Medical Thoracoscopy Versus Closed Pleural Biopsy

Thoracoscopy with pleural biopsies has been repeatedly shown as offering a high yield in patients with pleural effusion that remains undiagnosed despite physical examination, laboratory workup, and thoracentesis. A meta-analysis of 17 studies suggests that medical thoracoscopy (MT) has a high sensitivity (91%) for unexplained exudative pleural effusion (EPE) with minimal morbidity and no associated mortality.1 In fact, consensus guidelines on MT support its use in the diagnosis of EPE when thoracentesis results are inconclusive.2 Limiting factors to routine implementation of MT in clinical practice are costs and training. Thus, it appears that in some countries and institutions closed pleural biopsy (CPB) continues to play a role in the workup of unexplained EPE. Several studies, however, have evaluated the diagnostic yield of MT and CPB in unexplained EPE. MT is favored because of its higher diagnostic yield and safety profile.3–6 The study by Maturu et al adds to the existing body of evidence that justifies the use of MT as the best test in the diagnosis of unexplained EPE, even in areas with a high prevalence of tuberculosis. This is the largest retrospective study (n=348) that compares the use of CPB and MT and confirms that MT remains the procedure of choice for unexplained EPE, with a diagnostic yield of 93.2% versus 84.5% for CPB (P<0.05). The authors also highlight the change of practice over a 10-year period in a large tertiary referral center where initially pleural biopsies were performed with CPB and subsequently replaced by MT. In their center, MT was performed by following rigid or semirigid thoracoscopy techniques. Diagnostic yield was further improved (98.7%) by the point-of-care chest ultrasound used to guide the point of entry. Undeniable advantages of MT are pleural biopsies obtained under direct visual guidance and tactile feedback. However, not uncommonly, pleural space anatomy (adhesions, septations) and limited field of view may negatively impact the ability of direct tissue sampling during MT. Although biopsies are smaller with semirigid biopsy forceps, 2 small, randomized trials reported similar diagnostic yield using either technique. However, small samples obtained with the semirigid pleuroscope may be limited when deep pleural biopsies are needed (ie, mesothelioma, fibrotic pleural thickening). Technological advancements will likely overcome these limitations. Cryobiopsy has been recently demonstrated as a safe adjunct tool in improving the yield of MT.7 Larger tissue samples obtained through cryobiopsy were shown to be free from crush artifact and provided better samples for histologic analysis. Alternative and novel pleural imaging techniques, including narrow band imaging, autofluorescence, and optical coherence tomography, may allow for better selection of specific biopsy sites and may further improve the diagnostic yield of MT.8,9 One could argue that, in certain countries and institutions where MT is not available because of high cost or lack of expertise, CPB may provide an acceptable alternative. Expertise in CPB in North America, however, seems to be declining. A survey of Canadian Pulmonology training programs revealed that, as reported by the fellows, the ACCP-recommended number of at least 5 CPBs per year was met by only 5% of trainees.10,11 A more recent survey of interventional pulmonary (IP) fellowships did not even address training in CPB.12 In contrast, on the basis of the ACCP expert panel recommendations, trainees should perform at least 20 MT procedures in a supervised setting to establish basic competency and at least 10 procedures per year to maintain competency.11 MT is apparently performed an average of 26 times per year during IP fellowship training (range, 5 to 82). However, 50% of surveyed IP programs reported fewer MT procedures than what is recommended by the ACCP expert panel.12 To predict performance in these guidelines, the experts chose procedural volume primarily because of the absence of more suitable alternatives. It is probably true that the more procedures one performs, the better one becomes, but evidence suggests that these arbitrarily defined numbers are inadequate as sole markers of effective training as learners gain skills at different rates.13 As a result of dedicated IP fellowships, and regional, national, and international workshops, it is expected that MT will become widely available. Moving forward, in the era of competency-oriented training, standardized curricula using formative cognitive and technical skills assessments, and not arbitrary but highly debatable numbers of procedures, will be necessary to validate training programs.

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