Transcript ********* 1 - Pulmonology.gr

MEDICAL THORACOSCOPY IN THE
DIAGNOSIS
OF PLEURAL DISEASE
“ …a minimum invasive technique which allows
the examination of the pleural space in a spontaneously
breathing patient, offering great solutions…”
Dimitrios G Oikonomou
Interventional Pulmonologist
Interbalcan Medical Center, Thessaloniki, Greece.
MEDICAL THORACOSCOSPY
Definition
Medical thoracoscopy/pleuroscopy is a minimally invasive procedure that
allows access to the pleural space using a combination of viewing and
working instruments.
It also allows for basic diagnostic (undiagnosed pleural fluid or pleural
thickening ) and therapeutic (pleurodesis) procedures to be performed safely.
Interventional Pulmonary Procedures: Guidelines from ACCP
Chest 2003;123:1693-1717
•Thoracoscopy is not a new technique;
H.C.Jacobeus, the Swedish internist, was the
first to perform thoracoscopy in 1910, as a
diagnostic procedure for exudative pleuritis
•Thoracoscopy was “reinvented” at around
1980.
VATS vs Medical thoracoscopy
•Medical thoracoscopy is generally characterised as
thoracoscopy performed under local anaesthesia in the
endoscopy suite with the use of nondisposable
instruments, and is generally for diagnostic purposes.
•VATS is as a keyhole surgical procedure in the operating
room, under general anaesthesia with one-lung ventilation
using disposable instruments, generally for therapeutic
purposes
VATS vs Medical Thoracoscopy
Feature
Medical Thoracoscopy/
pleuroscopy
Purpose
Diagnosis/Pleurodesis
Location
Endoscope suite/operating room
Anesthesia
Local with moderate sedation
Technique
Instruments
Single puncture/Double puncture
Nondisposable
Simple
VATS
Minimally invasive
thoracic surgery
Operating room
Single lung ventilation
Multiple punctures
Disposable
Complex
VATS vs Medical Thoracoscopy
MT/P
MT/P or VATS
Pleural effusions
Spontaneous pneumothorax
Pleural effusions
of unknown etiology
Staging of lung cancer
Staging of diffuse
malignant mesothelioma
Pleurodesis by talc poudrage
or any other agent
Staging
Pleurodesis by talc poudrage
Empyema (stage I/II)
Drainage
Diffuse pulmonary diseases
Localised lesions
Chest wall/diaphragm
Sympathectomy/splachnicectomy
VATS
Lung procedures
Lung biopsy
Lobectomy
Pneumonectomy
Decortication
Lung volume reduction surgery
Pleura procedures
Pleurectomy(pneumothorax)
Drainage/decortication(empyema stage III)
Esophageal procedures
Excision of cyst,benign tumors,
esophagectomy,anti-reflux procedures,
mediastinal procedures.
Resection of mediastinal mass
Thoracic duct ligation
Pericardial window
Sympathectomy
INDICATIONS FOR MEDICAL THORACOSCOPY
• Diagnosis of pleural effusion
• Pleural biopsy
• Spontaneous pneumothorax
• Empyema (early stage)
• Chemical pleurodesis
INDICATIONS FOR MEDICAL THORACOSCOPY
•Thoracoscopy is the gold standard for the diagnosis and
treatment of pleural diseases. Its diagnostic yield is 95% in
patients with malignant pleural disease, with approximately
90% successful pleurodesis for malignant pleural effusion and
95% for pneumothorax.
•Pleural effusion of unknown origin remains the commonest
indication of pleuroscopy and is considered to be one of the
techniques with the highest diagnostic yield in “aspiration
cytology negative exudative effusions”.
PLEURAL EFFUSION: THE FIRST STEPS
Diagnostic thoracocenthesis
• Thoracocenthesis is indicated as the first step in the work-up of
practically every pleural effusion of unknown origin
•Total and differential cell counts, biochemical study (including total
proteins, lactate dehydrogenase (LDH), glucose, adenosinedeaminase
(ADA)
•Cytology analysis should also be included in the initial work-up.
• Thoracocenthesis provides information allowing classification of the
effusion in 90% of patients.
•A definite diagnosis is obtained in 20% of the patients after initial
thoracentesis
•After the first analysis, the effusion has to be classified into either
transudate or exudate following the criteria of LIGHT
•The cause remains unclear in 25% of the pleural effusions, and about half
of those will later on be diagnosed with a MPE
Should thoracoscopy always be performed
in non-specific pleuritis?
•The alternative to thoracoscopy is a wait-and-see approach.
•In patients with no diagnosis at the end of 8-15 days,
thoracoscopy should be carried out.
MALIGNANT PLEURAL EFFUSIONS
•One of the leading causes of exudative effusions;
42-77% of exudative effusions are secondary to malignancy
•Nearly all neoplasms can involve the pleura
•Lung cancer is the most common
•Breast carcinoma is the second most common
•Lymphomas (Hodgkin and non-Hodgkin)
are also important cause of MPE
SENSITIVITY (%) OF DIFFERENT BIOPSY METHODS IN MALIGNANT
PLEURAL EFFUSIONS
(Loddenkemper et al, 1983b)
Eventual results in 709 patients with exudative pleuritis
after thoracoscopy
709
pleuritis e.c.i.
318 malignant pleuritis
(45%)
391 non-malignant
pleuritis
(55%)
183 true benign disease
(26%)
208 inconclusive
(29%)
177 true benign
24.7%
31 malignant pleuritis
4.3%
( Janssen 2003)
Final diagnosis in 31 patients with false-negative
thoracoscopy.
Mesothelioma
Non-Hodgkin lymphoma
Adenocarcinoma
Non small cell lung cancer
Small cell lung cancer
Breast cancer
Other cancer
10
5
4
4
1
3
4
KEY POINTS
•Medical thoracoscopy has an overall diagnostic yield above 85% for MPE
•Patients who after undergoing diagnostic thoracoscopy are not found to
have a MPE are highly unlikely to develop one during at least the following
3 years (Mouchantaf F, Villanueva AG, J Bronchol Intervent Pulmonol 2009;
16:25–27)
•Thoracoscopic findings result in important changes in treatment in patients
with MPE;clinical management is influenced by thoracoscopy (Harris et al,
Chest 1995; 107: 845–852)
•Thoracoscopy is the procedure of choice to differentiate between resectable
and unresectable cancer if there is also pleural effusion; in case of pleural
metastasis, the stage of disease migrates to IIIB, with a prognosis of stage IV
EQUIPMENT FOR THORACOSCOPY
•Flexible bronchoscope
•Semi-rigid thoracoscope
•Minithoracoscopy (2&3mm, 2 points of entry)
•The standard equipment for thoracoscopy (as
developed by Boutin) is the 7mm rigid thoracoscope
Complications of medical thoracoscopy:
one of the safest procedures
•Subcutaneous emphysema 0.6–4.9%
•Air leak 0.5–8.1%
•Air embolism 0.2%
•Empyema 0.5–2.7%
•Hemorrhage (major)%
•Shock 0.2%
•Cardiac arrhythmias 2%
•Chest wall seeding by malignancy 0.5–4%
CONTRAINDICATIONS OF MEDICAL THORACOSCOPY
•Absolute contraindication:
•Absence of potential pleural space ( 6-10 cm usually due to
extensive adhesions).
•Relative contraindications:
•Uncorrectable coaggulopathy
•Multiple pleural adhesions
•Unstable cardio-respiratory status
•Uncontrollable cough
•Inability to lie flat for an hour
Summary: advantages of medical thoracoscopy
in the diagnosis of pleural effusions.
•Fast and definate biopsy diagnosis including TB culture
and hormone receptor assay
•Biopsies not only from chest wall pleura but also from
diaphragm
•Staging in lung cancer and diffuse mesothelioma
•Exclusion of malignancy and tuberculosis with high
probability
•Gold standard for scientific studies
Summary: advantages of medical thoracoscopy
in the treatment of pleural effusions.
•Complete and immediate fluid removal
•Evaluation of loculations
•Evaluation of the reexpansion potential of the lung
•Early start to drug treatment
•In addition better diagnosis+staging
•Talc poudrage for pleurodesis with uniform distribution
of talc, under visual control.