Cryobiopsy as a Salvage Technique Following Negative Flexible Forceps Biopsy of the Pleura Under Rapid On-Site Evaluation Guidance: A Prospective Study

Background: Medical thoracoscopy is a minimally invasive technique to inspect the pleural space and to perform biopsy of pleural lesions under direct vision. In this study, the diagnostic utility of thoracoscopy for undiagnosed exudative lymphocytic pleural effusions from a tertiary care respiratory center will be discussed. Materials and Methods: In a retrospective analysis of thoracoscopic procedures, we performed between September 2017 and August 2019, the yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed exudative lymphocytic pleural effusions was evaluated. Undiagnosed exudative pleural effusions were defined as pleural effusions where an etiologic diagnosis could not be ascertained by initial pleural fluid biochemical and microbiological analysis, including protein, sugar, lactate dehydrogenase, Gram and acid-fast bacilli stains and Mycobacterium tuberculosis culture, pleural fluid adenosine deaminase levels, and at least two pleural fluid cytologies negative for malignant cells or other definite causes. We analyzed the clinical, radiological, cytological, and histopathological data of the patients and also the complications of thoracoscopy. Results: We performed thoracoscopy in 68 cases of undiagnosed exudative pleural effusions using the rigid thoracoscope. The overall diagnostic yield of thoracoscopic pleural biopsy was 95.6% in patients with undiagnosed exudative pleural effusions. Malignant pleural effusion was diagnosed in 67.6% of patients, while tuberculosis was diagnosed with pleural biopsy in 25% of patients. Three cases of subcutaneous emphysema, 2 cases of postprocedure fever were observed, and one patient had prolonged air leak. Conclusion: Medical thoracoscopy has a good diagnostic yield in patients with undiagnosed exudative lymphocytic pleural effusions and is a safe procedure as well.

BackgroundRigid forceps is commonly used for pleural biopsies during medical thoracoscopy in undiagnosed pleural effusion, and recently, the use of cryoprobe for pleural biopsies was encouraged, as the procedure is effective and safe.ObjectiveThis study compared between rigid forceps and cryoprobe pleural biopsies regarding biopsy characteristics, diagnostic yield, and tissue viability in patients with undiagnosed exudative pleural effusion who underwent medical thoracoscopy.Patients and methodsA total of 30 patients with undiagnosed exudative pleural effusion were selected for medical thoracoscopy, and pleural biopsies were taken by rigid forceps and cryoprobe in the same setting. All biopsies were processed for histopathology examination.ResultsOf the 30 patients, 18 (60%) were males and 12 (40%) were females, with mean age of 51.03 years. The most frequent diagnosis was mesothelioma (43.3%) followed by chronic nonspecific inflammation (23.3%), metastatic carcinoma (16.6%) and tuberculosis (16.6%). Biopsies of rigid forceps (mean: 0.8193 cm2) were larger than cryoprobe (mean: 0.3377 cm2) but with less depth. Tissue viability of cryoprobe biopsies was better than rigid forceps biopsies, and the diagnostic yield of both techniques was the same.ConclusionCryobiopsies obtained during medical thoracoscopy is technically feasible and safe with high diagnostic value. Biopsies of cryoprobe were smaller than that of rigid forceps but were deeper and with better preserved cellular architecture. These results will encourage the use of cryotechnique for diagnosis of undiagnosed exudative pleural effusion.

Background: Medical Thoracoscopy is gaining interest among the pulmonologists. But the non-availability of the procedure in all hospitals, high cost and non-availability of expert clinicians and staff are the main problems experienced in a developing countries Aims: 1. To compare the diagnostic yield of bronchoscopic,closed pleural& thoracoscopic biopsies in undiagnosed pleural effusions. 2. To see whether combined bronchoscopy & closed pleural biopsy will be sufficient or not, in diagnosing pleural effusion where medical thoracoscopy is not available. Methodology: A prospective observational study among 25 patients, admitted at our centre with undiagnosed exudative pleural effusion, s. Closed pleural biopsy, medical thoracoscopy and then 48 hours later bronchoscopy were done in all. The results and complications of the procedures were recorded and analysed. Results: Out of the 25 patients, we could attain a diagnosis in 21 cases. Among them 16 had malignancy and 5 had tuberculosis. The overall sensitivity of the three procedures are as follows: closed pleural biopsy- 28.5%, bronchoscopy- 14.2%, medical thoracoscopy- 95.2%, combined pleural biopsy & bronchoscopy- 42.8%.The complication rate was lowest for bronchoscopy (4%), followed by medical thoracoscopy (8%) and closed pleural biopsy (16%). Conclusion: Medical thoracoscopy is a comparatively safe procedure, having the highest diagnostic yield among three studied procedures in the evaluation of undiagnosed exudative pleural effusions When bronchoscopy is combined with closed pleural biopsy , the diagnostic yield is increased (than that of individual yield), but cannot be a substitute for medical thoracoscopy.

Pleural effusion is due to the pathological accumulation of pleural fluid in the pleural space, 25%-30% of which may remain undiagnosed despite the combination of biochemical, microbiological, and pathological tests and closed pleural biopsy. Medical thoracoscopy may help physicians diagnose such cases. We aimed to study the diagnostic yield of medical thoracoscopy in patients with undiagnosed exudative pleural effusion and assess the safety profile of the medical thoracoscopy. A cross-sectional descriptive study was conducted on 105 patients with undiagnosed pleural effusion. Medical thoracoscopy was performed using an Olympus semi-rigid thoracoscope (LTF 160 Evis Pleurovideoscope, Japan) as per standard protocol. Multiple pleural biopsies were taken and sent for histopathology examination, NAAT (nucleic acid amplification test), and MGIT (mycobacteria growth indicator tube). Post-procedure, the patients were evaluated for any complications. A total of 105 patients were enrolled in the study. The mean ± SDage was 55.1 ± 13.6 years. Sixty-three (60%) patients were males. The diagnostic utility of medical thoracoscopy was found in 94 (89.5%) patients. The diagnosis of tuberculosis (TB) was made in 34 (32.3%) patients, and 48 (45.7%) patients were diagnosed with malignant pleural effusion. Adenocarcinoma of the lung was the most common malignancy diagnosed (32 patients, 66.6%). Five (5.31%) patients had dual etiology of pleural effusion:tubercular and malignancy. The most common complication was chest pain following the procedure (99.4%). One patient developed pneumomediastinum and was managed conservatively. There were no major adverse events after the procedure. Medical thoracoscopy has a high diagnostic yield and favorable safety profile with minimal complications. Excessive reliance on the level of ADA (adenosine deaminase) may further delay the diagnosis. Dual etiologies like TB coexisting with malignancy should be considered in TB high-burden countries.

Thoracoscopy has long been established as the procedure of choice for various chest diseases, among which is undiagnosed pleural effusions. Thoracoscopy does not only visualizes the extent of the disease but allows adequate tissue biopsy sampling. The aim of the present study was to detect outcomes and complications of medical thoracoscopy in undiagnosed pleural effusion. This study was conducted on 50 patients with unexplained exudative pleural effusion referred for medical thoracoscopy at Abbassia Chest Hospital. Medical thoracoscopy is a safe and valuable tool for the diagnosis of pleural effusion, particularly for patients with suspected malignancy. Overall cost-effectiveness of thoracoscopy is better due to its better yield and lesser duration of hospital stay. Medical thoracoscopy gave a definitive diagnosis with a diagnostic yield of 96%. Histopathological results of thoracoscopic pleural biopsy revealed that the most common diagnosis was malignancy (92%), followed by tuberculous pleurisy (2%), and fibrotic pleurisy (2%); only 4% of the patients remained undiagnosed. The most common malignant pathological type was malignant pleural mesothelioma (60%), followed by metastatic adenocarcinoma (12%). According to the residence of studied patients, we found that environmental exposure to asbestos has a relationship with mesothelioma in patients living in Shoubra El-Kheima and Helwan. Medical thoracoscopy is a safe tool for diagnosing pleural effusion; although no major complications were found in the present study, minor complications occurred only in 10% of the patients. Medical thoracoscopy is a valuable tool in the diagnosis of undiagnosed pleural effusion. It is a simple and safe method with a high diagnostic yield and low complication rates.

Introduction: Pleural effusions are one of the most common entities encountered by pulmonologists worldwide which have a very long list of causes. Initial workup of these patients begins with a chest X-ray and percutaneous or Ultrasound (USG) guided thoracocentesis followed by biochemical and cytological evaluation of the fluid to ascertain the cause of effusion. A 20 to 25% of cases remain undiagnosed even after thoracocentesis and closed pleural biopsy. Medical Thoracoscopy is emerging as a safe diagnostic procedure in these patients. Aim: To detect the diagnostic yield of medical thoracoscopy in cases of undiagnosed exudative lymphocytic pleural effusion and to study the complications associated with it. Materials and Methods: This was a prospective observational study, carried out in the Department of Pulmonary Medicine, JN Medical College and hospital, Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India, from August 2016 to August 2018. Undiagnosed exudative pleural effusion was defined as pleural effusion with Adenosine Deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy. Thoracoscopic examination of the pleural space using flexi-rigid thoracoscopy was done and biopsy was taken from suspected areas and the tissue obtained, was send for histopathological examination. The results were presented as mean±SD (Standard Deviation) or percentage. Differences in categorical data were compared using the chi-square test or the Fisher-exact test. A p-value of <0.05 was considered statistically significant. Results: Fifty patients underwent thoracoscopy for undiagnosed pleural effusion. Most common gross thoracoscopy finding was nodules which was seen in 23 patients. Malignancy was the most common histopathological finding, seen in 22 patients. Minor complications were seen in five patients. A final diagnosis could be made in 41 patients; the diagnostic yield was 82%. Conclusion: Medical thoracoscopy should be performed in all patients in which radiological and pleural fluid examinations could not lead to a definitive diagnosis as it has high sensitivity and a very low rate of complications.

Establishing the etiology of exudative pleural effusions in the setting of an unrewarding pleural fluid analysis often requires biopsies from the parietal pleura. However, it may be noted that diagnosis such as pulmonary embolism and connective tissue diseases can result in an exudative pleural effusion where a pleural biopsy can yield nonspecific results. Medical thoracoscopy (MT) is a minimally invasive procedure performed under local anesthesia or moderate sedation with excellent yield and favorable safety profile. We analyzed the diagnostic yield of MT for exudative pleural effusions after employing a rigid diagnostic algorithm. The study was undertaken to ascertain the yield of MT in establishing the diagnosis in diagnosis of exudative pleural effusions, to find out the relative contribution of pleural tuberculosis (TB) as a cause of undiagnosed exudative pleural effusion, to describe the etiology of undiagnosed exudative pleural effusion in patients undergoing MT and to determine the correlation between pleural fluid adenosine deaminase (ADA) levels and TB pleuritis in patients undergoing MT. This was a retrospective study. Patients with undiagnosed exudative pleural effusion were included in the study. MT was performed with semirigid thoracoscope (Olympus LTF 160) under local anesthesia and conscious sedation. Gross appearance and ADA level of pleural fluid were noted. Pleural biopsy material was subjected to histopathology examination and culture for mycobacteria along with cartridge-based nucleic acid amplification test for TB. The yield of MT for establishing the etiology of pleural effusion and the relative contribution of tuberculous pleuritis as a cause of undiagnosed pleural effusion was ascertained. Correlation of pleural fluid ADA levels was done with a final diagnosis of TB pleuritis in patients undergoing MT. Twenty-five patients with undiagnosed exudative pleural effusion underwent thoracoscopy of which 16 were male and 9 were female. MT was able to establish the diagnosis in all cases, providing a diagnostic yield of 100%. Histopathological examination of biopsy specimens yielded a diagnosis of malignant involvement of pleura in 10 patients and granulomatous pleuritis consistent with TB in 14 patients. Pleural TB contributed to 60% of undiagnosed pleural effusions in the present study. The mean ADA value among those who turned positive was 56.338 and 35.300 among those who turned negative using genexpert, which was found to be statistically significant. A value of 31 IU/L showed a sensitivity of 93.3% and specificity of 99.8% and hence can be taken as a cut off value for the diagnosis of pleural TB based on receiver-operating characteristic analysis. TB contributed to 60% of undiagnosed exudative pleural effusions in the present study. MT had 100% yield in the diagnosis of undiagnosed exudative effusions. Pleural fluid ADA levels may help in differentiating TB versus malignant effusion.

Background: Establishing the etiology of exudative pleural effusions in low ADA level (<40IU/L) often requires biopsies from the pleura. Medical thoracoscopy (MT) is a minimally invasive procedure performed under local anesthesia. Aim: To assess diagnostic yield of medical thoracoscopy in undiagnosed exudative pleural effusion with low ADA (<40 IU/L). To detect the association of pleural fluid ADA in different thoracoscopic diagnosis. Methods: This was a prospective observational study over a period of one year. Patients with undiagnosed exudative pleural effusion were enrolled in the study. MT was performed with rigid thoracoscope (OptymetCE0197) under local anesthesia. ADA level of pleural fluid was noted. Pleural biopsy material was subjected to histopathology examination and culture for mycobacteria along with cartridge‑based nucleic acid amplification test for TB. Incidence of percentage of tuberculosis and malignancy in low ADA level was calculated. Results: 106 patients with undiagnosed exudative pleural effusion underwent thoracoscopy of which were 56 male and 50 female. MT was able to establish the diagnosis in 96 cases, providing a diagnostic yield of 90.5%. Pleural TB contributed to 35.8% of undiagnosed pleural effusions in the present study. The mean ADA value was 33.9 and 19.6 in tuberculosis and malignant pleural effusion respectively which was found to be statistically significant. Among patients diagnosed as tuberculosis Mycobacterial Tuberculosis was detected on CBNAAT in 18%, while CBNAAT was negative in 82% cases. A cut off 28.5 IU/L for pleural fluid ADA, the sensitivity and specificity were 88.5% and 76.7% respectively based on receiver‑operating characteristic analysis (AUC0.88). Conclusion: Medical Thoracoscopy is a valuable diagnostic tool for undiagnosed exudative pleural effusion. It is a simple and safe procedure without significant morbidity and mortality. Thoracoscopy should be done as soon as possible in low ADA value whenever it is available. As significant number of tuberculosis patients are seen in even in low ADA(<40IU/L) setting.

Role of thoracoscopic pleural lavage and brush in undiagnosed exudative pleural effusion

Background:Medical thoracoscopy is a minimally invasive procedure used in diagnostic and therapeutic applications for pleural diseases. In this study, we describe our experience in the outcome and analysis of thoracoscopy in undiagnosed pleural effusion presenting to our center.Materials and Methods:This is a prospective study conducted over last 2 years. We performed thoracoscopy in 129 cases of undiagnosed exudative pleural effusions using rigid thoracoscope. Clinical, radiological, cyto and histopathological data of the patients were collected prospectively and analyzed.Results:The overall diagnostic yield of thoracoscopic pleural biopsy was 110/129 (85.2%) in patients with undiagnosed pleural effusion, and 19/129 (14.8%) patients remained unexplained. Histopathological diagnosis confirmed malignancy in 66.4% patients (both primary and metastatic pleural carcinoma), tuberculosis in 28.2%, others including parapneumonic effusion in 4 cases followed by multiple myeloma, lupus pleuritis, and pulmonary langerhans cell histiocytosis in one case each. Procedure-related mortality was nil. Minor complications related to the procedure include hemorrhage, subcutaneous emphysema, etc.Conclusion:Thoracoscopy is relatively a safe and well-tolerated procedure with high diagnostic accuracy in undiagnosed pleural effusions, decreasing the need of formal diagnostic thoracotomy. Every chest physician must, therefore, consider this procedure to decrease the time lag in achieving the final diagnosis and to initiate the treatment as early as possible.

Exudative pleural effusions are commonly encountered in clinical practice, but in about one-fourth of cases, etiology remains elusive after initial evaluation. Medical thoracoscopy with semirigid thoracoscope is a minimally invasive procedure with high diagnostic yield for diagnosing pleural diseases, especially these undiagnosed exudative pleural effusions. In tubercular endemic areas, often, these effusions turn out to be tubercular, but the diagnosis of tubercular pleural effusion is quite challenging due to the paucibacillary nature of the disease. Although culture is the gold standard, it is time-consuming. Cartridge-based nucleic acid amplification test (CBNAAT) is a novel rapid diagnostic test for tuberculosis (TB) and has been recommended as the initial diagnostic test in patients suspected of having extrapulmonary TB (EPTB). We conducted a prospective observational study of 50 patients with undiagnosed pleural effusion admitted to our tertiary care hospital. The primary aim of the study is to evaluate the diagnostic performance of CBNAAT on thoracoscopic guided pleural biopsy and compare it with conventional diagnostic techniques like histopathology and conventional culture. Of 50 undiagnosed pleural effusions, TB (50%) was the most common etiology. The overall diagnostic yield of semirigid thoracoscopy in this study was 74%. Our study showed that CBNAAT of pleural biopsies had a sensitivity of 36% only but a specificity of 100%. The sensitivity of CBNAAT was not far superior to the conventional culture. Tuberculosis (TB) is a common cause of undiagnosed pleural effusion in our set-up. CBNAAT testing of pleural biopsy, though, is a poor rule-out test for pleural TB, but it may aid in the early diagnosis of such patients.

IntroductionPleural diseases involve the parietal and visceral pleura and may be of either inflammatory or malignant origin, with pleural effusions. Medical thoracoscopy (MT) is a procedure involving internal examination and biopsy of masses within the pleural and thoracic cavity. It is a valuable tool that enables a wide variety of diagnostic and therapeutic procedures.AimThe aim of this work was to assess the role of MT in patients with exudative undiagnosed pleural effusion.Patients and methodsA total of 42 patients with undiagnosed exudative pleural effusion were admitted to Chest Department, Faculty of Medicine, Beni-Suef University. They were subjected to written informed consent,full history, clinical examination, sputum analysis, chest radiography, chest computed tomography, ECG, routine liver and kidney functions tests, complete blood count, coagulation profile, viral markers, and Tuberculin test. Diagnostic thoracentesis was done. The pleural fluid was subjected to testing for sugar, protein, lactate dehydrogenase, adenosine deaminase, cytopathology, Gram’s stain, and acid-fast bacilli smear and culture. Patients in whom the pleural effusion remained undiagnosed were subjected to MT.ResultsThis study was applied on 42 patients with inconclusive cytological results: 20 were malignant (nine malignant pleural mesothelioma and 11 metastases), five had tuberculous pleurisy, eight had empyema, and nine had nonspecific pleurisy. Regarding pleural fluid cytological analysis, five cases were positive for atypical mesothelial cells.ConclusionMT is a valuable tool in the diagnosis of undiagnosed exudative pleural effusion. It is simple and safe, with high diagnostic yield and lower complication rates.

Context Exudative pleural effusion is a diagnostic dilemma that includes many steps; one of them is obtaining a definite diagnosis through pleural biopsy. Cryoprobes are being increasingly used for obtaining larger specimens with fewer crush artifacts. However, the safety and feasibility of cryoprobe biopsy compared with standard forceps for pleural biopsy have not been fully assessed. Aims To evaluate the diagnostic value, size, and quality of the specimens obtained by flexible cryoprobe in comparison with those obtained by flexible forceps probe during medical thoracoscopy in patients with exudative pleural effusion and to assess the possible complications from the procedure. Settings and design This interventional prospective study was carried out at the endoscopy unit at Chest Department and Tuberculosis Assiut University Hospital. Patients and methods This study included 60 patients with undiagnosed exudative pleural effusion. Medical thoracoscopy was carried out for all the patients, and pleural biopsies were taken from the parietal pleura using a conventional rigid forceps probe and flexible cryoprobe in the same settings. Results Cryoprobe biopsy established a definite diagnosis in 55/60, with 91.6% diagnostic yield, whereas forceps biopsy had a definite diagnosis in 53/60, with 88.3% diagnostic yield. The size of cryoprobe biopsy was significantly larger in comparison with the forceps biopsy (26.56 ± 22.16 vs. 17.38 ± 12.08 mm2; P<0.001). The depth of pleural biopsy was evaluated by the presence of extrapleural fat cells, which were significantly higher in cryoprobe biopsy in comparison with forceps biopsy [21 (35%) vs. 11 (18.3%); P=0.03]. There were no significant complications or procedure-related deaths. Conclusions Cryobiopsy is a possible safe and effective alternative to conventional forceps probe biopsy in the diagnosis of exudative pleural effusion with a larger, deeper, and less number of biopsies. It was also found that cryoprobe biopsy had a better diagnostic yield, sensitivity, and accuracy.

Introduction: Pleural effusion is a medical condition characterized by the accumulation of fluid in the pleural cavity. Medical thoracoscopy, also known as pleuroscopy, is a minimally invasive procedure with a high diagnostic yield. It is an ideal diagnostic tool for resource-limited countries like Nepal. However, the data regarding the use of thoracoscopy to observe undiagnosed exudative pleural effusion is not sufficient in Nepal. The aim of this study was to find the prevalence of undiagnosed exudative pleural effusion with the help of thoracoscopy. Methods: A descriptive cross-sectional study was conducted using retrospective data of patients who underwent medical thoracoscopy for undiagnosed exudative pleural effusion at the chest unit, Department of Medicine, between the period of 01 Jan 2018 to 31 July 2024 after obtaining ethical approval from the Institutional Review Board. Whole sampling method was used. The data of patients undergoing medical thoracoscopy for undiagnosed exudative pleural effusion during the study period were included. The data with missing information and incomplete diagnoses were excluded from the study. Data were entered and analyzed in IBM SPSS Statistics version 25.0. Results: Out of 3201 admissions of patients, the prevalence of undiagnosed exudative pleural effusion was found to be 45 (1.41%). Effusion was gross in 25 (55.5%) patients. Effusion was found to be on the right side in 25 patients (55.5%). Conclusions: The prevalence of undiagnosed exudative pleural effusion in our study was found to be lower than other studies in similar settings.

Background: Medical thoracoscopy is performed under local anesthesia and conscious sedation. It has a very high diagnostic yield with fewer complications and offers oppor-tunity to perform concurrent pleurodesis. Aim of Study: The aim of this prospective study is to compare thoracoscopically obtained parietal pleural biopsies by rigid forceps and cryoprobe biopsies during medical thoracoscopy in patients with exudative pleural effusion. Patients and Methods: The study included 50 patients have undiagnosed exudative pleural effusion (clinically, laboratory and radiologically); all were admitted in Al-Hussein University Hospital in Chest Department, fifty patients were implemented to medical thoracoscope after written consent. Results: Comparing between Rigid forceps and Cryoprobe biopsies as regard number of biopsies revealed highly statistical significant difference (p-value <0.001) between Rigid forceps and Cryoprobe biopsies as regard number of biopsies (170 Rigid forceps, 96 Cryoprobe). The most common definitive diagnostic results were malignant mesothelioma (32) 64% (26 Epithelial type 52%, 6 dysmoplastic type 12%). Conclusion: Pleural cryobiopsies through rigid thoracos-copy is a simple and safe procedure. It has a high diagnostic yield similar to rigid forceps biopsy. Biopsies using cryoprobe are now widely used in interventional pulmonology.