Role of Closed-Needle Biopsy in the Diagnosis of Malignant Mesothelioma of the Pleura

Abstract

We appreciate the comments of Dr. Roggli and agree with him that closed-needle biopsy is not always sufficient to make the diagnosis of malignant mesothelioma of the pleura. There is no single diagnostic test, pathologic or otherwise, for malignant mesothelioma of the pleura. Some biopsy samples will require more pathologic testing than others to help separate malignant mesothelioma from adenocarcinoma. However, not all biopsy samples require all pathologic tests to be performed on them for a diagnosis to be made. The histochemical stains Alcian blue and colloidal iron can be positive in both malignant mesothelioma and adenocarcinoma. In malignant mesothelioma, Alcian blue and colloidal iron can stain positive due to their reaction with hyaluronic acid. In adenocarcinoma, Alcian blue and colloidal iron can stain positive due to their reaction with chondroitin sulfate. Hyaluronidase can be used to help separate the two. Exposure of the tissue to hyaluronidase will digest hyaluronic acid present in a mesothelioma; on subsequent exposure to Alcian blue or colloidal iron, the mesothelioma will fail to stain. However, hyaluronidase will not digest the chondroitin sulfate present in adenocarcinoma; on subsequent exposure to Alcian blue or colloidal iron the adenocarcinoma will still result in a positive reaction. There are many antibodies available for use in immunohistochemical testing to differentiate malignant mesothelioma from adenocarcinoma. Of these antibodies, CEA is the most useful. However, no single antibody is diagnostic. Although some authors have found electron microscopy to be useful,1Dewar A. Valente M. Ring N.R. Corrin B. Pleural mesothelioma of the epithelial type and pulmonary adenocarcinoma: an ultrastructure and cytochemical comparison.J Pathol. 1987; 152: 30916Crossref Scopus (51) Google Scholar others have found this not to be the case.2Suzuki Y. Churg J. Kannerstein M. Ultrastructure of human malignant diffuse mesothelioma.Am J Pathol. 1976; 85: 241-262PubMed Google Scholar, 3Churg A. Diseases of the pleura.in: Thurlbeck W.M. Pathology of the lung. Thieme-Stratton, New York1988: 769-802Google Scholar At the time of our diagnoses of malignant mesothelioma of the pleura, electron microscopy was not available at our institution. In our study, we were able to make a diagnosis of malignant mesothelioma of the pleura in 20 cases utilizing some of the pathologic tests available. In these 20 cases, tissue was obtained at closed-needle biopsy of the pleura in 12. In 10 of these 12 cases a diagnosis of malignant mesothelioma of the pleura was made without subjecting the patient to an open pleural biopsy. These findings show that the yield of malignant mesothelioma of the pleura by closed-needle biopsy, in their study, is higher than previously recorded. We suggest that this finding may be due to the improvement in pathologic tests that have become available in the past 10 years. In light of these findings, we suggest that a closed-needle biopsy be performed before proceeding to open pleural biopsy when a diagnosis of malignant mesothelioma of the pleura is considered. The advantage to the patient, as well as the considerable reduction of hospital costs, in making a diagnosis by closed-needle biopsy is obvious. However, should a closed needle biopsy be nondiagnostic, we surely do not suggest that the investigation stop there. On the contrary, if a closed-needle biopsy is nondiagnostic for malignant pleural mesothelioma, open pleural biopsy or thoracoscopy should be performed. Role of Closed-Needle Biopsy in the Diagnosis of Malignant Mesothelioma of the PleuraCHESTVol. 105Issue 1PreviewThe article by Beauchamp et al,1 which appeared in the October 1992 issue of Chest, purports to test the hypothesis that closed-needle biopsy may be sufficient in many cases to make a diagnosis of malignant mesothelioma of the pleura. In a study of 20 consecutive patients with a histopathologic diagnosis of mesothelioma, the diagnosis was made by closed-needle biopsy alone in 12 cases. Therefore, the authors argue, closed-needle biopsy is sufficient to make a diagnosis of mesothelioma. The circular nature of this reasoning is obvious, and in and of itself is sufficient to invalidate the conclusions of the study. Full-Text PDF