Aspect of Thoracoscopic Biopsy in Pleural Malignancy

BACKGROUND Medical thoracoscopy, in the educated fingers of a pulmonologist, is a secure and powerful process for the diagnosis and treatment of many pleural diseases. If the centres for thoracoscopy are available, thoracoscopy should be carried out on those undiagnosed sufferers due to its excessive sensitivity in malignant and tuberculous pleural effusions. That is why the ultimate decade witnessed an interest in thoracoscopy as a diagnostic device for pleural diseases. In the existing study, we wanted to describe our experience with the function of thoracoscopic biopsy in patients who underwent thoracoscopy for diagnostic purposes. METHODS The study protocol and ethical approval were taken by the Institutional Review Board for human studies of B. J. Medical College, Gujarat. It was a prospective study conducted in the Department of Pulmonary Medicine, B. J. Medical College, Ahmedabad, between July 2014 and November 2016. 39 patients who underwent medical thoracoscopy for undiagnosed pleural effusions were enrolled in this study. Undiagnosed pleural effusion was defined as failure to achieve a diagnosis by initial pleural fluid analysis including pleural fluid adenosine deaminase (ADA) levels and at least three pleural fluid analyses negative for malignant cells. Diagnostic pleural fluid aspiration was done to obtain pleural fluid specimens. RESULTS In the present study with the help of thoracoscopy, 36 (92.31 %) patients were diagnosed successfully while only 3 patients remained undiagnosed. In the present study, on thoracoscopic examination 21 (53.85 %) patients had pleural nodules, 5 (12.82 %) patients had pleural thickening, 5 (12.82 %) patients had pleural plaquelike erythema. The remaining patients had other uncommon findings e.g. nonspecific pleuritis 3 (7.69 %). CONCLUSIONS Among all the patients with undiagnosed exudative pleural effusion, irrespective of smoking status which fails to respond to conventional medical management, diagnostic thoracoscopy should be considered as early as possible. The diagnostic yield of thoracoscopy for pleural pathology remains very high (92.3 %). KEYWORDS Diagnosis, Malignant Pleural Effusion, Thoracoscopy.

The Diagnostic Role of Lung Ultrasound in Critically Ill Patients In Comparison With Chest X-Ray

Purpose To compare between lung ultrasound and chest X-ray in diagnosis of different lung pathologies in critically ill patients using lung CT as a gold standard. Methods Comparative prospective randomized single group observational study was conducted in the Critical Care unit (medical and surgical ICU). The study was conducted upon fifty patients (28 females &22 males) with a mean age of 58 years (SD ± 15.55; (19 - 82) presented to Kom Hamadah Hospital during a period of one year starting from July 2018 to July 2019, with acute dyspnea as the primary complaint or developed acute dyspnea and or tachypnea during their ICU stay were evaluated for the presence of pleural effusion, pneumothorax, alveolar-Interstitial Pathology and consolidation by LUS and CXR for detecting the sensitivity and specificity of each modality with CT chest done as a reference in cases of doubt. Results The comparison between Sensitivity and Specificity of US finding was (86.8% for parenchymal disease, 100.0% for pleural diseases) and (100.0% for parenchymal diseases, 94.7% for pleural diseases) respectively while CXR finding was (65.8% for parenchymal diseases, 75.0% for pleural diseases) and (58.3% for parenchymal diseases), (92.1% for pleural diseases) respectively among studied patients. Conclusion Transthoracic ultrasound is valuable for the evaluation of a wide variety of chest diseases, particularly mechanically ventilated patient. The advantages of low cost, bedside availability and no radiation exposure have made ultrasound an indispensable diagnostic tool in ICU. Lung ultrasound is more sensitive than chest x-ray in diagnosis and follow up chest diseases) PNX, alveolar-interstitial syndromes, parenchymal consolidations, and pleural effusion (LUS is an interesting medical method that is complementary to bedside CXR and reduces the need to use a CT scan.

Objective Thoracoscopic Criteria in Differentiation between Benign and Malignant Pleural Effusions

<b><i>Background:</i></b> Thoracoscopy is the “gold standard” diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces. <b><i>Methods:</i></b> A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen. <b><i>Results:</i></b> In the benign group, inflammation was the predominant finding in 65% (<i>n</i> = 33; costoparietal), 44% (<i>n</i> = 21; visceral), and 42% (<i>n</i> = 15; diaphragmatic). Nodules were detected in 24% (<i>n</i> = 12; costoparietal), 8% (<i>n</i> = 4; visceral), and 8% (<i>n</i> = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (<i>n</i> = 33; costoparietal), 32% (<i>n</i> = 13; visceral) and 48% (<i>n</i> = 17; diaphragmatic). Inflammation was detected in 44% (<i>n</i> = 20; costoparietal), 25% (<i>n</i> = 10; visceral), and 29% (<i>n</i> = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces. <b><i>Conclusion:</i></b> This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in &#x3e;1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.

Pleural Manometry—Basics for Clinical Practice

Purpose of Review The aim of this paper is to present basic data on pleural manometry and to outline the advances in its use as both a research tool enabling a better understanding of pleural pathophysiology and as a clinical tool useful in management strategy planning in patients with pleural diseases. To discuss updates and current trends in the development of pleural manometry, a search of the literature on pleural manometry published in recent years was performed. Recent Findings The technique of pleural manometry has significantly evolved over the last 40 years from simple water manometers to electronic or digital devices which enable the measurement and recording of instantaneous pleural pressure. Although to date it is mainly used as a research tool, pleural manometry has the potential to be applied in clinical practice. Recent studies demonstrated that monitoring of pleural pressure changes during therapeutic thoracentesis does not seem to be helpful in predicting re-expansion pulmonary edema and procedure-related chest discomfort. On the other hand, measurement of pleural elastance plays an important role in the diagnosis of unexpandable lung in patients with malignant pleural effusion facilitating determination of the optimal management strategy. Additionally, it allows for study of newly discovered phenomena, including pleural pressure pulse assessment and the impact of continuous positive airway pressure and cough on pleural pressure. Summary Pleural manometry is an established technique of pleural pressure measurement. Despite recent advances, its role in clinical practice remains undetermined.

Added value of diffusion-weighted MRI in assessment of pleural lesions

Background There are many causes of pleural disease including variable benign and malignant etiologies. DWI is a non-enhanced functional MRI technique that allows qualitative and quantitative characterization of tissues based on their water molecules diffusivity. The aim of this study was to evaluate the diagnostic value of DWI-MRI in detection and characterization of pleural diseases and its capability in differentiating benign from malignant pleural lesions. Results Conventional MRI was able to discriminate benign from malignant lesions by using morphological features (contour and thickness) with sensitivity 89.29%, specificity 76%, positive predictive value 89%, negative predictive value 76.92%, and accuracy 85.37%. ADC value as a quantitative parameter of DWI found that ADC values of malignant pleural diseases were significantly lower than that of benign lesions (P < 0.001). Hence, we discovered that using ADC mean value of 1.68 × 10-3 mm2/s as a cutoff value can differentiate malignant from benign pleural diseases with sensitivity 89.3%, specificity 100%, positive predictive value 100%, negative predictive value 81.2%, and accuracy 92.68% (P < 0.001). Conclusion Although DWI-MRI is unable to differentiate between malignant and benign pleural effusion, its combined morphological and functional information provide valid non-invasive method to accurately characterize pleural soft tissue diseases differentiating benign from malignant lesions with higher specificity and accuracy than conventional MRI.

STUDY OF HISTOPATHOLOGICAL SPECTRUM OF LESIONS IN PLUERAL BIOPSY.

Pleural diseases, both neoplastic (primary and metastatic) and non-neoplastic, exhibit similar clinical, radiographic and gross features, including pleural pain, pleural-based masses or pleural thickening, and pleural effusions. However, the treatments and prognoses of these diverse conditions vary greatly. As such, accurate diagnosis of pleural disease is critical, and histological interpretation of pleural biopsies is extremely important for correct diagnosis. Methods: A prospective study was conducted in Department of Pathology, Government Chest hospital, Osmania Medical college, Telangana, during March 2019 to March 2020 that evaluated 65 patients with history of pleural effusion, mass involving pleura and pleural thickening. Detailed history, clinical examination, Radiological Imaging along with pleural biopsy with Abram needle was performed in all the 65 Patients. The biopsy specimens were formalin xed and the sections were stained with Hematoxylin and Eosin. Result: The patients aged from 15 to 90 years, average age at presentation was 46.2 yrs. Of total 65 cases 20 were female (31%) and 45(69%) were male. The commonest clinical presentation was shortness of breath with cough. In 65 cases pleural effusion in 58 cases (89%), mass lesion in the lung 6 cases (9%) and pleural thickening 1 case (2%) was preliminary nding on radiology. Histo-pathological evaluation revealed 46 cases (69%) were inammatory lesions. 8cases (12%) were neoplastic lesions and 11(19%) cases were inadequate sampling. Of 46 inammatory lesions 12 cases (26%) were granulomatous lesions. Of 8 neoplastic lesions 1 case (12%) was malignant mesothelioma with calretinin and WT1 positive on Immunohistochemistry. Conclusion: A Pleural Biopsy is a safe, cost effective modality of investigation which not only guides us to diagnosis but also helps in nding out metastatic involvement in a primary Lung tumor. In inammatory lesions it at times aids in differentiating between granulomatous versus non granulomatous when correlated along with the ndings of pleural uid analysis. But lack of expertise in performing the blind procedure and sample inadequacy are some of the limiting factors in having good satisfactory Pleural Biopsy.