Indications for diagnostic thoracoscopy
- Francis D Sheski, MD
Francis D Sheski, MD
- Associate Professor of Clinical Medicine
- Indiana University School of Medicine
- Section Editors
- Praveen N Mathur, MB, BS
Praveen N Mathur, MB, BS
- Section Editor — Interventional Pulmonology
- Professor of Clinical Medicine
- Indiana University School of Medicine
- V Courtney Broaddus, MD
V Courtney Broaddus, MD
- Section Editor — Pleural Disease
- Professor of Medicine
- University of California San Francisco
Thoracoscopy involves a percutaneous approach to placement of an endoscopic instrument within the pleural space, allowing direct visualization and biopsy of the pleura. Unlike video-assisted thoracic surgery (VATS), in which the surgeon uses a thoracoscope to assist with performance of minimally invasive surgery, the purpose of "medical thoracoscopy" is to provide access to the pleura for evaluation and, in some cases, management of pleural disease . Open pleural biopsy is now largely done during medical thoracoscopy.
The major indication for diagnostic medical thoracoscopy is an exudative pleural effusion of unknown etiology. Often at the time of thoracoscopy, the etiology turns out to be mesothelioma, lung cancer, tuberculosis, or a benign pleural disorder. In some hands, medical thoracoscopy is used to evaluate diffuse pulmonary parenchymal disease.
The British Thoracic Society Pleural Disease Guideline 2010 supports medical thoracoscopy as the tool to investigate exudative pleural effusions undiagnosed by other means, like thoracenteses [2,3].
PLEURAL EFFUSION OF UNKNOWN ETIOLOGY
Algorithms for investigating pleural effusions of unknown etiology typically begin with thoracentesis (see "Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology"). Pleural fluid is analyzed for cellular contents, chemistries, smears and culture of microorganisms, and cytology. However, cytological examination of even large effusions is diagnostic in only 60 to 80 percent of patients with metastatic pleural involvement [4-6] and fewer than 20 percent of patients with mesotheliomas . Thoracentesis with percutaneous closed needle biopsy may be diagnostic in 60 percent of malignant pleural effusions [8,9].
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