|Year : 2018 | Volume
| Issue : 2 | Page : 93-98
Comparison between ultrasound-guided Abrams needle and medical thoracoscopic pleural biopsies in exudative pleural effusion
Osama F Mansour1, Amal A Abd-Aziz1, Mahmoud M El-Habashy1, Samy S El-Dahdouh1, Waleed A Mousa2, Amal A El-Koa1
1 Department of Chest, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
|Date of Submission||16-Jan-2018|
|Date of Acceptance||08-Mar-2018|
|Date of Web Publication||14-Jun-2018|
Amal A El-Koa
Chest Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, 32862
Source of Support: None, Conflict of Interest: None
Background The actual diagnosis of pleural disease (especially for malignancy) depends on the histopathological finding obtained through pleural biopsy or positive pleural fluid cytology result. Pleural tissue biopsies can be obtained by several methods: blind, image-guided, thoracoscopic, or open surgical pleural biopsies. The diagnostic yield of image-guided sampling is increased owing to the ability to precisely target an abnormal area of the pleura.
Aim The aim of this work was to compare between ultrasound-guided Abrams needle and medical thoracoscopic pleural biopsies (MT-PB) in exudative pleural effusion and see the diagnostic yield of ultrasound-guided pleural biopsy.
Patients and methods This study included 40 patients with exudative pleural effusion admitted to Chest Department, Menoufia University Hospital, during the period from August 2015 to November 2017. All had pleural thickening in contrast-enhanced thoracic computed tomography scan. All patients underwent ultrasound-guided Abrams’ needle followed by MT-PB.
Results Compared with MT-PB, the sensitivity and specificity of ultrasound-guided Abrams needle pleural biopsy were 81.58 and 100%, respectively. No difference was identified between the yields of the two methods.
Conclusion Ultrasound-guided Abrams needle pleural biopsy considers an alternative to medical thoracoscopy in exudative pleural effusions associated with pleural thickening.
Keywords: medical thoracoscopy, pleural biopsy, ultrasound
|How to cite this article:|
Mansour OF, Abd-Aziz AA, El-Habashy MM, El-Dahdouh SS, Mousa WA, El-Koa AA. Comparison between ultrasound-guided Abrams needle and medical thoracoscopic pleural biopsies in exudative pleural effusion. Egypt J Chest Dis Tuberc 2018;67:93-8
|How to cite this URL:|
Mansour OF, Abd-Aziz AA, El-Habashy MM, El-Dahdouh SS, Mousa WA, El-Koa AA. Comparison between ultrasound-guided Abrams needle and medical thoracoscopic pleural biopsies in exudative pleural effusion. Egypt J Chest Dis Tuberc [serial online] 2018 [cited 2018 Jul 21];67:93-8. Available from: http://www.ejcdt.eg.net/text.asp?2018/67/2/93/234179
| Introduction|| |
Pleural effusion is a common clinical problem with various etiologies. It has a prevalence of ∼4% among patients in pulmonary practice .
The most efficient and cost-effective approach to exudative pleural effusion that is not diagnosed by means of pleural fluid analysis and ancillary investigations remains uncertain, especially when the pleural tissue is essential for diagnosis .
Blind or unassisted closed pleural biopsy has a modest yield. Diagnosis will be obtained in less than 60% of pleural malignancy cases , and approximately 80–87% in cases of tuberculous pleuritis ,. Medical thoracoscopy (MT) or surgical thoracoscopy has a diagnostic yield of ∼91–95% for pleural malignancy and up to 100% for pleural tuberculosis and remains the gold standard in this setting ,.
Transthoracic ultrasound (TUS) is a useful method in detecting the presence of pleural effusion. It also helps in assessment of its nature, quantification of its volume, and detection of the presence of septation, pleural thickening, pleural nodules, or pleural-based tumors ,. It also can be used to guide the closed pleural biopsy to increase its diagnostic yield and minimize its risk compared with blind procedures with a safe selection of the biopsy site ,,.
| Aim|| |
The aim of this work was to compare between the yield of ultrasound-guided Abrams needle and MT pleural biopsies in exudative pleural effusion and see the diagnostic sensitivity of ultrasound-guided pleural biopsy.
| Patients and methods|| |
This prospective study was a comparative randomized experiment that was carried out on 40 patients with exudative pleural effusion of undetermined etiology (following biochemical, bacteriological, and cytological analysis) admitted to the Chest Department, Menoufia University Hospital, in the period between August 2015 and November 2017.
A written informed consent was taken from each patient after explanation of the detailed procedure and purpose of the study. All patients have a normal bleeding profile (prothrombin time and concentration, international normalized ratio and platelet count) and pleural thickening found on computed tomography (CT) with adequate amount of pleural effusion. Patients with bleeding tendency, empyema, or cardiopulmonary instabilities were excluded from this work. All patients were subjected to TUS examination. Then, ultrasound-guided Abrams needle pleural biopsy (US-ANPB) was done followed by MT. All patients underwent initial TUS scans (Philips Affiniti 50 G; Germany) while sitting in prone, supine, or lateral decubitus position with screening of all zones. The parietal pleural thickness distance, associated visceral pleural thickness, associated pleural nodules or masses, or presence of adhesions were evaluated . The entry site was selected by the most lower accessible parietal pleural thickness or the thoracic parietal pleura close to the diaphragm .
Ultrasound-guided Abrams needle pleural biopsy
After localization of the best place to perform pleural biopsy, the skin was scrubbed with iodopovidone, and after anesthetizing the skin up to the parietal pleura by ∼10 ml of 2% lidocaine, a 0.5-cm transverse skin incision was made by a scalpel parallel to the upper border of the rib. The Abram needle was inserted, under real-time visualization, to be advanced along the inner aspect of the thoracic wall and away from the lung. At least four specimens were obtained from each patient, fixed in formaldehyde solution, and transferred for histological examination. One specimen was placed in a normal saline and sent for mycobacterial culture (if tuberculosis was clinically suspected) ,.
Medical thoracoscopic pleural biopsy
MT was performed through a single-puncture technique using a rigid thoracoscope (tekno rigid thoracoscope, made in Germany, double channel, 0° wide angle, lateral view, 10–268 mm working length, and 6-mm instrument cannel). The procedures were done with complete aseptic precaution under local anesthesia, conscious sedation, and potent analgesia. After entry of the thoracoscope into the pleural cavity, pleural fluid was aspirated slowly and intermittently to allow air to enter into the pleural cavity replacing the pleural fluid and facilitating the lung collapse with good visualization of pleural cavity. The entire pleural space was inspected and visualized for any abnormalities such as pleural adhesions, pleural nodules or masses and its distribution and pleural congestion. Multiple pleural biopsies (≥4 biopsy samples) were taken and fixed in formaldehyde solution (for histological examination) and one specimen was placed in a normal saline (for mycobacterial culture), if tuberculosis was clinically suspected. In those patients with no visualized abnormality in pleural, biopsies were taken from the parietal pleura and sent for histopathological examination ,.
Statistical presentation and analysis was conducted by using the mean and SD and χ2-test by SPSS version 22 (SPSS, Inc., Chicago, Illinois, USA), and P value less than 0.05 was accepted to be significant.
| Results|| |
The present study included 40 patients [20 (50%) males and 20 (50%) females; the mean age was 57.8±9.84 years] with exudative pleural effusion of undetermined etiology (following biochemical, bacteriological, and cytological analysis) who underwent US-ANPB followed by medical thoracoscopic pleural biopsy (MT-PB).
By comparing the findings of TUS examination and MT examination of all patients, it was founded that MT is superior to TUS in detecting costal pleural nodules, with highly statistically significant difference (P=0.001), but there was no statistical significant difference between them regarding the detection of diaphragmatic nodules (P=0.644), visceral nodules (P=0.363), costodiaphragmatic recess nodules (P=0.263), pleural masses (P=1.00), or pleural adhesions or septations (P=1.00) ([Table 1]). [Figure 1] shows the CT, TUS, and MT of male patient 55 years old with right exudative pleural effusion in which pleural thickening and masses are clearly visible.
|Table 1 Comparison between transthoracic ultrasound and medical thoracoscopic finding among studied group (N=40)|
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|Figure 1 Male patient 55 years old with exudative pleural effusion. (a) axial contrast-enhanced CT scan showing right sided pleural effusion with heterogeneously enhancing nodular pleural-based masses, (b) TUS showing pleural effusion with pleura thickening with pleural mass, (c,d) Medical Thoracoscopic picture showing pleural thickening, nodulation and masses.|
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[Table 2] shows the overall histopathological results obtained by US-ANPB and MT-PB with its statistically significant difference, where 31 of 40 patients were diagnosed by US-ANPB (77.5%) and nine (22.5%) cases were undiagnosed (four cases with atypical mesothelial hyperplasia and five cases with thick fibrotic pleura), whereas 38 of 40 patients was diagnosed by MT-PB (95%) and two (5%) cases still undiagnosed (thick fibrotic pleura). There was no statistical significant difference between both techniques regarding the diagnosis.
|Table 2 Comparison between histopathological finding of ultrasound-guided Abrams needle pleural biopsy and medical thoracoscopic pleural biopsies among the studied patients (N=40)|
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By measuring the validity of US-ANPB among the 40 patients regarding the histopathological diagnosis revealed that it has 81.58% sensitivity, 100% specificity, and 82.5% diagnostic accuracy ([Table 3] and [Figure 2]).
|Table 3 The diagnostic accuracy of ultrasound-guided Abrams needle pleural biopsy compared with medical thoracoscopic pleural biopsies|
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[Table 4] shows the relation between US-ANPB histopathological finding and the distance of the most thickened part obtained by TUS examination. There was a statistical significant difference (P=0.002).
|Table 4 Relation between ultrasound-guided Abrams needle pleural biopsy histopathological finding and parietal pleural thickness distance founded by transthoracic ultrasound among studied patients|
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| Discussion|| |
In this study, of 40 patients (mean age was 57.8±9.84 years) who underwent US-ANPB, 31 patients were diagnosed with an overall sensitivity of 81.58%, specificity of 100%, and diagnostic accuracy of 82.5% whereas MT-PB could diagnose 38 patients. The most common etiology among the diagnosed patients was malignancy (31/38) ([Table 3]).
The most common etiology among the mean age of the studied patients was malignancy; this was agreed with the findings of Prabhu and Narasimhan , Mohamed et al. , and Nattusamy et al.  where they studied patients with undiagnosed pleural effusion, and most of the patients in their studies were within the mean age group.
The high diagnostic yield of MT-PB [38/40 (95%)] is consistent with multiple studies that have reported the diagnostic yield of thoracoscopy ranging from 70 to 97% ,,,,. This is explained by the advantage of good visualization of the pleural cavity including costal, diaphragmatic, and visceral pleura as well as the lung which gives a chance to gain good information on the extent of the disease; in addition, it allows visualized and adequate pleural tissue sampling.
MT, however, requires a degree of experience, requires general anesthesia or sedation, and requires chest tube drainage with inpatient stay being substantially more expensive than image-guided biopsy and has the potential of failure owing to adhesions with a higher complication rate . On the contrary, US-ANPB can potentially be performed in most medical facilities, provided that the operator is competent in US and closed pleural biopsy techniques, and it is more rapid, more accessible, and cheaper than MT .
The increased sensitivity of the US-ANPB technique used in this study (81.58%) is consistent with the sensitivity in multiple studies using Abrams needle under ultrasound guidance, such as Benamore et al.  (76%), Koegelenberg et al.  (75% in malignancy), Bolliger et al. (83%) , Mohamed et al.  (75%), Sobhy et al.  (77.8%) and Koegelenberg et al.  (83.3%).
The diagnostic yield of US-ANPB [31/40 (77.5%)] in this study in contrast to the lower diagnostic yield of blinded method of previous studies (<65% for pleural malignancy) ,,, may be explained by the use of TUS to identify the entry site, which was from the thoracic parietal pleura close to the diaphragm or from the most thickened accessible parietal pleural (patients with no pleural thickening on the CT scan were excluded from our study) where the spread from pleural metastases is more likely to be initially found ,, and as shown in [Table 4], there was a high statistical significant difference between the distance of parietal pleural thickness and the US-ANPB finding (P=0.002).Regarding the comparison between the ability of TUS to detect the pleural nodules and its sites, pleural masses, or pleural adhesions versus MT, this study revealed that MT is superior to TUS in detecting of costal pleural nodules with highly statistically significant difference (P=0.001), but there was no statistical significant difference between them regarding the detection of other findings ([Table 1]).
This coincides with the study of Sobhy et al.  in comparing the ability to detect pleural nodules or the pleural masses by TUS versus MT, and this study revealed that there was no statistically significant difference between TUS and MT (P=0.570 and 0.752, respectively). The significance in detecting costal pleural nodules by MT over the TUS may be explained by proper visualization and exploration of the costal pleura by MT especially for smaller nodules that may not be detected by TUS .
Cassanelli et al.  studied the accuracy of TUS in detecting pleural adhesion, and they founded that TUS is an effective method for predicting pleural adhesions before thoracic surgery with the sensitivity was 80.6%. In the study of Khalil et al. , the findings of fibrous adhesions reported on TUS were consistent with MT findings, with missing of one case by TUS owing to obesity.
| Conclusion|| |
Thoracoscopy has a superior diagnostic yield and is therefore considered the investigation of choice. US-ANPB have a high diagnostic rate, which makes it an alternative to MT-PB, and MT should be reserved for cases that are not diagnosed by closed biopsies.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]