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Medical thoracoscopic versus ultrasound guided transthoracic pleural needle biopsy in diagnosis of pleural lesions


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Medical thoracoscopic versus ultrasound guided

transthoracic pleural needle biopsy in diagnosis

of pleural lesions

Ali M. Abdella


, Gehan H. AboEl-Magd


, Khaled A. Dewan


, Dina A. Elgohary



Chest Department, Faculty of Medicine, Tanta University, Egypt


Radiology Department, Faculty of Medicine, Tanta University, Egypt

Received 13 November 2015; accepted 14 December 2015 Available online 30 December 2015

KEYWORDS Pleural effusion; Medical thoracoscopy; Ultrasound guided biopsy

Abstract Background: Medical thoracoscopy increases the diagnostic yield in patients with undi-agnosed pleural effusion. Ultrasound guided pleural biopsies are safe procedures with high diagnos-tic yields.

Objective: To compare safety and efficacy of medical thoracoscopic versus ultrasound guided transthoracic needle biopsy in the diagnosis of pleural lesions.

Patients and methods: 40 patients with undiagnosed pleural lesions were divided into 2 groups. After clinical, radiological examination and laboratory investigations; pleural biopsies were taken by ultrasound guided needle biopsy and medical thoracoscopy in group I and II respectively.

Results: Complications in group I were in the form of pain in 2 patients (10%), hemoptysis in 1 (5%), while complications in group II were pain in 4 (20%), failure of the lung to expand in 5 (25%), pneumothorax in 5 (25%) and wound infection in 3 patients (15%).

Final histopathological diagnosis in group I was parapneumonic effusion in 3 patients (15%), inflammatory lung lesion in 1 (5%), pleural fibroma in 2 (10%), malignant mesothelioma in 4 (20%), sarcoma in 1 (5%), adenocarcinoma in 1 (5%), squamous cell carcinoma in 4 (20%), and metastatic adenocarcinoma in 1 (5%). Final histopathological diagnosis in group II was pleural TB in 4 patients (20%), inflammatory lung lesions in 2 (10%), malignant mesothelioma in 6 (30%), adenocarcinoma in 5 (25%), and metastatic adenocarcinoma in 2 (10%). The diagnosed cases were 17 (85%) and 19 (95%) in groups I and II respectively.

Conclusions: Medical thoracoscopy is an important diagnostic method for the diagnosis of undi-agnosed pleural effusion while it is concluded that US guided pleural biopsy is more useful in cases of pleural lesions without effusion.

Ó 2015 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Tel.: 01006413962.

E-mail address:gehan19@yahoo.com(G.H. AboEl-Magd).

Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.


The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

www.elsevier.com/locate/ejcdt www.sciencedirect.com


0422-7638Ó 2015 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).



Pleural effusion is defined as the abnormal collection of fluid in the pleural space resulting from excessive fluid production or decreased absorption[1]. Pleural effusion is one of the most common clinical conditions in pulmonology clinics and in hos-pitals. The relative annual incidence of pleural effusion is esti-mated to be 320 per 100,000 people in industrialized countries [2].

Ultrasound (US) has found a firm place in chest medicine as an aid for assessing pleural effusions at the bedside[3]. This development was facilitated by the advent of affordable, light-weight and mobile US units. US can also visualize solid lesions arising from the pleura, chest wall and anterior mediastinum, and even lung tumors and consolidations are detected without difficulty provided that they extend to the parietal pleura. US is an ideal tool to assist with biopsy procedures. It can fre-quently replace Computed Tomographic (CT) guidance at much lower cost[4].

Medical thoracoscopy is a minimally invasive procedure performed by the pneumologist in an endoscopy suite; it is much less invasive requiring only local anesthesia with con-scious sedation and only one or two points of entry. It also allows for basic diagnostic (undiagnosed pleural fluid or pleu-ral thickening) and therapeutic procedures (pleurodesis) to be performed safely[5].


To compare safety and efficacy of medical thoracoscopic ver-sus ultrasound guided transthoracic needle biopsy in diagnosis of pleural lesions.

Patients and methods

This study was carried out in Chest and Radiology Depart-ments, Faculty of Medicine, Tanta University Hospitals from April 2013 to October 2014. This study was approved by Research Ethics Committee, Faculty of Medicine, Tanta University; an informed written consent was taken from each patient. Forty patients with undiagnosed pleural lesions were enrolled in this study; the patients were divided into two groups: group I included 20 patients in whom Tru-cut needle biopsy was carried out guided by ultrasonography for the diag-nosis of pleural lesions. Group II included 20 patients in whom medical thoracoscopy was performed for the diagnosis of pleu-ral lesions by biopsy taking.

Inclusion criteria

 Patients with evidence of exudative pleural effusion (according to Light’s criteria)[6]for which a specific diag-nosis could not be determined by cytological, chemical and bacteriological methods. Also, patients with peripheral pleural lesion that was accessible by ultrasound guided nee-dle biopsy was eligible for this study.

 Lesions involving or abutting the pleura equal to or more than 20 mm in diameter on US were sampled.

Exclusion criteria

 Cardiovascular instability.

 Lack of patient cooperation, e.g. intractable cough, inabil-ity to remain motionless or altered consciousness.

 Bleeding diathesis (international normalized ratio (INR) <1.3 or platelet count of <50,000 per mm3), patients on anticoagulant therapy (oral anticoagulants should be stopped before the procedure for at least 72 h).

 Contralateral pneumonectomy.

 Borderline respiratory failure and patients on mechanical ventilation.

 Severe chronic obstructive pulmonary disease (FEV1 < 1 liter or <35% predicted).

 Pyogenic cutaneous lesion.  Empyema.

 Liver failure or renal failure.

 A relative contraindication in cases of extensive pleural adhesions to do medical thoracoscopy[7].

All patients were subjected to the following

(1) Thorough history taking and clinical examination. (2) Chest X-ray (postro-anterior and lateral views) before

and after the procedure.

(3) Recent Computed Tomography (CT) of the chest with contrast.

(4) Laboratory studies including coagulation profile (including bleeding and clotting times, prothrombin time and activity)

(5) Preoperative evaluation: arterial blood gases (ABG), electrocardiogram (ECG), and pulmonary function tests if clinically indicated.

(6) Color Doppler ultrasound in suspected vascular lesions. (7) Clinical and radiological follow up of patients over 1 week after the procedure to detect the occurrence of any complications.

(8) The biopsy guided by ultrasonography in group I was carried out using Tru-cut needle biopsy in different calibers.

(9) The biopsy samples were sent for histopathological examination. Ultrasound guided transthoracic pleural biopsy was performed under local anesthesia and was performed without sedation as much as possible.

Procedure of ultrasound guided pleural needle biopsy in group I The procedure was done using ultrasound (Mindray DT 20 Italy), patient was kept fasting at least 6 h before biopsy, a sterile field was created. The same transducers used for diag-nostic ultrasonography (Logic GA 400) could be used for biopsy: convex array or sector scanning transducers with a fre-quency of 2–5 MHz which allows scanning through intercostal spaces. The presence of an ultrasound window with the absence of bone or air overlying the lesion and the absence of any vital organs along the needle path was necessary for biopsy. The angle of needle entry and the depth of the lesion could be determined.


The preferred position for the procedure was the sitting position, with the subject’s arms folded across the chest and supported by a bedside table. Local anesthesia in the form of subcutaneous injection of xylocaine 2%. Percutaneous ultrasound-guided pleural biopsy was done with a 14 or 16 gauge cutting needle (Quistello (MN) – Italy). Cores were obtained by using a biopsy gun.

The introducer was advanced into the rib interspace, the patient should hold his breath as it was advanced into the tar-get lesion. Resistance could be encountered when entering the lesion, whenever the introducer needle was opened to the atmosphere; the patient was again asked to hold breath. The stylet was removed, and the cutting needle was inserted, adjusted to the desired depth if applicable. The cutting needle should be oriented with the cutting aspect directed caudally to avoid laceration of intercostal vessels and nerves. The needle should be immediately discharged after insertion. Specimens were harvested until yielding at least three macroscopically sat-isfactory specimens for histopathological examination (trans-ported in formalin 10%). Chest X-ray was done for all patients. All patients were observed for at least 1 h before dis-charge and complications were noted.

Thoracoscopy procedure in group II

Thoracoscopic procedure was done using rigid thoracoscopy (Karl Storz; Tuttlingen, Germany) and its equipment and videoscopy unit (camera (Karl Storz Endoskope Telecam Pal 20211020), light source (Pentax LH-150 PC). The patient was lying down with the diseased site being the upper most with continuous monitoring of pulse, blood pressure, oxygen saturation using a portable monitor, and oxygen supply was connected to the patient. A rolled-up sheet was placed under the patient’s thorax to spread apart all the intercostal spaces on the exposed side of the chest wall.

The operator was in front of the patient, the assistant was usually behind the patient, the instruments were within the reach of the operator and the assistant, and the monitor was placed at the head of the operating table. Anesthesia with Lidocaine 2% about 30–40 mL was given to anesthetize the skin, subcutaneous tissue and muscles till pleura, along with I.V. agent for sedation, analgesia, and amnesia (5 mg Droperi-dol, 5–10 mg Pethidine). A needle thoracentesis with an 18-gauge needle was performed to confirm the presence of the fluid before the start of the procedure. The incision was usually along the mid-axillary line between the fifth and sixth inter-costal spaces.

With a scalpel, a vertical incision is made through the skin and subcutaneous tissue, at the site previously chosen and appropriate to the size of the trocar to be used, then proceed-ing to blunt dissection of subcutaneous tissue and the inter-costal muscles with curved artery forceps.

The entire pleural surface should be inspected in a system-atic fashion including the parietal pleura of the chest wall, dia-phragm, lung, mediastinum, heart, and vascular structures. Biopsy was typically performed under direct vision using the optical biopsy forceps inserted via the original port. A lateral ‘lift and peel’ technique was used, this technique produces ade-quately sized biopsies. Many biopsies were taken and placed in formalin for histopathology and in saline for culture, particu-larly for TB.

Statistical analysis

Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation and chi-square test by SPSS V. 20 and P < 0.05 accepted to be significant.


Table 1shows the characteristics of patients in the two groups. Regarding clinical presentations in group I; dyspnea was found in 15 patients (75%), chest pain in 5 patients (25%), cough in 12 patients (60%), fever in 2 patients (10%) and haemoptysis in 4 patients (20%). In group II; dyspnea was found in 8 patients (40%), chest pain in 7 patients (35%), cough in 9 patients (45%), haemoptysis in 1 patient (5%) but there was no patient complained of fever. There was no significant statis-tical difference between two studied groups regarding clinical presentations (P > 0.05).

Radiological presentations in group I were pleural effusion with pleural based mass in 2 patients (10%), pleural effusion with pleural thickening in 1 patient (5%), pleural thickening only in 6 patients (30%), pleural mass only in 9 patients (45%) and pleural nodules only in 2 patients (10%). While in group II; pleural effusion only was found in 9 patients (45%), pleural effusion with pleural based mass in 1 patient (5%), pleural effusion with underlying collapse in 7 patients (35%) and pleural effusion with pleural thickening in 3 patients (15%) (Figs. 1 and 2).

Pleural fluid analysis was done for all patients presented with pleural effusion and sent for chemical, bacteriological and cytological analysis. No significant statistical difference was found between two studied groups as regards pleural fluid analysis (Table 2).

Complications of the procedures were in the form of pain at the site of biopsy which was present in 2 patients (10%) in group I and 4 patients (20%) in group II, Hemoptysis in 1 patient (5%) in group I, while in group II, no cases were detected. Failure of the lung to expand was not detected in any patient in group I while in group II, 5 patients (25%) were

Table 1 Characteristics of patients in the two groups.

Parameter Group I (N = 20) Group II (N = 20) tor X2 P Age (years) Mean ± SD 61.75 ± 12.33 49.85 ± 10.5 3.286t 0.002* Gender Male n (%) 13 (65%) 12 (60%) 0.000x 1.00 Female n (%) 7 (35%) 8 (40%) Smoking history Non smoker n (%) 8 (40%) 11 (55%) 1.474x 0.478 Ex-smoker n (%) 6 (30%) 3 (15%) Current smoker n (%) 6 (30%) 6 (30%) * P< 0.05, tttest, x Chi-square.


detected. Pneumothorax was not present in any patient of group I while in group II; 5 patients (25%) were detected. 3 cases out of 5 responded to oxygen inhalation via face mask while 2 cases did not respond because of extensive adhesions in one case and mesothelioma in the other case. Wound infec-tion was not present in any patient in group I while in group II, 3 patients (15%) were detected (Table 3).

Follow up of patients after US guided pleural needle biopsy and medical thoracoscopy (Table 4)

Oxygen saturation: was recorded using pulse oximetry. Length of hospital stay: calculated from the day of perform-ing the procedure to the day of discharge from hospital.

Chest X ray presentations: chest X ray was done for all patients one day after the procedure. The final histopatholog-ical diagnosis presented inTable 5shows that significant statis-tical difference between two studied groups in cases of pleural tuberculosis and parapneumonic effusion (P < 0.05).

The sensitivity of ultrasound guided needle pleural biopsy in diagnosis of pleural lesions was 85% as 17 out of 20 cases were diagnosed by ultrasound guided pleural biopsy. While the diagnostic sensitivity of medical thoracoscopy was 95% as 19 cases out of 20 cases were diagnosed by medical thora-coscopy with no significant statistical difference between the two procedures (P > 0.05).


The present study aimed to compare safety and efficacy of medical thoracoscopic versus ultrasound guided transthoracic needle biopsy in the diagnosis of pleural lesions. In this study, we have presented the data of 40 patients who were divided into two groups. Group I (20 patients) in whom Tru-cut needle biopsy was performed guided by ultrasonography for the diag-nosis of pleural lesions and group II (20 patients) who under-went thoracoscopy for the diagnosis of undiagnosed pleural lesions.

Exudative pleural effusions are frequently encountered in pulmonary practice. Determination of a specific diagnosis can represent a major challenge. Thoracoscopy is the investiga-tion of choice in exudative pleural effusions where a diagnostic pleural aspiration is inconclusive and malignancy is suspected [8].

The clinical findings in this study were consistent with Sahn et al. [9]who found that shortness of breath and chest pain were the most common symptoms in pleural effusion. Also, Dhital et al.[10]reported that the most common clinical symp-toms were in the form of shortness of breath (83%), cough (67%) and fever (66%).

In this study, regarding radiological presentations it was noticed that in group I, pleural effusion only was not found in any case while in group II, pleural effusion only was present in 9 cases this means that patients with pleural effusion only were not eligible for ultrasound guided pleural needle biopsy due to the absence of pleural thickening or nodules for biopsy taking but they were highly eligible for medical thoracoscopy. This is in agreement with Kamel and Kaffas[11]who found

Figure 1 CT chest (mediastinal window) demonstrating right circumferential pleural thickening with fluid density obliterating right hemithorax with partial underlying lung collapse toward the hilum.

Figure 2 Ultrasound image of a case of undiagnosed pleural effusion with underlying pleural lesions during biopsy taking.

Table 2 Characteristics of pleural fluid in the two groups.

Group I Mean ± SD Group II Mean ± SD t P Protein 5.233 ± 0.462 8.215 ± 11.962 0.423 0.676 Glucose 111.667 ± 35.642 127.200 ± 59.371 0.436 0.667 LDH 479.667 ± 184.825 610.385 ± 354.028 0.618 0.543 ADA 17.833 ± 14.886 19.680 ± 10.531 0.271 0.789


that ultrasound guided biopsy could not be performed in cases of pleural effusion only due to the absence of pleural thickness, nodulation or masses.

In the present study, it was found that thoracoscopic appearances were mostly confirmed histologically, as the pres-ence of nodules mostly indicates malignancy, while diffuse thickening, adhesions and plaques suggest tuberculosis or other inflammatory pleural affections. Histopathological diag-nosis was matched with the gross appearance in some studies [12–14]. However, they definitely need biopsies and histopathological diagnosis. Another study reported that tho-racoscopic appearances were not reliable, and that it was dan-ger to rely upon inspection of the pleura alone without biopsies [15].

On reporting complications of the procedures in this study, pneumothorax was detected in 5 patients (25%) of group II while not detected in group I. Three cases out of 5 cases responded to oxygen inhalation via face mask while 2 cases did not respond because of extensive adhesions in one case and mesothelioma in the other case.

In agreement with this study Benamore et al.[16]reported that the rate of new pneumothorax detected by chest radiogra-phy was 4.7% in cases that underwent medical thoracoscopy and complications were encountered in 25% of patients.

Diacon et al. [17] found that 3 (3%) patients had pneu-mothorax relieved by chest tube insertion, 1 (1%) patient with a small wound required a single suture, 1 (1%) patient devel-oped dyspnea relieved by bronchodilators, minor events were transient pain requiring medication in 5 (5%) patients, mild and transitory haemoptysis in 2 patients (2%) and vasovagal reaction in 2 patients (2%). In contrast to our results; some

studies [18,19] conducted using ultrasound guided pleural biopsies found that the pneumothorax was the common com-plication in their studies.

Some investigators [18] found that the total number of diagnosed cases using ultrasound guided pleural biopsies was 24 (80%); 9 cases as mesothelioma (30%), 8 as bronchogenic carcinoma with pleural metastasis (7 adenocarcinoma, 1 large cell carcinoma), tuberculous effusion in 2 cases (6.7%), inflammatory lung masses in 3 cases (10%), para-pneumonic effusion in 2 cases (6.7%) and 6 cases were not diagnosed (20%).

In our study, it could not be accessible to obtain biopsies from 3 patients (15%) in group I. This may be due to that the lesions were in contact with the chest wall for less than 1 cm regardless of their size and location, location behind a rib was considered to be a contraindication, also in small lesions <20 mm or in pleural effusion without underlying pleural masses it was difficult with a high failure rate in taking the biopsy. In-group II, unfortunately it could not be accessi-ble to obtain biopsies from 1 patient (5%) of all the studied patients; this is because of the presence of extensive adhesions. In agreement to these results Francois et al.[20]performed diagnostic thoracoscopy in 149 cases and reported failure to reach the diagnosis in 10 cases (6.8%). They explained this fail-ure by the presence of extensive pleural adhesions that limited the access to the pleural cavity. Sophie and Robin [21] described failure to obtain biopsies in 3 cases out of 50 cases (6%) during medical thoracoscopy due to either extensive pleural adhesions or lack of any pleural abnormality during thoracoscopy.

In this study, the sensitivity of ultrasound guided pleural needle biopsy and medical thoracoscopy for diagnosis of cases was 85% and 95% for groups I and II respectively. Adams and Gleeson [22] reported that the overall accuracy of percuta-neous image guided biopsy was about 91%, which means that thoracoscopic biopsies may be superior to sonographic guided Tru-cut biopsies.

As the sensitivity of diagnostic thoracoscopy in this study was 95%, it indicates a high diagnostic yield of medical thora-coscopy. The diagnostic sensitivity in previous thoracoscopic studies varied from 66% to 100%[21,23–24].

There was partial agreement between this study and Kamel and Kaffas[11]study as they found that the mean diagnostic sensitivity of thoracoscopy was from 96.7% to 100%, and that of ultrasound guided pleural biopsy was 65%.

Table 3 Complications of the procedures in the two studied groups. Complications Group I n(%) Group II n(%) X2 P Failure to expand 0 5 (25%) 7.648 0.006*

Pain at the site of biopsy 2 (10%) 4 (20%) 0.797 0.372 Wound infection 0 3 (15%) 4.402 0.036* Pneumothorax 0 5 (25%) 7.648 0.006* Hemoptysis 1 (5%) 0 1.412 0.235 *P< 0.05, X2: Chi-square.

Table 4 Follow up of patients in the two groups.

Follow up of patients Group I n (%) Group II n (%) X2or t P Oxygen saturation

Mean ± SD

94.54 ± 2.44 95.44 ± 1.88 1.307t 0.199 Length of hospital stay in days

Mean ± SD

4.25 ± 3.83 7.40 ± 4.90 2.265t 0.029*

Chest X ray presentations Pneumothorax n (%) 0 5 (25%) 5.991x 0.014*

Collapsed lung n (%) 0 1 (5%) 1.412x 0.235 * P< 0.05, t ttest, x Chi-square.


In contrast, one study[25] concluded that the diagnostic value of medical thoracoscopy was 81.25%, another study [26]found that thoracoscopy had a diagnostic value of 86% in pleuropulmonary diseases.

Some authors who reported that thoracoscopy is a diagnos-tic procedure for pleural cavity related diseases with 92–97% sensitivity and 99% specificity and these results were in agree-ment with the results of this study[27].

Also, thoracoscopy has the disadvantage of requiring gen-eral anesthesia or sedation, requiring chest tube drainage and inpatient stay, having the potential of failure due to adhesions preventing pneumothorax, being substantially more expensive than image-guided biopsy, and having a higher complication rate[13,28]. Some authors have also shown that it is safe to biopsy the pleura with the Tru-cut needle under ultrasound guidance in situations in which the pleura is thickened and when the pleural effusion is small in amount or loculated [22]. Nithya et al. [29]concluded that medical thoracoscopy is a better diagnostic tool in the hands of pulmonologists in cases of undiagnosed exudative pleural effusions.


Medical thoracoscopy is an important diagnostic method for the diagnosis of undiagnosed exudative pleural effusion but with minimal or no role in cases of thickened pleura without pleural effusion. Ultrasound guided needle pleural biopsy may be helpful in cases of thickened pleura in the absence of pleural effusion. It is concluded that US is more useful in cases of pleural lesions without pleural effusion.

Conflict of interest

There is no conflict of interest. References

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patients, Int. J. Pulm. Med. 2 (2003) 1531–1535.

Table 5 Comparison between the two studied groups regard-ing final histopathological diagnosis.

Histopathological diagnosis Group I (n)% Group II (n)% X2 P Pleural TB 0 4 (20%) 5.991 0.014* Parapneumonic effusion 3 (15%) 0 (0%) 4.402 0.036*

Inflammatory lung lesion 1 (5%) 2 (10%) 0.367 0.545 Pleural fibroma 2 (10%) 0 2.878 0.090 Malignant mesothelioma 4 (20%) 6 (30%) 0.536 0.464 Sarcoma 1 (5%) 0 1.412 0.235 Adenocarcinoma 1 (5%) 5 (25%)

2.50 0.113 Squamous cell carcinoma 4 (20%) 0

Small cell lung cancer 0 0 0.000 1.000 Metastatic adenocarcinoma

(other than lung)

1 (5%) 2 (10%) 0.367 0.545 Undiagnosed cases 3 (15%) 1 (5%) 1.158 0.282



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[26]E.A. El-Gamal, Thoracoscopy as a Diagnostic and Therapeutic Tool in Pleuropulmonary Diseases (MD thesis), Mansoura University, Faculty of Medicine, 1992.

[27]S.A. Sahn, Pleural effusion in lung cancer, Clin. Chest Med. 1 (1993) 189–200.

[28]R.J. Harris, M.S. Kavuru, A.C. Mehta, The impact of thoracoscopy on the management of pleural disease, Chest 845–52 (1995).

[29]Haridas Nithya, K.P. Suraj, T.P. Rajagopal, P.T. James, Chetambath Ravindran, Medical thoracoscopy vs closed pleural biopsy in pleural effusions: a randomized controlled study, J. Clin. Diagn. Res. 8 (5) (2014) MC01–MC04.


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