Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases

Our plain-English summary of Prospective Study of the Utility of Computed Tomography Triage of Pleural Biopsy Strategies in Patients With Pleural Diseases, by M. Metintas, G. Ak, S. Metintas, et al (Journal of Bronchology & Interventional Pulmonology, 2019).

The study

• Authors: M. Metintas, G. Ak, S. Metintas, H. Yildirim, E. Dündar, N. Rahman
• Journal: Journal of Bronchology & Interventional Pulmonology
• Published: 2019;26(3):210-218
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: This study aimed to prospectively evaluate the efficacy and reliability of a diagnostic workup, triaging pleural biopsy method according to baseline computerized tomography (CT) findings in the diagnosis of pleural diseases.

Methods: Patients with pleural pathology were divided into 3 arms according to findings on CT scan images. Arm A: patients with pleural thickening/lesion in addition to pleural effusion. These patients underwent CT scan-guided Abrams' needle pleural biopsy. Arm B: patients with pleural effusion alone or suspected benign asbestos pleurisy. This group underwent medical thoracoscopy (MT). Arm C: patients with only pleural thickening. This group underwent ultrasonography-guided cutting needle pleural biopsy. MT was planned in patients who did not have a specific diagnosis in the CT scan-guided Abrams' needle pleural biopsy group. When patients with a histopathologic diagnosis of fibrinous pleuritis after MT were assessed in terms of the risk factors for malignant pleural diseases, we offered a further invasive procedure.

Results: A total of 164 patients were enrolled in the study. Diagnostic sensitivity after the initial procedure was 90.2% in Arm A, 93.3% in Arm B, 95.2% in Arm C, and 92.4% in the entire workup. The negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy. Five cases who had a diagnosis of fibrinous pleuritis after MT were detected to have risk factors, 4 of which (80%) indicated malignant disease. Complication rates were low and acceptable.

Conclusion: Use of CT scans to triage an appropriate pleural biopsy method is associated with high diagnostic success. We recommend that the proposed diagnostic workup in this study may be used as a diagnostic algorithm for pleural diseases that require a histopathologic analysis. Determination of risk factors predicting malignant disease in patients where fibrinous pleuritis is reported after MT would be useful for clinical practice.

In plain English

This prospective Turkish study (2010 to 2014) tested choosing a pleural biopsy method from each patient's first CT scan. Patients with fluid plus pleural thickening or a needle-accessible lesion had a CT-guided Abrams' needle biopsy. Those with fluid alone, a lesion out of the needle's reach, or suspected benign asbestos pleurisy (definite asbestos exposure) had medical thoracoscopy. Those with thickening alone had an ultrasound-guided cutting needle biopsy. Of 164 patients, 104 had malignant pleural disease, 15 tuberculous pleurisy and 45 benign disease. The whole workup had a sensitivity of 92.4% (95% CI 86.1 to 96.5). Five of 17 patients whose Abrams' biopsy showed only fibrinous pleuritis later proved to have malignant disease. Among 37 with that result after thoracoscopy or cutting needle biopsy, 4 of 5 with predefined risk factors had malignant disease; follow-up found none in the 32 without risk factors. Across the three arms, 11, 14 and 3 patients had complications, out of 76, 81 and 23 procedures respectively; one patient needed transfusion. The authors concluded the workup could serve as a diagnostic algorithm, noting one negative predictive value rested on only 2 patients.

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: Prospective diagnostic study in which patients were assigned to one of three biopsy methods according to their initial CT findings
• Who was studied: 164 analysed patients with undiagnosed pleural disease (169 enrolled, 5 excluded or lost to follow-up), Chest Diseases Department, Eskisehir Osmangazi University Medical Faculty, Turkey, December 2010 to June 2014
• Exposure: The study evaluated diagnostic procedures, not an exposure. These were CT-guided Abrams' needle biopsy, medical thoracoscopy, and ultrasound-guided cutting needle biopsy. Patients with suspected benign asbestos pleurisy (defined by definite asbestos exposure) or a lesion inaccessible to the Abrams' needle were assigned to medical thoracoscopy.
• Main results:
  • At final diagnosis, 104 of 164 (63.4%) had malignant pleural disease, 15 (9.1%) had tuberculous pleurisy, and 45 (27.4%) had benign pleural disease
  • Diagnostic sensitivity of the entire workup was 92.4% (95% CI 86.1-96.5, from Table 2)
  • Diagnostic sensitivity by method was 90.6% for CT-guided Abrams' needle biopsy, 93.3% for medical thoracoscopy and 95.2% for ultrasound-guided cutting needle biopsy, with 100% specificity for each
  • The initial procedures gave the correct diagnosis in 155 of 164 patients (94.5%)
  • The false-negative rate after the initial procedure was 5.4% (9 of 164)
  • Negative predictive value of the entire workup was 90.4% for malignant pleural mesothelioma, 97.1% for metastatic malignant pleural diseases, and 100% for tuberculous pleurisy
  • Of 17 patients whose CT-guided Abrams' biopsy was reported as fibrinous pleuritis, 5 were eventually diagnosed with malignant pleural disease (3 malignant pleural mesothelioma, 2 metastatic)
  • Of 35 thoracoscopy patients with fibrinous pleuritis, 4 with risk factors underwent VATS, and 3 of these had malignant pleural mesothelioma. The 31 without risk factors had no malignancy detected after 3 years.
  • Among 37 patients with fibrinous pleuritis after thoracoscopy or cutting needle biopsy, 5 had risk factors and 4 of these had malignant disease. There were no false negatives among the 32 without risk factors.
  • In Arm A (CT-guided Abrams' biopsy), 11 patients (14.4%) had complications, in a total of 76 procedures; all were minor
  • In Arm B (thoracoscopy), 14 patients had complications, in a total of 81 procedures (reported as 14/81: 17.2%), including one major bleeding that required blood transfusion
  • In Arm C (ultrasound-guided cutting needle biopsy), 3 of 23 (13.0%) experienced complications
• The authors' conclusion: The authors recommended that the proposed CT-based workup can be used as a diagnostic algorithm for pleural diseases requiring histopathologic analysis.
• Limitations the authors state:
  • The negative predictive value for ultrasound-guided cutting needle biopsy was based on only 2 patients
  • The authors could not state that CT guidance was better than ultrasound guidance for Arm A patients

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Biopsy, Pathology, CT Scan, Pleural Thickening, Pleural Effusion, Pleurisy, Medical Thoracoscopy, Pleural Mesothelioma.

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)
• 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)
• Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases — M. Metintas, I. Ucgun, et al. (2002)
• Physician-based ultrasound-guided biopsy for diagnosing pleural disease — R.J. Hallifax, J.P. Corcoran, et al. (2014)
• Delayed-Phase Enhancement for Evaluation of Malignant Pleural Mesothelioma on Computed Tomography: A Prospective Cohort Study — A. Patel, L. Roshkovan, et al. (2021)
• Diagnostic Performance of Ultra-Low-Dose Computed Tomography for Detecting Asbestos-Related Pleuropulmonary Diseases: Prospective Study in a Screening Setting — M. Schaal, F. Severac, et al. (2016)

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