Malignant Pleural Effusion: A Continued Relevance of Closed Needle Pleural Biopsy

Introduction: Thoracocentesis and pleural biopsy are recommended for the evaluation of undiagnosed exudative pleural effusion. There are multiple etiologies associated with them, out of which malignancy is one of them. Hence, the diagnosis of malignant pleural effusion (MPE) has been proposed in recent perspectives. We aimed to find the profile of MPE, efficacy of percutaneous closed needle pleural biopsy (PCNPB) in diagnosing MPE, overall yield, and complication rate to evaluate the continued relevance of this traditional procedure. Methods: This was a prospective study carried out on consecutive consenting patients at the Department of Pulmonary Medicine at a tertiary care hospital from July 2016 to May 2018. The diagnosis was based on cytobiochemical, microbiological, and histopathological results along with clinical history. Data were analyzed with respect to pleural fluid assessment in terms of cytobiochemical and microbiological evaluation; while pleural biopsy was studied histopathologically. Results: Two hundred and fifty patients with exudative pleural effusion were enrolled. Tuberculosis (218, 87.2%) was the most common etiology followed by malignancy (22, 8.8%). The most common presenting complaint was chest pain (100%) followed by dyspnea (90.47%). Metastatic adenocarcinoma was found in 81.81% followed by mesothelioma in 18.18%. The sensitivity of pleural biopsy for malignancy was found to be 63.63% (p < 0.003, odds ratio [OR]: 2.01), and those fulfilling Leung's criteria, sensitivity was found to be 90.90% (p < 0.001, OR: 3.67). The sensitivity of pleural fluid for malignancy was 18.18% (p < 0.05, OR: 1.51). All cases of mesothelioma have asbestos exposure. The complication in the form of mild post-pleural biopsy pain was encountered in 10%, which required mild analgesics. Other complications in the form of self-resolving pneumothorax were seen in 6%, which increased hospital stay to 2�days and self-resolving hematoma (3%). Conclusion: In this modern era, PCNPB still holds high sensitivity, efficacy rate, and relevance for diagnosing MPE with less complication rate, less hospital stay, and can be done on a daycare basis. Also, we have very less research and paperwork regarding this topic.

Role of pleural biopsy in patients of undiagnosed exudative pleural effusion

Introduction: Sometimes etiological diagnosis of pleural fluid is not possible by cytology, biochemical and microbiological examinations and labeled as undiagnosed exudative pleural effusion. Our aim of this study to make an etiological diagnosis in such undiagnosed exudative cases with pleural biopsy. Material and method: In this study patients with undiagnosed exudative pleural effusion, where the diagnosis was not made by laboratory investigations were included. Pleural tissue was obtained by Abram’s Needle and sent for histopathology and culture to find mycobacterium tuberculosis. Result: Out of 45 patients 34 (75.5%) were males and 11 (24.5%) were females. The side of pleural effusion was right-sided in 30 (66.6%) and left-sided in 15 (33.4%). The mean value of polymorphs and lymphocytes count was 7.24% and 92.76% respectively. Pleural fluid was hemorrhagic in 10 (22.22%) patients, straw-colored in 30 (71.11%) patients, and clear in 5 (11.11%) patients. The mean level of glucose was 65.66 mg/dl, the lowest being nil and highest being 110 mg/dl. The mean level of protein was 5.54 gm/dl (range 3.7-7.21 gm/dl). The mean value of the pH of pleural fluid was 65.44. Histopathology showed granulomatous inflammation compatible with tuberculosis in 24 (53.3%) cases, metastatic malignancy in 7 (15.5%) cases, chronic inflammation in 10 (22.3%) cases. In 4 (8.9%) cases pleural tissue was inadequate to give any opinion. Among 7 cases of malignancy, 5 (71.42%) cases showed adenocarcinomas and 2 (28.58%) cases showed squamous cell carcinoma. Conclusion: This study suggests that tuberculosis and malignancy are the two common etiologies for exudative pleural effusion. The role of pleural biopsy is pivotal as it helps in making the diagnosis in the majority of cases where other laboratory investigations fail to provide a diagnosis.

Role of biochemistry, cytology, and biopsy in the etiological diagnosis of pleural effusion- a clinical study

Introduction:Pleural effusion is the most common pleural disorder. It refers to excessive or abnormal accumulation of fluid in the pleural space. It is a commonly occurring medical problem caused by various pathological conditions. To treat patients appropriately, it is important to establish an accurate etiological diagnosis. Material and Method: This is an observational study conducted at a tertiary health care center. The pleural effusion was assessed clinically, biochemically, bacteriologically, cytologically, and histopathologically. Result: Tuberculosis was the most common etiology, followed by malignancy. A pleural biopsy was done in 70 patients. Pleural tissue was obtained in 65 cases. On histopathology,Malignancy was diagnosed in 15, tuberculosis in 35, and non-specific inflammation in 13 cases. Out of 35 histological proven tuberculosis cases, 26 cases had adenosine de-aminase (ADA) more than 70 u/l. Conclusion:Every pleural effusion is not due to tuberculosis but can be due to other causes, malignancy should always be excluded. Pleural fluid cytology and biopsy can give a definite diagnosis in a significant number of cases of pleural effusion. Tuberculosis is still the most common cause of pleural effusion followed by malignancy.

Comparison between Diagnostic Yield of Pleural Fluid ELISPOT and Thoracoscopic Guided Pleural Biopsy in Undiagnosed Pleural Effusion

Context: Despite recent advances in the available diagnostic modalities, diagnosis of pleural tuberculosis remains a challenge because of the low yield of conventional methods. Pleural biopsy is the gold standard for confirmation of diagnosis, which is invasive and cumbersome. The concentration of mycobacterial peptide-specific activated lymphocytes at the site of infection can be utilized as the basis for using IGRA (interferon-gamma release assays) based evaluation of undiagnosed exudative pleural effusions.  Aim: To evaluate the performance of IGRA (Enzyme-linked Immunospot (ELISPOT) in pleural fluid for the diagnosis of pleural tuberculosis in histopathologically confirmed cases. Settings and Design: A prospective observational study compared the utility of ELISPOT with thoracoscopy guided pleural biopsies for the diagnosis of tubercular pleural effusions. Methods and Material: Forty-two consecutive cases of undiagnosed pleural effusions were enrolled and subjected to thoracoscopy guided pleural biopsy. Thirteen patients were confirmed to have tuberculosis, 27 had malignancy, and 2 had normal pleura. A total of 1x103 pleural fluid mononuclear cells (PFMCs) were cultured in the presence of early secretory antigenic target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) for 24 hours. The individual spots were then counted using an automated analyzer ELISPOT reader system.  Results: The number of spots developed in the pleural fluid was significantly higher in tubercular pleural effusions as compared to non-tubercular effusions (CFP-10:154.76±14.61 vs 49.24±8.9; ESAT-6: 150.3±17.27 v/s 45.34±8.23, p<0.001). At a cut-off value of more than 67 spots taken as positive for tuberculosis, the sensitivity of the test was 100% (95% CI 75.29% to 100.00%), specificity was 96.5% (95 % CI 82.24% to 99.91%), positive predictive value was 92.86% (95 % CI 65.45% to 98.89%) and negative predictive value was 100%.  Conclusions: ELISPOT can be a useful non-invasive test for the evaluation of undiagnosed pleural effusions and making a diagnosis of pleural tuberculosis with confidence.

​Prevalence of Malignant Pleural Mesothelioma in Pleural Effusion Patients in Thanjavur Medical College Hospital: A Pilot Study

Background: The incidence of malignant pleural mesothelioma (MPM) has increased for some decades and was expected topeak between 2010 and 2020. The prevalence of MPM in India is unclear. No such study is available regarding MPM in India.Materials and Methods: After obtaining proper informed consent, patients presenting with pleural effusion were subject topleural biopsy, and the samples were then sent to histopathological confirmation of malignancy.Results: Histopathological evidence confirmed two cases of MPM of the 12 cases. Five of them were diagnosed with tuberculosispleuritis, while two cases had inflammatory pathology and two cases were confirmed to have been metastatic tumors.Conclusions: The present findings show that the prevalence of MPM is rather high at about 16%. A more comprehensivestudy is warranted based on our findings.

Características clínicas y epidemiológicas de los pacientes hospitalizados con derrame pleural / Clinical and epidemiological characteristics of patients hospitalized with pleural effusion

El derrame pleural tiene una prevalencia mundial de aproximadamente 400 de cada 100.000 habitantes y Venezuela tiene cifras similares. Se relaciona con múltiples patologías, por lo que determinar sus características podría ayudar a obtener un mejor diagnóstico y tratamiento. Métodos: Se realizó un estudio de casos, retrospectivo y descriptivo, obteniendo información de las historias de pacientes hospitalizados con derrame pleural en el servicio de Medicina Interna del Hospital Dr. Domingo Luciani en el período Enero 2010- Abril 2015. Resultados: La edad promedio fue de 49±19 años, género masculino (53%). Motivo de consulta: disnea (81%), dolor torácico (44%) y tos (37%). Los síntomas: disnea (92%), dolor pleurítico (58%) y fiebre (54%). Antecedentes personales: HTA (32%), DM (22%) e IC (20%). Radiografía de tórax: (60%) derrame pleural derecho y (26%) izquierdo. Tomografía de tórax realizada en (77%). Citoquímicos: (85%) exudado (53% mononuclear y 32% polimorfonucleares). La prueba de ADA positiva en 25%, cultivo para bacterias realizado en 89 casos, positivos 18%. Bloque celular con resultado inflamatorio (80%). Biopsia pleural realizada (22%): inflamatorio (36,4%), seguido por ADC metástasico (31,8%). Estancia hospitalaria > 15 días (76%) y el diagnóstico final fue infeccioso (51%). Conclusión: Contando con estos datos clínicos- epidemiológicos se puede caracterizar el comportamiento del derrame pleural en nuestro centro para el rápido y acertado diagnóstico, igualmente proponer una investigación prospectiva donde se analice el comportamiento de dicha enfermedad, y crear protocolos de actuación(AU)

Pleural effusion has a worldwide prevalence of approximately 400 per 100,000 inhabitants and Venezuela has similar statistics. It is related to multiple pathologies, which determine their characteristics which could help for better diagnosis and treatment. Methods: A retrospective descriptive case study was conducted, obtaining information from the charts of hospitalized patients with pleural effusion in Internal Medicine Dr. Domingo Luciani Hospital Venezuela in the period January 2010-April 2015. Results: Mean age 49 ± 19 years, male genre (53%). Complaints: dyspnea (81%), chest pain (44%) and cough (37%). Symptoms: dyspnea (92%), pleuritic pain (58%) and fever (54%). Personal history: hypertension (32%), DM (22%) and HF (20%). Chest x-ray: right pleural effusion (60%), left (26%). Chest tomography performed on (77%). Cytochemical: exudate: 85% (53% mononuclear and polymorphonuclear 32%). ADA testing positive in 25%. For bacteria culture: performed in 89 cases, 18% positive. Cell block inflammatory (80%). Pleural followed by metastatic ADC (31.8%). Hospital stay> 15 days (76%) and final diagnosis was infection (51%). Cause of discharge from hospital: improvement (80%). Conclusion: Having these clinical and epidemiological data can characterize the behavior of pleural effusion for quick and accurate diagnosis(AU)

Combined detection of pleural biopsy under medical thoracoscopy and serum tumor markers in diagnosis of pleural effusion with unknown reason / 中国内镜杂志

Objective To discuss combined detection of pleural biopsy under medical thoracoscopy and pulmonary serum tumor markers in diagnosis of pleural effusion with unknown reason.Methods 76 patients with pleural effusion caused by unknown reason from January 2014 to March 2016 were retrospectively analyzed. Pleural biopsy was conducted under medical thoracoscopy and sent for pathological examination, and 10 ml venous blood was collected from these patients upon admission for testing serum tumor markers (CEA, SCC-AG, ProGRP and CYFRA21-1).Results Among the 76 patients, there were 32 cases with benign lesions (14 with pulmonary tuberculosis, 9 with inlfammatory lesions, 6 with granulomatous inlfammation, 2 with empyema and 1 with hamartoma) and 44 cases with malignant lesions (18 with adenocarcinoma, 13 with squamous carcinoma, 6 with small cell lung cancer, 3 with adeno-squamous carcinoma, 2 with mesothelioma, 1 with large cell carcinoma and 1 with thymoma). The detection of serum tumor markers showed statistically significant differences in the levels of CEA, SCC-AG, ProGRP and CYFRA21-1 in serum between the malignant pleural effusion group and benign pleural effusion group (P = 0.021,P = 0.006,P = 0.003 andP = 0.010). The levels of various serum tumor markers in the malignant pleural effusion group were obviously higher than those in the benign pleural effusion group. According to the pathological results, patients with pleural effusions not caused by lung cancer (2 with mesothelioma and 1 with thymoma) were eliminated from 44 patients with malignant pleural effusions. The rest 41 patients with pleural effusions caused by lung cancer were divided into non-small cell lung cancer and small cell lung cancer according to the pathological types. The results showed that there were statistically signiifcant differences in the levels of CEA, ProGRP and CYFRA21-1 between non-small cell lung cancer and small cell lung cancer (P = 0.036,P = 0.005 andP = 0.008), while there was no statistically signiifcant difference in the level of SCC-AG (P = 0.811).Conclusions Due to high detection rate and high accuracy in detecting pleural effusions caused by unknown reason, medical thoracoscopy is of great signiifcance, especially for the diagnosis of malignant pleural effusions of pleural metastases. However, serum indicators may provide important reference values for us before the pathological results are available. Thus, it is an important means of diagnosing malignant pleural effusions caused by lung cancer and should be promoted in clinic.

Enfoque diagnóstico en el paciente con derrame pleural / Diagnostic approach in pleural effusion

En el estudio diagnóstico del paciente con derrame pleural se deben considerar la historia clínica y el análisis de las imágenes para acotar el diagnóstico diferencial. El uso adecuado de las técnicas de imágenes contribuye a realizar procedimientos en forma segura. Se debe realizar una toracocentesis diagnóstica y/o evacuadora y se debe analizar completamente el líquido pleural. A veces es necesario realizar biopsia pleural para lo cual existen diversas técnicas disponibles. En los pacientes con pleuritis crónica inespecífica se debe hacer seguimiento por dos años para evaluar el desarrollo de malignidad.

The diagnostic approach in patients with pleural effusion must begin considering clinical aspects and image interpretation. Different imaging techniques can safely guide invasive procedures. Diagnostic or therapeutic thoracentesis must be performed and pleural fluid must be completely analyzed. Some patient will require pleural biopsy, and different techniques are available. Patients with chronic unspecific pleuritis histological diagnosis after pleural biopsy, must be followed for two years long to be sure no malignancy is developed.

CT-Guided Core Needle Biopsy of Pleural Lesions: Evaluating Diagnostic Yield and Associated Complications

OBJECTIVE: The purpose of this study was to retrospectively evaluate the diagnostic accuracy and complications of CT-guided core needle biopsy (CT-guided CNB) of pleural lesion and the possible effects of influencing factors. MATERIALS AND METHODS: From September 2007 to June 2013, 88 consecutive patients (60 men and 28 women; mean [+/- standard deviation] age, 51.1 +/- 14.4 years; range, 19-78 years) underwent CT-guided CNB, which was performed by two experienced chest radiologists in our medical center. Out of 88 cases, 56 (63%) were diagnosed as malignant, 28 (31%) as benign and 4 (5%) as indeterminate for CNB of pleural lesions. The final diagnosis was confirmed by either histopathological diagnosis or clinical follow-up. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and complication rates were statistically evaluated. Influencing factors (patient age, sex, lesion size, pleural-puncture angle, patient position, pleural effusion, and number of pleural punctures) were assessed for their effect on accuracy of CT-guided CNB using univariate and subsequent multivariate analysis. RESULTS: Diagnostic accuracy, sensitivity, specificity, PPV, and NPV were 89.2%, 86.1%, 100%, 100%, and 67.8%, respectively. The influencing factors had no significant effect in altering diagnostic accuracy. As far as complications were concerned, occurrence of pneumothorax was observed in 14 (16%) out of 88 patients. Multivariate analysis revealed lesion size/pleural thickening as a significant risk factor (odds ratio [OR]: 8.744, p = 0.005) for occurrence of pneumothorax. Moreover, presence of pleural effusion was noted as a significant protective factor (OR: 0.171, p = 0.037) for pneumothorax. CONCLUSION: CT-guided CNB of pleural lesion is a safe procedure with high diagnostic yield and low risk of significant complications.

Medical Thoracoscopy: A Useful Diagnostic Tool for Undiagnosed Pleural effusion.

Objective. We aimed to assess the role of medical thoracoscopy in patients with undiagnosed pleural effusion. Methods. Patiens presenting with pleural effusion underwent three pleural aspirations. Patients in whom pleural fluid analysis was inconclusive underwent closed pleural biopsy for diagnostic confirmation. Patients in whom closed pleural biopsy was incolcusive underwent medical thoracoscopy using a rigid thoracoscope with a viewing angle of zero degrees was done under local anaesthesia and sedation with the patient lying in lateral decubitus position with the affected side up. Biopsy specimens from parietal pleura were obtained under direct vision and were sent for histopathological examination. Results. Of the 128 patients with pleural effusion who were studied, pleural fluid examination established the diagnosis in 81 (malignancy 33, tuberculosis 33, pyogenic 14 and fungal 1); 47 patients underwent closed pleural biopsy and a diagnosis was made in 28 patients (malignancy 24, tuberculosis 4). The remaining 19 patients underwent medical thoracoscopy and pleural biopsy and the aetiological diagnosis could be confirmed in 13 of the 19 patients (69%) (adenocarcinoma 10, poorly differentiated carcinoma 2 and mesothelioma 1). Conclusion. Medical thoracoscopy is a useful tool for the diagnosis of pleural diseases. The procedure is safe with minimal complications.

Evaluation of the diagnostic yield and safety of closed pleural biopsy in the diagnosis of Pleural Effusion.

Aim: To assess the diagnostic yield and safety of closed pleural biopsy in patients with pleural effusion. Methods: In all, 48 consecutive cases of pleural effusion were evaluated with complete pleural fluid biochemical and microbiological analysis, cytology, routine bacterial and mycobacterial cultures. In all these 48 cases of pleural effusion closed pleural biopsy was done with tru-cut biopsy needle and biopsy samples were sent for histopathology and mycobacterial culture. Results: Out of 48 cases, main causes of pleural effusion were Tuberculosis in 21(43.8%) cases, Malignancy in 14(29.2%) cases, paramalignant effusion in six (12.5%) cases, Empyema in three (6.3%) cases, transudative effusion in three (6.3%) cases and parapneumonic effusion in one (1.9%) case. Diagnostic yield of closed pleural biopsy was 62.2% in cases of all exudative pleural effusion, 76.2% in cases of tubercular pleural effusion and 85.7% in cases of malignant pleural effusion. There was no incidence of post pleural biopsy pneumothorax or hemothorax, underlining the safety of pleural biopsy procedure. Conclusion: Closed pleural biopsy provides the highest diagnostic yield in cases of pleural tuberculosis and malignancy, the two most important causes of exudative pleural effusion. In view of low cost, easy availability and very low complication rates, it is a very important diagnostic tool in the hands of a trained pulmonary physician in India.

Tuberculosis pleural: Utilidad de la reacción en cadena de la polimerasa en muestras de tejido / Pleural tuberculosis: use of the polymerase chain reaction in tissue samples

El diagnóstico etiológico del derrame pleural tuberculoso, es difícil. La clínica y los ensayos paraclínicos suelen ser inespecíficos. El objetivo de este trabajo fue evaluar la sensibilidad y especificidad de la reacción en cadena de la polimerasa en tejido pleural para el diagnóstico de tuberculosis en comparación con el cultivo e histopatología, en pacientes con derrame pleural que ingresaron al servicio de Medicina Interna del Hospital “Dr. Domingo Luciani”, Caracas, Venezuela, entre abril de 2005 y agosto de 2006. Se estudiaron 52 pacientes, M/F (30 (57,7 por ciento)/22 (42,3 por ciento), con una edad promedio de 39 años. El valor de sospecha clínica fue del 69,2 por ciento. El cultivo resultó positivo en 6 casos (11,5 por ciento) y se identificaron lesiones granulomatosas tuberculoides en 40,4 por ciento. La reacción en cadena de la polimerasa mostró una sensibilidad del 50 por ciento y especificidad del 61 por ciento. Se concluyó que es una prueba eficaz para el diagnóstico de tuberculosis pleural

The diagnosis of tuberculous pleural effusion is difficult. The clinical trials and paraclinical essays are often nonspecific. The aim of this study was to evaluate the sensitivity and specificity of the polymerase chain reaction in pleural tissue for the diagnosis of tuberculosis in comparison with the culture and histopathological studies in patients with pleural effusion admited to the service of Internal Medicine Hospital Dr. Domingo Luciani, Caracas, Venezuela, between April 2005 and August 2006. We studied 52 patients, M/F (30 (57.7 percent)/22 (42.3 percent), with an average age of 39 years. The value of clinical suspicion was 69.2 percent. The culture was positive in 6 cases (11.5 percent) and tuberculoides granulomatous lesions were identified in 40.4 percent. Polymerase chain reaction showed a sensitivity of 50 percent and specificity of 61 percent. It was concluded that it is an effective test for the diagnosis of pleural tuberculosis

Optimal level of sections for definite diagnosis in transbronchial biopsy and pleural biopsy specimens.

Objective: To determine optimal level of serial section in transbronchial and pleural biopsy that yield maximal definite diagnosis. Methods: A cross sectional study of 118 transbronchial biopsy and pleural biopsy specimens submitted with serial sectioning in 3 levels were performed. Specimens of 1 mm. in diameter were serially cut and slides at levels I, II, III (120, 240 and 360 µm.) from initial exposure of tissue in paraffin blocks were studied, and specimens of 2-3 mm. in diameter were cut at levels I, II, III (0, 120 and 240 µm.) after tissues in paraffin blocks were trimmed to expose maximal diameter. Comparisons of diagnoses of each level were done. Results: The percentages of definite diagnoses were 89, 95.8 and 93.2 in sections of level I, II and III, respectively. Chronic granulomatous lesions were found in section level II more than other levels, but there was no statistical significance. (P value 0.131, Chi-Square test) Conclusion: Transbronchial and pleural biopsy specimens should be cut deep to level II, one slide for hematoxylin-eosin staining and 3 unstained slides for further investigation.

Clinical characteristics and pleural biopsy values in pleural effusion patients treated Respiratory Department of Bach Mai Hospital from March 2002 to September 2003

221 patients with pleural effusion were treated in Bach Mai hospital from March 2002 to August 2003 were studied retrospectively in a cross-sectional investigation. Their 134 cases (60.6%) were tuberculosis plural effusion, 66 cases were pleural cancer and 17 cases (82.1%) undetermined. The common symptoms were cough, chest pain, dyspnoea and “3 reduce symdrome”, fever in 82.1% of tuberculosis pleural effusion. Biosy had determined the tuberculosis in 48.8% of cancer, cancer 19.4%, chronical inflammatory 31.9%. Pleural biopsy had got the sensitivity (Se)= 75% and specificity Sp = 97%. Biopsy in diagnosis of tuberculosis pleural effusion led to mild complication in 10% of patients

Detection of Mycobacterial DNA Using Nested Polymerase Chain Reaction of Pleural Biopsy Specimens: Compared to Pathologic Findings

BACKGROUND: Although there are many methods including AFB smear and culture, and the analysis of pleural fluid in the etiological diagnosis of pleural effusion, it is sometimes difficult to confirm a diagnosis especially in cases of incomplete pleural biopsies. Moreover, the high incidence of tuberculous pleuritis in young people caused confusion in the differential diagnosis of pleural effusion in Korea. The pathognomonic finding of tuberculous pleuritis in pleural biopsy is chronic granulomatous pleuritis (CGP) with caseous necrosis. But a biopsy does not always provide a definitive diagnosis, which shows in only 60~70% of all biopsies, because of either limitations in blind biopsies or inadequate specimens. An adequate biopsy also gives only limited information, such as chronic or nonspecific pleuritis. METHODS: We compared the clinical diagnosis, pathologic findings and detection of mycobacterial DNA using nested PCR of pleural biopsy tissues. We carried out the nested PCR for IS6110 insertion sequence of Mycobacterium tuberculosis using outer primer IS-1/IS-2 (5'-AGGCGTTGGTTCGCGAGGG-3' /5'-TGATGACGCCCTCGTTGCC-3') and inner primer IS-3/IS-4 (5'-CCAACCCGCTCGGTCTCAA-3' /5'-ACCGATGGACTGGTCACCC-3') in 52 pleural biopsy tissues which were pathologically diagnosed as tuberculous pleuritis, malignant pleuritis or non-specific pleuritis. RESULTS: Five (71.4%) of 7 cases clinically and pathologically confirmed tuberculous pleuritis diagnosed as chronic granulomatous pleuritis (CGP) with caseous necrosis revealed positive in nested PCR for M. tuberculosis. Seven (36.8%) of 19 cases diagnosed as CGP without caseous necrosis were positive. However, only 3 (25%) of 12 cases diagnosed as non-specific chronic pleuritis were positive by PCR for M. tuberculosis. Neither congestive heart failure nor malignancies with pleurisy showed a positive reaction. CONCLUSION: In this study, pathologic findings were significantly associated with the detection rate of mycobacterial DNA. And, even in patients with nonspecific or chronic inflammatory pleuritis, mycobacterial DNA could be detected by using nested PCR in pleural biopsy tissue with good specificity. Detection of mycobacterial DNA in pleural tissue might provide additional information for etiological diagnosis in patients with pleural effusion.

A Prospective Study of Ziehl-Neelsen Stain and Mycobacterial Culture of Pleural Fluid and Closed Pleural Biopsy Specimen in Tuberculous Pleural Effusion / 감염

BACKGROUND: Tuberculous pleural effusion is the most common extrapulmonary site of all disease due to Mycobacterium tuberculosis. The diagnosis of tuberculous pleural effusion is most often established by histologic examination of pleural biopsy specimens. This study documents the utility of smear and culture of pleural fluid and pleural biopsy specimens for tubercle bacilli. METHODS: Between March 1998 and August 1999, we performed thoracentesis with or without pleural bio-psies on 148 patients with pleural effusion according to protocol with Abrams needle. Before the pleural biopsy, a diagnostic thoracentesis was performed. Aliquots of pleural fluid (30 mL) were submitted for biochemical, cytologic, and bacteriologic studies, Ziehl-Neelsen staining and culture in Lowenstein-Jensen medium. At least five samples of parietal pleural tissue were obtained, one for mycobacterial study and another for histologic study. RESULTS: Thirty-seven of the 148 patients were proved to have tuberculosis (24 men and 13 women) with a median age of 32 years (range, 21~91). Pleural biopsy was performed on 35 of the 37 patients with tuberculous pleural effusion. Granuloma was present in 33 of the 35 patients investigated with acid-fast bacilli in 9 patients. The smear for acid-fast bacilli of pleural fluid was positive in 1 patient and the culture for M. tuberculosis was positive in 5 of 37 patients. Pleural biopsy culture was positive in 3 of 35 patients. The 2 patients who could not carry out the pleural biopsy were positive in pleural fluid and pleural tissue mycobacterial culture, respectively. CONCLUSION: In our test, Ziehl-Neelsen staining and culture for M. tuberculosis of pleural fluid and pleural specimen gave a higher yield (5.4%) than the histologic methods alone in establishing the diagnosis of tuberculous pleural effusion.

A Case of Metastatic Squamous Cell Carcinoma of the Skin Following a Pleural Needle Biopsy / 대한피부과학회지

The mechanisms of cutaneous metastases in internal malignant tumor are direct invasion, lymphatic spread, hamatologic dissemination and incidental inoculation in operation. Also, the diagnostic procedure such as percutaneous biopsy of internal tumor is another possible mechanism. A 73-year-old man presented with a solitary erythematous nodule on the right upper chest for 2 months. He has been treated for squamous lung carcinoma for 1 year. 2 months ago, pleural biopsy for pleural metastasis was done at the same site on the chest. Histopathologic examination of the nodule showed cutaneous metastasis of lung cancer around the dissected dermis which had been made by a needle in pleural biopsy.

The Role of Bronchoscopy in Determining the Etiology of Pleural Effusion / 결핵

BACKGROUND: Little information is available concerning the value of bronchoscopy in patients with a lymphocytic exudative pleural effusion in which percutaneous pleural biopsy have been regarded as cornerstone in investigating the etiology. Recenfly, a few reports suggest that bronchoscopy may be more effective diagnostic method in patients with unexplained pleural effusion accompanied by hemoptysis or other roentgenographic abnormalities, such as mass, infiltrate, atelectasis. METHOD: After initial examinations of sputum and pleural fluid through thoracentesis in 112 patients(male 75 cases, female 37 cases, mean age 53.2 years) who were admitted for evaluation of the cause of pleural effusion, we performed bronchoscopy and closed pleural biopsy in most patients with undiagnosed lymphocytic exudate and compared the diagnostic yield of both invasive methods according to hemoptysis or other roentgenographic abnormalities, and investigated the sole diagnostic contribution of bronchoscopy. RESULTS: Tuberculosis(57 cases, 51%) was the most common cause of pleural effusion Percutaneous pleural biopsy showed more diagnostic yield than bronchoscopy regardless of presence or absence of other clinical or radiologic abnormalities. In 25 cases with unknown etiology after pleural biopsy, additional diagnostic yield by bronchoscopy was 36% (4/11) in patients with associated features and only 7% (1/14) with lone effusion, and, as the sole mean for diagnsosis in all patients with pleural effusion, was only 4.5% (5/12) Condusion: In a region of high prevalence of tuberculosis as a cause of pleural effusion, percutaneous pleural biospy is more effective method when invasive method is required for confirmative diagnosis of unexplained lymphocytic exudative pleural effusion, and bronchoscopy is unlikely to aid in the diagnosis of lone pleural effusion.

Role of Percutaneous Pleural Needle Biopsy in the Diagnosis of Lymphocyte Dominant Pleural Effusion / 결핵

BACKGROUND: The percutaneous pleural needle biopsy have been regarded as cornerstone in the diagnosis of lymphocyte dominant pleural effusions of which acid fast bacilli smear and cytologic exam was negative. However, the complications of percutaneous pleural needle biopsy is not rare arid its diagnostic efficacy is not always satisfactory. Recently, pleural fluid adenosine deaminase (ADA) and carcinoembryonic antigen (CEA) are widely accepted as markers of tuberculous pleurisy arid malignant pleural effusion respectively. We designed this study to re-evaluate the role of percutaneous pleural needle biopsy in the diagnosis of lymphocyte dominant exudative pleural effusions whose APE smear, cytologic exam was negative. METHODS: Retrospective analysis of 73 cases of percutaneous pleural needle biopsy in case of lymphocyte dominant exudative pleural effusions whose AFB smear and cytoloic exam was negative from Jan 1994 to Feb 1996 was done. RESULT: In 35 cases, specific diagnosis was obtained(all cases were tuberculous pleurisy), arid in 3(1 cases specific diagnosis was not obtained in spite of getting adequate pleural tissues, and in the other 8 cases, percutaneous pleural biopsy failed to get pleural tissues. In 9 cases, complications were combined including pneuomothorax and hemothorax. All 49 cases of pleural effusions whose ADA value was higher than 40IU/L and satisfying other categories were finally diagnosed as tuberculous pleurisy, however, the pleural biopsy confirmed only 28 cases as tuberculous pleurisy. In 6 cases of pleural effusions of which CEA value is higher than l0ng/ml, the pleural biopsy made specific diagnosis n no case. Final diagnosis of above 6 cases consisted of 4 malignant of fusions, I malignancy associated effusion and I tuberculous pleurisy. CONCLUSION: In the diagnosis of 73 cases of lymphocyte dominant pleural effusions of which acid fast bacilli smear and cytologic exam was negative, percutaneous pleural biopsy diagnosed only in 35 cases. In the diagnosis of tuberculous pleurisy, the positive predictive value of higher ADA than 40 IU/L in lymphocyte dominant pleural effusion with negative AFB smear and negative cytologic exam was l00%. And the diagnostic efficacy of pleural biopsy was 57%. In cases of effusions with high CEA than 10ng/ml 83% and 0% respectively. Finally, we concluded that percutaneous pleural needle biopsy in the diagnosis of APE smear negative and cytologic exam negative lymphocyte dominant exudative pleural effusion was not obligatory especially in effusions with high ADA and low CEA value.