Thoracoscopic lung biopsy. Experimental and clinical preliminary study.

We have investigated thoracoscopic lung biopsy (TLB) as an alternative to surgical biopsy. TLB was performed under mild general anesthesia, with two openings: one for the telescope, and one for a 5 mm in diameter biopsy forceps connected to diathermocoagulating device. TLB was first tested on 14 dogs (22 TLB) and then on 75 subjects (77 TLB): 35 patients with pleural diseases and 40 patients with undiagnosed lung diseases despite previous investigations including transbronchial biopsy. TLB yielded a high rate of adequate samples (up to 5 x 5 x 5 mm) in both experimental (95 percent) and clinical series (96 percent). Overall sensitivity equalled 923 percent, ranging from 70 percent in peripheral localized lesions to 100 percent in diffuse lung diseases. The mean period of systematic drainage was 3.4 +/- 0.3 days, and the main complications we encountered were one transient blood-streaked sputum specimen and eight localized pneumothoraces during drainage. TLB is indicated when other medical procedures have failed, and has thus proved, in this series, to be as sensitive as surgical biopsy with less morbidity and no mortality.

Thoracoscopy in malignant pleural effusions.

In a consecutive series of 1,000 patients admitted since 1970 for pleural effusions, 215 with undiagnosed chronic effusions (with previous negative cytologic and needle biopsy results) underwent thoracoscopy. The investigation was usually performed under general anesthesia, originally with a 9-mm diameter cold light laparoscope, but, since 1978, with a 7-mm diameter thoracoscope of our design with biopsy forceps connected to a diathermocoagulating device. Thoracoscopy diagnosed 131 of 150 malignant effusions in the series. We observed no false positive results. A repeat pleural cytology and needle biopsy performed the day before thoracoscopy yielded only 41% positive results. The higher yield by our new thoracoscope (97% positive results, versus 78% with the laparoscope) can be accounted for by a better visualization of the pleural space, easier handling of biopsy material, and the systematic use of diathermocoagulation. Complications were rare, minor, and not life-threatening.

[Intrapleural talc in malignant pleural effusions (author's transl)]. / Le talcage pleural dans les pleurésies cancéreuses.

Intrapleural talc poudrage was carried out at the end of thoracoscopy in 77 patients after complete aspiration of fluid with uniform insufflation over the whole surface area of the pleura of 4 to 5 ml of pure talc, asbestos free. A continuous suction drain was left in place for 3 to 6 days. Amongst these patients, there were 57 cases of pleural effusion due to metastases and 20 mesotheliomas. A satisfactory result was obtained in 70 patients (91%). There were 7 failures. Fourteen mesotheliomas in which talc was used were compared with 14 further cases operated upon by pleurectomy. Both series were compared retrospectively in terms of age, sex, exposure to asbestos, histological type and the interval between the first symptom and treatment. In the talc series, there were 11 excellent results, 2 moderate and 1 nil. In the operated series there were 10 excellent results, 1 nil and 3 postoperative deaths. Survival of the patients was 395 +/- 55 days after the application of talc and 315 +/- 65 days after pleurectomy. There was thus a slight benefit in favour of the talc technique but this was not statistically significant. A figure of approximately 90% of satisfactory results is found in other series of the use of intrapleural talc published. This technique is thus effective and free of danger, and may be used in malignant effusions when techniques of local instillation of various substances and systemic chemotherapy have failed.

[Current indications for thoracoscopy]. / Indications actuelles de la thoracoscopie.

Thoracoscopy is performed at best with a rigid apparatus and a cold light source using a single or double site of entry into the chest. Biopsy under direct vision requires a double-spoon biopsy forceps that can be connected to diathermy to insure haemostasis and prevent any air leak age. Some authors prefer a local anaesthesia but a light general anaesthesia with or without intubation allows a safe and painless examination. Numerous biopsies can be obtained for subsequent examinations, like light or electron microscopy, immunofluorescence, bacteriology and mineral studies as well as search for hormonal receptors sites on tumours. Complications are rare and fatalities exceptional (4 cases in a review of the literature covering 3.384 cases. 2 of which occurred in a small series of 150 cases). In chronic pleurisies secondary to cancer, a diagnosis was made in 92% of cases. In suspected pleural mesothelioma, thoracoscopy allows both diagnosis and staging. In pleural tuberculosis, a diagnosis is obtained in 93% of cases. Talc pleurodesis in the treatment of chronic recurrent malignant pleural effusions is successful in 80%. In the treatment of spontaneous pneumothorax with a mean follow up of 10 years, only 6.6% recurred after talc poudrage, and functional sequelae were minimal; no talcomas induced mesotheliomas were seen in a review of 151 cases. Thoracoscopic lung biopsy has an 87 to 94% success rate depending on series, and is thus comparable to surgical biopsy with a markedly smaller morbidity and mortality. It should thus be used more widely by pneumologists.

[Lung biopsy by thoracoscopy (author's transl)]. / La biopsie pulmonaire par thoracoscopie. Etude préliminaire.

60 patients had 1 to 7 biopsies during thoracoscopy under light anaesthesia without tracheal intubation. Biopsies were performed under direct vision using a separation puncture. Double-spoon biopsy forceps (5 mm in diameter) connected to a 120 watt diathermy apparatus avoided any air leak age and ensured haemostasis as the biopsy was taken. The dry weight of the biopsies ranged between 5 and 40 mg, allowing appropriate studies with light or electron microscope, for bacteriological and mineral analysis, and for hormone receptors search in cancer cases. A size 20 to 30 Charrière drain was left for a mean of 3 days. No serious complications arose. Ten patients had a 38 degrees C fever for a few hours. In one case early in the study a drain had to be changed on the third day. An histopathological diagnosis was made in 12 out of 14 patients with localised pulmonary opacities and in all 14 cases with diffuse opacities. In 32 cases of pleural involvement the presence or absence of concomitant lung involvement could be demonstrated. Asbestos fibres counts by electron microscopy correlated fairly with previous exposure to asbestos. The sensibility of the technique was 96% (percent of true positives) and the specificity 100% (percent of true negatives). Thoracoscopic lung biopsy may thus be compared very favourably to techniques of lung biopsy and deserves a larger studies in order to confirm its low morbidity.

[Thoracoscopy in 1980. A general review (author's transl)]. / La Thoracvoscopie en 1980. Revue générale.

Examining the literature and their own experience, the authors reviewed the methods, the complications and indications of modern thoracoscopy. They considered the rigid cold light thoracoscope with diathermo-coagulation. The authors stressed the importance of the macroscopic appearance of the pleural cavity, and the need to take numerous biopsies. Several types of anesthesia can be used, although the authors prefer general anesthesia for the comfort of both the patient and the doctor. Complications are very rare, the main ones being hemorrhage, pulmonary perforation and contamination of the puncture route with cancer cells. The first two can be avoided by good technique and diathermo-coagulation. The latter can be prevented by systematic radiotherapy of the puncture route, in mesothelioma patients. Amongst the numerous indications mentioned, three are important: the etiological diagnosis of chronic effusion, where cancer is a major fear. In these cases, the authors get 97% of positive results. Spontaneous pneumothorax is also a good indication: thoracoscopy allows a useful separation of patients, into those who need surgical treatment, or those in whom local adhesion of the pleura with talcum powder would be effective. Finally, pulmonary biopsy via the thoracoscope is a reliable and effective technique in a large number of indications.

[Thoracoscopy in pleural mesothelioma. Diagnostic, prognostic and therapeutic interest (author's transl)]. / La thoracoscopie dans le mésothéliome pleural. Intérêt diagnostique, pronostique et thérapeutique.

Thoracoscopy with a single opening was carried out under general anesthesia with a cold light thoracoscope of 7 mm in diameter. Biopsies were taken under visual control for optical and electron microscopic examination. In a series of 40 mesotheliomas, 30 patients with pleural effusion underwent 36 thoracoscopies. In 29 patients the macroscopic lesions were compatible with the diagnosis of mesothelioma. The most specific aspects consisted in white-yellowish nodules, almost translucent, arising from the parietal pleura (9 patients). Another typical pattern, a dense pleural thickening, was found in 10 patients. In the remaining patients, the lesions observed were less specific. The biopsy was positive in 35/36 thoracoscopies (97%). A talc poudrage was carried out in 10 patients: their mean survival was 458 days. In ten matched mesothelioma patients who underwent pleurectomy the mean survival was only 395 days. In 12 patients at an early stage, the visceral pleura was not involved by the tumor: their mean survival was 636 days. In 11 patients both parietal and visceral pleura were involved by the tumor: their mean survival was 138 days: (p less than 0,001). It is concluded that in mesothelioma pleural effusions, thoracoscopy is a safe and efficient procedure in order to reach a precise diagnosis, prognosis and efficient palliative treatment of the effusion.

[Thoracoscopy in chronic pleural effusion (author's transl)]. / La thoracoscopie: intérêt actuel. Sa place dans le diagnostic des pleurésies chroniques.

123 patients with chronic pleurisy were investigated by thoracoscopy. The endoscopic biopsy is positive in 16 out of 17 cases of mesothelioma (96%), in 57 out of 72 cases of pleural metastasis (79%), and in 6 cases out of 7 pleural tuberculosis. Begnin pleural asbestosis was confirmed in 5. Endoscopic biopsy is thus more efficient than results obtained with pleural needle biopsy and exudative cytology. Thoracoscopy can be performed without any serious complications, this is not always true with open thoracotomy.

[Pulmonary biopsy with Steel's needle. Practical value]. / La biopsie pulmonaire à l'aiguille de Steel. Valeur pratique

Eighty-seven biopsies were performed on 76 patients with the pneumatic trephine of Steel: -- 87% of biopsies were interpretable; -- 22% of fragments revealed only unspecific lesions or normal lung tissue; -- 65% of samples gave a credible histological diagnosis. Occurring incidents were mostly pneumothorax (41%) usually minor ones. In only 2 patients was drainage necessary. The superiority of the Steel method over the others arises from its usefulness in diffuse pneumopathies and its being better tolerated.