Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study

Our plain-English summary of Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study, by F.X. Blanc, K. Atassi, J. Bignon, et al (Chest, 2002).

The study

• Authors: F.X. Blanc, K. Atassi, J. Bignon, B. Housset
• Journal: Chest
• Published: 2002;121(5):1677-83
• Cited by: 91 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Study Objectives: Unlike thoracocentesis and closed pleural biopsy (CPB), medical thoracoscopy permits biopsy with direct visualization. In a 6-year retrospective study of patients having undergone at least one medical thoracoscopy, we analyzed the diagnostic yield of thoracoscopy and its value in the management of pleural disease.

Setting/patients: From January 1, 1989, to December 31, 1994, 168 medical thoracoscopies were performed on 154 patients (123 men; mean age +/- SE, 61 +/- 1 years), of which 149 were diagnostic and 19 were indicated for therapeutic assessment in malignant mesothelioma (MM). Prior to thoracoscopy, at least one CPB had been performed in 120 of 149 cases, yielding a diagnosis in 96 cases.

Results: Thoracoscopy challenged the CPB-based diagnosis in 43 of 96 cases. In 66 cases of nonspecific inflammation diagnosed by CPB, thoracoscopy revealed MM in 16 cases, adenocarcinoma in 10 cases, undetermined carcinoma in 3 cases, and pleural tuberculosis in 3 cases. In 18 cases in which the CPB diagnosis was MM, thoracoscopy, performed for precise staging, challenged the diagnosis in 4 cases. In 12 cases of carcinoma diagnosed by CPB, thoracoscopy specified the histologic type in 7 cases. Thoracoscopic diagnoses were found to be erroneous in 10 of 149 cases, mainly owing to pleural adhesions that limited access to the pleural cavity. There was one thoracoscopy-related death, one case of sepsis, and six cases of empyema.

Conclusions: Medical thoracoscopy appears to be efficient and relatively safe in the management of pleural disease. Pleural adhesions can lower its diagnostic value.

In plain English

This retrospective study from a hospital chest department in Créteil, France, reviewed 154 patients who had 168 medical thoracoscopies between 1989 and 1994. In a medical thoracoscopy, a lung specialist uses a scope to look inside the chest and take biopsies under local or regional anesthesia. Of these procedures, 149 were done to make a diagnosis. Asbestos exposure was recorded for 73 patients (47.4%). Thoracoscopy changed 43 of 96 diagnoses previously made by closed (needle) pleural biopsy (44.8%). Where needle biopsy had shown only nonspecific inflammation, thoracoscopy found cancer in 29 cases and pleural tuberculosis in 3. In 18 cases where needle biopsy had indicated malignant mesothelioma, thoracoscopy found adenocarcinoma in 3 and nonspecific inflammation in 1. The authors reported a diagnostic efficiency of 93.3% (139 of 149 cases). Ten thoracoscopic diagnoses were later changed, and in 6 of these, adhesions limited access to the chest cavity. One death was related to thoracoscopy, and 38 of the 154 patients had at least one complication. The authors concluded that medical thoracoscopy was a relatively safe, high-yield diagnostic tool in their experience.

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 all medical thoracoscopies performed in one hospital chest department over 6 years
• Who was studied: 154 patients (123 men, 31 women) who underwent 168 medical thoracoscopies in the chest department of a hospital in Créteil, France, between January 1, 1989 and December 31, 1994. Of 169 patients originally identified, 15 were excluded for incomplete data. 149 procedures were diagnostic; 19 were done to assess a treatment in patients with malignant mesothelioma.
• Exposure: The study examined the diagnostic procedure (medical thoracoscopy compared with prior closed pleural biopsy), not asbestos exposure itself. Exposure to asbestos was recorded as part of each patient's medical history; no fiber types, products, jobs or doses were reported.
• Main results:
  • 73 of the 154 patients (47.4%) had asbestos exposure recorded. Among the 44 thoracoscopic diagnoses of malignant mesothelioma, 31 patients reported exposure (the article prints "asbestosis exposure").
  • Thoracoscopy modified 43 of 96 diagnoses previously made by closed pleural biopsy (44.8%).
  • In the 66 cases where closed pleural biopsy showed nonspecific inflammation, thoracoscopy revealed malignancy in 29 cases and pleural tuberculosis in 3 cases.
  • In the 18 cases where closed pleural biopsy diagnosed malignant mesothelioma, thoracoscopy revealed adenocarcinoma in 3 cases and nonspecific inflammation in 1 case.
  • Thoracoscopy yielded a precise diagnosis in 43 of 90 cases (47.8%) in which closed pleural biopsy had been nondiagnostic.
  • Thoracoscopy corrected the closed-biopsy diagnosis in 11 of 30 patients (36.7%) thought to have pleural malignancy.
  • The diagnostic efficiency of medical thoracoscopy was 93.3% (139 of 149 diagnostic procedures).
  • Of the 10 thoracoscopic diagnoses later modified, 6 involved extensive adhesions that limited access to the pleural cavity.
  • There was one thoracoscopy-related death (0.6% of procedures), caused by bleeding that could not be controlled. 38 of the 154 patients had at least one complication. The article gives this as 22.6%, which matches 38 of 168 procedures rather than 38 of 154 patients. Empyema occurred in 6 of 168 procedures (3.6%).
• The authors' conclusion: The authors concluded that, in their experience, medical thoracoscopy was a relatively safe and high-yield (93.3%) diagnostic tool, despite one death from uncontrollable bleeding. They also concluded that their results support its use when pleural malignancy is suspected on the basis of thoracocentesis and closed pleural biopsy.
• Limitations the authors state:
  • Extensive pleural adhesions limited access to the pleural cavity and accounted for most of the later-modified thoracoscopic diagnoses.
  • Telling malignant mesothelioma apart from adenocarcinoma can be very difficult, even with large biopsy specimens.
  • The authors could not say whether surgical thoracoscopy would have avoided the thoracotomies that followed medical thoracoscopy.
  • The mortality rate (0.6%) and the mean hospital stay were higher than previously reported. The authors attributed the longer stay partly to admissions for other reasons and to pleurodesis.

Topics

Medical terms in this study, explained in our Lexicon: Medical Thoracoscopy, Pleural Biopsy, Biopsy, Thoracoscopy, Mesothelioma, Inflammation, Adenocarcinoma, Carcinoma.

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• Semi-Rigid Thoracoscopic Punch Biopsy Using a Hybrid Knife with a High-Pressure Water Jet for the Diagnosis of Pleural Effusions — Y. Yin, R. Eberhardt, et al. (2016)
• First report of probe based confocal laser endomicroscopy during medical thoracoscopy — O. Bonhomme, B. Duysinx, et al. (2019)
• Medical thoracoscopy in the diagnosis of unexplained pleural effusion — M.L. Wilsher, A.G. Veale (1998)
• Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience — J. Leemans, C. Dooms, et al. (2018)

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