Medical thoracoscopy in the diagnosis of unexplained pleural effusion

Our plain-English summary of Medical thoracoscopy in the diagnosis of unexplained pleural effusion, by M.L. Wilsher, A.G. Veale (Respirology, 1998).

The study

• Authors: M.L. Wilsher, A.G. Veale
• Journal: Respirology
• Published: 1998;3(2):77-80
• Cited by: 28 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Approximately 20% of pleural effusions remain without an established aetiology after evaluation. Thoracoscopy has a very high sensitivity for the diagnosis of both benign and malignant diseases and greatly increases the diagnostic yield for pleural effusion. We sought to evaluate the diagnostic yield and safety of medical thoracoscopy at this institution. The records of all patients undergoing medical thoracoscopy for the evaluation of undiagnosed pleural effusion between 1990 and 1996 were reviewed. The procedure was performed under local anaesthesia with sedation using a Stortz rigid thoracoscope. Fifty-eight patients had thoracoscopy, most having had two (range: 1-6) non-diagnostic pleural aspirations and biopsies of the pleura. Nineteen patients were found to have mesothelioma and nine metastatic malignancy. Three patients were considered likely to have tuberculous pleural disease, six had asbestos related benign pleural fibrosis and three post-cardiotomy syndrome. There was one chylous effusion of uncertain aetiology, one posttraumatic and two other benign effusions, both of which resolved without clear aetiology. On seven occasions the pleural space could not be adequately accessed, but none of these patients had prior computerized tomography (CT) or ultrasound of the pleural space. There were five false negative diagnoses of malignancy, but no false positives. The diagnostic sensitivity for pleural malignancy was 85% and specificity 100%. There were no major complications, but four patients had late tumour seeding at the thoracoscopy site. Medical thoracoscopy is a safe procedure with a high diagnostic yield. Pre-operative evaluation of the pleural collection using ultrasound or CT increases the likelihood of successful access to the pleural space and may increase diagnostic yield.

In plain English

This study reviewed the records of all 58 patients at Green Lane Hospital, Auckland, New Zealand, who had medical thoracoscopy between 1990 and March 1996. Medical thoracoscopy means looking inside the chest with a rigid telescope. These patients had a pleural effusion (fluid around the lung) of unknown cause. Thirty-eight had a clear history of asbestos exposure. Biopsies taken during the procedure confirmed pleural cancer in 28 patients, 19 of them mesothelioma. Fifteen patients were found to have a benign effusion. Seven of them had a clear history of asbestos exposure, which was thought to be the likely cause. In the 51 patients whose pleural space was adequately entered, thoracoscopy diagnosed pleural cancer with 85% sensitivity and 100% specificity. Five cancers were missed, three of them later diagnosed as mesothelioma. The pleural space could not be adequately entered in seven patients, none of whom had prior ultrasound or CT. There were no major complications, but four patients had seeding at the entry site, two of whom had mesothelioma. The authors concluded the procedure was safe with a high diagnostic yield.

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 review (audit) of hospital records of patients who had medical thoracoscopy
• Who was studied: 58 patients (51 male, 7 female, mean age 63, range 41 to 85) who had medical thoracoscopy for unexplained pleural effusion at Green Lane Hospital, Auckland, New Zealand, between 1990 and March 1996
• Exposure: This study looked at a diagnostic procedure, not at an asbestos exposure. Thirty-eight of the 58 patients had a clear history of asbestos exposure. No fiber types, jobs or doses were reported.
• Main results:
  • Thoracoscopic pleural biopsy confirmed pleural malignancy in 28 patients, of whom 19 had mesothelioma
  • Of the nine patients with metastatic pleural tumours, seven had adenocarcinoma, one squamous cell carcinoma and one lymphoma
  • There were five false negative diagnoses of malignancy; three of these patients were eventually diagnosed with mesothelioma
  • Of the 15 patients eventually diagnosed with benign pleural effusion, seven had a clear history of asbestos exposure, which was thought to be the likely cause
  • Three patients were considered to have pleural tuberculosis, one of them culture positive
  • In seven patients the pleural space could not be adequately entered; none of these seven had prior ultrasound or CT
  • In the 51 patients whose pleural space was adequately entered, thoracoscopy had a sensitivity of 85% and specificity of 100% for pleural malignancy
  • Overall diagnostic yield was 80%, rising to 90% when only patients with full pleural access were counted
  • There were no major complications
  • One patient had a wound infection, and four had seeding at the entry site, two of whom had mesothelioma
• The authors' conclusion: The authors concluded that medical thoracoscopy is safe and well tolerated with a high diagnostic yield, and that screening the pleural space beforehand with ultrasound or CT further increases this likelihood
• Limitations the authors state:
  • The authors noted that what the pleura looks like through the scope can be misleading. Three patients with benign disease were thought by appearance to have mesothelioma.

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: Medical Thoracoscopy, Pleural Effusion, Thoracoscopy, Pleura, Mesothelioma, Fibrosis, Ultrasound.

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)
• Medical thoracoscopy, results and complications in 146 patients: a retrospective study — M. Hansen, P. Faurschou, et al. (1998)
• Thoracoscopy in the early diagnosis of malignant pleural effusions — C. Boutin, P. Cargnino, et al. (1980)
• Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative — Z.S. DePew, D. Wigle, et al. (2014)
• Outcomes and complications following medical thoracoscopy — F.J. Brims, M. Arif, et al. (2012)
• The safety of medical thoracoscopy in a group at high risk for complications — M. Metintas, G. Ak, et al. (2013)

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