MPM, 11 (4.4%) were later diagnosed with malignancies: 10 MPM and 1 metastatic carcinoma
  • Among the 10 patients later diagnosed with MPM, the median time from first biopsy to re-examination was 5 months (range 1–22)
  • In the 10 later-diagnosed MPM patients, insufficient tissue at the first biopsy was attributed to very early stage without visible tumour (4 patients), intrathoracic inflammation (4) and desmoplastic MPM (2)
  • In the 4 very-early-stage patients, pleural fluid cytology before surgery was positive in all four. Total parietal pleurectomy in 3 of them showed tumour invasion in only a few lesions.
  • In patient 10, who could not have more surgery, molecular testing of the first biopsy specimen found a homozygous p16 deletion in 87.5% of atypical cells. This patient was diagnosed with desmoplastic MPM.
• The authors' conclusion: The authors concluded that 9.8% of patients diagnosed with AMP or NSP at the first VATS pleural biopsy were later diagnosed with MPM because of insufficient tissue. They concluded that definitive diagnosis by VATS pleural biopsy is sometimes difficult at a very early stage, with intrathoracic inflammation, and in desmoplastic MPM.
• Limitations the authors state:
  • All clinical records were collected retrospectively from a single institution
  • Decisions about follow-up and re-examination were left to the surgeons
  • Over the long study period, diagnostic guidelines were revised and new diagnostic techniques were introduced
  • Growing surgical and pathological experience may have affected results: re-examination was more frequent in the first 200 patients (8 cases) than in the second 200 (3 cases)

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Pleural Biopsy, Pleural Mesothelioma, Thoracic Surgery, Video-Assisted Thoracoscopic Surgery (VATS), Atypical Mesothelial Proliferation, Carcinoma, Intrathoracic, Inflammation.

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