Investigation of pleural effusion: comparison between fibreoptic thoracoscopy, needle biopsy and cytology

Our plain-English summary of Investigation of pleural effusion: comparison between fibreoptic thoracoscopy, needle biopsy and cytology, by W.M. Edmondstone (Respiratory Medicine, 1990).

The study

• Author: W.M. Edmondstone
• Journal: Respiratory Medicine
• Published: 1990;84(1):23-6
• Cited by: 31 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Twenty-eight patients with exudative pleural effusion have been investigated by fibreoptic thoracoscopy, Abrams needle biopsy and pleural fluid cytology. Sixteen patients had previously had negative pleural biopsies and cytology. Twenty effusions were malignant (16 mesothelioma, four metastatic carcinoma), seven were due to nonspecific inflammation and in one case no abnormality was found. The diagnostic yield for all three techniques combined was 85%, for thoracoscopy alone 65%, Abrams biopsy 60% and cytology 45%. In 12 patients presenting without previous investigation all eight malignant effusions were correctly diagnosed by at least one of the techniques with individual sensitivities of 75% for thoracoscopy, 63% for Abrams and 38% for cytology. Of the 16 patients who had previously had negative investigations 12 had malignant effusions, nine (75%) of which were diagnosed by a combination of the techniques. In this group, the individual sensitivities were 58% for both thoracoscopy and Abrams and 50% for cytology. A correct diagnosis of malignancy was made by a combination of needle biopsy and cytology in 75% of patients with previous investigations and 88% of those without. Fibreoptic thoracoscopy added only two diagnoses of malignancy to those obtained by Abrams and cytology. The limitations of the technique render it unsuitable for routine investigation of pleural effusions.

In plain English

This study, from the Royal Naval Hospitals at Haslar and Plymouth in the U.K., compared three ways of finding the cause of fluid around the lung (exudative pleural effusion) in 28 patients aged 45 to 77, all but two male. Each patient had fibreoptic thoracoscopy (a flexible scope passed into the chest), Abrams needle biopsy, and examination of cells in the fluid (cytology). Sixteen had already had negative biopsies and cytology. Twenty effusions were malignant: 16 mesothelioma and four metastatic carcinoma. Seven were nonspecific inflammation. At least one technique diagnosed 17 of the 20 malignant effusions (85%). Thoracoscopy found 13 (65%), needle biopsy 12 (60%) and cytology nine (45%). Needle biopsy and cytology together found 75%, and thoracoscopy added only one extra cancer diagnosis in each of the two patient groups. In four patients, dense adhesions blocked the view and thoracoscopy missed the cancer. The author linked the high share of mesothelioma to asbestos-related disease in two naval dockyard communities, and noted that this may make comparison with other studies invalid. The author concluded that the technique's limitations make it unsuitable for routine investigation of pleural effusions.

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: Diagnostic comparison study in a series of patients: each patient underwent fibreoptic thoracoscopy, Abrams needle biopsy and pleural fluid cytology, and the diagnostic yields were compared
• Who was studied: 28 patients with exudative pleural effusion (pleural fluid protein above 40 g per litre), aged 45-77 (mean 65), all but two male, at the Royal Naval Hospitals, Haslar and Plymouth, U.K. 16 had previously had negative Abrams biopsies and cytology. Study dates are not given.
• Exposure: Asbestos exposure was not measured or studied. The study compared diagnostic techniques. The author attributed the large proportion of mesothelioma to a high prevalence of asbestos-related disease in two communities with large naval dockyards. No fiber types are named.
• Main results:
  • Of the 28 effusions, 20 were malignant: 16 mesothelioma and four metastatic carcinoma. Seven were nonspecific pleuritis, and in one case no abnormality was found.
  • All patients: one or more of the three techniques diagnosed 17 of the 20 malignant effusions, an overall diagnostic yield of 85%
  • All malignant effusions: thoracoscopy diagnosed 13 (65%), Abrams biopsy 12 (60%) and cytology nine (45%)
  • All malignant effusions: Abrams biopsy, cytology or both diagnosed 75%
  • Previously investigated group (16 patients): 12 had malignant effusions, and nine of these (75%) were diagnosed by a combination of the techniques. Individual sensitivities were 58% for both thoracoscopy and Abrams biopsy and 50% for cytology.
  • Group without previous investigation (12 patients): eight had malignant effusions, and all eight were diagnosed by at least one technique. Thoracoscopy diagnosed six, Abrams five, cytology three, and Abrams biopsy plus cytology seven.
  • Thoracoscopy added only one extra diagnosis of malignancy in each of the two groups
  • Of the seven false negatives at thoracoscopy, three looked like tumour but the biopsies were negative. In the other four, dense adhesions obscured the view and malignancy was missed.
  • Carcinoma (non-mesothelioma) effusions: thoracoscopy diagnosed only one of four cases
  • Safety: there were no early complications. Tumour extension at the wound site occurred in one patient with metastatic adenocarcinoma.
• The authors' conclusion: The author concluded that the limitations of fibreoptic thoracoscopy make it unsuitable for routine investigation of pleural effusions. The author also concluded that this and other series suggest the fibreoptic bronchoscope is less suitable for thoracoscopy than the rigid instrument.
• Limitations the authors state:
  • Comparison with other studies may not be valid because of the unusual make-up of this patient group, which had a preponderance of mesothelioma.
  • The large proportion of mesothelioma may have biased the results against thoracoscopy and in favour of Abrams biopsy.
  • No patient had CT scanning before thoracoscopy.
  • Physicians in areas without a high prevalence of mesothelioma may obtain better results than this study did.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Effusion, Thoracoscopy, Needle Biopsy, Cytology, Fluid Cytology, Mesothelioma, Carcinoma, Inflammation.

Related studies

• Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial — M. Metintas, G. Ak, et al. (2010)
• Comparison of antibodies to HBME-1 and calretinin for the detection of mesothelial cells in effusion cytology — P.A. Fetsch, A. Simsir, et al. (2001)
• Thoracoscopy in the early diagnosis of malignant pleural effusions — C. Boutin, P. Cargnino, et al. (1980)
• 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)
• The potential value of comparative genomic hybridization analysis in effusion-and fine needle aspiration cytology — H. Nagel, H.J. Schulten, et al. (2002)
• Medical thoracoscopy in the diagnosis of unexplained pleural effusion — M.L. Wilsher, A.G. Veale (1998)

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