Medical thoracoscopy (MT) is a minimally invasive procedure that utilizes a semirigid pleuroscope in order to visualize the pleural space and perform biopsies for diagnostic purposes in patients with pleural disease. Pleural fluid analysis can only establish the diagnosis in approximately 75% of cases overall and 60% of malignant effusions [
We performed a retrospective cohort study including all adult patients who underwent planned outpatient MT for assessment of pleural disease between December 2007 and February 2014 at The Ottawa Hospital (TOH), with a follow-up period of at least 2 years. Our study was approved by the Ottawa Health Sciences Research Ethics Board. TOH is a tertiary care academic hospital with 1100 beds and services a catchment area of approximately 1 million people.
We included all consecutive patients who were referred to our outpatient pleural effusion clinic who underwent outpatient MT. Patients were referred from the local city or adjacent rural areas. All patients were evaluated by an interventional pulmonologist and had undiagnosed pleural disease or have confirmed metastatic cancer and required additional tissue for cancer characterization and mutational analyses. Contraindications to MT included absence of a pleural space, irreversible bleeding diathesis, hemodynamic instability, or evidence of pleural infection. Procedural informed consent for MT was obtained in all patients.
Study variables were collected from patient charts, using a standardized chart abstraction instrument. We collected several patient and procedural related variables including age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, baseline dyspnea index (BDI), transition dyspnea index (TDI) two weeks after procedure, number of prior thoracenteses, computed tomography (contrast or noncontrast) imaging results, procedural duration, medication used for conscious sedation, volume of pleural fluid drained, pleural fluid analysis, endoscopic findings, histologic diagnosis, need for additional diagnostic procedures, complications, and time to IPC removal. The primary outcome was the safety of performing outpatient MT as measured by rates of complications and need for admission after procedure. Secondary outcomes included need for repeat diagnostic procedure, need for repeat pleural diagnostic procedure, and patient symptom scores as measured by TDI after procedure. The BDI and TDI were measured in patients to track symptomatic improvement. A BDI of less than 6 reflects severe dyspnea, and the minimal clinically significant TDI is one [
All procedures were performed in the endoscopy suite. After positioning the patient in the lateral decubitus position with the affected side up, an appropriate entry site was marked using bedside ultrasound guidance. The patient was connected to cardiac, blood pressure, and pulse oximetry monitors. Moderate conscious sedation with midazolam and fentanyl was administered. The patient continued breathing spontaneously and was provided with supplemental oxygen provided by nasal cannula as needed. The skin was cleaned and the patient draped in sterile fashion. 10–15 mL of 1% lidocaine solution was used to anesthetize the planned entry site, and a small incision was made. Kelly forceps were then used to blunt dissect to the pleural space and an 8 mm disposable trocar was inserted. A semirigid pleuroscope (Olympus LTF-160) was then inserted through the trocar and all the pleural fluid was aspirated. The pleural cavity was inspected with the exception of the lung apex. Any parietal pleural abnormalities were biopsied. Random biopsies of the posterior parietal pleura were performed in the absence of visible abnormalities. Biopsies were sent for pathology and for microbiology including acid fast bacilli. At the end of the procedure, an IPC (PleurX) was subsequently inserted and connected to a water seal suction device at −20 cm H2O pressure, followed by −40 cm H2O pressure. The patients were disconnected from suction once no further air leak was noted in the underwater seal despite intentional cough. Postprocedural chest X-rays were performed immediately off suction and two hours after to confirm lung reexpansion. Discharge criteria included observation for at least two hours, adequate pain and nausea control, oxygen saturations returned to baseline or improved, hemodynamic stability, and absence of pneumothorax or stable pneumothorax on two-hour postprocedure chest X-ray. After two hours of observation, patients without significant complications were discharged with oral analgesic.
Home care nursing was arranged to perform drainages three times per week, and all patients followed up in the pleural effusion clinic in two weeks. Subsequent follow-up was arranged every six to eight weeks. The IPC was kept in place until drainages were less than 50 mL with two consecutive drainages, and there was no increase in pleural effusion size on chest X-ray. At IPC removal, the skin was cleaned and draped in a sterile fashion. 10 mL of lidocaine 1% was used to anesthetize the insertion site, and the IPC was dissected out and removed.
Repeat procedures were performed if the suspicion of malignancy was still high despite negative pleural biopsies. The chosen procedure was based on clinician assessment and may include CT-guided needle biopsies, surgical VATs, or bronchoscopy with endobronchial ultrasound.
We used means, medians, standard deviations, and interquartile ranges to describe continuous variables and proportions to describe categorical variables. Comparisons between categorical variables were made with
A total of 218 outpatient MT and IPC insertions were completed between December 2007 and February 2014 at TOH. The mean age (±SD) was 68.2 (±12.5) years. Refer to Table
Patient characteristics.
Characteristic |
|
---|---|
Age (mean ± SD) | 68.2 ± 12.5 |
|
|
|
|
Male | 114 (52.3) |
Female | 104 (47.7) |
|
|
|
|
1 | 39 (17.9) |
2 | 106 (48.6) |
3 | 64 (29.4) |
4 | 9 (4.1) |
|
|
|
3.7 ± 1.3 |
|
5.6 ± 2.0 |
|
|
|
|
0 | 32 (14.7) |
1 | 133 (61.3) |
>1 | 52 (24.0) |
|
|
|
|
Single effusion alone | 19 (9.9) |
Bilateral effusion | 46 (24.0) |
Pleural nodularity | 61 (31.8) |
Pleural thickening | 79 (41.1) |
Adenopathy | 57 (29.7) |
Pulmonary nodules | 51 (26.6) |
Mass | 33 (17.2) |
Calcified pleural plaques | 14 (7.3) |
No recent CT | 26 (11.9) |
|
|
Indwelling pleural catheter already in place at time of procedure ( |
8 (3.7) |
Procedural details are summarized in Table
Procedural details.
Procedural detail | |
|
|
Mean procedure time in minutes (mean ± SD) | 46.7 ± 13.6 |
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|
|
|
Midazolam dose in mg (mean ± SD) | 2.2 ± 0.6 |
Fentanyl dose in mcg (mean ± SD) | 92 ± 40.4 |
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Pleural fluid removed at time of procedure (mL ± SD) | 1513 ± 1054 |
|
|
|
|
Preexisting catheter ( |
8 (3.7) |
Catheter inserted at time of procedure ( |
210 (96.3) |
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|
|
|
Normal | 10 (4.6) |
Nodular abnormalities | 106 (48.6) |
Pleural thickening | 128 (58.7) |
Adhesions | 95 (43.6) |
Pleural plaques | 24 (11.0) |
Erythema/inflammatory changes alone | 6 (2.8) |
Pathology findings are outlined in Table
Pathology results.
Pathology |
|
---|---|
|
130 (59.6) |
Non-small-cell lung cancer | 47 (21.6) |
Adenocarcinoma | 42 (19.3) |
Squamous | 3 (1.4) |
Large cell | 2 (0.9) |
Mesothelioma | 20 (9.2) |
Epithelioid | 13 (6.0) |
Sarcomatoid | 3 (1.4) |
Biphasic | 4 (1.8) |
Others | 63 (28.9) |
Small-cell lung cancer | 2 (0.9) |
Breast | 27 (12.4) |
Renal | 2 (0.9) |
Ovarian adenocarcinoma | 7 (3.2) |
Papillary serous | 4 (1.8) |
Melanoma | 2 (0.9) |
Colorectal | 1 (0.5) |
Chronic lymphocytic leukemia | 4 (1.8) |
Lymphoma/lymphoproliferative | 2 (0.9) |
Parotid | 1 (0.5) |
Sarcoma | 2 (0.9) |
Thyroid | 1 (0.5) |
Laryngeal | 2 (0.9) |
Esophageal | 1 (0.5) |
Vulvar | 1 (0.5) |
Carcinoma unknown primary | 4 (1.8) |
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Nonspecific pleuritis | 64 (29.4) |
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Reactive mesothelial changes | 10 (4.6) |
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Atypical mesothelial changes | 9 (4.1) |
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Granulomatous pleuritis | 3 (1.4) |
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Eosinophilic pleuritis | 1 (0.5) |
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Hematoma | 1 (0.5) |
We found that pleural nodularity identified on endoscopy had good sensitivity (76%) and specificity (91%) for malignancy in our cohort (Table
Performance characteristics of endoscopic findings related to malignancy, in 218 patients undergoing medical thoracoscopy for diagnostic purposes.
Endoscopy findings | Sensitivity |
Specificity |
PPV |
NPV |
---|---|---|---|---|
Pleural nodules | 76 (52.3–65.7) | 91 (82.6–95.8) | 92.5 (85.2–96.4) | 72.3 (62.9–80.2) |
Pleural thickening | 55.8 (46.8–64.5) | 37 (27.2–48) | 56.3 (47.2–64.9) | 36.7 (26.9–47.5) |
Adhesions | 36.4 (28.3–45.4) | 46.1 (35.6–56.9) | 49.5 (39.1–59.9) | 33.3 (57.5–74.8) |
Erythema | 18.6 (12.5–26.6) | 73 (62.4–81.6) | 50 (35.4–64.5) | 38.2 (31–46) |
Calcified pleural plaques | 3.9 (1.4–9.3) | 93.3 (85.4–97.2) | 45.5 (18.1–75.4) | 40.1 (33.4–47.1) |
Pleural plaques | 6.2 (2.9–12.2) | 94.4 (86.8–97.9) | 61.5 (32.3–84.9) | 41 (51.9–65.8) |
Postprocedure details.
|
|
Days before catheter removal (median days, IQR) | 34 (14.0–81.5) |
Repeat diagnostic procedure performed ( |
11 (5.0) |
Repeat diagnostic pleural procedure performed ( |
9 (4.1) |
|
|
|
|
New diagnosis made | 8 (3.7) |
Mesothelioma | 6 (2.8) |
Non-small-cell lung cancer | 1 (0.5) |
Thymoma | 1 (0.5) |
Of the 218 outpatient MT and IPC insertions performed, only two patients (0.9%) required hospital admission after procedure. One patient had significant enlarging pneumothorax requiring connection to suction while the other patient had a syncopal event after procedure. Both were discharged after a short hospital stay. A total of four patients required administration of a reversal agent during the procedure for difficulties resulting from conscious sedation; three of these patients received below average doses of sedation. IPC related complications include 8 patients (3.7%) with nondraining IPC requiring intervention and 6 patients (2.8%) who developed pleural infection. The IPC remained in place for a median of 34 days after the procedure. Tumor seeding along the MT and IPC tract was noted in 4 patients (1.8%); all 4 of these patients had a diagnosis of mesothelioma. There was no procedure associated mortality.
Complications.
Complication |
|
---|---|
Blocked catheter requiring intervention | 8 |
Pleural infection | 6 |
Tumor growth at catheter site | 4 |
Sedation reversal agent administered | 4 |
Admission required after procedure | 2 |
This large Canadian cohort adds further evidence that outpatient MT can be performed safely and effectively. Furthermore, our outcomes are comparable to prior reports in this regard [
We did not exclude patients on the basis of performance status alone. In fact, 33.5% of patients who had this procedure as an outpatient had an ECOG greater than two. We believe there are several important factors that contributed to the safe completion of the procedure in our patients. First, this is both a diagnostic and therapeutic procedure, and most patients feel better after completion than they did at the time of initial assessment. Second, our patients underwent moderate conscious sedation, similar to the doses administered for bronchoscopy in most Canadian centers, rather than general anesthesia. By avoiding excess sedation, patients were able to breathe spontaneously and became fully awake quickly after the procedure was complete. Third, adequate observation time is important to assess for complications. For example, some patients may have a small pneumothorax that may be due to either a trapped lung, small alveolar pleural fistula, or procedure related. We found that if the pneumothorax had not enlarged after two hours of observation, then they were safe to be discharged home and reviewed in clinic in two weeks. Only one patient in our cohort required a short hospitalization for an enlarging pneumothorax that was captured by the two-hour follow-up chest X-ray. Fourth, IPC follow-up and care by home care nursing services are important to avoid hospital visits. Home care nursing has contact information for our clinic and is able to easily obtain troubleshooting assistance. If the concerns are not easily addressed over the phone, an extra clinic follow-up visit can be arranged. Also patients in further rural areas can be treated at home due to home care services. We feel this arrangement is vital to the safety and efficacy of our outpatient program.
The complications experienced were generally minor and the low rates were comparable to previously published data [
Pleural nodularity was an excellent predictor of malignancy with a positive predictive value of 92.5% and negative predictive value of 72.3%. The sensitivity was 76% and specificity 91% (Table
NSP and reactive mesothelial changes were the most common nonmalignant pathological diagnosis in our cohort (34%). The follow-up of this group of patients is an evolving area of interest. Prior reports have suggested that between 3.5 and 12% of patient with this finding will end up with a diagnosis of pleural malignancy generally made within one year of follow-up, particularly mesothelioma [
In our cohort of patients undergoing both MT with IPC insertion, the median time to catheter removal was 34 days. In a review of IPC insertions without MT, the median time to catheter removal was reported to be between 44 and 60 days [
Our study has several limitations. Our follow-up period was a minimum of two years, which may limit our conclusions as to the final outcomes of patients with NSP. However, prior data suggests that one-year follow-up was sufficient and is consistent with our cohort [
MT combined with IPC placement can be used safely and successfully as an outpatient procedure. Particularly in Canada, where the healthcare system is publically funded and resource allocation is carefully scrutinized, outpatient MT may be a convenient and potentially cost-saving alternative to inpatient operative procedures, although this requires further study. We believe that MT should be a key component of pleural disease treatment programs.
The authors have no financial disclosures to declare.
The authors have no conflicts of interest to declare.