Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions

To the Editor: Blind needle biopsy of the pleura: why not?

K. Psathakis, V. Skouras
European Respiratory Review 2011 20: 120-122; DOI: 10.1183/09059180.00000711
K. Psathakis
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: kpsazakis@hol.gr
V. Skouras
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • PDF
Loading

To the Editor:

We read with great interest the excellent review by Janssen [1] in the September issue of the European Respiratory Review, where the author highlights the position of thoracoscopy in the current diagnostic armamentarium of pneumonology and nicely concentrates the up-to-date knowledge in the field.

As a general comment, we would say that thoracoscopy is not a panacea for the diagnosis of pleural effusions; however, the value of blind needle biopsy of the pleura (or closed-pleural biopsy; CPB) may not actually be so limited.

Thoracoscopy is essentially the best way to biopsy the pleura. However, not all diseases that affect the pleura can be diagnosed by pleural biopsy, even with the best techniques. The main histological abnormalities of the pleura that demonstrate disease specificity are those associated with malignant and granulomatous disorders, the most frequent representative of the latter disease category being tuberculosis (TB) [2, 3]. Thus, pleural biopsy (and thoracoscopy) can virtually diagnose two main disorders: malignant pleural effusions (MPEs) and TB pleuritis. In the case that the patient does not suffer from either of them, the pathologist will most probably diagnose “nonspecific pleuritis”. Although “not specific”, this diagnosis can exclude malignancy because of the high negative predictive value of thoracoscopy for MPEs [4]. This observation highlights another important indication of thoracoscopy, which is the exclusion of malignancy (as well as TB).

In the aforementioned review, comparing the performance of the three main nonsurgical methods of pleural biopsy for the diagnosis of MPEs (table 1 in the review by Janssen [1]), i.e. CPB, thoracoscopy and image-guided pleural biopsy (under computed tomography or ultrasound guidance), the inferiority of CPB for this specific purpose is demonstrated (sensitivity 45%). However, for the diagnosis of the other main disorder that can be diagnosed by pleural biopsy, namely TB pleuritis, the performance of both CPB and thoracoscopy is much better (sensitivity 79% and 100% respectively) [5], while to the best of our knowledge there are no available data for image-guided pleural biopsy. Based on the information depicted in this table, the author concludes that CPB “should no longer be used in a setting where image-guided pleural biopsies can be obtained” and that CPB “is only indicated in areas with high incidence of TB and limited medical resources”. Although this conclusion might reflect the general opinion regarding CPB, we do not totally agree with this position.

First of all, for the diagnosis of MPEs it is unknown if the suggestion for the usage of image-guided pleural biopsy instead of CPB, which is mainly based on the results of the study by Maskell et al. [6], can be equally applied in less experienced and/or less specialised centres in the field. Before advising pneumonologists to stop performing CPB, we should probably consider whether all radiologists are trained to obtain image-guided pleural biopsies and if they will be available when we need them.

Regarding thoracoscopy, not all patients with an MPE are appropriate candidates for this method. Poor performance status, severe dyspnoea or significant pain due to bone metastases, that does not allow the patient to obtain the typical body position for thoracoscopy, might be indications for a more conservative approach. The alternative of CPB might then be offered if tissue information is considered necessary for the patient's further work-up. For these individual cases, a diagnostic sensitivity of 45% for CPB, although “low” compared to 95% for thoracoscopy, might still be a reasonable option. If 45% of patients with MPE are expected to gain some benefit from this technique then, why not try?

In comparison to thoracoscopy, CPB is much less invasive, less painful and perhaps more tolerable from the patient’s perspective. In fact, CPB is not very different from a simple thoracocentesis regarding the technique itself, as well as the overall complications. Its great advantage of simplicity and negligible complication rate may save time and effort for the medical staff and discomfort for patients. These benefits are unequivocally important, especially in patients who suffer from malignancy and have a limited life expectancy. Obviously, CPB should not be considered as an equal alternative of thoracoscopy. However, it could be performed as a complementary technique in the context of diagnostic or therapeutic thoracocentesis. Indeed, some of these interventions, at times, may precede the decision for thoracoscopy, as it is important to evaluate the rate of recurrence of the pleural fluid or if lung re-expansion is possible.

In the case of TB pleuritis the option of CPB might be even stronger because of its high diagnostic sensitivity, which in some studies approximates that of thoracoscopy [7]. In view of these data, one might choose to perform CPB before proceeding to thoracoscopy in a case suspicious for TB, and this approach might be acceptable in both high- and low-incident areas. In our clinic we have performed thoracoscopy for the past 6 yrs, with the main indication being that of undiagnosed pleural effusions. Unfortunately, we have not had the opportunity to thoracoscopically diagnose a TB pleutiris, as the few patients we had were diagnosed by CPB. And we do not believe we did wrong. However, it should always be stressed that even for TB, in case of a nondiagnostic CPB, the best answer remains thoracoscopy.

In addition to all the aforementioned issues, there are two more different but equally important parameters. The first is that of the patient's preferences. If the patient does not wish to be involved in thoracoscopy then other options should be available, including blind needle biopsy. The second has to do with the training of chest physicians. If tertiary hospitals, which are usually responsible for the training of the new specialists in pulmonary medicine, choose to eliminate CPB from their diagnostic tools, then the newer generations of pneumonologists will not be familiar with this technique at all. This means that in the near future the pneumonologists who are going to staff hospitals “with limited resources” will actually not be able to perform pleural biopsies. In that case, will the surgeons diagnose TB for us or should we proceed into patients’ transfers between hospitals to obtain a small piece of tissue?

In conclusion, we believe that sensitivity alone might not be the only criterion for a physician to opt for a diagnostic test. Pneumonologists should ideally master the full spectrum of the available diagnostic methods in their field and then choose the most feasible option for their patients on a case by case basis.

Footnotes

  • Statement of Interest

    None declared.

  • Provenance

    Submitted article, peer reviewed.

  • ©ERS 2011

REFERENCES

  1. ↵
    1. Janssen JP
    . Why you do or do not need thoracoscopy. Eur Respir Rev 2010; 19: 213–216.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Light RW,
    2. Lee YCG
    1. Cagle PT
    . Pleural histology. In: Light RW, Lee YCG, eds. Textbook of Pleural Diseases. London, Hodder Arnold, 2003; pp. 249–255.
  3. ↵
    1. Rodriguez-Panadero F,
    2. Janssen JP,
    3. Astoul P
    . Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006; 28: 409–421.
    OpenUrlFREE Full Text
  4. ↵
    1. Janssen JP,
    2. Ramlal S,
    3. Mravunac M
    . The long-term follow-up of exudative pleural effusion after nondiagnostic thoracoscopy. J Bronchol 2004; 11: 169–174.
    OpenUrlCrossRef
  5. ↵
    1. Diacon AH,
    2. Van de Wal BW,
    3. Wyser C,
    4. et al
    . Diagnostic tools in tuberculous pleurisy: a direct comperative study. Eur Respir J 2003; 22: 589–591.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Maskell NA,
    2. Gleeson FV,
    3. Davies RJ
    . Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003; 361: 1326–1330.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Gopi A,
    2. Madhavan SM,
    3. Sharma SK,
    4. et al
    . Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest 2007; 131: 880–889.
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top
View this article with LENS
Vol 20 Issue 120 Table of Contents
  • Table of Contents
  • Table of Contents (PDF)
  • Cover (PDF)
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
To the Editor: Blind needle biopsy of the pleura: why not?
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
To the Editor: Blind needle biopsy of the pleura: why not?
K. Psathakis, V. Skouras
European Respiratory Review Jun 2011, 20 (120) 120-122; DOI: 10.1183/09059180.00000711

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
To the Editor: Blind needle biopsy of the pleura: why not?
K. Psathakis, V. Skouras
European Respiratory Review Jun 2011, 20 (120) 120-122; DOI: 10.1183/09059180.00000711
Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Footnotes
    • REFERENCES
  • Info & Metrics
  • PDF

Subjects

  • Respiratory clinical practice
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Reply to: “Nicotine or tobacco abstinence?”
  • Nicotine or tobacco abstinence?
  • Biochemical shunt: where and how?
Show more Correspondence

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERR

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising
  • Sponsorship

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN: 0905-9180
Online ISSN: 1600-0617

Copyright © 2023 by the European Respiratory Society