Role of medical thoracoscopy in the diagnosis of pleural effusions

BackgroundMedical thoracoscopy (semi-rigid and rigid thoracoscopy) have revolutionized the management of undiagnosed pleural effusions. Though semi-rigid thoracoscopy has a good diagnostic yield in malignant and tubercular effusions, its role in the management of a complicated pleural effusions is debatable. Hence, rigid thoracoscopy becomes handy in these cases. The present study looked into the role of medical thoracoscopy in the diagnosis of pleural effusions in different conditions.MethodsThis study included all patients who underwent medical thoracoscopy at our center between May-2010 and March-2020. Basic demographics data, type of medical thoracoscopy used, and histopathology details were collected and analyzed.ResultsA total of 373 patients were subjected to medical thoracoscopy (202 semi-rigid thoracoscopy and 171 rigid thoracoscopy). Out of whom 246 (66%) were males, the mean age was 51.9 ± 13.2 years. Diagnosis was achieved in 370 patients with a yield of 99.2%. The diagnostic yield in semi-rigid thoracoscopy was 99.5% with lung malignancy being the most common diagnosis (41%; n = 81), followed by tuberculosis (31%; n = 61). The diagnostic yield in rigid thoracoscopy was 100% in our study. Along with high diagnostic yield, complete drainage and lung expansion was seen in 93.5% (160 out of 171 patients) without requiring a second procedure.ConclusionsSemi-rigid thoracoscopy and rigid thoracoscopy should complement each other in the diagnosis of pleural effusions. Rigid thoracoscopy should be considered as the procedure of choice in a complicated pleural effusion.     

135例胸腔积液患者内科胸腔镜检查及临床意义

目的探讨内科胸腔镜检查对不明原因胸腔积液患者的临床意义。方法分析内科胸腔镜检查135例患者的临床资料。结果135例中,经胸腔镜胸膜活检确诊104例（77．0％）,其中病理为恶性肿瘤和结核性胸膜炎各51例（49．0％）,脓胸2例（1．9％）。135例胸腔积液患者经胸腔镜检查病因诊断阳性率85．9％。恶性肿瘤和结核性胸膜炎患者经胸腔镜胸膜活检阳性率分别为79．7％和91．1％。结论内科胸腔镜检查对不明原因胸腔积液患者有获得病理诊断、病因诊断及准确肺癌分期等临床意义。     

A case of benign asbestos pleural effusion suspected on thoracoscopic examination under local anesthesia]

We report the case of a 92-year-old man with a 13-year history of occupational asbestos exposure who presented with a complaint of dyspnea. In September 2001, bilateral pleural effusions were revealed on chest radiography, and continued to progress despite treatment for heart failure. Chest CT revealed calcification of the pleura but no abnormal findings in the lung fields. Both pleural effusions were exudative and lymphocytes were the predominant cells contained in them. Antituberculous chemotherapy had no effect on the exudates. In March 2002, thoracoscopy was performed under local anesthesia (medical thoracoscopy). Plaque was recognized on the parietal pleura; however, the serosal surfaces of the parietal and visceral pleura were smooth, and no evidence of malignancy, especially malignant mesothelioma, was noted. The patient's condition was diagnosed as benign asbestos pleural effusions. Prednisolone was administered, and these effusions gradually decreased. Cases of benign asbestos pleural effusion occurring simultaneously with massive bilateral effusions are rare. Thoracoscopy aided in the differential diagnosis of this case.     

Endoscopic approach to pulmonary diseases: Clinical utility of medical thoracoscopy in diagnosis of pleural diseases

Thoracoscopy is useful for diagnosis of a number of lung diseases. We report our recent experience of medical thoracoscopy performed under local anesthesia in 142 cases. Of 124 patients with pleural effusion, 46 had pleuritis carcinomatosa, 11 had pleuritis tuberculosa, and 10 had malignant mesothelioma. We evaluated the utility of thoracoscopic observation and pleural biopsy in these three diseases. Almost of patients with malignant pleural effusion initially undiagnosed by the cytology of pleural effusion were diagnosed by thoracoscopy. Especially in malignant mesothelioma, thoracoscopy allowed accurate diagnosis. No serious complication was observed. Since medical thoracoscopy under local anesthesia is a rapid, easy, safe, and well-tolerated procedure with an excellent diagnostic yield, it is recommended as a diagnostic procedure for cases with pleural effusion.     

Etiology and prognostic significance of massive pleural effusions

It has been stated that malignancy is the most common aetiology of massive pleural effusions. To determine the most frequent causes of massive pleural effusions and to assess the diagnostic yield of different diagnostic procedures and survival, we prospectively studied 1084 patients with pleural effusion. Massive pleural effusions were identified in 121 of 1084 patients (11.2%). Compared with non-massive pleural effusions, massive pleural effusions were significantly more likely to be malignant (53.7% vs. 38.3%, P=0.03) or secondary to cirrhosis (9.9% vs. 2.6%, P=0.0000). On the other hand, massive pleural effusions were significantly less likely to be secondary to infection (10.7% vs. 19.2%, P=0.003) or congestive heart failure (0.8% vs. 6.7%, P=0.03). There was a significant increase in the yield of diagnostic studies in patients with massive malignant pleural effusions (56.9% for cytological studies and 36.9% for biopsies). On the other hand, there was no difference in the diagnostic yield of microbiological and histological studies in the group of tuberculous pleural effusions. In our study population, patients with non-massive malignant pleural effusions had a significantly better survival than those with massive malignant pleural effusions, with a median survival of 8 months (95% confidence interval, 7-9) compared with 5 months (95% confidence interval, 4-6) (P=0.0009). We conclude that malignancy is the most common cause of a massive exudative effusion. Massive malignant pleural effusions are associated with worse survival, independent of age and histologic subgroup, than are non-massive malignant pleural effusions.     

Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy

STUDY OBJECTIVES: Thoracoscopic pleural biopsy is highly accurate in the diagnosis of pleural malignancy. However, no scientific evidence is currently available to guide the physician's decision as to when and in which patients with pleural effusion thoracoscopy is indicated. The application of predictive criteria of malignancy might improve the indication of thoracoscopy in patients with undiagnosed pleural effusion. METHODS: Prospective study of 93 patients referred for thoracoscopy at a tertiary hospital. Clinical variables were obtained prior to thoracoscopy by clinical history and review of previous data, patient interview, and physical examination. Radiologic variables were obtained by evaluation of chest radiograph and chest CT images by two independent readers. After thoracoscopy, all patients without a diagnosis were sent for long-term follow-up. RESULTS: Thoracoscopy demonstrated 94% sensitivity and 100% specificity in the diagnosis of pleural malignancy. Variables, which in a multivariate model are associated with pleural malignancy, include a symptomatic period > 1 month, absence of fever, blood-tinged pleural fluid, and chest CT scan findings suggestive of malignancy. Receiver operating characteristic analysis showed that the use of these four criteria offered adequate classification in 95% of patients. Twenty-eight patients had all four criteria, and all had malignancy; 21 patients had at most one criterion, and none had malignancy. CONCLUSION: Clinical and radiologic criteria of patients with pleural effusion permit different risk levels for pleural malignancy to be distinguished. Consequently, application of the four proposed criteria permits better indication of thoracoscopy in patients with undiagnosed pleural effusion.     

Thoracoscopy for the diagnosis of pleural disease

OBJECTIVE: To assess the accuracy and safety of thoracoscopy for the evaluation of pleural disease. DESIGN: Prospective evaluation of patients referred for thoracoscopy. SETTING: University hospital specializing in chest diseases. PATIENTS: We studied 102 patients with pleural disease, the cause of which had not been determined after initial investigation, including thoracentesis and needle biopsy. Eighty-six patients had pleural effusion, 11 had pleural mass, and 5 had pleural effusion in association with a known primary lung carcinoma. INTERVENTION: All patients had thoracoscopy under local anesthesia with mild sedation. Visually directed biopsies were done of parietal pleura. MEASUREMENTS: We recorded clinical characteristics, laboratory data, findings and duration of thoracoscopy, and any complications associated with the procedure. Hospital and clinic follow-up records were reviewed, and patients were contacted by telephone 12 and 24 months after thoracoscopy to assess their health status. MAIN RESULTS: One hundred and four thoracoscopies were done in 102 patients. A definitive diagnosis was established in 95 patients: 42 had malignant pleural disease and 53 had benign pleural disease. A diagnosis of benign pleural disease using thoracoscopy could not be confirmed in the remaining 7 patients because of insufficient follow-up information. Overall, thoracoscopy was 96% accurate with a sensitivity of 91%, a specificity of 100% and a negative predictive value of 93% for the diagnosis of pleural malignancy. Thoracoscopy was well tolerated under local anesthesia and entailed hospitalization for less than 24 hours in most cases. No deaths occurred, although 1.9% of patients had major complications, and 5.5% had minor complications. CONCLUSIONS: Among patients with pleural disease remaining undiagnosed after usual initial investigation, thoracoscopy done under local anesthesia is a rapid, safe, and well-tolerated procedure with an excellent diagnostic yield that is equivalent to that of thoracotomy.     

Diagnostic yield of semi rigid thoracoscopy in unexplained exudative pleural effusion- Experience from tertiary care hospital of east India

IntroductionIn most of the pleural effusion, fluid analysis generally gives the etiological diagnosis but in almost 20% it remains unclear. This study was designed to determine the diagnostic yield of a pleural biopsy using semi rigid thoracoscope and its complication rates.Materials and methodsThis was a retrospective observational study conducted in the Department of Pulmonary Medicine, AIIMS Patna. All the patients diagnosed as unexplained pleural effusion between Jan 2018 and December 2019 were included in the study.ResultsTotal 76 out of 97 patients with unexplained exudative pleural effusion underwent medical thoracoscopy in the given period of 2 years. The mean age of the patients was 57.63 years. There were 46 males and 30 females. 38 patients (50%) had right-sided pleural effusion. More than half (52.6%) of study patients were on Anti-tubercular treatment in which only 11.84% had tuberculosis. In both unilateral and bilateral pleural effusion, the proportions of small, moderate, and large size of pleural effusions were 10.52, 42.10, and 47.36%, respectively. Thoracoscopy yielded a definitive diagnosis in 66 out of 76 patients (86.84%), and in 10 patients (13.15%), biopsy was inconclusive. Of 76 patients, malignancy was confirmed in 58 (76.31%), and tuberculosis in 8 (11.84%) patientsConclusionThis study concludes that, medical thoracoscopy with semi-rigid thoracoscope is an invaluable tool in the diagnosis of patients with unexplained exudative pleural effusion. It is a very simple and safe method with high diagnostic yield and associated with few complications. Malignancy was found to be the most common cause of unexplained exudative pleural effusion     

Investigation of pleural effusion: comparison between fibreoptic thoracoscopy, needle biopsy and cytology

Twenty-eight patients with exudative pleural effusion have been investigated by fibreoptic thoracoscopy, Abrams needle biopsy and pleural fluid cytology. Sixteen patients had previously had negative pleural biopsies and cytology. Twenty effusions were malignant (16 mesothelioma, four metastatic carcinoma), seven were due to nonspecific inflammation and in one case no abnormality was found. The diagnostic yield for all three techniques combined was 85%, for thoracoscopy alone 65%, Abrams biopsy 60% and cytology 45%. In 12 patients presenting without previous investigation all eight malignant effusions were correctly diagnosed by at least one of the techniques with individual sensitivities of 75% for thoracoscopy, 63% for Abrams and 38% for cytology. Of the 16 patients who had previously had negative investigations 12 had malignant effusions, nine (75%) of which were diagnosed by a combination of the techniques. In this group, the individual sensitivities were 58% for both thoracoscopy and Abrams and 50% for cytology. A correct diagnosis of malignancy was made by a combination of needle biopsy and cytology in 75% of patients with previous investigations and 88% of those without. Fibreoptic thoracoscopy added only two diagnoses of malignancy to those obtained by Abrams and cytology. The limitations of the technique render it unsuitable for routine investigation of pleural effusions.     

可弯曲电子内科胸腔镜在不明原因胸腔积液诊断中的应用

目的了解可弯曲电子内科胸腔镜在不明原因胸腔积液诊断中的应用价值。方法自2005年7月至2007年3月，应用可弯曲电子内科胸腔镜对我院呼吸科病房中60例不明原因的胸腔积液患者进行胸腔镜检查，其中男36例，女24例。对所有通过胸腔积液常规、生化、微生物学及细胞学等实验室检查或通过诊断性抗结核治疗仍不能明确其积液原因的患者进行内科胸腔镜检查。结果经检查，60例不明原因的胸腔积液患者中恶性肿瘤32例（53％），结核16例（27％），阴性结果或慢性炎症5例（8％），肺炎合并胸膜炎4例（7％），粘连严重未能看到胸壁者3例（5％）。恶性肿瘤中肺腺癌最常见。术后并发症中伤口疼痛最常见，对症治疗可缓解。未出现肺水肿、感染、拔管延迟等并发症。结论可弯曲电子内科胸腔镜是一项简单、安全、有效的检查方法。在临床上，可帮助我们进一步明确胸腔积液的病因，特别是对于不明原因的胸腔积液。     

Prevalence and characteristics of pleural effusions in superior vena cava syndrome

OBJECTIVE AND BACKGROUND: The prevalence and characteristics of pleural effusions occurring in adults with the superior vena cava (SVC) syndrome are unknown. The purpose of the present study was to characterize these pleural effusions. METHODS: Charts of patients diagnosed with SVC syndrome at a tertiary care referral centre were reviewed. Radiographs were evaluated for the presence and size of pleural effusions, presence and location of masses and mediastinal width. If a pleural effusion was present, the patient's chart and a pre-existing database on pleural effusions were searched to determine whether the effusion was sampled and the results of any laboratory investigations on the fluid. RESULTS: The SVC syndrome occurred in 78 patients. Malignancy was the aetiology in 60% of the cases and bronchogenic carcinoma was the most common malignancy. An intravascular device was the aetiology in the majority of benign cases. Pleural effusion was found in 70% of patients with a malignant aetiology and 58% of those with a benign cause (P=0.345). The mean size of the effusions was larger in malignant cases (P=0.012). Of the 44 effusions 22 were sampled (17 in malignancy and five with benign processes); none was transudates, 20 (91%) were exudative (four of these were chylous) and the remaining two were reported as exudates but did not have pleural chemistries documented. CONCLUSIONS: More than half of patients with SVC syndrome have pleural effusions, regardless of the aetiology. However, the effusions are larger when associated with malignancy. The majority of these effusions are exudative and occasionally chylous. None was transudates.     

内科胸腔镜联合快速现场评估对不明原因胸腔积液的诊断价值

目的 探讨内科胸腔镜联合快速现场评估(ROSE)对不明原因胸腔积液的诊断价值及临床应用.方法 回顾性分析98例不明原因胸腔积液患者的临床资料,其中内科胸腔镜联合ROSE检查的患者52例,未联合ROSE检查的患者46例.比较两组患者胸膜活检情况、二次检查率、并发症发生率、诊断率,分析ROSE结果 与术后病理一致性及ROS...     

Percutaneous needle pleural biopsies in pleural effusion of uncertain aetiology in a Nigerian teaching hospital

Clinical observation shows that most of the patients with pleural effusion of undetermined aetiology in a Nigerian teaching hospital receive antiTB drug trials. This observation prompted the authors to evaluate the role of percutaneous needle pleural biopsy as a diagnostic tool in effusions of uncertain aetiology. Thirty-seven patients with pleural effusion of uncertain aetiology were investigated by percutaneous pleural biopsies using Abrams pleural biopsy needle over an 18-month period. In 34, the aetiology was established giving a sensitivity of 92%. Non-specific pleurisy/empyema remains the commonest cause of effusion (41%), followed closely by malignancies (29.4%) and TB pleurisy (22%), respectively. Percutaneous needle pleural biopsies establish diagnosis of malignancy in 91% of the cases with 72% of the malignancies originating from the lung. There is a significant association between malignancy and pleural effusion of uncertain aetiology in patients above 40 years of age (P = 0.022). The empirical use of antiTB drugs in the absence of investigative results suggestive of the diagnoses should be discouraged. Instead concerted effort should be made to establish the cause of such effusion.     

Eosinophilic pleural effusions

Eosinophilic pleural effusions, defined as a pleural effusion that contains at least 10% eosinophils, may be caused by almost every condition that can cause pleural disease. Eosinophilic pleural effusion occurs most commonly during conditions associated with the presence of blood or air in the pleural space, infections, and malignancy. Drug-induced pleural effusions, pleural effusions accompanying pulmonary embolism, and benign asbestos pleural effusions are also among the common causes of eosinophilic pleural effusion. No etiology is found in as many as one third of patients. Because studies evaluating different diagnostic approaches with eosinophilic pleural effusions are lacking, the authors suggest that certain noninvasive and invasive diagnostic tools must be used based on the patient's clinical characteristics.     

Use of a panel of tumor markers (carcinoembryonic antigen, cancer antigen 125, carbohydrate antigen 15-3, and cytokeratin 19 fragments) in pleural fluid for the differential diagnosis of benign and malignant effusions

STUDY OBJECTIVE: The diagnostic value of tumor markers in pleural fluid is subject to debate. The aim of this study was to evaluate the diagnostic performance of several tumor markers in common use for detecting malignant pleural disease. DESIGN: Blinded comparison of four tumor markers in pleural fluid with a confirmatory diagnosis of malignancy by pleural cytology or thoracoscopic biopsy. SETTING: Two teaching hospitals in Spain. PATIENTS AND METHODS: A total of 416 patients (166 with definite malignant effusions, 77 with probable malignant effusions, and 173 with benign effusions) were enrolled. Among them, there were 42 patients recruited from one of the participant centers with thoracoscopic facilities, who had false-negative fluid cytology findings and malignancy confirmed by medical thoracoscopy. Tumor markers in pleural fluid were determined either by electrochemiluminescence immunoassay (carcinoembryonic antigen [CEA], carbohydrate antigen 15-3 [CA 15-3], cytokeratin 19 fragments [CYFRA 21-1]) or microparticle enzyme immunoassay (cancer antigen 125 [CA 125]) technologies. Cutoff points that yielded 100% specificity (ie, all patients with benign effusions had levels below this cutoff) were selected for each marker. RESULTS: Malignant pleural effusions (PEs) had higher levels of pleural fluid markers than did effusions due to benign conditions. At 100% specificity, a pleural CEA > 50 ng/mL, CA 125 > 2,800 U/mL, CA 15-3 > 75 U/mL, and CYFRA 21-1 > 175 ng/mL had 29%, 17%, 30%, and 22% overall sensitivities, respectively. The combination of the four tumor markers reached 54% sensitivity, whereas the combined use of the cytology and the tumor marker panel increased the diagnostic yield of the former by 18% (95% confidence interval, 13 to 23%). More than one third of cytology-negative malignant PEs could be identified by at least one marker of the panel. CONCLUSIONS: No single pleural fluid marker seems to be accurate enough as to be introduced in the routine workup of PE diagnosis. However, a tumor marker panel may represent a helpful adjunct to cytology in order to rule in malignancy as a probable diagnosis, thus guiding the selection of patients who might benefit from further invasive procedures.     

Pleural controversy: Closed needle pleural biopsy or thoracoscopy—Which first?

The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91-95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy.     

Pleural effusions: is thoracoscopy a reliable investigation? A retrospective review.

In this paper, we consider the results of thoracoscopy in a busy thoracic unit where the referring physicians place their greatest emphasis upon simple standard investigation of pleural disease. Between 1985 and 1989 620 patients with a pleural effusion of unknown aetiology were referred to our thoracic medical unit. Initial investigations included aspiration of pleural fluid for cytology and culture, and blind pleural biopsy for histological examination. Recourse to thoracoscopy was only taken in the absence of a diagnosis or non-resolution of the patients symptoms and signs. Of these 620 patients only 48 (8%) remained without a diagnosis and were referred for thoracoscopy. Histological assessment of biopsies obtained at thoracoscopy revealed malignancy in 24 patients (50%) and benign conditions in 16 patients (33%). In eight patients (17%) no conclusive diagnosis was established; in this latter group, six patients continued with their symptoms and further invasive investigations revealed malignancy. In this setting where thoracoscopy was used as a last resort, the sensitivity for thoracoscopy was 83% and the specificity was 100% with a predictive value of a negative result being 25%. In conclusion, from our experience, the majority of pleural disease may be diagnosed using simple techniques but thoracoscopy can be very helpful in the more complex cases. Moreover, inconclusive histology following thoracoscopy is an indication for further investigation if the condition does not improve.     

Pleural Lavage: A Novel Diagnostic Approach For Diagnosing Exudative Pleural Effusion

Patients with pleural effusions frequently present a diagnostic and therapeutic challenge. The diagnosis is based on the interpretation of the results of thoracentesis or pleural biopsy. When a malignant tumor metastasizes to the pleura, tumor cells can be seeded over the mesothelial surface or in the subserous layer. In the former situation, tumor cells are abundant in pleural fluid, but in the latter, few malignant cells are exfoliated into the pleural cavity, and microscopic deposits may not be visualized at thoracoscopy. Pleural lavage cytologic study at the time of thoracoscopy has not been studied. The purpose of this study was to assess the value of thoracoscopic pleural lavage as an adjuvant in the diagnostic workup of patients with exudative pleural effusions. Fifty patients with exudative pleural effusions were investigated by pleural fluid cytologic findings, Abram's pleural biopsy, thoracoscopy, and pleural lavage cytologic findings. After aspiration of all pleural fluid, 300 mL saline was instilled into the pleural cavity and then recovered for cytologic analysis. The final diagnoses were 32 malignant (64%), 15 tuberculous (30%), and 3 idiopathic (6%) effusions. In the malignant group, thoracoscopic biopsy had the highest yield (94%) followed by lavage cytologic analysis (84%), fluid cytologic analysis (62%), and biopsy with Abram's needle (50%). The sensitivity of combined thoracoscopy and lavage cytologic analysis was 96%. In the patients with tuberculous pleuritis, the yield from the pathologic examination of the biopsy specimen was 93% with thoracoscopy and 60% with the Abrams needle. The diagnostic yield with cytologic analysis on pleural lavage fluid is significantly higher than that on pleural fluid. This is probably because the cells in the lavage fluid are fresher and better preserved than those in the regular pleural fluid, which may have undergone degenerative changes, yielding false-negative results. Pleural lavage cytologic analysis should be performed in patients with suspected malignant pleural effusion who are subjected to diagnostic thoracoscopy, because it may provide additional information to thoracoscopic biopsy. Accepted for publication: 21 November 2000     

Frozen section of pleural biopsies at medical thoracoscopy assists in correctly identifying benign disease

OBJECTIVES: Medical thoracoscopy and thoracoscopic talc poudrage (TTP) are accepted procedures in the management of pleural effusions. The relative merits of TTP compared with pleurodesis via intercostal catheter (ICC) continue to be debated. However, of the two procedures, only medical thoracoscopy allows both tissue diagnosis and pleurodesis to be achieved reliably in one procedure. The aim of this study was to assess the feasibility and accuracy of using frozen section analysis of samples taken during medical thoracoscopy to assist the thoracoscopist's decision to complete the procedure with a TTP. METHODOLOGY: Twenty patients with undiagnosed pleural effusions after at least one diagnostic pleurocentesis underwent medical thoracoscopy and biopsy. RESULTS: Frozen sections were easily performed within the timeframe of medical thoracoscopy. The final diagnosis based on paraffin sections was malignant in 10 cases and benign in 10 cases. Frozen section at the time of thoracoscopy (before TTP) correctly identified nine of 10 cases as being benign and six of 10 cases as malignant. In the malignant group, reasons for incorrect identification as benign were sampling from superficial benign adipose tissue overlying the malignant deposits, difficult access to the most involved parts of the pleura and intense cellular infiltrate initially thought to be benign. CONCLUSION: Frozen sections taken during medical thoracoscopy have the potential to facilitate decision-making prior to pleurodesis, particularly for accurate identification of benign histology on thoracoscopic pleural biopsies, in order that pleurodesis is not performed unnecessarily.     

Medical thoracoscopy in an Australian regional hospital

Medical thoracoscopy is not widely available in Australia. A medical thoracoscopy service has been set up in a regional hospital using no specialized equipment and at minimal cost. Of the first 100 procedures carried out, 89 were for investigation of pleural effusion, 6 for pneumothorax and 6 for empyema. Of the 89 pleural effusions, 73 were diagnosed as malignant (43 carcinoma, 24 mesothelioma, 3 lymphoma, 2 melanoma and 1 sarcoma). The sensitivity for a malignant diagnosis was 94.5%, with 100% specificity. Four patients had unsuspected tuberculous effusions. Pleurodesis was carried out with instillation of dry sterile talc in 67 cases. In 92.5% of these, no further drainage procedure was needed. There was one fatality caused by pre-existing sepsis in a debilitated patient with disseminated carcinoma. Medical thoracoscopy is a simple, safe and cost-effective technique for diagnosing and treating pleural effusions and provides a useful service in the setting of a regional hospital.