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Closed pleural biopsy to diagnose mesothelioma: Dead or alive?
Lung Cancer 65 (2009) 388–389
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Letter to the Editor Closed pleural biopsy to diagnose mesothelioma: Dead or alive?
a r t i c l e Keywords: Mesothelioma Biopsy Abrams
i n f o
a b s t r a c t This letter explores the role of closed pleural biopsy in the diagnosis of malignant mesothelioma. Through retrospective analysis of local data, we found that closed pleural biopsy had a sensitivity of 44% in the diagnosis of malignant mesothelioma. It should therefore still be considered as a first line investigation in suspected mesothelioma especially in centres where CT-guided or thoracoscopic pleural biopsy are not immediately available. © 2009 Elsevier Ireland Ltd. All rights reserved.
Dear Sir,
Table 1 Mode of diagnosis and time taken to generate histological report.
Malignant pleural mesothelioma (MPM) has an expected peak incidence in the UK between the years 2011 and 2015 [1]. In anticipation of increased numbers, there is a need to establish an effective algorithm within respiratory departments for its diagnosis. British Thoracic Society guidelines place less emphasis on the role of closed pleural biopsy (using an Abram’s needle) in patients with suspected MPM and suggest that CT-guided or thoracoscopic pleural biopsy are the gold standard investigations [2]. We wished to evaluate diagnostic methods and outcomes from closed pleural biopsy using an Abrams needle as a relatively non-invasive initial procedure in the diagnosis of MPM in Aberdeen Royal Infirmary, Scotland, UK over an 8-year period. All patients diagnosed with MPM between January 2000 and December 2008 were identified retrospectively by interrogation of the local pathology department and Health Intelligence databases. Patient records were then scrutinised to identify the methods used for diagnosis. We identified 119 patients diagnosed with MPM in this time period. Of these, 95 underwent closed pleural biopsy as a first line tool to obtain histology; doing so provided a definitive diagnosis in 44 (46%), in 20 (21%) the result was “suspicious” of MPM and proved non-diagnostic in 31 (33%). Where MPM was diagnosed using Abrams needle, the histological subtypes were epithelioid in 26 (59%), sarcomatous in 7 (16%), biphasic in 6 (14%) and not defined in 5 (11%). Many of the patients with suspicious and non-diagnostic closed pleural biopsy (n = 42) went on to have further procedures; all outcomes and time taken to generate a histological report are shown (Table 1). Our findings indicate that a role still exists for Abrams needle biopsy in patients with suspected MPM as it correctly identified 44% of unselected cases over an 8-year period. In these patients, the diagnosis of MPM was only considered definitive when invasion was identified, despite the fact that closed pleural biopsy may result in superficial samples. Tru-cut needles can provide larger samples with less crush artefact, however when used for closed pleural biopsy, they may provide diagnostic sensitivity comparable
Diagnostic biopsy method
n (%)
Median time to histological report from 1st hospital assessment (days)
Abrams needle Thoracoscopic Image-guided Post-mortem Othera
44 (46%) 40 (42%) 2 (2%) 8 (8%) 1 (1%)
15 (range 2–144) 35 (range 21–496) 21 & 42 72 (range 28–456) 6
0169-5002/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2009.05.005
a “Suspicious” Abrams biopsy result: no further tissue considered necessary following multi-disciplinary team discussion.
to Abrams needle biopsy [4]. Moreover, tru-cut biopsies are more technically challenging and involve use of a cutting needle which can increase the risk of bleeding and pneumothorax. Although CT-guided and thoracoscopic biopsies have greater diagnostic sensitivity than an Abrams needle biopsy [3] the practical application of these costlier procedures may be limited by resources and time delays in many centres. In summary, it therefore still appears reasonable to consider a closed pleural biopsy – which can easily be carried out as a day case – in suspected MPM providing operators perform the procedure following appropriate training. Conflicts of interest There are no actual or potential conflicts of interest for any of the authors. References [1] Hodgson JT, McElvenny DM, Damton AJ, Price MJ, Peto J. The expected burden of mesothelioma mortality in Great Britain from 2002 to 2050. Br J Cancer 2005;92:587–93. [2] British Thoracic Society Standards of Care Commission. BTS Statement on malignant mesothelioma in the UK. Thorax 2007;62(Suppl. II):ii1–19. [3] Maskell N, Gleeson FV, Davies RJ. Standard pleural biopsy vs CT guided cutting needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003;361:1326–30. [4] McLeod DT, Ternouth I, Nkamza N. Comparison of the Tru-cut biopsy needle with the Abrams punch for pleural biopsy. Thorax 1989;44:794–876.
Letter to the Editor / Lung Cancer 65 (2009) 388–389
Kris M. McLaughlin a,∗ , Keith M. Kerr b , Graeme P. Currie a a Department of Respiratory Medicine, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK b Department of Pathology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
389 ∗ Corresponding
author. Tel.: +44 1224 551208; fax: +44 1224 551210. E-mail address: [email protected] (K.M. McLaughlin) 14 April 2009
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Letter to the Editor Closed pleural biopsy to diagnose mesothelioma: Dead or alive?
a r t i c l e Keywords: Mesothelioma Biopsy Abrams
i n f o
a b s t r a c t This letter explores the role of closed pleural biopsy in the diagnosis of malignant mesothelioma. Through retrospective analysis of local data, we found that closed pleural biopsy had a sensitivity of 44% in the diagnosis of malignant mesothelioma. It should therefore still be considered as a first line investigation in suspected mesothelioma especially in centres where CT-guided or thoracoscopic pleural biopsy are not immediately available. © 2009 Elsevier Ireland Ltd. All rights reserved.
Dear Sir,
Table 1 Mode of diagnosis and time taken to generate histological report.
Malignant pleural mesothelioma (MPM) has an expected peak incidence in the UK between the years 2011 and 2015 [1]. In anticipation of increased numbers, there is a need to establish an effective algorithm within respiratory departments for its diagnosis. British Thoracic Society guidelines place less emphasis on the role of closed pleural biopsy (using an Abram’s needle) in patients with suspected MPM and suggest that CT-guided or thoracoscopic pleural biopsy are the gold standard investigations [2]. We wished to evaluate diagnostic methods and outcomes from closed pleural biopsy using an Abrams needle as a relatively non-invasive initial procedure in the diagnosis of MPM in Aberdeen Royal Infirmary, Scotland, UK over an 8-year period. All patients diagnosed with MPM between January 2000 and December 2008 were identified retrospectively by interrogation of the local pathology department and Health Intelligence databases. Patient records were then scrutinised to identify the methods used for diagnosis. We identified 119 patients diagnosed with MPM in this time period. Of these, 95 underwent closed pleural biopsy as a first line tool to obtain histology; doing so provided a definitive diagnosis in 44 (46%), in 20 (21%) the result was “suspicious” of MPM and proved non-diagnostic in 31 (33%). Where MPM was diagnosed using Abrams needle, the histological subtypes were epithelioid in 26 (59%), sarcomatous in 7 (16%), biphasic in 6 (14%) and not defined in 5 (11%). Many of the patients with suspicious and non-diagnostic closed pleural biopsy (n = 42) went on to have further procedures; all outcomes and time taken to generate a histological report are shown (Table 1). Our findings indicate that a role still exists for Abrams needle biopsy in patients with suspected MPM as it correctly identified 44% of unselected cases over an 8-year period. In these patients, the diagnosis of MPM was only considered definitive when invasion was identified, despite the fact that closed pleural biopsy may result in superficial samples. Tru-cut needles can provide larger samples with less crush artefact, however when used for closed pleural biopsy, they may provide diagnostic sensitivity comparable
Diagnostic biopsy method
n (%)
Median time to histological report from 1st hospital assessment (days)
Abrams needle Thoracoscopic Image-guided Post-mortem Othera
44 (46%) 40 (42%) 2 (2%) 8 (8%) 1 (1%)
15 (range 2–144) 35 (range 21–496) 21 & 42 72 (range 28–456) 6
0169-5002/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2009.05.005
a “Suspicious” Abrams biopsy result: no further tissue considered necessary following multi-disciplinary team discussion.
to Abrams needle biopsy [4]. Moreover, tru-cut biopsies are more technically challenging and involve use of a cutting needle which can increase the risk of bleeding and pneumothorax. Although CT-guided and thoracoscopic biopsies have greater diagnostic sensitivity than an Abrams needle biopsy [3] the practical application of these costlier procedures may be limited by resources and time delays in many centres. In summary, it therefore still appears reasonable to consider a closed pleural biopsy – which can easily be carried out as a day case – in suspected MPM providing operators perform the procedure following appropriate training. Conflicts of interest There are no actual or potential conflicts of interest for any of the authors. References [1] Hodgson JT, McElvenny DM, Damton AJ, Price MJ, Peto J. The expected burden of mesothelioma mortality in Great Britain from 2002 to 2050. Br J Cancer 2005;92:587–93. [2] British Thoracic Society Standards of Care Commission. BTS Statement on malignant mesothelioma in the UK. Thorax 2007;62(Suppl. II):ii1–19. [3] Maskell N, Gleeson FV, Davies RJ. Standard pleural biopsy vs CT guided cutting needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003;361:1326–30. [4] McLeod DT, Ternouth I, Nkamza N. Comparison of the Tru-cut biopsy needle with the Abrams punch for pleural biopsy. Thorax 1989;44:794–876.
Letter to the Editor / Lung Cancer 65 (2009) 388–389
Kris M. McLaughlin a,∗ , Keith M. Kerr b , Graeme P. Currie a a Department of Respiratory Medicine, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK b Department of Pathology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
389 ∗ Corresponding
author. Tel.: +44 1224 551208; fax: +44 1224 551210. E-mail address: [email protected] (K.M. McLaughlin) 14 April 2009