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
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary, Critical Care, and Sleep Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
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 pulmonary parenchymal disease.
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 [2-4] 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 [6,7].
Thoracoscopy in patients with a pleural effusion of unclear etiology often yields a specific diagnosis. As an example, in a series of 1000 consecutive patients with pleural effusions, 215 patients had pleural effusions of unknown etiology despite repeated thoracentesis and percutaneous needle biopsy of the pleura . Thoracoscopy resulted in a diagnosis of malignancy in 150 (70 percent) of the patients, including mesothelioma in 35 patients. Similar levels of diagnostic accuracy have been reported by other investigators [8-13].
- Loddenkemper R. Thoracoscopy--state of the art. Eur Respir J 1998; 11:213.
- Salyer WR, Eggleston JC, Erozan YS. Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Chest 1975; 67:536.
- Dines DE, Pierre RV, Franzen SJ. The value of cells in the pleural fluid in the differential diagnosis. Mayo Clin Proc 1975; 50:571.
- Light RW. Pleural diseases, Lea & Febiger, Philadelphia 1990.
- Legha SS, Muggia FM. Pleural mesothelioma: clinical features and therapeutic implications. Ann Intern Med 1977; 87:613.
- Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:588.
- Scerbo J, Keltz H, Stone DJ. A prospective study of closed pleural biopsies. JAMA 1971; 218:377.
- Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 121 consecutive surgical procedures. Ann Thorac Surg 1989; 48:66.
- Oldenburg FA Jr, Newhouse MT. Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia. Chest 1979; 75:45.
- Weissberg D, Kaufmann M. Diagnostic and therapeutic pleuroscopy. Experience with 127 patients. Chest 1980; 78:732.
- Loddenkemper R. Thoracoscopy: results in non cancerous and idiopathic pleural effusions. Poumon Coeur 1981; 37:261.
- Loddenkemper R, Mai J, Scheffler N, Brandt HJ. Prospective individual comparison of blind needle biopsy and of thoracoscopy in the diagnosis and differential diagnosis of tuberculous pleurisy. Scand J Respir Dis Suppl 1978; 102:196.
- Pepper JR. Thoracoscopy in the diagnosis of pleural effusions and tumours. Br J Dis Chest 1978; 72:74.
- Cantó A, Blasco E, Casillas M, et al. Thoracoscopy in the diagnosis of pleural effusion. Thorax 1977; 32:550.
- Wu MH, Hsiue RH, Tseng KH. Thoracoscopy in the diagnosis of pleural effusions. Jpn J Clin Oncol 1989; 19:116.
- Enk B, Viskum K. Diagnostic thoracoscopy. Eur J Respir Dis 1981; 62:344.
- Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271.
- Sakuraba M, Masuda K, Hebisawa A, et al. Diagnostic value of thoracoscopic pleural biopsy for pleurisy under local anaesthesia. ANZ J Surg 2006; 76:722.
- Metintas M, Ak G, Dundar 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.
- Canto A, Rivas J, Saumench J, et al. Points to consider when choosing a biopsy method in cases of pleurisy of unknown origin. Chest 1983; 84:176.
- Cantó A, Ferrer G, Romagosa V, et al. Lung cancer and pleural effusion. Clinical significance and study of pleural metastatic locations. Chest 1985; 87:649.
- Meyer PC. Metastatic carcinoma of the pleura. Thorax 1966; 21:437.
- Rodrîguez-Panadero F, Borderas Naranjo F, López Mejîas J. Pleural metastatic tumours and effusions. Frequency and pathogenic mechanisms in a post-mortem series. Eur Respir J 1989; 2:366.
- Breen D, Fraticelli A, Greillier L, et al. Redo medical thoracoscopy is feasible in patients with pleural diseases - a series. Interact Cardiovasc Thorac Surg 2009; 8:330.
- Davidson AC, George RJ, Sheldon CD, et al. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988; 43:327.
- Marchetti G, Valsecchi A, Indellicati D, et al. Ultrasound-guided medical thoracoscopy in the absence of pleural effusion. Chest 2015; 147:1008.
- Ryan CJ, Rodgers RF, Unni KK, Hepper NG. The outcome of patients with pleural effusion of indeterminate cause at thoracotomy. Mayo Clin Proc 1981; 56:145.
- Decker DA, Dines DE, Payne WS, et al. The significance of a cytologically negative pleural effusion in bronchogenic carcinoma. Chest 1978; 74:640.
- Faurschou P, Francis D, Faarup P. Thoracoscopic, histological, and clinical findings in nine case of rheumatoid pleural effusion. Thorax 1985; 40:371.
- Boutin C, Viallat JR, Cargnino P, Rey F. Thoracoscopic lung biopsy. Experimental and clinical preliminary study. Chest 1982; 82:44.
- Brandt HJ. [Pulmonary biopsy under visual control (author's transl)]. Poumon Coeur 1981; 37:307.
- Dijkman JH, van der Meer JW, Bakker W, et al. Transpleural lung biopsy by the thoracoscopic route in patients with diffuse interstitial pulmonary disease. Chest 1982; 82:76.
- Kapsenberg PD. Thoracoscopic biopsy under visual control. Poumon Coeur 1981; 37:313.
- Rodgers BM. Thoracoscopy in children. Poumon Coeur 1981; 37:301.
- Rodgers BM, Moazam F, Talbert JL. Thoracoscopy. Early diagnosis of interstitial pneumonitis in the immunologically suppressed child. Chest 1979; 75:126.
- Bonniot JP, Homasson JP, Roden SL, et al. Pleural and lung cryobiopsies during thoracoscopy. Chest 1989; 95:492.
- Wall CP, Gaensler EA, Carrington CB, Hayes JA. Comparison of transbronchial and open biopsies in chronic infiltrative lung diseases. Am Rev Respir Dis 1981; 123:280.