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Pleural biopsy with the Vim-Silverman needle
54
Tubercle, Lond., (1958), 4 o, 54
Pleural Biopsy with the Vim-Silverman Needle Pleural effusion is one of the more frequent chest diseases in the Uttar Pradesh, the state with the largest population in India. During the last seven years at the Gandhi Memorial and Associated Hospitals, Lucknow, 27o patients were treated in whom investigations had failed to give pathological evidence of the cause. T h e difficulties of finding tile causes of effusions are well known and both thoracotomy and needle biopsy have been employed to obtain tissue for histological examination. Sutcliff and others (1953) took biopsy specimens by thoracotomy in 22 patients; 17 of these were tuberculous. The predominant histological findings in these were fibrosis and giant cells in all, tubercles in I2 and caseation in xo. Stead and others (2955) did an exploratory thoracotomy in 24 patients with unexplained effusion. In 15 there was definite evidence of tuberculosis of the underlying lung. The pleura was thick, fibrous and granulomatous and showed typical caseous tubercles. In I I of these acid fast bacilli were demonstrated. Small and others (i955) reported 5 cases of pleural effusions in which they were unable to isolate tubercle bacilli. They tried pleural biopsy by a simple procedure. T h e thoracic surgeon excised an oblong section of pleura approximately I. 5 cm. • 3 cm. through an 8 cm. incision in an appropriate intercostal space. Tim visible pleural space was examined and the underlying h m g palpated. On histological examination of the material all the 5 specimens showed evidence of tuberculous infiltration. T h e y recommended the routine use of the method in the diagnosis of pleural effusion of unknown cause. By thoracotomy the pathologist is provided with a bigger piece of tissue, but it needs the help of a thoracic surgeon. T o make it easier, De Francis and others (i955) adopted a simple technique for pleural biopsy with a Vim-Silverman needle. T h e hazards were no more than those associated with simple thoracentesis. T h e y performed it in 6 cases, and 2 showed tuberculous infiltration of the tissues. More recently, Donohoe et al. (I957) have reported pleural biopsy in 45 patients, with adequate pleural tissue in 33 cases (73 per cent). Technique T h e method described by De Francis and others (x955) , with solne modifications, was used. T h e following are required: Vim-Silverman needle; two clamps; a scalpel; syringes - 2 c.c. and 3 ~ c.c.; black silk suture; 2 per cent procaine. T h e patient was premedicated with a dose of chloral hydrate 2o gr. and potassium bromide 2o gr., half an hour before the operation. T h e biopsy site was previously determined by x-ray and fluoroscopie examination of the chest. 2 per cent procaine was used for local anaesthesia, which was carried down to the pleura. With the patient in the sitting position over a 'heart' table, a small incision was made at the biopsy site and the needle, to wlfich a 3 ~ c.c. syringe was attached, inserted into the appropriate interspace along the upper margin of the lower rib. Constant traction was applied on the plunger of the syringe while the needle was advanced to reach the pleural cavity, l'hfid for bacteriological examination was collected, and the needle withdrawn little by little till tile point when no more fluid came out on suction. T h e needle was withdrawn a fraction of an inch from tiffs point and a clamp applied to the shaft of the needle adjacent to the skin. T h e needle was then
PLEURAL BIOPSY
55
withdrawn completely and the same distance (from the clamp to the tip) measured off on the Vim-Silverman needle and a clamp applied. The biopsy shaft was witlidrawn and obturator inserted. T h e needle was then advanced through the skin incision to the distance marked off by the clamp. The obturator was removed, th e biopsy needle put in itsplace and the outer needle carried forward approximately I cm., with the biopsy needle held in place. Both portions of the needle were then rotated through 360 degrees and withdrawn together. The skin was closed with one silk suture and sterile dressing applied. The tissue brought out in the biopsy shaft was placed in formol saline; sections were made and stained with haematoxylin and eosin for study. Material T h e material for tiffs study consisted of: (x) Pieces of pleura obtained at necropsy from 25 medico-legal cases, to study the normal structure of the pleura. (To avoid post-mortem decomposition, only those cases in which necropsy was done within twenty-four hours of death Were taken.) (2) Thirty-five cases of pleural effusion without x-ray abnormality in the lung or tubercle bacilli in the sputum. (3) Three cases of empyema. (4) Four cases of effusion secondary to malignant diseases of lung and pleura. (5) Four cases of pleural effusion secondary to known pulmonary tuberculosis. In all of them sputa were positive for tubercle bacilli. (6) Pieces of pleura obtained at necropsy where there appeared to be pleural thickening or adhesions (3 cases). Results The method was found to be a simple one. In fact, it gave no more discomfort than a simple thoracentesis. No patient objected to its use. Pleural tissue was obtained in all cases. In a few cases biopsy was done a second time to get a larger specimen. Contrary to the experience of De Francis and his colleagues, pleural tissue was obtained in all the cases whether the pleura was minimally or moderately thickened. One is tempted to conclude that, if a biopsy is done with proper technique and skill, it is possible to get a piece of pleural tissue, sufficient for histological study, in all cases of pleural effusion. In no case were any complications encountered. However, the following should be kept in m i n d - h a e m o r r h a g e , pneumothorax, sinus formation, pleural contamination, injury to lung and liver. HISTOLOGIGAL FINDINGS
Normal Pleura.-All specimens showed essentially the same structure; under low power there were bands of connective tissue and fibroblasts with a layer of endothelium. T h e basement m e m b r a n e ofthe endothelial layer was clearly seen under high power (Fig. I). Pleural Effusion Without Apparent Lung Disease.-35 cases were studied and the following results obtained: (a) Evidence of tuberculous infiltration - 4 cases (i I per cent) (Fig. 2). (b) Fibrous tissue infiltrated with lymphocytes, mononuclear cells and plasma cells - 27 cases (77 per cent). (c) Fibrous tissue without inflammatory cells - 4 cases (I I per cent). T h e number of cases with histological evidence of tuberculosis in this group is 9comparatively low, T h e following factors are suggested. The pleura'presents a vast surface and the biopsy needle takes out only a small piece of tissue, which m a y not be a representative sample of the whole membrane.
56
TUBERCLE
FxG. t. - Normal pleura obtained at necropsy.
Fxc. 2. - Tuberculous tissue in a portion of pleura obtained by needle biopsy.
F o r the histological diagnosis of tuberculosis, caseation, giant cells, or epithelioid cells must be present. T o have these cells the needle must take out a tubercle. T h e tubercles usually do not form a continuous sheet over the pleura. I n some cases pleural biopsy was done in two places. I n one case, a biopsy done after admission ~howed lymphocytes and plasma cells. T h e pleura was felt to be thickened, and another biopsy was done a week later. This showed the full picture of tuberculous granulation tissue. Most of the patients admitted into the hospital came through the h a n d s of other physicians, after receiving one or two courses of anti-tuberculosis treatment. It is felt that this m a y have been a factor, because we observed that 3 o f the 4 biopsy positive cases had had no anti-tuberculosis treatment prior to hospital admission. C h e m o t h e r a p y produces healing o f the tubercles, hence positive 9evidence of tuberculous infiltration m a y not be obtained in such cases. I n this series there were 4 cases (I I per cent) in which only fibrous tissue without cellular infiltration was found. This suggests that the pleura was healthy, the effusion being p r o b a b l y an allergic manifestation. Empyema.- T h r e e cases were studied. All the specimens showed signs of chronic inflammation, i.e. fibrous tissue infiltrated by lymphocytes and mononuclears. alIalignant Disease of the Lung and Pleura.- Four cases were studied. I n I, a p a t i e n t . suspected of having a pleural neoplasm, the tissue consisted o f an aggregation o f darkly staining polyhedral or irregular cells with a prominent nucleus. N o mitotic figures were seen. It was thought to be malignant tissue, p r o b a b l y an endothelioma. I n 3 patients believed to have bronchial carcinoma (I with a confirmed l y m p h node metastasis) the specimen contained fibrous tissue only. A l t h o u g h pleural biopsy w a s not helpful in these 3 cases, it can certainly assist the diagnosis in some instances. "Thus, a w o m a n aged 45 years had h a e m o r r h a g i c pleural fluid. Examination of the
PLEURAL BIOPSY
57
fluid was negative for tubercle bacilli and a cancer was suspected. Because of her age and a positive tuberculin skin test, a pleural biopsy was done, which confirmed tile tuberculous nature of the effusion. Effusions Secondary to Pulmonary Tuberculosis.- Four cases were studied. O f thcse, one showed evidence of tuberculous infiltration of the pleura. Causes of failure in tile other 3 cases appeared to be the same as in the other pleural effusion cases, i.e. the large surface of tile pleura and previous antituberculosis treatment. Pleural Adhesions and Thickening.- Three specimens were studied from cases of bronchial carcinoma, cirrhosis of the liver and diabetes mellitus. The last 2 showed fibrous tissue infiltrated with chronic inflammatory cells, and the first showed fibrous tissue only. Comment
From the results obtained, and because of the simplicity of the technique, we feel that pleural biopsy is a useful diagnostic inethod for investigating the cause of a pleural effusion. Bacteriological examinations of the fluid do help in some such cases to arrive at an aetiological diagnosis, and pleural biopsy confirms a further proportion, iu whom other methods have been unsuccessful. Pleural biopsy also has an important part to play in the diagnosis of plcural tumours and effusions thought to be secondary to malignant tumours. Being a simple procedure we feel that it should be done routinely. Summary Pleural biopsy by tile Vim-Silverman needle was done in 35 cases of pleural effnsion without radiographic evidence of lung disease or bacteriological evidence of tuberculosis; 3 cases of elnpyema; 4 of effusion secondary to malignant disease of tlm lung and pleura; and 4 cases of effusion sccondary to pulmonary tuberculosis. Four biopsies of the group with pleural effusions without apparent cause and one of the effusions secondary to known pulmonary tuberculosis showed tuberculous tissue. One of the cases of malignant effnsion showed evidence of malignancy. There were no complications in any case. Our grateful thanks are due to Prof V. S. Mangalik and his colleagues of the Department of Pathology for the biopsy slides, and to the various patients who allowed biopsy to be done.
Department of ~Iedichle, Medical College, Lucknow, hzdia. References De Francis, N., Kiosk, E., and Albano, E. (1955) New Engl. ,7. ~Ied., ",52, 948Donohoe, 1~,. F., Katz, S., and Matthews, M . J . (z957) Amer..~. ~lIed., 2"~)883.
S.S. MISRA. U. (3. SHAR.~m.
SnmII, M.J., and Landman, .M. 0955) 37. Amer. reed.Ass., x58, 9o7. Stead, W. W., Eichenholz, A., and Stauss, II. K. (1955) Amer. Rev. Tuberc., 7x) 473. Sutcliff, W. D., IIugbes, F., and Rice, M. L. (t953) Transactions of the t~2th Conference on the Chemotherapy of Tuberculosis, p. x75, Veterans Admin., Washington.
E
Tubercle, Lond., (1958), 4 o, 54
Pleural Biopsy with the Vim-Silverman Needle Pleural effusion is one of the more frequent chest diseases in the Uttar Pradesh, the state with the largest population in India. During the last seven years at the Gandhi Memorial and Associated Hospitals, Lucknow, 27o patients were treated in whom investigations had failed to give pathological evidence of the cause. T h e difficulties of finding tile causes of effusions are well known and both thoracotomy and needle biopsy have been employed to obtain tissue for histological examination. Sutcliff and others (1953) took biopsy specimens by thoracotomy in 22 patients; 17 of these were tuberculous. The predominant histological findings in these were fibrosis and giant cells in all, tubercles in I2 and caseation in xo. Stead and others (2955) did an exploratory thoracotomy in 24 patients with unexplained effusion. In 15 there was definite evidence of tuberculosis of the underlying lung. The pleura was thick, fibrous and granulomatous and showed typical caseous tubercles. In I I of these acid fast bacilli were demonstrated. Small and others (i955) reported 5 cases of pleural effusions in which they were unable to isolate tubercle bacilli. They tried pleural biopsy by a simple procedure. T h e thoracic surgeon excised an oblong section of pleura approximately I. 5 cm. • 3 cm. through an 8 cm. incision in an appropriate intercostal space. Tim visible pleural space was examined and the underlying h m g palpated. On histological examination of the material all the 5 specimens showed evidence of tuberculous infiltration. T h e y recommended the routine use of the method in the diagnosis of pleural effusion of unknown cause. By thoracotomy the pathologist is provided with a bigger piece of tissue, but it needs the help of a thoracic surgeon. T o make it easier, De Francis and others (i955) adopted a simple technique for pleural biopsy with a Vim-Silverman needle. T h e hazards were no more than those associated with simple thoracentesis. T h e y performed it in 6 cases, and 2 showed tuberculous infiltration of the tissues. More recently, Donohoe et al. (I957) have reported pleural biopsy in 45 patients, with adequate pleural tissue in 33 cases (73 per cent). Technique T h e method described by De Francis and others (x955) , with solne modifications, was used. T h e following are required: Vim-Silverman needle; two clamps; a scalpel; syringes - 2 c.c. and 3 ~ c.c.; black silk suture; 2 per cent procaine. T h e patient was premedicated with a dose of chloral hydrate 2o gr. and potassium bromide 2o gr., half an hour before the operation. T h e biopsy site was previously determined by x-ray and fluoroscopie examination of the chest. 2 per cent procaine was used for local anaesthesia, which was carried down to the pleura. With the patient in the sitting position over a 'heart' table, a small incision was made at the biopsy site and the needle, to wlfich a 3 ~ c.c. syringe was attached, inserted into the appropriate interspace along the upper margin of the lower rib. Constant traction was applied on the plunger of the syringe while the needle was advanced to reach the pleural cavity, l'hfid for bacteriological examination was collected, and the needle withdrawn little by little till tile point when no more fluid came out on suction. T h e needle was withdrawn a fraction of an inch from tiffs point and a clamp applied to the shaft of the needle adjacent to the skin. T h e needle was then
PLEURAL BIOPSY
55
withdrawn completely and the same distance (from the clamp to the tip) measured off on the Vim-Silverman needle and a clamp applied. The biopsy shaft was witlidrawn and obturator inserted. T h e needle was then advanced through the skin incision to the distance marked off by the clamp. The obturator was removed, th e biopsy needle put in itsplace and the outer needle carried forward approximately I cm., with the biopsy needle held in place. Both portions of the needle were then rotated through 360 degrees and withdrawn together. The skin was closed with one silk suture and sterile dressing applied. The tissue brought out in the biopsy shaft was placed in formol saline; sections were made and stained with haematoxylin and eosin for study. Material T h e material for tiffs study consisted of: (x) Pieces of pleura obtained at necropsy from 25 medico-legal cases, to study the normal structure of the pleura. (To avoid post-mortem decomposition, only those cases in which necropsy was done within twenty-four hours of death Were taken.) (2) Thirty-five cases of pleural effusion without x-ray abnormality in the lung or tubercle bacilli in the sputum. (3) Three cases of empyema. (4) Four cases of effusion secondary to malignant diseases of lung and pleura. (5) Four cases of pleural effusion secondary to known pulmonary tuberculosis. In all of them sputa were positive for tubercle bacilli. (6) Pieces of pleura obtained at necropsy where there appeared to be pleural thickening or adhesions (3 cases). Results The method was found to be a simple one. In fact, it gave no more discomfort than a simple thoracentesis. No patient objected to its use. Pleural tissue was obtained in all cases. In a few cases biopsy was done a second time to get a larger specimen. Contrary to the experience of De Francis and his colleagues, pleural tissue was obtained in all the cases whether the pleura was minimally or moderately thickened. One is tempted to conclude that, if a biopsy is done with proper technique and skill, it is possible to get a piece of pleural tissue, sufficient for histological study, in all cases of pleural effusion. In no case were any complications encountered. However, the following should be kept in m i n d - h a e m o r r h a g e , pneumothorax, sinus formation, pleural contamination, injury to lung and liver. HISTOLOGIGAL FINDINGS
Normal Pleura.-All specimens showed essentially the same structure; under low power there were bands of connective tissue and fibroblasts with a layer of endothelium. T h e basement m e m b r a n e ofthe endothelial layer was clearly seen under high power (Fig. I). Pleural Effusion Without Apparent Lung Disease.-35 cases were studied and the following results obtained: (a) Evidence of tuberculous infiltration - 4 cases (i I per cent) (Fig. 2). (b) Fibrous tissue infiltrated with lymphocytes, mononuclear cells and plasma cells - 27 cases (77 per cent). (c) Fibrous tissue without inflammatory cells - 4 cases (I I per cent). T h e number of cases with histological evidence of tuberculosis in this group is 9comparatively low, T h e following factors are suggested. The pleura'presents a vast surface and the biopsy needle takes out only a small piece of tissue, which m a y not be a representative sample of the whole membrane.
56
TUBERCLE
FxG. t. - Normal pleura obtained at necropsy.
Fxc. 2. - Tuberculous tissue in a portion of pleura obtained by needle biopsy.
F o r the histological diagnosis of tuberculosis, caseation, giant cells, or epithelioid cells must be present. T o have these cells the needle must take out a tubercle. T h e tubercles usually do not form a continuous sheet over the pleura. I n some cases pleural biopsy was done in two places. I n one case, a biopsy done after admission ~howed lymphocytes and plasma cells. T h e pleura was felt to be thickened, and another biopsy was done a week later. This showed the full picture of tuberculous granulation tissue. Most of the patients admitted into the hospital came through the h a n d s of other physicians, after receiving one or two courses of anti-tuberculosis treatment. It is felt that this m a y have been a factor, because we observed that 3 o f the 4 biopsy positive cases had had no anti-tuberculosis treatment prior to hospital admission. C h e m o t h e r a p y produces healing o f the tubercles, hence positive 9evidence of tuberculous infiltration m a y not be obtained in such cases. I n this series there were 4 cases (I I per cent) in which only fibrous tissue without cellular infiltration was found. This suggests that the pleura was healthy, the effusion being p r o b a b l y an allergic manifestation. Empyema.- T h r e e cases were studied. All the specimens showed signs of chronic inflammation, i.e. fibrous tissue infiltrated by lymphocytes and mononuclears. alIalignant Disease of the Lung and Pleura.- Four cases were studied. I n I, a p a t i e n t . suspected of having a pleural neoplasm, the tissue consisted o f an aggregation o f darkly staining polyhedral or irregular cells with a prominent nucleus. N o mitotic figures were seen. It was thought to be malignant tissue, p r o b a b l y an endothelioma. I n 3 patients believed to have bronchial carcinoma (I with a confirmed l y m p h node metastasis) the specimen contained fibrous tissue only. A l t h o u g h pleural biopsy w a s not helpful in these 3 cases, it can certainly assist the diagnosis in some instances. "Thus, a w o m a n aged 45 years had h a e m o r r h a g i c pleural fluid. Examination of the
PLEURAL BIOPSY
57
fluid was negative for tubercle bacilli and a cancer was suspected. Because of her age and a positive tuberculin skin test, a pleural biopsy was done, which confirmed tile tuberculous nature of the effusion. Effusions Secondary to Pulmonary Tuberculosis.- Four cases were studied. O f thcse, one showed evidence of tuberculous infiltration of the pleura. Causes of failure in tile other 3 cases appeared to be the same as in the other pleural effusion cases, i.e. the large surface of tile pleura and previous antituberculosis treatment. Pleural Adhesions and Thickening.- Three specimens were studied from cases of bronchial carcinoma, cirrhosis of the liver and diabetes mellitus. The last 2 showed fibrous tissue infiltrated with chronic inflammatory cells, and the first showed fibrous tissue only. Comment
From the results obtained, and because of the simplicity of the technique, we feel that pleural biopsy is a useful diagnostic inethod for investigating the cause of a pleural effusion. Bacteriological examinations of the fluid do help in some such cases to arrive at an aetiological diagnosis, and pleural biopsy confirms a further proportion, iu whom other methods have been unsuccessful. Pleural biopsy also has an important part to play in the diagnosis of plcural tumours and effusions thought to be secondary to malignant tumours. Being a simple procedure we feel that it should be done routinely. Summary Pleural biopsy by tile Vim-Silverman needle was done in 35 cases of pleural effnsion without radiographic evidence of lung disease or bacteriological evidence of tuberculosis; 3 cases of elnpyema; 4 of effusion secondary to malignant disease of tlm lung and pleura; and 4 cases of effusion sccondary to pulmonary tuberculosis. Four biopsies of the group with pleural effusions without apparent cause and one of the effusions secondary to known pulmonary tuberculosis showed tuberculous tissue. One of the cases of malignant effnsion showed evidence of malignancy. There were no complications in any case. Our grateful thanks are due to Prof V. S. Mangalik and his colleagues of the Department of Pathology for the biopsy slides, and to the various patients who allowed biopsy to be done.
Department of ~Iedichle, Medical College, Lucknow, hzdia. References De Francis, N., Kiosk, E., and Albano, E. (1955) New Engl. ,7. ~Ied., ",52, 948Donohoe, 1~,. F., Katz, S., and Matthews, M . J . (z957) Amer..~. ~lIed., 2"~)883.
S.S. MISRA. U. (3. SHAR.~m.
SnmII, M.J., and Landman, .M. 0955) 37. Amer. reed.Ass., x58, 9o7. Stead, W. W., Eichenholz, A., and Stauss, II. K. (1955) Amer. Rev. Tuberc., 7x) 473. Sutcliff, W. D., IIugbes, F., and Rice, M. L. (t953) Transactions of the t~2th Conference on the Chemotherapy of Tuberculosis, p. x75, Veterans Admin., Washington.
E