What is the role of a medical thoracoscopy (pleuroscopy) in the workup of pleural effusion of unknown origin?

Answer

Idiopathic pleural effusions that have been sampled by thoracentesis are ideal for medical thoracoscopy. The direct visualization of the pleura allows for site-directed biopsy of abnormal parietal pleura. Additionally, it allows for examination of the visceral pleura and any clues that may lead to the diagnosis of the pleural effusion. Most interventional pulmonologists limit biopsy to the parietal pleura due to the risk for injury to the lung when sampling the visceral pleura.

Cytologic examination of pleural fluid is diagnostic in only 60-80% of patients with metastatic pleural involvement and in less than 20% in patients with mesothelioma.^[3] In cases for which the initial evaluation of a pleural effusion is nondiagnostic and malignancy is suspected, medical thoracoscopy and parietal pleural biopsy should be considered.^[4] Medical thoracoscopy with pleural biopsy establishes a diagnosis in more than 90% of the cases.^[5]

Biopsy forceps sampling parietal pleura.

View Media Gallery

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

Jacobaeus HC. The cauterization of adhesions in artificial pneumothorax treatment of pulmonary tuberculosis under thoracoscopic control. Proc R Soc Med. 1923. 16(Electro Ther Sect):45-62. [Medline].
Vial MR, Eapen GA, Casal RF, Sarkiss MG, Ost DE, Vakil E, et al. Combined pleuroscopy and endobronchial ultrasound for diagnosis and staging of suspected lung cancer. Respir Med Case Rep. 2018. 23:49-51. [Medline].
Colt HG. Thoracoscopy: window to the pleural space. Chest. 1999 Nov. 116(5):1409-15. [Medline].
Wang Z, Wu YB, Xu LL, Jin ML, Diao XL, Wang XJ, et al. Diagnostic value of medical thoracoscopy in malignant pleural effusion induced by non-Hodgkin's lymphoma. Oncol Lett. 2017 Dec. 14 (6):8092-8099. [Medline].
Lee P, Colt HG. State of the art: pleuroscopy. J Thorac Oncol. 2007 Jul. 2(7):663-70. [Medline].
Leemans J, Dooms C, Ninane V, Yserbyt J. Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience. Respirology. 2018 Jan 10. [Medline].
Li J, Gwilt P. The effect of malignant effusions on methotrexate disposition. Cancer Chemother Pharmacol. 2002 Nov. 50(5):373-82. [Medline].
Mahadevan A, Kanegaonkar R, Hoskin PJ. Third space sequestration increases toxicity of fludarabine--a case report. Acta Oncol. 1997. 36(4):441. [Medline].
Dickgreber NJ, Sorensen JB, Paz-Ares LG, et al. Pemetrexed safety and pharmacokinetics in patients with third-space fluid. Clin Cancer Res. 2010 May 15. 16(10):2872-80. [Medline].
Loddenkemper R, Grosser H, Gabler A. Prospective evaluation of biopsy methods in the diagnosis of malignant pleural effusions. Intrapatient comparison between pleural fluid cytology, blind needle biopsy and thoracoscopy. Am Rev Respir Dis. 1983. 127 (Suppl 4):114.
Rodriguez-Panadero F. Medical thoracoscopy. Respiration. 2008. 76(4):363-72. [Medline].
Heffner JE, Klein JS, Hampson C. Interventional management of pleural infections. Chest. 2009 Oct. 136(4):1148-59. [Medline].
Simoff M, Sterman D, Ernst A. Thoracic Endoscopy: Advances in Interventional Pulmonology. Malden, MA: Blackwell Publishing; 2006.
Medford AR, Bennett JA, Free CM, Agrawal S. Current status of medical pleuroscopy. Clin Chest Med. 2010 Mar. 31(1):165-72, Table of Contents. [Medline].
Beamis JF, Mathur PN, Metha AC. Interventional Pulmonary Medicine. New York, NY: Marcel Dekker; 2004.
Boutin C, Viallat JR, Aelony Y. Practical Thoracoscopy. Berlin: Springer Verlag; 1991.
Durheim MT, Kim S, Gulack BC, Burfeind WR, Gaissert HA, Kosinski AS, et al. Mortality and Respiratory Failure After Thoracoscopic Lung Biopsy for Interstitial Lung Disease. Ann Thorac Surg. 2017 Aug. 104 (2):465-470. [Medline].
Beamis JK, Mathur PN. Interventional Pulmonology. Singapore: McGraw Hill; 1999.

Media Gallery

Biopsy forceps sampling parietal pleura.
Talc pleurodesis on lung and parietal pleura.
Bulky metastasis on parietal pleura.
Examination for evidence of metastasis.
Pleural adhesions on medical thoracoscopy.
Patient positioning for medical thoracoscopy.
Trocar insertion for medical thoracoscopy.
Insertion of semirigid scope through trocar.
Olympus semirigid pleuroscope.
Olympus semirigid pleuroscope.
Olympus semirigid pleuroscope.
Semirigid pleuroscope in extension.
Semirigid pleuroscope in flexion.
Semirigid pleuroscope in neutral position.

of 14

Author

Shannon E Burke, DO Fellow in Pulmonary and Critical Care Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, St Louis University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Edward Charbek, MD, FCCP Assistant Professor of Internal Medicine, Associate Director of Pulmonary and Critical Care Fellowship Program, Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University School of Medicine; Medical Director, Kindred Hospital-St Louis

Edward Charbek, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Rajiv Malhotra, DO, MS, FCCP Assistant Professor of Internal Medicine, Division of Pulmonary and Critical Care, Department of Internal Medicine, Virginia Commonwealth University; Medical Director of Cardiac Surgery ICU, Associate Fellowship Director of Interventional Pulmonology, Virginia Commonwealth University Health System

Rajiv Malhotra, DO, MS, FCCP is a member of the following medical societies: American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, International Society for Heart and Lung Transplantation, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Hans J Lee, MD Assistant Professor of Medicine, Director of Pleural Disease Services, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine

Hans J Lee, MD is a member of the following medical societies: American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American Thoracic Society, Association of Interventional Pulmonary Fellowship Directors

Disclosure: Nothing to disclose.

Ray W Shepherd, MD Associate Professor of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University School of Medicine; Staff Physician, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center

Ray W Shepherd, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Christian Medical and Dental Associations, American Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Cecilia C Bergh, MD Fellow in Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center

Disclosure: Nothing to disclose.

What is the role of a medical thoracoscopy (pleuroscopy) in the workup of pleural effusion of unknown origin?

Answer

Related Questions:

References

Tables

Contributor Information and Disclosures