Pleural fluid cytological yield and visceral pleural invasion in patients with epithelioid malignant pleural mesothelioma.

INTRODUCTION: Malignant pleural mesothelioma (MPM) is an aggressive malignancy arising from mesothelial cells lining the pleura. Most commonly, it presents as a unilateral pleural effusion. MPM usually develops on the parietal pleural surface and later spreads to the visceral pleura. Visceral pleural involvement entails a more advanced disease stage and is therefore an important prognostic factor. Pleural fluid (PF) cytology is often the first diagnostic test, but the sensitivity in the literature varies from 4 to 77%. However, no data are available for the diagnostic yield of cytological PF analysis with regard to the visceral pleural involvement. The aim of this study is to assess whether PF cytological yield is related to the extent and pattern of visceral pleural invasion, as assessed by thoracoscopy. METHODS: Medical records of all patients who underwent thoracoscopy for suspicion of malignant pleural effusion from two hospitals were reviewed. Patients were selected if they initially underwent a diagnostic thoracentesis before thoracoscopy, if visceral pleural appearance during thoracoscopy was clearly documented, and MPM confirmed on pleural tissue biopsy. RESULTS: Seventy-five patients were selected. Forty-five patients had a positive PF cytology on thoracentesis, while 30 had a negative PF cytology. Thoracoscopy showed parietal pleural invasion in all subjects. Interestingly, 82% of patients with positive PF cytology on thoracentesis had visceral pleural involvement, whereas only 30% of those with negative PF cytology had visceral pleural invasion. The pattern of visceral pleural invasion consisted of pleural masses, nodules, or pleural thickening. A multivariate regression identified visceral pleural invasion (p < 0.001) as the only independent factor predicting the positivity of cytology on pleural effusion. CONCLUSION: In epithelioid MPM, PF cytological yield was significantly higher in patients with visceral pleural invasion assessed by thoracoscopy. Positive PF cytology is associated with a more advanced disease.

100 years of thoracoscopy: historical notes.

In the historical evolution of thoracoscopy, which was initiated exactly one century ago by Hans Christian Jacobaeus, two distinct periods can be identified: one between 1910 and 1955, characterised by its use for the lysis of pleural adhesions to obtain therapeutic pneumothorax in lung tuberculosis, and the subsequent period which has seen the development of diagnostic applications, principally due to pulmonologists and, after 1990, the start of an exclusively surgical thoracoscopy called video-assisted thoracoscopic surgery or VATS to perform video-assisted interventions.

Minithoracoscopy: a complementary technique for medical thoracoscopy.

Minithoracoscopy, currently defined as thoracoscopy with instruments of a diameter between 2 and 5 mm, is part of the general evolution of endoscopy towards mini-invasiveness. Its most relevant indications in the field of medical thoracoscopy are small effusions, pleural effusions in patients with narrow intercostal spaces and suspected tuberculous pleurisy in areas of low incidence of tuberculosis. In general, it increases the versatility of medical thoracoscopy.

The diagnosis of sarcoidosis pleurisy by medical thoracoscopy: report of three cases.

Pleural effusion in sarcoidosis is infrequent. The data on thoracoscopic observations of sarcoidosis pleurisy are limited. The present study describes three cases of sarcoid-related pleurisy diagnosed by medical thoracoscopy and discusses the thoracoscopic features of sarcoid pleuritis. The appearance of pleural nodules was completely different in the three cases, and the distribution of nodules of sarcoidosis was heterogenously located in the pleural surfaces. Pleural disease in sarcoidosis could be proved easily by sampling visible nodules, and pleural fluid could be aspirated without complications during thoracoscopy. Due to symptomatic pleurisy of sarcoidosis, therapy was given as systemic corticosteroid. In conclusion, thoracoscopy may be an appropriate alternative technique to obtain an accurate diagnosis in sarcoid pleurisy.

Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.

BACKGROUND: Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1-9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion. METHODS: We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. FINDINGS: No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0-0.54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1.2%), including one case of respiratory failure due to unexplained bilateral pneumothorax. INTERPRETATION: Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.

Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy.

INTRODUCTION: In cases of empyema, some form of intervention, either chest tube drainage, thoracoscopy, video-assisted thoracic surgery (VATS), or thoracotomy, with or without pleural fibrinolysis, is required. What the best approach is and when and how to intervene is a matter of debate. STUDY OBJECTIVE: To analyze the safety and outcome of medical thoracoscopy in the treatment of multiloculated empyema. METHODS: We report a retrospective series of 127 patients with thoracic empyema treated with medical thoracoscopy from 1989 to 2003 in three hospitals in Switzerland and Italy. All patients had multiloculated empyema as identified by chest ultrasonography. In the absence of multiloculation, or in case of fibrothorax, simple chest tube drainage or surgical VATS/thoracotomy were performed, respectively. RESULTS: Mean age +/- SD was 58 +/- 18 years (range, 9 to 93 years). In 47%, a microbiological diagnosis was made. Complications occurred in 9% of patients (subcutaneous emphysema, n = 3; air leak of 3 to 7 days, n = 9). No mortality was observed. Forty-nine percent of patients received postinterventional intrapleural fibrinolysis. Medical thoracoscopy was primarily successful in 91% of cases. In four patients, the insertion of an additional chest tube or a second medical thoracoscopy was required. Finally, 94% of patients were cured by nonsurgical means. Six percent of patients required surgical pleurectomy, mostly through thoracotomy. CONCLUSION: Multiloculated empyema as stratified by ultrasonography can safely and successfully be treated by medical thoracoscopy.