Medical Thoracoscopy Not the Only Good Way to Biopsy Complex Pleural Effusion

For the diagnosis of people with pleural effusion, an initial image-assisted Abrams needle biopsy (IA-ANPB) can match medical thoracoscopy (MT) in diagnostic accuracy in some cases, a small randomized controlled trial found.

IA-ANPB diagnosis had a sensitivity of just 69.7% with a negative likelihood ratio of 0.30 in patients with pleural effusion only, underperforming when compared with MT’s sensitivity of 96.9% and negative likelihood ratio of 0.03 (P=0.009).

However, among patients who also had pleural thickening or lesions alongside pleural effusion, IA-ANPB’s sensitivity climbed to 88.1% with a negative likelihood ratio of 0.12, which was statistically on par with MT’s sensitivity of 95.4% and negative likelihood ratio of 0.05 (P=0.207), reported Muzaffer Metintas, MD, of Eskisehir Osmangazi University, Turkey, and co-authors in CHEST.

False negative rates were 30.3% for IA-ANPB and 3.1% for MT in pleural effusion alone, and were 11.9% and 4.7%, respectively, in pleural effusion with pleural thickening or lesions.

“Although image-guided or assisted needle biopsies and MT have greatly improved the diagnostic accuracy in pleural disease, the critical issue today is to increase the diagnostic success of the initial procedure to reduce costs, complications, and hospital workload and to increase patient comfort,” the investigators wrote.

“IA-ANPB should be performed if there is a pleural thickening or a localized lesion on the pleura accompanied by effusion on CT and within reach of the needle. MT should be performed in patients with only an effusion or a lesion the needle cannot reach on CT,” Metintas and colleagues said. “Also, MT can be used as the second procedure in patients diagnosed with fibrinous pleuritis after IA-ANPB in both groups. Patients who cannot be diagnosed after MT should be evaluated for risk factors for malignant pleural disease before planning further procedure.”

The group noted that MT is widely accepted as the superior method for diagnosing pleural disease, citing high diagnostic sensitivity, low complication rates, and the possibility of definitive therapeutic intervention. However, high costs and long procedure times may be barriers to patients.

To enter the present study, patients had to have an exudative pleural effusion with no known diagnosis following prior radiological, lab, or cytological examinations. Patients younger than 18 and older than 90 years old, those with presence of parapneumonic effusion, contraindications to pleural biopsy or MT, who had pleural thickening or a pleural-based mass without pleural effusion, or who had another disease that might affect CT or ultrasound assessments were excluded.

CT findings put patients into pleural effusion only (group one) or pleural effusion with thickening/lesion (group two) classifications. Once placed within their respective groups, patients were randomized to receive either IA-ANPB or MT.

IA-ANPB was performed in the pulmonary endoscopy room and the entry site selected based on CT. At biopsy, the needle entry site was checked for pleural lesion/thickening and injury to blood vessels using ultrasound. Four to six biopsy specimens were taken from the parietal pleura.

Medical thoracoscopy involved a rigid thoracoscope in patients under mild sedation and local anesthesia. At least six biopsy specimens were taken from abnormal sites of parietal pleura at thoracoscopy.

Across groups, the average age was in the early- to mid-60s and the cohort counted more men than women. The pleural effusion with thickening/lesion group randomized to IA-ANPB had a disproportionate amount of men (73.6%) compared with other study arms.

There was no difference in the distribution of malignant and benign diagnoses between IA-ANPB and MT arms.

The authors reported similar complication rates between the two diagnostic methods in their study — 8.5% for IA-ANPB and 15.8% for MT. There were five cases of subcutaneous emphysema in the MT group (versus zero in IA-ANPB) and four cases of prolonged air leak (versus zero). Hypotension was recorded in two patients each.

The single-center nature of the study was a major limitation, the investigators acknowledged.

“As there is no randomized prospective study comparing two needles under the guidance of using the same imaging modality, combined use of CT scans and [ultrasound], we do not yet know whether the cutting needle will give similar diagnostic accuracy and reliability,” they added. “A prospective randomized study based on the subject is needed.”

Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow

Disclosures

Study authors reported no study funding and no relevant disclosures.

Primary Source

CHEST

Source Reference: Metintas M, et al “Image-assisted pleural needle biopsy or medical thoracoscopy: which method for which patient? A randomized controlled trial” CHEST 2024; DOI:10.1016/j.chest.2024.03.038.

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