2008 - Diagnostic Procedure for Pleural Disease (Pearson's Thoracic and Esophageal Surgery, Ch.84 2008 p.1033-1041)

Key Points

Diagnosis of pleural diseases is based on a comprehensive history and physical examination.

Simple, minimally invasive techniques such as thoracentesis can provide uid, cells, and tissue for analysis, which lead to diagnosis in the majority of cases.

VATS or pleuroscopy can aid in diagnosis when less invasive techniques fail to yield a diagnosis. More invasive procedures such as thoracotomy are rarely required.

HISTORY AND PHYSICAL EXAMINATIONA thorough history and physical examination is the initial diagnostic procedure in understanding a pleural problem. The past history may identify clues that lead to a list of potential causes for the underlying pleural pathology. Additional his-torical factors focus on a previous or current history of cancer and its associated treatments. Known diseases associated with pleural effusions include heart failure, end-stage renal disease with or without dialysis, cirrhosis, and global hypoalbumine-mia. A recent history of upper respiratory tract infection may uncover an undiagnosed pneumonic infection complicated by a parapneumonic effusion or frank empyema. Patients pre-senting with deep venous thrombosis and pulmonary embo-lism may have recently traveled or suffered lower extremity trauma or surgery. Exposures to asbestos and tuberculosis (TB) are associated with pleural processes that may require additional workup.

Dyspnea at rest or on exertion is the most common symptom of patients with pleural diseases. The degree of shortness of breath may relate to the extent of the pleural process or underlying related pulmonary issues but may also re ect a combination of the pleural process, the patients preexisting comorbidities, and the rapidity with which the problem developed. Massive but slowly progressive accumu-lation of uid in an otherwise healthy person with normal underlying lung function can result in minimal symptoms. Pain is another common symptom. It may be pleuritic from pleural irritation, somatic from direct invasion of the chest wall, or more of a pressure-type discomfort from the uid accumulation. Diaphragmatic irritation may cause shoulder pain. Finally, patients may complain of a cough, usually dry, often relieved by evacuation of the pleural space.

The physical examination adds little to the diagnostic aspect of management except when palpable adenopathy is identi ed or a warm, red, uctuant chest or ank mass is identi ed with empyema necessitatis (Fig. 84-1). Wound or skin nodules found in recent biopsy sites raise the suspicion for mesothelioma, a malignancy that has a strong tendency to grow in needle tracts and incisions. Much of the physical examination is accomplished with thoughts of planning a diagnostic procedure. Percussion of the chest wall is used to identify a relative area of dullness on the affected side. The affected side will also have an absence of breath sounds, and the trachea may be shifted away from the affected side with a large tension hydrothorax or toward the affected side if there is signi cant ipsilateral loss of lung volume associated with the pleural process. Radiographs are used to con rm the clinical impression, re ne the differential diagnosis, and plan

1033

DIAGNOSTIC PROCEDURES FOR PLEURAL DISEASESchapter

84 Brian E. LouieEric Vallires

Diseases of the pleural space are common in a thoracic surgical practice, and although their management may seem simple, their diagnosis often presents a challenge. In patients presenting with pleural problems, a thorough history and physical examination remain the basis for the physicians initial assessment and differential diagnosis. Radiography is helpful in providing clues to a diagnosis by distinguishing between pleural uid and a mass and by allowing evaluation of the adjacent lung and pleura. A de nitive diagnosis, however, usually requires a diagnostic procedure to provide uid, cells, or tissue for analysis and microscopic review. This chapter reviews the range of pleural diseases in relation to the diagnostic procedures, their indications, and techniques.

Although a wide range of diseases can involve the pleura and the pleural space, these can be narrowed down to two forms: pleural uid and pleural mass or masses (Table 84-1). Pleural effusions are the most common disturbances of the pleural space. Effusions may be secondary to increased capil-lary permeability (in ammation, infection, tumor implants); decreased oncotic pressure (liver failure, malnutrition); increased hydrostatic pressure (congestive heart failure, renal failure); increased intrapleural pressure (atelectasis); or decreased lymphatic drainage (carcinomatosis, tumor com-pression, radiation). Often, the effusion results from a com-bination of mechanisms. As a result, these processes produce uid that may be serous, sanguineous, chylous, or purulent. Less commonly, a solid process or tumor may involve the pleural surfaces. Masses in the pleural lining are predomi-nantly malignant. Of these, secondary malignancies are more common, most frequently from lung, breast, ovarian, or gas-trointestinal primaries. Primary malignancies of the pleura and mesothelioma are seen with increasing frequency, and most cases are related to a remote asbestos exposure. Benign lesions of the pleural surface may be pleural plaques or soli-tary brous tumors.

Ch084-F06861.indd 1033Ch084-F06861.indd 1033 1/21/2008 1:53:10 PM1/21/2008 1:53:10 PM

Section 4 Pleura1034

ThoracentesisBowditch1 reported on three cases of so-called paracentesis thoracis as a diagnostic and therapeutic procedure in 1852. The technique was described to him and rst used in the United States by Wyman of Cambridge. He described the procedure as a puncturing of the thoracic cavity by means of an exploring trocar and removal of the accumulated uid or air by suction catheter. A bleeding diathesis is the only abso-lute contraindication to thoracentesis. Relative contraindica-tions include an uncooperative patient and a small amount of uid.2 Ultimately, the goal of a diagnostic thoracentesis is to provide uid, cells, and tissue for analysis.

Technique of ThoracentesisKrausz3 described thoracentesis with the patient seated with arms resting comfortably on a table and leaning forward slightly. After clinical and radiographic con rmation of the patients effusion, an appropriate site in the midscapular line on the affected side is selected, opposite to the level of the clinically identi ed diaphragm on the contralateral side. Alternatively, the site may be localized by bedside thoracic ultrasonography. Under sterile conditions, local analgesia is instituted; a needle or angiocatheter is advanced perpendicu-lar to the skin at the superior edge of the rib. Negative pres-sure is applied with suction as the needle is advanced. Loss of resistance and return of uid con rm access to the effu-sion. The soft angiocatheter is advanced over the needle, and the needle is withdrawn. The angiocatheter is temporarily occluded with a nger while a three-way stopcock is con-nected to the angiocatheter on one end and to drainage tubing with a volume regulator on the other. The volume regulator controls the rate of evacuation, avoiding a rapid evacuation of uid. We prefer either gravity drainage into a collection

TABLE 84-1 Diseases of the Pleura and Pleural Space

FluidEffusionCongestive heart failureHepatic failureRenal failureHypoalbuminemiaHemothoraxChylothoraxEmpyema and parapneumonic effusionBacterialFungalTuberculousMalignant effusion

MassMesotheliomaMetastatic malignancySolitary brous tumorPleural plaques

A B

Necissitatis

Thoracotomy scar Mild rednesswith bulge

FIGURE 84-1 Empyema necessitatis. Thirty years after right pneumonectomy, this patient presented with new and increasing right chest wall and arm erythematous mass. A, Computed tomography scan. B, Clinical picture.

a diagnostic procedure. Further information on the radiology of the pleural space is contained in Chapter 83.

DIAGNOSTIC PROCEDURESThe goal in any diagnostic pleural procedure is to obtain uid, cells, and/or tissue that may lead to a diagnosis using the least invasive and safest method. Often, thoracentesis, which is the least invasive procedure, provides a diagnosis. The addi-tion of pleural biopsy, either closed or thoracoscopic, increases the success of diagnosis. In 2006, open thoracotomy is rarely needed to obtain a diagnosis. Bronchoscopy and mediastinos-copy can be used selectively as adjunct procedures.


Chapter 84 Diagnostic Procedures for Pleural Diseases 1035

bag or drainage into vacuumed sterile bottles to allow for ease of transportation of the specimen to the laboratory. This technique has been modi ed by the use of central venous catheters,4 Tuohy loss-of-resistance needles,5 or intravenous tubing and drip bottles.

Patients may experience distress and severe coughing spells if too much uid is drained too fast. This can be avoided by controlling the rate at which the effusion is drained. To avoid the rare but potentially lethal complication of re-expansion pulmonary edema (RPE), seen after rapid evacuation of chronic large pleural collections, we recommend limiting the amount of uid drained to a volume of about 1 L per session (see later discussion). For smaller effusions, we prefer to evacuate the majority of the uid rather than to limit the thoracentesis to small volumes used solely for diagnostic purposes. If the patient develops a cough, chest tightness, or discomfort, the procedure needs to be terminated. With this approach, the complications are minimal and the occurrence of RPE is eliminated.

After the uid has stopped draining or if the patient devel-ops persistent cough and discomfort, the drainage tubing is clamped and removed. Gentle pressure is applied to the site for several minutes to prevent bleeding. We routinely obtain a postprocedure chest radiograph. The presence of a pneu-mothorax after thoracentesis does not always equate to the presence of a lung injury and air leak. Often, particularly if a chronic effusion was tapped, pneumothorax re ects failure of the lung to re-expand. A follow-up radiograph obtained a few hours later may help differentiate these two scenarios.

The entire volume of uid is sent for analysis, usually to four different laboratories. For undiagnosed effusions, we request the following tests:

Biochemistry for lactate dehydrogenase (LDH), protein, pH, and glucose

Microbiology for Gram staining and cultures (including fungal and TB cultures)

Hematology for cell counts and differential Cytology

Additional tests may be requested, depending on the char-acter of the uid and the patients clinical presentation; these may include measurements of amylase, lipase, cholesterol, and triglycerides.

ResultsOverall, thoracentesis provides clinically useful information in 92% of pleural effusions if pleural uid analysis is com-bined with the clinical presentation (Collins and Sahn, 1987).6 Empyema, chylothorax, and hemothorax are easily identi ed with simple tests. Distinguishing between other nonmalig-nant and malignant effusions requires cytologic and biochem-ical analysis to determine the nature of the effusion.

For malignant pleural disease, the diagnostic results of tho-racentesis vary with the underlying cancer. Pleural uid anal-ysis has historically established a diagnosis in 50% to 87% of cases. Prakash and Reiman7 showed that cytology analysis is superior to pleural biopsy alone. Newer technologies, such as immunocytochemistry,8 tumor marker identi cation, uores-

cence in situ hybridization (FISH),9 and reverse transcriptasepolymerase chain reaction (RT-PCR),10 have improved the pathologists ability to determine the origin of the cells.

The rate of success of pleural uid cytologic analysis depends on several factors:

1. Tumor type2. Specimen examination3. Number of specimens submitted

It has long been known that certain tumors are more likely to be detected in the pleural space. Cytology is more effec-tive in patients with metastatic adenocarcinomas of breast, ovary, colon, and lung origins; it is less effective in patients with lymphomas, squamous cell carcinomas, and mesothelio-mas.11 Central squamous cell carcinomas of the lung have a lower likelihood of positive pleural uid,12,13 because the effu-sion seen with these cancers is paramalignant and relates to bronchial or lymphatic obstruction rather than direct pleural involvement. Historically, malignant mesotheliomas were very dif cult to differentiate from metastatic adenocar-cinomas on the basis of pleural uid cytology alone. Today, immunohistochemical evaluation of the cells allows better diagnostic differentiation. Still, immunohistochemical analy-sis of pleural biopsy specimens is often needed, and occasion-ally electron microscopy is required, to con rm a diagnosis of mesothelioma.14

The method by which the pleural uid is processed and prepared is often overlooked in its ability to be diagnostic. In general, effusive samples are prepared by one of two methods, the cell block or the smear technique, after centrifugation of the specimen. Separately, these methods have equivalent results. But, when cell blocks and smears were compared with smear cytology alone in diagnosing malignant effusions, the use of both methods doubled the identi cation of malig-nant cells.15 Logic would dictate that, when using the con-centrating techniques to process effusive samples, sending larger volumes of uid should provide greater yield. This, however, has not been supported by retrospective studies,16 and the optimal amount of uid required for retrieval and subsequent diagnosis remains unproven. Currently, amounts from as little as 10 mL17 to several hundred milliliters2 have been reported as having a 56% to 60% success in diagnosing a malignant effusion, yet many cytology departments request more volume for analysis.

The number of specimens examined also improves the diagnostic accuracy of cytology studies. Pleural uid cytology is diagnostic in only 60% of patients with one specimen. This rate is improved by 27% with a second specimen and by another 5% with a third specimen (Light, 1999).18,19 Repeated examination after therapeutic thoracentesis has the potential advantage of providing newly shed and better preserved cells for analysis.20

Biochemical pleural uid analysis is paramount in deter-mining the exact cause of the effusion. Pleural effusions seen annually in the United States are predominantly secondary to congestive heart failure and pneumonia (Table 84-2). Lights criteria (Box 84-1) can be used to separate transu-dates from exudates (Romero-Candeira et al, 2002).21 If the clinical suspicion suggests a transudative effusion but Lights



the same technique was used with ultrasound guidance, the rate of pneumothorax was 0%.

RPE is a rare but signi cant and potentially lethal compli-cation that is usually unilateral, at times becomes bilateral, and develops within 12 to 24 hours after drainage. Two clin-ical factors are thought to predispose to the occurrence of this problem:

1. The chronicity (>3 days) of the lung collapse, whether it is secondary to an effusion or an undrained pneumothorax

2. The rapidity with which re-expansion is allowed to occur26,27

The pathophysiology of RPE is believed to be an increased capillary leakiness resulting from the mechanical stress applied to the re-expanding lung and also possibly an ischemia-reperfusiontype injury.

The treatment of RPE is supportive, and at times intuba-tion and mechanical ventilation are required. If the patient survives beyond the rst 48 hours, full recovery is the norm. Prevention is really the key. Even though most patients can withstand rapid evacuation of large effusions without seque-lae, it is probably prudent to adopt a universal approach to these large effusions and avoid one-time large-volume thora-centesis. One approach is to limit the rapidity with which the effusions are drained, to limit the volume drained in one continuous period (e.g., stop draining for a period of 1-2 hours with every liter of uid evacuated), and to terminate the procedure if the patient develops chest discomfort, dis-tress, or a cough.26

Percutaneous Pleural BiopsyPercutaneous or closed pleural biopsy was introduced by De Francis and colleagues28 in 1955 using a Vim-Silverman needle to diagnose pleural TB. This was followed by the develop-ment of similar needles by Cope29 and Abrams.30 The designs of these needles are similar, with a needle inside a trocar and a side hole to purchase the parietal pleura. Each needle has proved to be successful at obtaining parietal pleura without inadvertently damaging the underlying lung. Currently, Vim-Silverman, Cope, and Abrams needles are used with equal success that is more dependent on the operator than on the type of needle.

Pleural biopsies are indicated in patients with exudative pleural effusions that remain undiagnosed after biochemical and cytologic analysis. Frequently, biopsies are used to diag-nose pleural TB, mesothelioma, and other tumors of the pleura.

TechniqueAlthough the technique for closed pleural biopsy depends on the needle selected, the general approach is the same. Often, but not always, the pleural biopsy is done in tandem with thoracentesis. After local anesthesia is provided, a small nick is made in the skin over the selected site. The cannula and needle are inserted until pleural uid is aspirated. After the needle is withdrawn slightly, the trocar is advanced into the thoracic cavity, thus exposing the notched part of the trocar.

TABLE 84-2 Annual Incidence of Pleural Effusions in the United States

Cause Incidence

Congestive heart failure 500,000

Pneumonia 300,000

Malignant disease 200,000

Pulmonary embolism 150,000

Viral illness 100,000

Post heart surgery 60,000

Cirrhosis with ascites 50,000

Gastrointestinal disease 25,000

Collagen vascular disease 6,000

Tuberculosis 3,000

From Light RW: Update on Pleural Diseases. Presentation to the Washington Thoracic Society. September 27, 2005. Seattle, Washington.

Box 84-1 Lights Criteria for Exudative Effusion

An exudative effusion meets one or more of the following criteria (a transudate meets none):

Pleural uid-to-serum protein ratio 0.5Pleural uid-to-serum lactate dehydrogenase (LDH) ratio 0.6Pleural uid LDH >2/3 of upper normal limit for serum

criteria are weakly positive in favor of an exudate (protein ratio


While the needle is being withdrawn, gentle angled or lateral pressure is applied on the trocar to catch the parietal pleura in the notch. When the parietal pleura is engaged, a slight resistance is felt. The needle is readvanced and twisted to perform a cutting motion and excise a 2-mm portion of pleura and underlying muscle. Gentle skin pressure is applied to tamponade any bleeding. Pleural uid may be aspirated before or after the pleural biopsy, remembering that a small amount of pleural uid may provide a small safety cushion between the underlying lung and the needle.

ResultsThe rate of diagnosis with closed pleural biopsies varies with the disease. In cases of malignancy, closed pleural biopsies yield a diagnosis in approximately 60% (range, 38%-67%) of patients.2 It is important to emphasize that a nondiagnostic or normal pleural biopsy does not rule out malignancy. Nance and colleagues31 reviewed 385 undiagnosed effusions and compared cytologic examination and pleural biopsy. Pleural uid cytology was superior to blind pleural biopsy in making a diagnosis of malignancy in a ratio of nearly 2:1. The addition of closed pleural biopsies to pleural uid analysis in the diag-nosis of malignancy provided only a slight bene t over cyto-logic examination alone.

Pleural TB is the best process to evaluate by closed pleural biopsy; yields of up to 90% have been reported (Poe et al, 1984).32 In pleural TB, this technique is clearly superior to cytologic examination (Poe et al, 1984).32-34 This high diag-nostic return simply re ects the fact that pleural TB is a diffuse process that affects the entire pleural surface. Moreover, when pleural specimens are cultured, the diagnos-tic yield for pleural TB is enhanced.33 Occasionally, patients with rheumatoid arthritis, systemic lupus erythematosus, or sarcoidosis have granulomatous pleuritis on pleural biopsies. Negative culture for TB reliably rules out TB pleuritis in these patients (Poe et al, 1984).32

Pleural-based and juxtapleural tumors can successfully be diagnosed with percutaneous biopsies. In recent years, image-guided percutaneous biopsies have replaced the blind bedside approach and carry a much better diagnostic accuracy. In one series, ultrasound-guided biopsies of 91 pleural and juxta-pleural lesions of 2 cm or more in size were performed with virtually no complications.35 Diagnostic specimens were obtained in 85% of cases, and 100% of patients with mes-othelioma were accurately diagnosed. Although this tech-nique is accurate to make a diagnosis of mesothelioma, identi cation of the speci c subtype is limited by the size of the specimen and usually requires multiple pleural samples.14 In a randomized trial, Maskell and colleagues36 compared blind Abrams needle biopsy to Abrams needle biopsy under CT guidance in patients with unilateral, undiagnosed, exuda-tive pleural effusions who had previously undergone at least one negative cytologic examination. CT-guided biopsy had a sensitivity of 87%, compared with 47% for blind Abrams needle biopsy. The bene ts of image-guided biopsy are obvi-ously the possibilities of targeting the biopsy and of accessing narrow areas such as the costophrenic recesses, where malig-nancy is preferential.37

ComplicationsComplications of closed needle pleural biopsy are infrequent when the procedure is performed by or supervised by a well-trained specialist (Poe et al, 1984).32 Overall complication rates are less than 10% (Poe et al, 1984).31,32 Pneumothorax is the most common complication and accounted for the majority of complications in all reported series. Hemothorax and subcutaneous hematoma were also reported. In the series of 414 consecutive biopsies reported by Nance and associates in 1991, the liver was biopsied twice and the kidney once. In this series, there were two deaths, both related to massive hemothorax.31

Recent InnovationsTwo innovative variations using the tools of closed pleural biopsy have been reported. Emand and Rezaian38 reported on a novel approach using a cytologic brush introduced into the pleural cavity via the cannula of a pleural biopsy needle. With uoroscopic guidance, a cytology brush is advanced into the chest through a Cope needle. The brush is then moved back and forth three times to obtain specimens. Closed pleural brushing was compared with pleural uid cytology and closed pleural biopsy in 43 patients with suspected malignant effu-sion. Brushing was positive for malignant cells in 91%, 67%, and 58% of cases, respectively. Complications were more frequent with brushing and included hypotension, arrhyth-mia, cough, and pain. There were no pneumothoraces in the brushing group.

In a similar fashion, Uthaman and colleagues39 advanced an 8 Fr Bioptome via a 9 Fr sheath placed into the thoracic cavity by the Seldinger technique. Using uoroscopy, the Bioptome can be advanced and curled back on itself to biopsy multiple sites. They reported an average of 14 Bioptome biopsies per patient in 28 patients undergoing the procedure. Sixty-eight percent of biopsies yielded a diagnosis of either tuberculous pleuritis (n = 18) or malignancy (n = 1); 9 patients had non-speci c pleuritis as an initial diagnosis, and on follow-up two of these turned out to be malignant. Complications included cough, pain, and subcutaneous emphysema.

Pleuroscopy and ThoracoscopyThoracoscopy was rst described in 1910 by Professor H. C. Jacobaeus in Sweden.40 Over the next 15 years, he used the thorakoscope to make two entry points to access and lyse pleural adhesions in the creation of arti cial pneumothorax for the treatment of TB. The term pleuroscopy was coined by Fourestier and Duret in their report on the diagnosis of pleural malignancies using pleuroscopy.41 After a brief period of disuse, Boutin and colleagues repopularized the use of diagnostic thoracoscopy in 1981, reporting on its use in 1000 cases of chronic pleurisy.42

Innumerable instruments have been used to perform tho-racoscopy over the years. They range from exible and rigid bronchoscopes to simple or video-assisted mediastinoscopes. Currently, most thoracic surgeons have adapted the laparos-copy equipment for use in the thoracic cavity. We prefer to use the term pleuroscopy for single-port exploration of the pleural space and reserve the term thoracoscopy to denote



the use of multiple ports and video equipment to visualize the thoracic cavity.

Direct visualization of the pleural space for the purposes of biopsy for diagnosis is required in about 20% of patients with pleural effusions who have not had a diagnosis made after cytologic examination and closed pleural needle biopsy. Indications for diagnostic thoracoscopy are listed in Table 84-3.43,44

Technique of PleuroscopyPleuroscopy is usually performed through the intercostal space with the patient under local, regional, or general anesthesia. Most patients undergoing pleuroscopy are posi-tioned supine, with a roll under the operative side to raise that side of the thoracic cavity. The ipsilateral arm can be supported on an arm board, above the head or dangled across the chest. Our current preference is to use the mediastino-scope with or without video with the patient under general anesthesia (Fig. 84-2). An alternative is to use a single-port

working thoracoscope. Depending on our goals, a single- or double-lumen endotracheal tube is used. Because lung col-lapse is not mandatory for this technique, it is ideal for patients who are too compromised to tolerate double-lumen intubation and single-lung ventilation but require exploration and drainage of a complicated pleural collection. If a single-lumen endotracheal tube is used, ventilation may need to be held periodically to allow for adequate visualization above the costophrenic recesses and other dif cult angles. Unless there is a de nite target site identi ed by imaging, our incision usually corresponds to the fth or sixth interspace in the anterior axillary line, along the line of an eventual posterola-teral thoracotomy.

After complete drainage of the pleural uid, the pleural surfaces are examined for abnormalities. With the video-mediastinoscope, the entire thoracic cavity can be examined through a single port. There are potential advantages of this single-port approach in the evaluation of patients who poten-tially may have mesothelioma and may be considered for extrapleural pneumonectomy as part of future treatment plans. First, each port site is at risk for tumor implantation and growth. Second, every area where the parietal pleura has been breached is prone to technical dif culties at the time of extrapleural dissection. For the same technical reasons, it is probably best to site the single port along the potential incision line for extrapleural pneumonectomy, thus facilitat-ing resection of the tract and access to the extrapleural plane. At the completion of the procedure, a chest tube can be guided into place through the scope and the incision closed tightly around the secured drain.

Technique of ThoracoscopyStandard thoracoscopy is performed with the patient in full lateral decubitus position, with the bed exed to drop the ipsilateral hip to a point parallel to or below the chest (Fig. 84-3). A double-lumen endotracheal tube is always used. We prefer to have two lenses available: a 5-mm and a 10-mm 30-degree scope. Unless there is a targeted area or speci c area of interest, we often use our potential chest tube site as

TABLE 84-3 Indications for Diagnostic Pleuroscopy or Thoracoscopy

Unexplained pleural effusion

Pleural mass biopsy

Thoracic malignancy and pleural effusion

Mesothelioma

Unexplained pericardial effusion

Pneumothorax

Traumatic hemithorax

Foreign bodyintrapleural

To facilitate unusual thoracotomy incision

To evaluate mediastinal lymph nodes (stations 5 or 6)

Adapted from Deslauriers J, Carrier G, Vallieres E: Diagnostic proce-dures for pleural diseases. In Pearson FG et al (eds): Thoracic Surgery. Philadelphia, Churchill-Livingstone, 2002, pp 1140-55.

Pleural metastasisA B

FIGURE 84-2 A and B, Using the mediastinoscope for pleuroscopy to identify a pleural metastasis.



X X

X

FIGURE 84-3 Right lateral decubitus position with patient exed for video-thoracoscopy. X denotes potential port site placements.

A

B

3rd rib

Sympathetic chain

FIGURE 84-4 A, Normal pleura. Note the translucency with the sympathetic chain and vessels. B, Nonspeci c pleuritis. Note the erythema and loss of translucency.

the port of entry, anteriorly. One or two additional ports, as necessary, are placed after complete drainage of the pleural uid and initial assessment of the thoracic cavity. Over the years, we have moved our port sites anteriorly as much as possible: the intercostal spaces are wider in the front, and there is less chest wall discomfort that way during recovery.

At either pleuroscopy or thoracoscopy, nger palpation of the adjacent parietal pleura is rst completed and then a thorough examination of the thoracic cavity is performed, with particular attention paid to the paravertebral gutter and the costophrenic recesses. These dependent areas often harbor pathologic changes.45 Any abnormal areas are biopsied

and sent to the pathology and microbiology laboratories, asking for bacterial cultures, TB testing, and fungal studies. Frozen section evaluations are recommended so that ade-quate samples can be taken and the yield of the procedure increased. In addition, con rmation of a malignancy by frozen section allows completion of the procedure with a talc poudrage in appropriate situations. To minimize the risks of postoperative air leaks, biopsies of the visceral pleura need to be restricted to situations in which no other sites are likely to return a diagnosis. If no abnormalities are felt or seen, blind parietal pleural biopsies need always be performed in the areas of greatest risk, such as the gravity-dependent paraver-tebral gutter and costophrenic angles.

The normal pleural space reveals only a trace of uid on exploration and is lined with a translucent membrane that readily allows for identi cation of all anatomic structures (Fig. 84-4A). In patients with pleural disease, the most common nding is that of a nonspeci c pleuritis where there is increased vascularization, redness, and edema (see Fig. 84-4B). The translucency is lost, and the pleura is thickened. With increasing chronicity, the pleura becomes whitish, opaque, and thicker. Benign pleural plaques and granulomas are readily identi able. Metastatic lesions appear as small nodules, masses, or polypoid lesions (Fig. 84-5). They can also appear as whitish plaques across the lower half of the thoracic cavity. Occasionally, a gelatinous morass remains after drainage of pleural uid. This so-called jelly sh46 can be processed by frozen section or permanent paraf n section to yield a malignant diagnosis.

The appearance of mesothelioma varies with the stage at presentation. Biopsies of normal pleura or benign-looking pleural plaques, particularly over the diaphragm or in the



TABLE 84-4 Complications of Thoracoscopy

Bleeding (entry site, adhesions, biopsy site)

Prolonged air leak

Subcutaneous emphysema

Empyema

Cardiac arrhythmia

Entry site implant or metastasis

Persistent pain

costophrenic angles, have often returned a diagnosis of malig-nancy. More often, the pleura is studded with small, friable, vascular lesions and thick viscous uid. In late presentations, the tumor mass is whitish and friable (Fig. 84-6).

ResultsDespite the assertion that direct examination of the pleural space has utility, there is a surprising dearth of literature on the topic. Two series have provided a good evaluation of the procedure. In 1991, Menzies and Charbonneau47 reported, in

a collective review of 1500 thoracoscopies performed at dif-ferent centers, a diagnostic accuracy of more than 90% and an associated morbidity rate of less than 3%. In 1995, Harris and coworkers44 reviewed 182 patients undergoing thoracos-copy at The Cleveland Clinic. They estimated that thoracos-copy directly in uenced treatment in 85% of the patients. Complications were seen in 20% of patients, and the opera-tive mortality rate was 0.5%.

In experienced hands, diagnostic thoracoscopy is a safe procedure with few complications. Common complications are listed in Table 84-4. Empyemas are related to prolonged placement of chest tubes and are usually associated with incomplete re-expansion of the lung and persistent uid drainage. Early chest tube removal in these situations, despite failure of re-expansion and persistent drainage, minimizes the risk for infection. A problematic complication is that of port site recurrence, particularly with mesothelioma. Boutin and colleagues showed that a single-dose prophylactic radiation treatment to the port site eliminates this complication completely.48

Recent AdvancesA recent report by Mohamed and associates49 described the use of pleural space lavage with 300 mL of normal saline in 50 patients with exudative pleural effusions as a complement to thoracoscopy after evacuation of the pleural space. The diagnostic accuracy of the lavage returns was 22% better than that of uid cytology alone and almost as good as that of direct thoracoscopic biopsies. Although this technique is described as an adjunct to thoracoscopy, it could potentially be adapted as an adjunct to bedside diagnostic thoracentesis via an angiocatheter or central venous line.

OTHER PROCEDURES

Open ThoracotomyOpen thoracotomy is rarely indicated in the evaluation of the pleura and pleural space diseases in the current environment of video-assisted thoracoscopy.50 Statistically, the odds of establishing a diagnosis at thoracotomy after a complete eval-uation including a thorough thoracoscopic examination (with blind biopsies, if no abnormality is seen) are quite low. In 1981, Ryan and colleagues51 reported on the outcomes of 51 patients who underwent open thoracotomy for undiagnosed effusion: 61% had resolution of their effusion, 25% were diagnosed with malignancy between 12 days and 6 years after

Tumor

FIGURE 84-5 Metastatic pleural disease from an ovarian carcinoma.

FIGURE 84-6 Mesothelioma.



thoracotomy, and 13% remained undiagnosed. Close follow-up of such patients, with repeat evaluation and thoracoscopy if needed, is probably the best approach, compared with submitting them to a thoracotomy. Occasionally, thoracot-omy is required for diagnosis in the presence of abnormal pleura and a completely fused and obliterated pleural space that renders thoracoscopy impossible. If this is the case, a small incision with or without resection of a short segment of rib, potentially targeted with CT correlation, is usually all that is required to obtain parietal pleural tissue.

BronchoscopyThe role of bronchoscopy in the evaluation of undiagnosed pleural disease is controversial. In a group of 28 patients with an undiagnosed effusion but no mass or lobar atelectasis on chest radiography, bronchoscopy was diagnostic in only 4% of cases.52 In one report, Chang and Perng53 reviewed 140 patients with undiagnosed pleural effusions. Patients were grouped according to their chest radiographic ndings, and all underwent bronchoscopy. In patients who had additional radiographic ndings beyond that of a pleural effusion, bron-choscopy was de nitely more likely to be helpful. Another report, by Williams and Thomas,54 described a diagnostic rate for bronchoscopy of 1 in 7 for patients with an undiagnosed pleural effusion and no other radiographic evidence of a mass lesion or atelectasis. Therefore, in the presence of an undiag-nosed effusion and chest radiographic abnormalities other than the effusion, we believe that bronchoscopy is indicated. In the absence of additional radiographic abnormalities, bron-choscopy contributes very little, but it is simple to obtain at the time of pleuroscopy or thoracoscopy and adds very little risk and morbidity.

MediastinoscopyThere is no role for routine mediastinoscopy in the evaluation of pleural disease. However, if associated mediastinal aden-opathy is identi ed by imaging, this outpatient procedure may potentially yield a diagnosis and avoid the need for pleuroscopy/thoracoscopy, particularly in situations in which pleural uid evacuation is not required and attempts at chem-ical pleurodesis are not planned.

SUMMARYIf a patient presents with a pleural abnormality on clinical examination that is con rmed by plain chest radiographs, the clinician has a variety of diagnostic techniques to establish a diagnosis. History and physical examination are the corner-stones in the evaluation of a patient with pleural abnor-malities. Thoracentesis with biochemical uid analysis and repeated cytologic uid examination yields a diagnosis in most cases. The addition of closed pleural biopsies, particu-

larly for tuberculous pleuritis, and directed pleural biopsies via pleuroscopy or thoracoscopy can increase the diagnostic yield to almost 100%. Recent innovations such as pleural lavage and closed pleural brushing show great promise but require con rmatory studies before widespread use. A care-fully structured diagnostic plan based on the patients history can provide a diagnosis with minimal cost and patient morbidity.

COMMENTS AND CONTROVERSIESOne of the most important aspects of the investigation of pleural effusions is assessment of the clinical setting in which the effusion has occurred. A patient who develops an effusion in conjunction with a pneumonia, for instance, is likely to have a parapneumonic effusion. Likewise, a patient with known congestive heart failure who develops a right-sided effusion or a woman who develops a new pleural effusion after having been treated for breast cancer is likely to have a diagnosis related to the clinical history.

If the cause of the effusion is not clinically obvious, thoracentesis is the next step, and the procedure is usually performed under ultrasound guidance. It is diagnostic in 50% to 60% of cases, with higher yields for processes such as empyema (turbid or purulent uid), hemothorax (bloody uid), and chylothorax (clear milky uid). With the advent of video-thoracoscopic examinations, percutane-ous pleural biopsies with the Abrams or Cope needles are seldom indicated or done.

Thoracoscopy allows direct access to 90% to 100% of the pleural surfaces, and in experienced hands it has a diagnostic accuracy of almost 100% while being associated with minimal morbidity. Very seldom, open thoracotomy is indicated if the pleural space is oblit-erated or if one wishes to proceed immediately with a surgical procedure such as decortication or pulmonary resection.

While investigating a pleural effusion, it is most important to have a methodical approach, which will not only reduce the costs of investigation but also minimize patient morbidity.

J. D.

KEY REFERENCES

Collins TR, Sahn SA: Thoracocentesis: Clinical value, complications, technical problems, and patient experience. Chest 91:817-822, 1987.

Light RW: Useful tests on the pleural uid in the management of patients with pleural effusions. Curr Opin Pulm Med 5:245-249, 1999.

Poe RH, Israel RH, Utell MJ, et al: Sensitivity, speci city, and predictive values of closed pleural biopsy. Arch Intern Med 144:325-328, 1984.

Porcel JM, Vives M, Cao G, et al: Measurement of pro-brain natriuretic peptide in pleural uid for the diagnosis of pleural effusions due to heart failure. Am J Med 116:417-420, 2004.

Romero-Candeira S, Hernandez L, Romero-Brufao S, et al: Is it mean-ingful to use biochemical parameters to discriminate between transu-dative and exudative pleural effusions? Chest 122:1524-1529, 2002.


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2008 - Diagnostic Procedure for Pleural Disease (Pearson's Thoracic and Esophageal Surgery, Ch.84 2008 p.1033-1041)