Is there a diagnostic role of pleural needle biopsy in the diagnosis of pleural diseases? NO*

Is there a diagnostic role of pleural needle biopsy in the diagnosis of pleural diseases? NO*

Marc Noppen, MD, PhDInterventional Endoscopy Clinic and Respiratory Division &Chief Executive OfficerUniversity Hospital AZ-VUBBrussels,Belgium E-mail: [email protected]

* Except for…

Summary

• History & Facts

• Principles

• Limits of the technique

• Can we improve the diagnostic yield ?

• When should close pleural biopsies be considered ?

History & Facts

• CPB Introduced by De Francis in 1955• Literature of the time suggests yield 33-80% with

TB being highest (Colls 1961)• Scarbo et al, 1971

– Prospective study (rare)– 222bx/163pts (Abram’s needle, fluid or not no impact)– 61 TB or CA– Final Dx 92%

• 66 neoplasm (CPB dx’d 26)• 49 TB (CPB dx’d 35)

History & Facts

• Poe et al, 1984• Retrospective review, f/u 12-72 months• 211 CPB/207 adequate• Yield

– Malignant neoplasm 54 (sensitivity 65%)– Granulomatous disease 10 (1 False + TB, sensitivity

90%)– Nonspecific or Normal 143 (68%)– CA or TB found later in 30 of 143– Specificity 99%, PPV 98%, NPV 77%

History & Facts

• Kuaban, et al 1995 Cameroon

• 336 patients• 54 CA (16.1%)

– CPB 32 (59.3%)– Cytology 36 (66.7%)– Both 48 (88.9%)

• 176 TB (52.4%)

• Al-Shimemeri, et al 2003, Saudi Arabia

• 116 bx/122 pts• 54 dx (after 12

exclusions) (49.1%)• 10 CA, 35 TB, 9

empyema• 56 nonspecific

(50.9%)

History & Facts

• Blanc et al, France 2002• 168 thoracoscopy in 154

pts• 149 dx• 120/149 CPB-->96 dx• Dx challenged in 43 0f 96

by thoracoscopy• Of 66 nonspecific CPB,

16 MM, 10 Adeno, 3 other CA, 3 TB, 10 erroneous CPB

• Nusair et al 2002, Israel• 44 pts/13 (29%) dx by

CPB• 10 CA• 10/30 (33%) with CA CPB

non-diagnostic• LDH < 510 best predictor

of negative CPB

History & Facts

• Chakrabarti B, et. al. The role of Abrams percutaneous pleural biopsy in the investigation of exudative pleural effusions. Chest. 2006;129:1549-1555.

– Urban hospital, 1997-2003, Liverpool, UK– Retrospective via pathology database– Exudates, non-dx thoracentesis– 75 patients (64% male, age mean 72), 59/75

(79%) pleural tissue– No difference in quality between fellow or

resident levels– Yield of pleural tissue trended towards better

if 4-6 bx taken rather than up to 3 (NS)

Summary

• History & Facts

• Principles




Principles

• Indication : Diagnostic work-up of a pleural exudate of unknown cause– Carcinomas

• Lung• Mesothelioma• Metastatic

– Tuberculosis– Other

• Principle : To obtain a sample of patietal pleura for microscopic investigation

Principles of the technique

• Fluid must be present• Preop look for coagulopathy• Contra-indications

– Bleeding diathesis– AC– <50-75K platelets (? Transfuse)– Skin issues– Inability to tolerate– Empyema

• Like thoracentesis– Go lateral in elderly people….


• Abram’s vs. Cope• Upright, confirm fluid• Prep like thoracentesis• Local anesthetic• 1/4 cm skin incision• Introduce needle, feel “pop” (Abram’s preferred)• Hook pleura (450 at 3, 6 and 9 o’clock)• In and out or aspirate into syringe• Specimens for AFB/Fungal cx and histopathology

(minimum 3). Fluid also.• Jimenez, et al 2002: optimal bx # 4 for path, dx on 1st

54% increases to 89% at 4.




Summary

• History & Facts

• Principles




Limits of the technique

• “Why are my biopsies so often negative..?”

Biopsies Cyto Biopsies+cyto Diagnosis

85% Tuberculosis

43% 58% 65% Carcinomas

20% 25% 36% Mesothelioma


• “Why are my biopsies so often negative..?”– The biopsies do not contain pleura– (neoplastic) invasion of the pleura is

discontinuous ( the biopsy did not hit the target )

– In a patient with a known carcinoma the exudate is not directly related to the neoplasm ( para-neoplastic effusion)


• “Why are my biopsies so often negative..?”– The biopsies do not contain pleura

Kirsch, Chest 1997

• 30 patients with tuberculous pleural effusion• 4 to 10 biopsies/patient• sensitivity of microscopy 87 %• 40 % of the biopsies contained pleura

if ≥ 6 biopsiesif ≥ 2 biopsies pleura +Sensitivity = 100%


• “Why are my biopsies so often negative..?”– Neoplastic invasion of the pleura is

discontinuous• The biopsy did not hit the

target• The parietal pleura is not

involved

(47% of cases)


• “Why are my biopsies so often negative..?”– Paraneoplastic effusions

• Related to local consequences of the tumor– Lymphatic obstruction– Postobstructive pneumonia



• Related to local consequences of the tumor– Atelectasis with transsudate



• Related to systemic consequences of the tumor– Pulmonary emboli



Related to local consequences of the tumor• lymphatic obstruction• post-obstructive pneumonia (para-pneumonic effusion)• atelectasis (transsudate)• Chylothorax• Superior cava syndrome (transsudate)

Related to systemic effects of the tumor• pulmonary emboli• hypoalbuminemia (transsudate)

Related to treatments• Radiotherapy• Chemotherapy (methotrexate, cyclophosphamide,

Mitomycine, Bleomycine, Procarbazine)


• Complications

Pneumothorax (2.9-8.4%)

Vasovagal Syncope (2.3%)

Hemothorax (.4%)

Cardiac Arrest and Death reported (.4%)

Wang ed., Biopsy Techniques in Pulmonary Disorders, Raven, 1989

Summary

• History & Facts

• Principles




Can we improve the diagnostic yield?

• Increase the number of biopsies

• Repeat the biopsies• Furhter sectioning of negative tissue samples• Aditional examinations


• Increase the number of biopsies– Kirsch et al, Chest 1997

• 30 patients with tuberculous pleural effusion

• 4 to 10 biopsies/patient

• sensitivity of microscopy 87 %

• 40 % of the biopsies contained

pleura


• Repeat biopsies at another site in a second attempt

Neoplastic exudate with first negative attempt

Yield of second attempt:

Schools, Tex J Med 1963 26%Scerbo, JAMA 1971 30%Hoff, Am J Clin Pathol 1975 27%


• Further sectionning of negative tisuue specimens : increase to more than 3 sections per specimen does NOT increase diagnostic yield ( Kirsch, Chest 1997 and Mungat, Thorax 1980 )


• Additional Examinations• pleural effusions in tuberculosis nb of specimens sent for culture• Sensitivity of culture

60 % if 1 specimens sent for culture (Kirsch, Chest 1997)68 % if > 50 % specimens sent for culture (Scharer, ARRD 1986)

• In patients with negative histology, cultures are positive in only10 % of the cases (Bueno, Arch Intern Med 1990)

• Search for AFB in sputumpositive in only 4 % of cases (Epstein, Chest 1987)


• Additional Examinations• pleural effusions in malignancy : add

cytologyClosed pleural biopsy Cytology

44% 62%

74% Loddenkemper, ERJ 1993

Summary

• History & Facts

• Principles




When should closed pleural biopsies be considered?

• Is closed pleural biopsy a relic from the past?– In most cases, but not an unreasonable

step– Often need subsequent procedures for dx or rx– Yield unimpressive compared to thoracoscopy and little added to thoracentesis

• Exceptions: strong suspicion of TB; situations where closed biopsy will expedite next step or is best option; consider local needs, resources and patient characteristics; teaching(?)

Documents

Is there a diagnostic role of pleural needle biopsy in the diagnosis of pleural diseases? NO*