|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 4
| Issue : 3 | Page : 104-111 |
|
Role of flexi-rigid thoracoscopy in undiagnosed pleural effusions and correlation of visual appearance of pleura on thoracoscopy with the final diagnosis
Pallavi Periwal1, Arjun Khanna2, Deepak Talwar3
1 Department of Pulmonary Medicine and Critical Care, AANCH Hospital, Jaipur, Rajasthan, India
2 Department of Pulmonary Medicine and Critical Care Medicine, Yashoda Superspeciality Hospital, Kaushambi, Uttar Pradesh, India
3 Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
| Date of Submission | 30-Nov-2021 |
| Date of Decision | 14-Jan-2022 |
| Date of Acceptance | 19-Feb-2022 |
| Date of Web Publication | 12-May-2022 |
Correspondence Address:
Pallavi Periwal
Department of Pulmonary Medicine and Critical Care, AANCH Hospital, Jaipur
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/japt.japt_47_21
Background: Undiagnosed pleural effusions (UPE) account for roughly 25% of cases of all pleural effusions. Minimally invasive flexi-rigid thoracoscopy has high diagnostic yield. Some previous studies have looked into the correlation of the thoracoscopic findings and the final etiological diagnosis, however, data are scarce. This study is aimed to know the role of flexi-rigid thoracoscopy in establishing etiological diagnosis in undiagnosed, treatment naïve pleural effusion patients and the correlation of thoracoscopic findings with the final diagnosis. Materials and Methods: A retrospective descriptive observational study was conducted on 84 newly diagnosed patients in whom pleural effusion remained undiagnosed at the Department of Respiratory, Sleep, Allergy and Critical Care Medicine at the Metro Centre for Respiratory Diseases, Metro Hospital, Noida. Data from hospital records of patients, who were subjected to flexi-rigid thoracoscopy, was collected between January 2010 and December 2013 and analyzed. The diagnostic yield of pleural biopsy using flexi-rigid thoracoscope in UPEs was assessed and the visual appearance of pleura on thoracoscopy was correlated with the final diagnosis. Results: The diagnostic yield of flexi-rigid thoracoscopy in UPEs is 89.28%. When nonspecific pleuritis is considered as a diagnosis, the diagnostic yield increases to 97.6%. The pleural biopsy histopathological examination revealed Nonspecific pleuritis in 14.2% of patients, granuloma consistent with tuberculosis (TB) in54.8%, malignancy in 28.6% of patients confirmed on immunohistochemistry and in 2.3% the diagnosis remained inconclusive. Out of the 12 patients, two were diagnosed to have TB on the basis of pleural biopsy acid-fast bacilli culture showing mycobacterium TB. Post coronary artery bypass graft pleuropericardial effusion, chylothorax, and congestive heart failure were diagnosed in 1 case each, while the diagnosis remained uncertain in 7. The thoracoscopic finding of adhesions had negligible and no statistically significant correlation to the final diagnosis. The presence of pleural nodularity had a negative correlation with nonspecific pleuritis and a positive correlation with malignancy although statistically insignificant. It was seen that small and uniform nodules had a positive correlation with TB. The presence of large and variable-sized nodules had a strong positive correlation with malignancy. The presence of diaphragmatic nodules has a positive correlation with malignancy. Pleural infiltration has a strong positive correlation with malignancy and negative correlation with TB. Conclusion: Flexi-rigid pleuroscopy is an excellent modality to investigate UPE since it has a high diagnostic yield, is minimally invasive and safe procedure. The presence of a variable distribution of nodules, large nodules, diaphragmatic nodules, visceral pleural infiltration has a strong positive correlation with malignancy and increases the likelihood of malignancy as the final diagnosis. However, the visual appearance of the pleura is a subjective finding and possibly more informative when used by an experienced pulmonologists in combination with the pleural biopsy for the final diagnosis.
Keywords: Flexi-rigid thoracoscopy, pleuroscopy, semi-rigid thoracoscopy, undiagnosed pleural effusion
How to cite this article:
Periwal P, Khanna A, Talwar D. Role of flexi-rigid thoracoscopy in undiagnosed pleural effusions and correlation of visual appearance of pleura on thoracoscopy with the final diagnosis. J Assoc Pulmonologist Tamilnadu 2021;4:104-11 |
How to cite this URL:
Periwal P, Khanna A, Talwar D. Role of flexi-rigid thoracoscopy in undiagnosed pleural effusions and correlation of visual appearance of pleura on thoracoscopy with the final diagnosis. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2023 Mar 31];4:104-11. Available from: https://www.japt.in//text.asp?2021/4/3/104/345085 |
| Introduction | |  |
The etiology of pleural effusion is not evident following diagnostic thoracocentesis and pleural fluid (PF) analysis in up to 25% of patients.[1],[2] Such a pleural effusion is classified as an undiagnosed pleural effusion (UPE). In such a case, pleural histopathological study is needed for making a definitive etiological diagnosis. Numerous studies have been published from around the world, demonstrating the role of medical thoracoscopy in UPE.
It allows visualization of pleural cavity and permits biopsy of target pleural lesions under direct visual guidance.[3] Flexi-rigid thoracoscopy is a minimally invasive procedure, performed in a spontaneously breathing patient under minimal anesthesia.[4] It has been shown to have a high diagnostic yield ranging from 86.2% to 100% in UPE.[5],[6],[7],[8]
The visual appearance of pleura on thoracoscopy has also been previously correlated with the final diagnosis.[9],[10] They are described as nodules, masses, pleural infiltration, pleural thickening, polypoid lesions and “candle wax drops” pattern. The visual appearance of pleura on thoracoscopy has also been previously correlated with the final diagnosis.[3] It has been shown that the presence of pleural nodules, pleural infiltration, and hemorrhagic fluid were clinical predictors of malignancy.[11]
Our aim is to study the role of flexi-rigid thoracoscopy in establishing etiological diagnosis in undiagnosed, treatment naïve pleural effusion patients and the correlation of thoracoscopic findings with the final diagnosis.
There are no large published reports on the experience with flexi-rigid thoracoscope from India in the diagnosis of previously undiagnosed and untreated pleural effusions and correlation of thoracoscopic findings with the final etiological diagnosis.
| Materials and Methods | | |
A retrospective descriptive observational study was conducted on 84 newly diagnosed patients in whom pleural effusion remained undiagnosed at the Department of Respiratory, Sleep, Allergy, and Critical Care Medicine at the Metro Centre for Respiratory Diseases, Metro Hospital, Noida. Data from hospital records of patients, with noncontributory biochemical and cytological PF analysis, who were subjected to flexi-rigid thoracoscopy was collected between January 2010 and December 2013 and analyzed.
Semi-rigid thoracoscopy procedure was considered diagnostic if the histopathological examination of the pleural biopsy showed definitive features of malignancy or granulomatous inflammation suggestive of tuberculosis (TB) or positive microbiological investigations or nonspecific pleuritis.
The diagnostic yield of pleural biopsy using flexi-rigid thoracoscope in UPEs was assessed and the visual appearance of pleura on thoracoscopy was correlated with the final diagnosis. Nodules were defined as small if <5 mm in size and large if >5 mm in size.
Medical thoracoscopy procedure
The procedure was carried out under conscious sedation. Local anesthesia was achieved with 2% lignocaine, usually a maximum of 10 ml. It was infiltrated into the selected intercostal space from the skin level to the parietal pleura. A 1–1.5 cm linear incision (usually in the mid axillary line) was given and blunt dissection was performed to gain entry to the pleural space with a 10 mm size plastic trocar, which was inserted into the port of entry. Semi-rigid thoracoscopy was performed using the Olympus, LTF-Type 160 semi-rigid thoracoscope the scope has a 22 cm rigid insertion shaft with a 5 cm flexible tip and has a 2.8 mm internal working channel for introduction of forceps and other accessories. The high-resolution video imaging system provides sharp clear images. The angulation range of flexible tip is Up 160°/Down 130°.
The entire pleural space was thoroughly inspected and visualized abnormalities were noted such as pleural adhesions (thick, thin, or both), pleural nodules and distribution, and pleural infiltration (visceral/parietal). Multiple pleural biopsies (about 10–12 biopsy samples) were taken under vision from the abnormal areas of parietal pleura by a shearing movement of the thoracoscope and the samples were collected. Pleural biopsies were subjected to detailed histopathological analysis/immunohistochemistry (IHC) and interpreted by experienced pathologists. Adhesiolysis was performed if required. International Classification of Diseases was secured and connected to underwater seal bag. Once the lung expanded and drain output had decreased to <50 mL per 24 h, the chest drain was removed.
Inclusion criteria
All patients with undiagnosed, treatment-naive pleural effusions were included in the study.(UPE will be defined as previously untreated exudative, discordant or transudative pleural effusions with adenosine deaminase (ADA) level <60 IU/L and a negative PF cytology for malignancy). In suspected cases further, Brain natriuretic peptide (BNP), Amylase, Triglycerides and Cholesterol in PF and computed tomography-pulmonary angiogram was done.
Statistical analysis
All the statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY, USA). The clinical profile of patients was analyzed by Chi-square test for qualitative variables and Student's t-test for quantitative variables. Correlation between quantitative and qualitative outcomes was assessed using Pearson/Spearman correlation. 5% probability level was considered as statistically significant, i.e., P < 0.05.
| Results | | |
Of the 84 included in the study, 56 (66.7%) were male and 28 (33.3%) were female. Thirty-seven (44%) patients were smokers while 47 (56%) were nonsmokers. The age of patients ranged from 20 to 91 years with a mean of 60.85 ± 17.96 years.
Most of the patients 81% (68) had straw-colored PF, 12 (14.3%) patients had hemorrhagic PF and 4 (4.8%) had turbid PF. Eighty-two (97.6%) pleural effusions were exudative, while 1 (1.2%) was a discordant effusion and 1 (1.2%) was a transudative pleural effusion.
PF cytology was negative for malignant cells in all cases but suspicious or atypical cells were seen in 12 (14.28%) cases. PF acid-fast bacilli (AFB) stain was positive in one patient while none of the patients had PF gram stain or pyogenic culture positive. PF AFB culture showed Mycobacterial TB in 19 (22.6%) patients. However, among confirmed TB and nonspecific pleuritis, its positivity was seen in 33.1% (19/60). PF gene Xpert was positive in 11 (13.1%) patients for mycobacterium TB (MTB) and it was negative in 73 (86.9%) patients but was positive in 23.9% (11/46) patients with tubercular pleural effusions.
The thoracoscopic findings [Table 1] were documented and analyzed in all the 84 study patients. Pleural adhesions were present in 32 patients and absent in 52. They were few in 24 patients and extensive in eight patients. Pleural adhesions were thin in 18, thick in five patients and both thick and thin pleural adhesions were present in nine patients.
Pleural nodularity was seen in 67 patients and was absent in 17. The size of the nodules was small in 63 and large-sized pleural nodules were seen in 24 patients. Variable-sized nodules were seen in 27 patients. The nodules were diffusely distributed in 41. Nodules on the diaphragmatic pleura were seen in 31. Visceral pleura was involved in 44 of the total 84 patients analyzed.
Pleural infiltration was seen in 12 cases. Thoracoscopic finding was reported normal in 13 cases.
The pleural biopsy histopathological examination revealed nonspecific pleuritis in 12 (14.2%) patients, granuloma consistent with TB in 46 (54.8%), malignancy in 24 (28.6%) patients confirmed on IHC, and in 2 (2.3%) the diagnosis remained inconclusive among all the 84 patients [Table 2].
Pleural biopsy AFB smear (AFB) was positive for MTB in 5 (5.90%) patients while AFB culture was positive for MTB in 13 (15.5%). 19/46 cases were culture positive when PF and pleural biopsy were combined in analysis.
Adenocarcinoma was the most common malignancy with 18 (75%), 2 (8.3%) patients had squamous cell carcinoma, and 1 (4.1%) patient had a histopathological diagnosis of small cell cancer, malignant mesothelioma, leiomyosarcoma, and primitive neuroendocrine tumor each.
Epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation were tested in patients of adenocarcinoma. Of the 16 patients tested 10 (62.5%) were positive for EGFR mutation and 6 (37.5%) were negative. Only 2 (12.5%) patients were positive for ALK mutation.
The final Clinico-radiologico-pathological diagnosis was TB in 46 (54.8%) cases and malignancy in 24 (28.6%) cases.
Nonspecific pleuritis was reported in 12 (14.28%) patients. Out of the 12 patients, 2 were diagnosed to have TB on the basis of pleural biopsy AFB culture showing MTB. Post coronary artery bypass graft (CABG) pleuropericardial effusion, chylothorax, and congestive heart failure were diagnosed in 1 case each, while the diagnosis remained uncertain in 7 (58.33%) out of the 12 patients [Figure 1]. | Figure 1: Patients of non-specific pleuritis after clinico-radiologico-pathological correlation
Click here to view |
Hence, the diagnostic yield of flexi-rigid thoracoscopy in UPEs is 89.28%. When nonspecific pleuritis is considered as a diagnosis, the diagnostic yield increases to 97.6%.
The thoracoscopic finding of adhesions when present or absent, whether few or extensive, and the type of adhesions, i.e., thick or thin had negligible and no statistically significant correlation to the final diagnosis [Table 3].
[Table 4] shows the presence of pleural nodularity had a negative correlation with nonspecific pleuritis (r = −0.387, P < 0.01) and a positive correlation with malignancy although statistically insignificant (r = 0.318, P > 0.01). It was seen that small nodules had a negative correlation with nonspecific pleuritis (r = −0.393, P < 0.01) and positive correlation with TB (r = 0.249. P < 0.05).
The presence of large nodules had a strong positive correlation with malignancy (r = 0.475, P < 0.01) and a negative correlation with TB (r = −2.72, P < 0.05). Uniform distribution of nodules had a positive correlation with TB (r = 0.409, P < 0.01) and negative correlation with malignancy (r = −0.249, P < 0.05). Variable nodules has a strong positive correlation with malignancy (r = 0.524, P < 0.01) and a negative correlation with TB (r = −0.348, P < 0.05). The presence of diaphragmatic nodules has a positive correlation with malignancy (r = 0.390, P < 0.01) and a negative correlation with TB (r = −0.247, P < 0.05).
As shown in [Table 5], pleural infiltration has a strong positive correlation with malignancy (r = 0.570, P < 0.01) and negative correlation with TB (r = −0.381, P < 0.01).
The most common complication following thoracoscopy was pain at the local site and was seen in 17 (20.2%) patients. Ten (11.9%) patients had localized subcutaneous emphysema. Re-expansion pulmonary edema was present in 4 (4.8%), procedure-related minor bleeding was seen in 3 (3.6%) cases, postprocedure fever and infection was present in 2 (2.4%) and 1 (1.2%) patients respectively. There was no air leak or procedure-related mortality.
| Discussion | | |
For the diagnostic workup an UPE following a thoracocentesis, the next step is obtaining pleural tissue for evaluation. There are a number of methods available to obtain pleural biopsy to ascertain the histopathological diagnosis. A medical thoracoscopy is a valuable tool in assessing UPE. It is a minimally invasive and safe procedure. Both rigid and semi-rigid thoracoscopy can be used. Studies have reported rigid thoracoscopy to be superior to the semi-rigid one, however according to an Indian study,[12] the diagnostic yield of semi-rigid thoracoscopy is comparable to rigid thoracoscopy when pleural biopsy is adequately performed.
The results of a meta-analysis which included 17 studies and 755 patients suggest that semi-rigid thoracoscopy has good sensitivity (91%) and excellent specificity (100%) in diagnosis of exudative pleural effusions of undetermined cause.[13]
In our study, of the 84 patients included, 66.7% were male and 33.3% were female. The mean age was 60.85 ± 17.96 years. We found the diagnostic yield of flexi-rigid thoracoscopy to be 89.28%. The diagnostic yield in global studies varies from 86.2% to 100%[5],[6],[7],[8],[12],[14],[15],[16],[17],[18],[19],[20],[21],[22] This heterogeneity is probably due to the difference in selection criteria as well as different geographical locations of the study. Also, few of the researchers have included nonspecific pleuritis as a definite diagnosis, for example, study by Prabhu and Narasimhan[21] with 97% diagnostic yield included nonspecific pleuritis as a diagnosis obtained by the biopsy. Also to be noted is the time period when the studies were performed, as in 2010 study by Thangakunam et al.[14] did not mention nonspecific pleuritis in nondiagnostic thoracoscopies. However, the more recent studies conducted have excluded the National Strategic Plan from their diagnostic yield. If we include nonspecific pleuritis in our results the overall diagnostic yield increases to 100%.
The most common definite diagnosis was TB (54.8%) in our study. Cell blocks were made from PF and examined for AFB smear and culture. Pleural biopsy AFB smear was positive for MTB in 5 (5.90%) patients and pleural biopsy AFB culture was positive for MTB in 13 (15.5%) subjects (19 cases when PF and pleural biopsy cultures were combined). This analysis was done on PF sample collected at the time of thoracoscopy. The previous fluid analysis was negative. This is in contrast to the previously published Indian studies where the prevalence of TB on pleural biopsy is much lower as compared to malignancy.[12],[14],[20],[21],[22] India being endemic for TB, most patients with pleural effusions receive some form of anti-tubercular treatment even prior to confirmation of the diagnosis. In our study, we have only included subjects with no history of Anti-tuberculosis therapy (ATT) intake prior to thoracoscopy and this might explain the higher prevalence of TB in our study. Furthermore, AFB culture of pleural biopsy added to chronic pleuritis leading to the diagnosis of TB in 2 cases. For the diagnostic workup an UPE following a thoracocentesis, the next step is obtaining pleural tissue for evaluation as can be seen in [Flow chart 1]. Although we included 3 cases with ADA >60 on account of high clinical suspicion of malignancy only 1 case was confirmed to be tubercular. However, selection bias cannot be completely ruled out. Even amongst the smoker males, despite malignancy being the provisional diagnosis, TB was diagnosed in more than half the cases (58.33%). Thus, it appears that in patients who present with UPEs, TB should be considered as an important etiology of the underlying effusion. Our study ascertains that flexi-rigid medical thoracoscopy is a good procedure to diagnose TB in a country with a high prevalence of the disease especially when pleural biopsy cultures for MTB are added to it.
The diagnostic yield of malignancy in UPE was 28.6%. Previous studies have reported malignancy in 15%–63%.[7],[12],[20],[21],[22],[23] The most common histopathological diagnosis was adenocarcinoma (18/24) as was reported in all previous studies.[20],[21],[22],[23] Sixteen patients with adenocarcinoma lung were tested for treatable mutations and 62.5% (10/16) were tested positive for EGFR mutation while 12.5% (2/16) adenocarcinoma patients were positive for ALK mutation. Squamous cell carcinoma was reported in two patients, small cell carcinoma lung, malignant mesothelioma, leiomyosarcoma, and primitive neuroendocrine tumor were seen in one case each.
Nonspecific pleuritis was reported in 16.7% of cases in our study. The incidence of nonspecific pleuritis varies from 0% to 38% in earlier reports and highest reported from PGIMER Chandigarh.[7],[12],[20],[21],[22],[23] Davies et al.[24] reported that as many as 12% of cases of nonspecific pleuritis turn out to be malignant in etiology on a long-term follow-up. In our study, it was seen that the pleural biopsy AFB culture was positive in 2 of these patients on 6 weeks' follow-up. One patient had a post CABG pleuro-pericardial effusion, one had exudative pleural effusion secondary to diastolic heart failure as ascertained by highly raised PF BNP level, and another patient was diagnosed to be having chylothorax with a PF triglyceride level more than 110 mg/dl. The remaining nine patients remained undiagnosed despite flexi-rigid pleuroscopy.
The visual appearance of pleura on thoracoscopy has also been previously correlated with the final diagnosis. It has been shown that the presence of pleural nodules, pleural infiltration, and hemorrhagic fluid were clinical predictors of malignancy.[11] The most recent study[12] on the subject revealed that small-sized uniformly distributed nodules were suggestive of TB and large and variable nodules were suggestive of malignancy. The findings of small versus large nodules were observer dependent. Our study showed the same findings, i.e., smaller and uniformly distributed nodules were associated with TB whereas larger, variable-sized nodules, pleural infiltration, visceral pleural, and diaphragmatic pleural involvement were associated with malignancy. Thoracoscopic view of various pleural findings can be seen in [Figure 2]. | Figure 2: (a) Thoracoscopic view of the pleura showing small coalescing cheesy nodules. Histopathological examination showing caseating granulomas and langhans giant cells consistent with tuberculosis. (b) Thoracoscopic view of the pleura showing pleural infiltration. Histopathological examination showing tumor cells arranged in glands and tubules with occasional papillary formation consistent with adenocarcinoma lung. (c) Thoracoscopic view of the pleura showing variable sized nodules on the visceral and parietal pleura. Histopathological examination necrosis and neoplastic cells in sheets with eosinophilic cytoplasm and pyknotic nuclei consistent with squamous cell carcinoma. (d) Thoracoscopic view of the pleura showing variable sized large nodules on the visceral and parietal pleura. (d) Histopathological examination infiltration by neoplastic cells round to spindle with scant to moderate cytoplasm, hyperchromatic nuclei suggestive of metastatic carcinoma. It was confirmed to be a malignant neuroendocrine tumour on Immunohistochemistry
Click here to view |
We observed that pleural adhesions were present in 38% of patients. They were few in 75% patients and extensive in 25% patients. They were thin in 56.25%, thick in 15.63% of patients and both thick and thin pleural adhesions were present in 28.12% patients. The thoracoscopic finding of adhesions when present or absent, whether few or extensive, and the type of adhesions, i.e., thick or thin had no statistically significant correlation to the final diagnosis.
Pleural nodularity was seen in 79.76% patients. The presence of pleural nodularity had a negative correlation with nonspecific pleuritis and a positive correlation with malignancy although statistically insignificant.
The size of the nodules was an independent predictor of malignancy. The size of the nodules was small in 94.02% and large-sized pleural nodules were seen in 35.82% patients. It was seen that small nodules had a negative correlation with nonspecific pleuritis and positive correlation with TB. The presence of large nodules had a strong positive correlation with malignancy and a negative correlation with TB.
Variable-sized nodules were seen in 40.29% patients. The nodules were diffusely distributed in 61.19%. Nodules on the diaphragmatic pleura were seen in 46.26% patients in this study. Uniform distribution of nodules had a positive correlation with TB and negative correlation with malignancy.
Variable nodules had a strong positive correlation with malignancy. The presence of diaphragmatic nodules has a positive correlation with malignancy and a negative correlation with TB. Visceral pleural infiltration was seen in 14.28% of the total 84 patients analyzed. The presence of variable distribution of nodules, large nodules, diaphragmatic nodules, visceral pleural infiltration has a strong positive correlation with malignancy and increases the likelihood of malignancy as the final diagnosis.
Flexi-rigid thoracoscopy is a safe procedure with minimal complications. In our study, the most common complication following thoracoscopy was pain at the local site. Our study showed that there was no procedure-related major complications or mortality. This finding is in concordance with previous studies.[12],[21],[22] In view of its high diagnostic yield, it is expected that in near future empirical treatment by ATT would no longer be practiced as this procedure will be available everywhere and practiced by many more pulmonologists. Moreover, ATT for all lymphocytic, exudative effusions delays the diagnosis of malignancy besides putting the patient at risk for ATT-induced side effects.
The limitations of this study are that it is a retrospective single-center study. The recommended long-term follow for patients with nonspecific pleuritis on pleural biopsy is not available. Further studies are required for this entity.
| Conclusion | | |
Flexi-rigid thoracoscopy is an excellent modality to investigate UPE since it has a high diagnostic yield, is minimally invasive, and safe procedure, which can be easily performed by a pulmonologist well versed with bronchoscopy, because of the similarity in maneuverability and instrumentation.
TB is still the most common cause of UPE and addition of pleural tissue for AFB culture not only yields definitive diagnosis but also provides additional opportunity to diagnose sensitive or resistant TB. Malignancy being the second most common cause of UPE clarifies the merit of obtaining HPE in such cases. Here, also the addition of pleural tissue can be subjected to mutation tests for targeted therapies. Nonspecific Pleuritis seen as the remaining cause of UPE is becoming an entity and has been shown to be associated with malignancy.
The presence or absence of adhesions do not correlate with TB or malignancy and hence, should not interpret as suggestive of any specific disease so as to avoid wrong treatment.
It was seen that small nodules and uniform distribution of nodules had a high likelihood of being TB. The presence of variable distribution of nodules, large nodules, diaphragmatic nodules, visceral pleural infiltration has a strong positive correlation with malignancy and increases the likelihood of malignancy as the final diagnosis. However, the visual appearance of the pleura is a subjective finding and possibly more informative when used by an experienced pulmonologists who has performed several procedures. We believe pleural biopsy in combination with the thoracoscopic appearance of pleura will be more contributory toward the final diagnosis. More studies are needed to ascertain this.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Collins TR, Sahn SA. Thoracocentesis. Clinical value, complications, technical problems, and patient experience. Chest 1987;91:817-22.  |
| 2. | Venekamp LN, Velkeniers B, Noppen M. Does 'idiopathic pleuritis' exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy. Respiration 2005;72:74-8. |
| 3. | Shrestha BK, Adhikari S, Thakur BK, Kadaria D, Tamrakar KK, Devkota M. Medical thoracoscopy for undiagnosed exudative pleural effusion: Experience from two tertiary care hospitals of Nepal. JNMA J Nepal Med Assoc 2020;58:158-64. |
| 4. | Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thoracoscopy. Curr Opin Pulm Med 2009;15:313-20. |
| 5. | Loddenkemper R, Boutin C. Thoracoscopy: Present diagnostic and therapeutic indications. Eur Respir J 1993;6:1544-55. |
| 6. | Haridas N, Suraj KP, Rajagopal TP, James PT, Chetambath R. Medical thoracoscopy vs. closed pleural biopsy in pleural effusions: A randomized controlled study. J Clin Diagn Res 2014;8:MC01-4. |
| 7. | Maturu VN, Dhooria S, Bal A, Singh N, Aggarwal AN, Gupta D, et al. Role of medical thoracoscopy and closed-blind pleural biopsy in undiagnosed exudative pleural effusions: A single-center experience of 348 patients. J Bronchology Interv Pulmonol 2015;22:121-9. |
| 8. | Metintas M, Ak G, Dundar E, Yildirim H, Ozkan R, Kurt E, et al. Medical thoracoscopy vs. CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: A randomized, controlled trial. Chest 2010;137:1362-8. |
| 9. | Boutin C, Cargnino P, Viallat JR. Thoracoscopy in the early diagnosis of malignant pleural effusions. Endoscopy 1980;12:155-60. |
| 10. | Boutin C, Viallat JR, Cargnino P, Farisse P. Current indications for thoracoscopy. Rev Fr Mal Respir 1981;9:309-18. |
| 11. | Mohan A, Naik S, Naseer R, Boon C, Mills J, Pandey RM, et al. Performance characteristics of semirigid thoracoscopy in pleural effusions of undetermined etiology. J Bronchology Interv Pulmonol 2010;17:289-94. |
| 12. | Dhooria S, Singh N, Aggarwal AN, Gupta D, Agarwal R. A randomized trial comparing the diagnostic yield of rigid and semirigid thoracoscopy in undiagnosed pleural effusions. Respir Care 2014;59:756-64. |
| 13. | Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: A meta-analysis. Chest 2013;144:1857-67. |
| 14. | Thangakunam B, Christopher DJ, James P, Gupta R. Semi-rigid thoracoscopy: Initial experience from a tertiary care hospital. Indian J Chest Dis Allied Sci 2010;52:25-7. |
| 15. | Wang Z, Tong ZH, Li HJ, Zhao TT, Li XY, Xu LL, et al. Semi-rigid thoracoscopy for undiagnosed exudative pleural effusions: A comparative study. Chin Med J (Engl) 2008;121:1384-9. |
| 16. | Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical thoracoscopy in pleural disease: A 6-year retrospective study. Chest 2002;121:1677-83. |
| 17. | Tscheikuna J. Medical thoracoscopy: Experiences in Siriraj Hospital. J Med Assoc Thai 2006;89 Suppl 5:S62-6. |
| 18. | Ishida A, Miyazu Y, Iwamoto Y, Kanoh K, Zaima M, Inoue T. Medical thoracoscopy using a flexirigid thoracoscope in the diagnosis of pleural effusion of unknown cause. Chest 2005;128:320S-1S. |
| 19. | Ferrer J, Roldán J, Teixidor J, Pallisa E, Gich I, Morell F. Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy. Chest 2005;127:1017-22. |
| 20. | Mehta A, Rajesh V, Vishwam D, Sethu B, Patel V, Lakshmanan H. Value of semirigid thoracoscopy in pleural effusion. Pulmonary 2010;12:43-5. |
| 21. | Prabhu VG, Narasimhan R. The role of pleuroscopy in undiagnosed exudative pleural effusion. Lung India 2012;29:128-30. [Full text] |
| 22. | Nattusamy L, Madan K, Mohan A, Hadda V, Jain D, Madan NK, et al. Utility of semi-rigid thoracoscopy in undiagnosed exudative pleural effusion. Lung India 2015;32:119-26. [ PUBMED] [Full text] |
| 23. | Ash SR, Manfredi F. Directed biopsy using a small endoscope: Thoracoscopy and peritoneoscopy simplified. N Engl J Med 1974;291:1398-9. |
| 24. | Davies HE, Nicholson JE, Rahman NM, Wilkinson EM, Davies RJ, Lee YC. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg 2010;38:472-7. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|
Search Pubmed for