Clinical Application, Performance, and Common Pitfalls of Ultrasound-guided Pleural Biopsy: Our Local Experience
JCM Sitt, RKL Lee, AWH Chan, M Hui, KT Wong, SCH Yu
Hong Kong J Radiol 2016;19:103-10
DOI: 10.12809/hkjr1615368
Objectives: To investigate the diagnostic performance of ultrasound-guided pleural biopsy, and discuss its clinical applications, limitations, and pitfalls.
Methods: Clinical notes, pathological and microbiological reports, ultrasound and other imaging studies of 111 patients who underwent ultrasound-guided pleural biopsy from 1 January to 31 December 2014 were reviewed. The technique of the procedures was reviewed and correlated with the pathological yield of the specimens; any minor or major complications were identified. The application and usefulness of the biopsies in directing patient management were studied in view of the final patient outcome, which was determined by clinical and radiological follow-up of patients (range, 1-30 months).
Results: A total of 127 biopsies were performed (left: 64, right: 63) in 111 patients (59 male and 52 female). The mean age of patients was 69 (range, 23-101) years. Overall 89% (n = 113) of biopsies were performed with an 18G Temno needle, with a mean number of 1.4 cores; 75% (n = 83) of biopsies yielded a histologically conclusive specimen. When combined with the results of pleural aspirate cytology (n = 21) and microbiological assessment of both the pleural biopsy and pleural aspirate (n = 11), which were all obtained at the same procedure, a definitive diagnosis was made in up to 90% of cases (n = 115). The final diagnosis of these patients included primary lung carcinoma (n = 23, majority adenocarcinoma), tuberculosis (n = 18), pleural metastases (n = 10), lymphoma (n = 1), chylothorax (n = 1), pyogenic infection (n = 6), undifferentiated inflammation (n = 20), and ‘no significant abnormality / pathology detected’ (n = 28). A minority of cases remained inconclusive (7%) and the diagnosis was made upon further clinical assessment, including bronchoscopy (bronchoalveolar lavage) [n = 1] and fine-needle aspiration of cervical lymph node (n = 2). For those with a diagnosis made by pleural aspirate cytology or culture, the provision of a pleural biopsy allowed further molecular tests (e.g. tuberculosis–polymerase chain reaction, tumour marker staining, or immunohistochemical tests / mutation detection) to be made to guide further patient management. Major complications (3.9%) included pneumothorax and hydropneumothorax requiring chest drain insertion (n = 3), transfusion (n = 1), and localised infection (n = 1).
Conclusion: Ultrasound-guided pleural biopsy is a safe and useful procedure to help diagnose the aetiology of pleural effusions, in particular to obtain histological diagnoses for suspected tuberculosis and tumours, and to provide tissue for immunohistochemical testing in confirmed malignant conditions. Combination with pleural aspirate analysis and microbiological assessment is suggested to maximise its utility.
中文摘要
超聲引導下胸膜活檢的臨床應用、效用和常見的缺點：經驗分享
薛靜雯、李嘉樂、陳永鴻、許明媚、黃嘉德、余俊豪
目的：探討超聲引導下胸膜活檢的診斷表現，並研究其臨床應用、效用和常見的缺點。
方法：回顧2014年1月1日至12月31日期間共111例接受超聲引導下胸膜活檢的臨床紀錄、病理及微生物報告、超聲和其他影像學報告。回顧這項技術，並與樣本的病理學結果比較是否有任何相關，亦找出是否有任何輕微或嚴重的併發症。按病人的最終結果，並使用其臨床和放射學為期1-30個月隨訪的資料，來界定活檢對於治理病人的應用和用途。
結果：替111名病人（59男和52女）進行了127次活檢（左胸膜64例，右胸膜63例），病人平均年齡69歲（介乎23-101歲）。89%（113例）活檢使用18G Temno針進行，平均每例穿刺1.4次。75%（83例）得到決定性的病理樣本。同一個程序下得到的胸膜抽吸的細胞學結果（21例）和胸膜活檢及胸膜抽吸的微生物評估結果（11例）結合時，90%（115例）得出明確的診斷。最終診斷為原發性肺癌（23例，多為腺癌）、肺結核（18例）、胸膜轉移（10例）、淋巴瘤（1例）、乳糜胸（1例）、化膿性感染（6例）、未定性的炎症（20例）和「無顯著異常」（28例）。有少數病例（7%）的結果未能得出定論，須作進一步的臨床評估，包括支氣管鏡（支氣管肺泡灌洗）1例，頸部淋巴結的細針穿刺2例。至於那些按胸腔穿刺細胞學檢查或培養做出診斷的病例，胸膜活檢標本容許進一步的分子測試（如肺結核聚合酶鏈反應、腫瘤標誌物染色或免疫組化測試／突變檢測）來進一步決定治理病人的方法。主要併發症（3.9%）包括氣胸和需胸腔引流的液氣胸（3例）、輸血（1例）和局部感染（1例）。
結論：超聲引導下胸膜活檢是一種安全有用的程序，它有助診斷胸腔積液，尤其是對於疑似結核和腫瘤的病例可以達至病理學診斷，以及確診為惡性腫瘤的病例可以提供組織作免疫檢測。建議結合胸膜穿刺物分析和微生物評估使超聲引導下胸膜活檢發揮最大效用。