Points to Consider When Choosing A Biopsy Method in Cases of Pleurisy of Unknown Origin

Points to Consider When Choosing A Biopsy Method in Cases of Pleurisy of Unknown Origin* andj

Moya,

Blind

pleural

needle

biopsy

sometimes

effusion

nostic

Saumench,

M.D.;

R. Morera,

and diagnostic

used

to show

work-up

origin.

in

patients

the different

en reviewing

thoracoscopy are of a patient with We reviewed 203 diag-

in the

of unknown

thoracoscopies

effusion

M.D.;J.

with

location

the

world

malignant

pleural

ofpleural

medical

metastasis,

literature,

improved

types

positive

indices

of needles

vary

which

slightly

have

one

appeared.

from

one

The

to another,

moving to around 60 percent, in spite of the fact that the series are increasingly more numerous and consequently cant.’-”

the positive In turn, the

authors

from

percentages are results reported

diagnostic

to 100 percent

thoracoscopy

accuracy.

more signifiby different

are always

close

Our sole objective in writing why there is such a reliability two examination

this article difference

AND

is to explain between the

METHODS

In the work-up of a patient presenting with a pleural effusion of unknown origin and after ruling out an infectious process on the basis ofclinical history, our attitude, enhanced by our own experience, has evolved to the extent of performing a diagnostic thoracoscopy as a first step in the search for the etiology. We believe that the main ofdiagnostic

interest

is to rule

out or confirm

the

existence

of a

pleural carcinosis, and ifwe have a quick, almost absolutely certain diagnostic method, we shall be in a position to carry out adequate therapy in only three or four days after the patient’s admission. This will have a positive effect on hospital economic performance. Thus, we have been carrying out and evaluating diagnostic thoracoscopies for over ten years. We have chosen 203 patients with pleural effusion in whom the existence ofa pleural carcinosis in the form of gross nodulations was confirmed. Other cases with a different type of carcinosis’7 were rejected

for

complicate

even

this the

though

study

conditions

protocols

we

appearance divide

study

we were

positional

we

since

overall

state

convinced as the the

pleural

Manuscript

into:

176

de Espana,

they

L’Hospitalet

and

all

our

out,

to the

same

thoracoscopic

metastases,

size.

the

For graphic pleura,

Principes Spain.

de Espana

Barcelona,

gross

purposes,

visceral

pleura,

mediastinal

pleura,

diaphragmatic

location

in which

on a schematic

23. CS.

Spain

pleura

single

metastatic

One patient

location

and

cardiophrenic

is found

both

in a given

location

that

costal

pleura

the

mean

nodule

showing

sinus.

to represent invaded.

we

that The

the

white

observed.

whole dots

the

pleura, show

only

one for each

the

black

dots,

visceral

pleura,

parietal

or visceral,

either

not

by a dot.

dots,

With

within

a dot

(Fig 1). Every

is represented

by several

those

with

cavities

patient

have

and

is recorded

pleural

may thus be represented

metastatic

was

a metastatic

drawing

which

is the

we pleura

involved, but also the height of the metastatic seeding depending upon the side at which they are drawn, above or below the broken line crossing both pulmonary hili. For example, a patient in whom we have observed pleural metastases in the diaphragm, lower costal pleura and with the visceral pleura completely full of metastasis, will be represented with a white dot in the diaphragm, another one in the lower quadrant on the costal pleura, and a black dot within the visceral pleura. A sample

of each

histologic

location

is

The 203 examinations 1. Figure

2 represents

metastatic

spread

been

sent

to

the

pathology

laboratory

for

evaluation.

combined

them.

We

location

size

of the

there

point

out

the

and

pleural

since

shall

than

have been the

smaller

represented location

in this way in Figure as well

seedings.

Both

are no significant that

the

ones,

thus

as the

direction

hemithoraces

differences

larger

nodules

suggesting

of have

between

show

an upward

a lower path

of

growth.

In Figure 3 the incipient cases are represented. Only 39 patients have been recorded presenting small nodules in a number ranging from 1 to 10 and with only one pleural location. In spite ofthe small number

ofcases,

the

with the preceding above-mentioned metastatic case

is breast

suggestive

topography

figures. general

to the

pleura

cancer of direct

Only rules;

in the

ofmetastatic

disease

two patients

seem

one

vicinity

metastatic spread

Hospital,

23; revision accepted February Servicio de Cirugia Thoracica,

de Liobregat,

could

to carry

respond

the

costal

frequent

proposing In

of

and their

cavity

received November requests: Dr Canto,

less

were

nodulations.

*From the Thoracic Surgery Service, Hospitalet de Liobregat, Barcelona, Reprint Principes

are

we

that

situation

and consistency, the

these that

ofthe reach ofblind needle biopsy. Based on these find diagnostic thoracoscopy a superior procedure of its higher reliability, faster diagnostic results, no complications, and the possibility ofcarrying out in the same examination.

We pay individual attention to this last portion because of the frequency with which we have found tumor in this compartment, as we shall see later on. The recorded size is classified in three groups: small (less than 5 mm), medium (up to 2 cm) and large (above 2 cm). We consider the largest to be the initial nodules, ie, the oldest, and we believe that the small ones indicate the direction of growth and invasion. The

outside

2.I230

MATERIAL

some out data, we because slight or pleurodesis

observes that the accuracy rate of needle biopsy of the pleura in the work-up of a pleural effusion does not seem to increase in spite of the different and

point

M.D.;

M.D.

procedures

pleural

Rivas,

M.D.;J.

A Canto,

is a case ofthe

tumor

to submammary

correlates

well

not to follow the with

lung

(a), and costal

cancer a second

pleura

more

(b). RESULTS

On examining Figure to be affected in slightly

1, the right more cases

Biopsy Method

in Pleurisy

hemithorax is seen than the left, which

of Unknown

OilgIn (Canto

at

a!)

FIGURE

R

could be explained the liver and the from

this

organ.

the two lower

DIAPHRAG1 1

-

by the anatomic relationship with possibilities of tertiary metastases There

portions,

is a great divided

difference

between

by the broken

line,

and

1.

Location

ofpleural

metastases

in 203

patients.

L

the

upper

portions,

as seen

percent of the metastases tions of the hemithoraces. Alongside

at first are

sight.

found

the

As much

in the

pleura

as 84

lower

in Figure

por2, we

0

I

1..

%

%

37/203)

1O7 48 %

(

97/203

: 9%(60/203)) CARDI0-DIAPHRAQ 1ATIC

FIGURE

percentage cases.

2.

Pathway

ofpleural

of metastatic

involvement

spread

and

in the studied

DIAPHRA 1ATIC L

SINUS

P

%(86i203)

CHEST

I 84 I

2

I AUGUST,

1983

177

not correlate (Table 1).

with

the

different

histologic

types

found

CoNcLuSIoN

The

conclusions

years

from

the

protocolized

systematic in the

follows: The

low

reliability biopsy

origin

does

work,

of

results to type

finding new models; rather fact that there are metastatic not

be

reached

employing costal

with

“blind”

The

pleural

the bases

ofthe

the

case

available 3.

Location

ofearly

metastatic

seeding

in our

series.

expressed

obtained location

by dividing by the total

Outstanding been invaded This figure biopsy

in percentages

index

the number number of

because

upward

in

the

of dots at each cases examined.

even

if all the

reached a higher

biopsies

pathologic positive

said that the represented the

costal,

taken

tissue, index.

graph, locations other than the be reached by the blind method.

It may be tous invasion,

of metastases

from

costal

by the

we would As seen in pleura

may

direction of the carcinomaby arrows in Figure 2, is visceral

and

sinus

gresses

through

direct the

contact pleural

is reached the

and

costal

metastases adhesions.

minimal

metastatic

growth.

The

gross Table

then

pleura.

and As

disease appearance 1-Histologic

the

is,

follows

in

a similar

of the

3, pattern

of

in the

diagnostic

the

be

costal

pleura

in

Thus,

for

success.

effusion of suspected is not only more reliable,

thoracosof patients

malignant origin. but it also allows

complications

also

allows

non-existent

or negligible

us to carry

examination,

as

out

pleurodesis

reflected

only

sample

with

within

also

in

the

are

due

to

has its free of and the

review

same of the

literature. ACKNOWLEDGMENT: assistance

Thanks

in the

1 Abrams

preparation

LD.

2 Boutin

of this

A pleural

C, Arnaud

al. Les

a

biopsy

Dr.

Romagosa

for

manuascript.

l’aiguille

Lancet

incidents

d’Abrams.

biopsie

1958;

J, Choux

P, Viallat

pleurales:

Int#{233}r#{234}t se Ia

punch.

A, Farisse

biopsies

biopsie

(78/203) (47/203)

Epidermoid

10%

(20/203)

Mesothelioma

10%

(20/203)

5%

(10/203)

14%

(28/203)

Francis

pleura: 4 Donohoe etiologic

1:30-1

R, Aimard

et rentabilit#{233} actuelle

A propos

de

pleuroscopique.

1000

A, et de Ia

pr#{233}l#{233}vements.

Poumon-Coeur

1975;

H,

Klosh

E,

Albano

Preliminary

report.

RD.

Katz S, Matthews

diagnosis

E.

Needle

J

N Engi

of pleural

Med

biopsy 1955;

MJ. Pleural effusion.

Ann

of parietal

252:948-51

biopsy

as an aid in

Intern

Med

1958;

48:344-62 5

Types

23%

178

is the

risk,

does

38%

Carcinoma

biopsy

being, it seems to us that diagnostic is the method ofchoice in the workup

3 De

Undifferentiated

Unclassified

metastasis

time which is almost

the

Adenocarcinoma

Lymphoma

of the

locations

in

is no relation-

31:317

through

metastases

there

a needle

a higher

upward located

shortening the diagnostic-treatment effect on hospital stay. The procedure

pro-

Figure

obvious

it is recommended

lowest

to reach

with pleural The method

likewise,

by continuity

the

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