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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, PhD Interventional Endoscopy Clinic and Respiratory Division & Chief Executive Officer University Hospital AZ-VUB Brussels,Belgium E-mail: marc.noppen@az.vub.ac.be.

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

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  1. Is there a diagnostic role of pleural needle biopsy in the diagnosis of pleural diseases? NO* Marc Noppen, MD, PhD Interventional Endoscopy Clinic and Respiratory Division & Chief Executive Officer University Hospital AZ-VUB Brussels,Belgium E-mail: marc.noppen@az.vub.ac.be * Except for…

  2. Summary • History & Facts • Principles • Limits of the technique • Can we improve the diagnostic yield ? • When should close pleural biopsies be considered ?

  3. 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)

  4. 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%

  5. 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%)

  6. 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

  7. 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)

  8. Summary • History & Facts • Principles • Limits of the technique • Can we improve the diagnostic yield ? • When should close pleural biopsies be considered ?

  9. 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

  10. 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….

  11. Principles of the technique • 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.

  12. Principles of the technique

  13. Principles of the technique

  14. Principles of the technique

  15. Summary • History & Facts • Principles • Limits of the technique • Can we improve the diagnostic yield ? • When should close pleural biopsies be considered ?

  16. Limits of the technique • “Why are my biopsies so often negative..?” Biopsies Cyto Biopsies+cytoDiagnosis 85% Tuberculosis 43% 58% 65% Carcinomas 20% 25% 36% Mesothelioma

  17. Limits of the technique • “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)

  18. Limits of the technique • “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 biopsies if ≥ 2 biopsies pleura + Sensitivity = 100%

  19. Limits of the technique • “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)

  20. Limits of the technique • “Why are my biopsies so often negative..?” • Paraneoplastic effusions • Related to local consequences of the tumor • Lymphatic obstruction • Postobstructive pneumonia

  21. Limits of the technique • “Why are my biopsies so often negative..?” • Paraneoplastic effusions • Related to local consequences of the tumor • Atelectasis with transsudate

  22. Limits of the technique • “Why are my biopsies so often negative..?” • Paraneoplastic effusions • Related to systemic consequences of the tumor • Pulmonary emboli

  23. Limits of the technique • “Why are my biopsies so often negative..?” • Paraneoplastic effusions 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)

  24. Limits of the technique • 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

  25. Summary • History & Facts • Principles • Limits of the technique • Can we improve the diagnostic yield ? • When should close pleural biopsies be considered ?

  26. Can we improve the diagnostic yield? • Increase the number of biopsies • Repeat the biopsies • Furhter sectioning of negative tissue samples • Aditional examinations

  27. Can we improve the diagnostic yield? • 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

  28. Can we improve the diagnostic yield? • 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%

  29. Can we improve the diagnostic yield? • 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 )

  30. Can we improve the diagnostic yield? • 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 only 10 % of the cases (Bueno, Arch Intern Med 1990) • Search for AFB in sputum positive in only 4 % of cases (Epstein, Chest 1987)

  31. Can we improve the diagnostic yield? • Additional Examinations • pleural effusions in malignancy : add cytology Closed pleural biopsy Cytology 44% 62% 74% Loddenkemper, ERJ 1993

  32. Summary • History & Facts • Principles • Limits of the technique • Can we improve the diagnostic yield ? • When should close pleural biopsies be considered ?

  33. 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(?)

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