Physician-based ultrasound-guided biopsy for diagnosing pleural disease

Our plain-English summary of Physician-based ultrasound-guided biopsy for diagnosing pleural disease, by R.J. Hallifax, J.P. Corcoran, A. Ahmed, et al (Chest, 2014).

The study

• Authors: R.J. Hallifax, J.P. Corcoran, A. Ahmed, M. Nagendran, H. Rostom, N. Hassan, M. Maruthappu, I. Psallidas, A. Manuel, F.V. Gleeson, N.M. Rahman
• Journal: Chest
• Published: 2014;146(4):1001-1006
• Cited by: 103 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Definitive diagnosis of pleural disease (particularly malignancy) depends upon histologic proof obtained via pleural biopsy or positive pleural fluid cytology. Image-guided sampling is now standard practice. Local anesthetic thoracoscopy has a high diagnostic yield for malignant and nonmalignant disease, but is not always possible in frail patients, if pleural fluid is heavily loculated, or where the lung is adherent to the chest wall. Such cases can be converted during the same procedure as attempted thoracoscopy to cutting-needle biopsy. This study aimed to determine the diagnostic yield of a physician-led service in both planned biopsies and cases of failed thoracoscopy.

Methods: This study was a retrospective review of all ultrasound-guided, cutting-needle biopsies performed at the Oxford Centre for Respiratory Medicine between January 2010 and July 2013. Histologic results were assessed for the yield of pleural tissue, final diagnosis, and clinical follow-up in nonmalignant cases.

Results: Fifty ultrasound-guided biopsies were undertaken. Overall, 47 (94.0%) successfully obtained sufficient tissue for histologic diagnosis. Of the 50 biopsy procedures, 13 were conducted after failed thoracoscopy (5.2% of 252 attempted thoracoscopies over the same time period); of these 13, 11 (84.6%) obtained sufficient tissue. Thirteen of 50 biopsy specimens (26.0%) demonstrated pleural malignancy on histology (despite previous negative pleural fluid cytology), while 34 specimens (68.0%) were diagnosed as benign. Of the benign cases, 10 were pleural TB, two were sarcoidosis, and 22 were benign pleural thickening. There was one "false negative" of mesothelioma (median follow-up, 16 months).

Conclusions: Within this population, physician-based, ultrasound-guided, cutting-needle pleural biopsy obtained pleural tissue successfully in a high proportion of cases, including those of failed thoracoscopy.

In plain English

This study looked back at pleural biopsies at the Oxford Centre for Respiratory Medicine, England, from January 2010 to July 2013. Respiratory physicians used real-time ultrasound to guide a cutting needle into areas of thickened pleura, the membrane lining the chest, without puncturing the layer covering the lung. Of 252 attempted thoracoscopies (a camera examination inside the chest), 13 could not be completed and were switched on the spot to needle biopsy. Another 37 biopsies were planned in advance, giving 50 in all. The article did not study asbestos exposure. Enough tissue for diagnosis was obtained in 47 of 50 biopsies (94.0%): 11 of 13 after failed thoracoscopy and 36 of 37 planned biopsies. That difference was not statistically significant. Among 36 patients investigated for possible pleural malignancy, including mesothelioma, 13 had malignancy found on biopsy despite earlier negative fluid tests. During follow-up of patients with benign results, one developed disease clinically suggestive of mesothelioma. There were no immediate or delayed complications. The authors concluded the method obtained tissue in a high proportion of cases. They noted possible selection bias, follow-up under two years for some patients, and a specialist setting.

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 clinical practice) of ultrasound-guided, cutting-needle pleural biopsies
• Who was studied: 50 ultrasound-guided pleural biopsies at the Oxford Centre for Respiratory Medicine, England, January 2010 to July 2013. Of these, 13 were converted from 252 attempted thoracoscopies and 37 were planned in advance. Mean age was 65.0 years, and 39 of 50 patients were men.
• Exposure: No asbestos exposure was studied. The subject was a diagnostic procedure: real-time ultrasound-guided cutting-needle biopsy of areas of pleural thickening, performed by respiratory physicians, taking care that the needle did not penetrate the visceral pleura.
• Main results:
  • All biopsies: sufficient tissue for histologic diagnosis was obtained in 47 of 50 cases (94.0%).
  • Failed thoracoscopy: 13 of 252 attempted thoracoscopies (5.2%) were unsuccessful and were converted to biopsy. Of these 13 biopsies, 11 (84.6%) obtained sufficient tissue.
  • Planned biopsies: 36 of 37 (97.3%) yielded sufficient tissue. The difference from the failed-thoracoscopy group was not statistically significant (chi-square with Yates correction 0.96, P = .33).
  • Patients investigated for possible pleural malignancy: specimens from 13 of 36 (36.1%) showed pleural malignancy on histology despite previous negative cytology.
  • Patients with no significant pleural thickening in the midaxillary line on CT: 5 of 12 (41.7%) had malignant disease on biopsy from that area.
  • Patients with benign pleural thickening or fibrosis: during follow-up (median 15.5 months), one patient (6.3%) had progressive disease clinically suggestive of mesothelioma, counted as one false-negative diagnosis.
  • Final diagnoses: malignancy was the final diagnosis in 14 of 50 (28.0%), including one patient later diagnosed with mesothelioma at follow-up.
  • Patients with a history suggestive of pleural TB: 9 of 10 (90.0%) had TB confirmed by the biopsy sample.
  • All patients: there were no immediate or delayed complications, such as pneumothorax, pleural infection or intrapleural bleeding.
• The authors' conclusion: The authors concluded that, within this population, physician-based, ultrasound-guided, cutting-needle pleural biopsy obtained pleural tissue successfully in a high proportion of cases, including cases of failed thoracoscopy.
• Limitations the authors state:
  • As a retrospective audit of clinical practice, the study may be affected by selection bias influencing the high success rate.
  • Average follow-up of benign cases was 16 months, so not all patients had reached the 2 years of follow-up needed to establish true-negative results.
  • The biopsies were done at a specialist pleural center by experienced physicians, which may limit how well the findings apply to nonspecialist centers.

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: Ultrasound, Biopsy, Pleural Biopsy, Fluid Cytology, Thoracoscopy, Needle Biopsy, Histology, Pleural Thickening.

Related studies

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• Ultrasound-guided pneumothorax induction prior to local anaesthetic thoracoscopy — J.P. Corcoran, I. Psallidas, et al. (2015)
• Malignant pleural mesothelioma: US-guided histologic core-needle biopsy — A. Heilo, A.E. Stenwig, et al. (1999)
• A Single-Institution Experience in Percutaneous Image-Guided Biopsy of Malignant Pleural Mesothelioma — B.T. Welch, P.W. Eiken, et al. (2017)
• Minimally invasive, ionizing-free, and ultrasound-guided technique to biopsy anterior mediastinal masses: first 60 cases — B. Lorenzati, R. Cristofori, et al. (2018)
• 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)

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