Pleuroscopy and Pleural Biopsy with the Flexible Fiberoptic Bronchoscope

doi:10.1378/chest.67.5.527

Chest

Volume 67, Issue 5, May 1975, Pages 527-531

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Diagnostic pleuroscopy has been performed under local anesthesia in nine patients using a gas sterilized flexible fiberoptic bronchoscope inserted through a 1 to 2 cm chest incision into the pleural space. Pleuroscopy in one patient excluded recurrent neoplasm on the pleural aspect of a bronchopleural fistula. Another patient had a pleuroscopic biopsy of the lung, which was the only method successful in diagnosing a metastatic renal carcinoma. The other seven patients were studied for pleural effusions which were undiagnosed after study of pleural fluid and/or Abrams needle biopsy. In four of them pleural implants of carcinoma were visualized and proved by biopsy. Three patients had negative pleuroscopy, two of these also being negative at subsequent thoracotomy. One was not explored because of extrathoracic metastases. The procedures were performed with minimal patient discomfort and no serious complications.

Section snippets

Materials and Methods

Patients were selected because of undiagnosed pleural disease after the usual studies on pleural fluid and/or needle biopsy with the Abrams needle. One patient was examined because of postoperative bronchopleural fistula after an upper lobe lobectomy for carcinoma of the lung to determine if the resection line was free of tumor. Another patient developed a peripheral pleural-based lesion after nephrectomy for renal cell carcinoma. Pleuroscopic biopsy of the lesion was done for histologic

Case Reports

The following two cases are illustrative of the most common findings in the patients we have examined.

Results

A total of nine patients (Table 1) have been studied by pleuroscopy using the flexible fiberoptic bronchoscope. Seven of the patients had undiagnosed pleural effusions, one had a pleural lesion which appeared three years after nephrectomy for hypernephroma, and one had a postoperative bronchopleural fistula with possible neoplasm in the resection line as the cause of the fistula.

Six of the seven patients with undiagnosed pleural effusion have had a histologic diagnosis of carcinoma, either by

Discussion

Non-thoracotomy methods of obtaining diagnostic material from the pleura have been employed since 1954, and have included partial rib resection,¹⁴ limited incisions,¹⁵ cutting needles,16, 17, 18, 19, 20, 21 and thoracoscopy.4, 5, 6, 7, 8, 9, 10

Despite several large series demonstrating high diagnostic yields by thoracoscopy,7, 8, 9, 10, 11 the procedure has not been widely utilized. The usual approach to diagnosis of pleural disease has proceeded from thoracentesis with study of pleural fluid

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Cited by (25)

Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: A meta-analysis
2013, Chest
The usefulness of semirigid thoracoscopy in undiagnosed exudative pleural effusions (EPEs) has been variably reported in different studies. Herein, we perform a systematic review and meta-analysis to estimate the overall diagnostic yield and safety of semirigid thoracoscopy in EPE.
We searched the PubMed and EMBASE databases for studies reporting the outcomes of semirigid thoracoscopy in EPE. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The yield of semirigid thoracoscopy was analyzed by calculating the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic OR (DOR) for each study and pooling the study results using a random effects model. Heterogeneity and publication bias were assessed for individual outcomes. Sensitivity analysis was performed to explore the potential causes of heterogeneity.
Our search yielded 17 studies (755 patients with undiagnosed EPE). The sensitivity, specificity, PLR, NLR, and DOR of semirigid thoracoscopy was 91%, 100%, 4.92, 0.08, and 102.28, respectively. The area under the curve for the summary receiver operating characteristic curve was 0.93. There were negligible complications and no mortality. There was evidence of heterogeneity, which significantly decreased on sensitivity analysis after exclusion of smaller (< 25 participants) studies. There was no evidence of publication bias.
Semirigid thoracoscopy is an efficacious and safe procedure in diagnosis of EPE. Because of the small sample size, larger well-designed trials are required to confirm the results of this study. There is also a need for head-to-head comparison of semirigid and rigid thoracoscopy.
Medical Pleuroscopy
2013, Clinics in Chest Medicine
Citation Excerpt :
Rigid thoracoscopes allow a large working channel to be maintained but reduce the area of the pleural cavity which is easily accessible, especially if a single entry port is used. Practitioners identified the potential for a more flexible scope early on, with studies experimenting with the introduction of a standard flexible bronchoscope into the pleural space instead of a rigid scope.77,78 The conclusions were that that this adaptation could be made safely and easily but that more satisfactory biopsies were obtained using the standard instrument, perhaps because a lack of proximal rigidity reduces dexterity in the distal portion of the scope.
Diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: A comparative, age-dependent study
1998, Respiratory Medicine
Objective. To compare the value of closed percutaneous pleural biopsy versus pleuroscopy for diagnosis of undiagnosed exudative pleural effusion in an age-dependent manner.
Design. Prospective clinical study.
Setting. University hospitals.
Patients. Forty-nine consecutive patients with undiagnosed exudative pleural effusion following the initial clinical and paraclinical investigations, including bronchoscopy. Cases were divided into younger and older groups according to their ages.
Intervention. Closed pleural biopsy immediately followed by pleuroscopy with a flexible fiberoptic bronchoscope from the same incision site.
Results. In the older age group, pleuroscopy was superior to closed pleural biopsy for the diagnosis of the underlying pleural disease (P=0·0007), while they were almost equally diagnostic in the younger cases (P=0·58).
Conclusion. For those patients with undiagnosed exudative pleural effusion who are older than 50 years of age, pleuroscopy could be chosen as the first procedure of choice as compared to closed pleural biopsy if malignant pleural effusion is suspected.
Diagnostic flexible fiberoptic pleuroscopy in suspected malignant pleural effusions
1995, Chest
Up to 25% of malignant pleural effusions can remain undiagnosed following history, physical examination, thoracentesis, and percutaneous closed pleural biopsy. The next diagnostic procedure is often rigid thoracoscopy, an invasive procedure requiring an operating suite and usually a postprocedure chest tube. We performed flexible fiberoptic pleuroscopy using a fiberoptic bronchoscope in conjunction with a closed pleural biopsy on 12 patients with exudative pleural effusions that remained undiagnosed despite extensive clinical evaluation. A sterile 4.8-mm outside diameter flexible fiberoptic bronchoscope was placed into the pleural space during the course of a routine closed pleural biopsy. Pneumothorax was induced to allow visualization. Brush or forceps biopsy specimens of suspicious parietal pleural lesions were taken. Eight pleural spaces appeared smooth while four were diffusely studded on the parietal surface. Of these four, three were proven to have diffuse pleural adenocarcinoma using this procedure; the fourth proved ultimately to have pleural mesothelioma. On long-term follow-up (mean=17.7±11.4 months), no false-negative studies or unexpected morbidity was noted. Flexible fiberoptic pleuroscopy may provide a diagnosis in exudative pleural effusions when other less invasive procedures fail to do so and is well tolerated with minimal discomfort and risk.
A modified Abrams needle biopsy technique
1995, Chest
To compare the diagnostic sensitivity of a modified Abrams needle pleural biopsy technique (Al) with the standard Abrams (A2) and Cope needle biopsy methods. The modified Abrams pleural biopsy technique consisted of suctioning each tissue sample into a syringe without removing the needle completely from the chest until the completion of the entire procedure. Both the standard Abrams and Cope needle techniques required needle removal from the chest after each pleural biopsy.
Retrospective chart analysis.
Community teaching hospital affiliated with Stanford University.
Forty-seven patients (30 men and 17 women) with a mean age of 44.5 years (range, 19 to 81 years) who were referred to a pulmonary consultation service for pleural biopsy.
Two of us (C.M.K. and F.T.K.) used the modified Abrams technique and two of us (W.A.J. and A.C.C.) used the standard Abrams technique. The Cope needle was used as originally described.
We recorded the type of pleural biopsy needle and technique used in each patient. Biopsy specimen diameter and number of tissue samples obtained, final diagnoses, and complications were recorded.
The diagnostic sensitivity for tuberculous pleurisy was 82% for the modified Abrams method, 71% for the standard Abrams method, and 88% for the standard Cope technique (p≥0.3). There was no difference in size of tissue sample obtained (Al vs A2), number of biopsies, or complications among the three methods of pleural biopsy.
The modified method of Abrams needle biopsy demonstrates a diagnostic sensitivity for pleural tuberculosis (82%) that is equivalent to that for the standard Abrams or Cope methods.
Comparative studies using a rigid thoracoscope and fiberoptic bronchoscope to treat spontaneous pneumothorax
1991, Chest
Prior to 1978, the conventional treatment of pneumothorax generally consisted of conservative therapies such as rest, needle puncture, or thoracic cavity drainage; however, when conservative therapies were ineffective or relapse occurred, a thoracotomy was performed. Using a conventional therapeutic approach, 34 percent (11/32) of our patients required a thoracotomy. Consequently, in 1981, we began to use alternative therapies to reduce the need for thoracotomy. In this report, we describe the results of using a rigid thoracoscope and fiberoptic bronchoscope for the treatment of spontaneous pneumothorax. Initially, we treated 31 of 79 patients with a rigid thoracoscope and electrocoagulation therapy. Therapy was effective in 17 (55 percent) of the patients. Only 13 (16 percent) of the 79 patients required a thoracotomy, which represents a 50 percent reduction in incidence. Of the 14 cases in which therapy was ineffective, the major cause of failure was our inability to view a broad thoracic area and treat all blebs with a rigid thoracoscope. Subsequently, we developed a method using a fiberoptic bronchoscope (FB), which allows an unrestricted view of the thoracic area, in combination with electrocoagulation and fibrinogen or thrombin solution (or both) for the treatment of spontaneous pneumothorax. We treated 19 of 39 patients with the FB method. Treatment was effective in 15 (80 percent) of the patients. Only 4 (10 percent) of the 39 patients required a thoracotomy, which is a reduction of over 00 percent in our original incidence.

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Supported in part by Grant 3-T01-H L05991, National Institutes of Health, and by the Lerrigo Research Fund, Kansas Lung Association.

Manuscript received July 16; revision accepted September 17.

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Chest

Clinical InvestigationsPleuroscopy and Pleural Biopsy with the Flexible Fiberoptic Bronchoscope

Section snippets

Materials and Methods

Case Reports

Results

Discussion

Lancet

Surg Clin NS

J Thorac Cardiovasc Surg

Dis Chest

Lancet

Lancet

Pleural biopsy as an aid in the etiologic diagnosis of pleural effusion: Review of the literature and report of 132 biopsies

Ann Intern Med

Needle biopsy of the pleura in the diagnosis of pleural effusion

Q J Med

The cauterization of adhesions in artificial pneumothorax treatment of pulmonary tuberculosis under thorascopic control

Proc R Soc Med

Thoracoscopy as a method of exploration in penetrating injuries of the thorax

Dis Chest

Clinical Investigations
Pleuroscopy and Pleural Biopsy with the Flexible Fiberoptic Bronchoscope