S Verma, A Dubey, P Singh, S Tewerson, D Sharma
pleural biopsy, pleural effusion
S Verma, A Dubey, P Singh, S Tewerson, D Sharma. Efficacy and safety of pleural biopsy in aetiological diagnosis of pleural effusion. The Internet Journal of Infectious Diseases. 2008 Volume 7 Number 1.
Pleural effusion is a common chest problem, yet it is difficult to establish the aetiological diagnosis in as many as 20% cases, in spite of good history, thorough clinical , radiological and full examination of aspirated fluid. Prior to introduction of pleural biopsy the diagnosis of the cause of pleural effusion was more or less empirical. Closed pleural biopsy is a safe and simple alternative to open pleural biopsy1. Its utility in the diagnosis of pleural diseases has been the subject of many extensive report1-9. Despite of its worldwide acceptance and the widespread availability this investigation is not being used widely in India. We are reporting fifty cases in which this procedure formed an important part of the diagnostic evaluation, confirming both its usefulness and safety in the work up of patients of pleural effusion.
Material & Method
Consecutive 50 patients of pleural effusion were studied, who were more than 12 years of age, irrespective of sex with no other systemic diseases. All patients underwent preliminary investigations as indicated by their clinical presentation, including haematological, radiological, bacteriological and biochemical.
Pleural biopsy was done with Abraham's punch biopsy using standardizing technique10 with the variation that only one bite was taken instead of multiple bites. A chest skiagram was obtained in each case 4-6 hour after biopsy procedure, to identify the pneumothorax. All tissue obtained after biopsy were fixed in formalin and haematoxyline eosin (H & E) stained were prepared after taking thin section of the tissue.
Criteria for Histological Diagnosis
Tuberculosis inflammation: The section shows collection of epithelioid cells with or without caseation, surrounded by lymphocytes and giant cells of langhans type.
Suggestive of tuberculosis inflammation: There is collection of epithelioid cells, without presence of giant cells of lengthens type.
Chronic nonspecific inflammation: The section shows presence of chronic inflammatory cells e.g. lymphocytes, plasma cells and eosinophils with evidence of fibrosis.
Acute inflammation: The section shows fibrous inflammatory exudates with infiltration of polymorphonuclear cells.
Malignancy: The presence of groups of cells showing hyperchromatism and anaplasia is confirming of malignant infiltration of pleura.
Fibrosis: The pleura show fibroblastic proliferation with collaginasation and occasional inflammatory cells.
Normal pleura: consists of a membrane composed of loose or dense connective tissue contiguous to muscle lined by mesothelial cells.
Inadequate: The biopsy was labeled inadequate where the tissue shows fibro muscular of fibro fatty tissue only
50 patients above the age of 12 years were studied. Male were 34 and female were 16. Satisfactory tissue was obtained in 44 (88%) patients, 5 biopsy showed inadequate tissue while one patients showed no pleura. Of the 44 patients successfully biopsy, a definitive histopathological diagnosis was made in 24 (54.5%); 20 patients in addition has diagnosis of non specific inflammation. Details of pleural biopsy are listed in table 1.
None of our patients developed pneumothorax following biopsy. No patients have significant bleeding. 42 patients complained of chest pain at site of biopsy.
Since its original description in 1958 the technique of pleural biopsy has been adopted with no significant difference of safety and acceptable yield10. All reports are unanimous on its utility and safety. Critical patients have been evaluated without mishap. The diagnostic success rate has been reported to vary from 30% to 100% for different diseases with multiple bites2, 3,5,7,8. Our results are comparable to almost all previous studies. The factors which determine success include the number of samples taken2 and diffuseness of lesion in pleura. The safety of procedure has been emphasized. Common complications which are reported in the literature are pain at local site, bleeding and pneumothorax etc. The relative ease of performance, the obvious advantage over open biopsy and lack of any significant complication should prompt its more frequent use in Indian centers.
Dr. S. K. Verma, Associate Professor, Department of Pulmonary Medicine, CSM Medical University, UP, Lucknow, 226003 Telephone: 91- 0522- 2254346