Pleural Sonogram: Tissue Attributes and Guide for Forceps Biopsy

Research Article

Austin J Pulm Respir Med 2016; 3(2): 1045.

Pleural Sonogram: Tissue Attributes and Guide for Forceps Biopsy

Abumossalam AM¹*, Abdalla DA¹, Abd E¹_khalek AM² and Shebl AM³

¹Thoracic Medicine Department Mansoura University, Egypt

²Radiodiagnosis Department, Mansoura University, Egypt

³Pathology Department, Mansoura University, Egypt

*Corresponding author: Ahmed Mohammed Abumossalam, Mansoura University Hospital, Thoracic Medicine Department, Mansoura Gomheria Street 35516, Egypt

Received: August 04, 2016; Accepted: October 03, 2016; Published: October 05, 2016

Abstract

Methods: In our study forty two patients with exudative pleural effusion included in this study. They underwent TTU using Philips HD 5; superficial two dimensional probe 7-11 MHz for assessment of echographic features of pleural based lesions and observing their linkage with the final diagnosis carried out by ultrasound guided forceps biopsy by using Douay cervical biopsy forceps - 20 cm), trocar and cannula of Anderson needle and closing the inlet by rubber seal.

Results: Neoplastic disorders were arranged as metastatic adenocarcinoma by 57.1% followed by malignant lymphoma and malignant mesothelioma (each by 9.5%) and lastly squamous cell carcinoma (4.8%). Regarding non-neoplastic lesions; tuberculous pleurisy accounted for 7.1% while nonspecific pleurisy showed 11.9%. All echogenic parameters showed highly significant statistical differences among types of pleural lesions (p < 0.001).

Keywords: Forceps Biopsy- Pleural Ultrasound – Malignant- Sonographic features - Tubercuolous

Abbreviations

TTU: Transthoracic Ultrasound; MHz: Mega Hertz; HD: High Definition; US: Ultrasound; cm: centimeter; ml: milliliter; mg: milligram; SPSS: Statistical Package for Social Sciences; ANOVA: Analysis of Variance

Introduction

Ultrasonography (US) is a long-established complementary imaging modality in the diagnosis of pleural effusions. Technical development and ongoing scientific evidence have expanded the spectrum of application for sonography in diseases of the chest over the last few years [1]. With the proper examination method, the whole costal and diaphragmatic pleura can be visualized. According to estimates based on computed tomography, at least 60–70% of the pleura surface can be visualized sonographically [2]. The costal and diaphragmatic pleural segments are the frequent site for most of pleura diseases [3]. Chest sonography has been found useful in detecting pleural and pleural based lesions [4], and evaluating pleural involvement by lung tumor [5] as well as, defining localizing loculated or minimal effusion before thoracentesis [6-8]. The value of color duplex sonography of the pleura, however, has not been systematically evaluated, but it is helpful in distinguishing tumor-like lesions and infiltrations. Color duplex sonography, spectral Doppler sonography and contrast-enhanced sonography have achieved a position of significance in the differential diagnosis of space-occupying lesions at the level of the pleura [3]. Thoracoscopy and thoracotomy are the ultimate choice for diagnosing pleural effusion owing to feasibility to take biopsy from multiple pleural sites under vision. However, these latter procedures are associated with certain precautions, complications and discomfort to the patient [9,10]. US guidance increases the diagnostic success rate and decreases the complications associated with interventional procedures such as thoracocentesis, closed tube drainage for pleural effusion and needle biopsy of the pleura [11]. Moreover, it provides adequate tissue sampling of lesions for cytological, histological or microbiological analysis [12]. One of the image-guided procedures is forceps biopsy of the pleura under sonographic guidance which enable the physician to take biopsy from multiple pleural sites and can meet the shortfall between the needle biopsy and those invasive procedures [13,14]. So this work aimed to assess the value of TTU to diagnose pleural based lesions based on sonomorphological criteria and as guidance for forceps tissue biopsy as an alternative method for conventional blind pleural biopsy.

Patients and Methods

A prospective interventional simple double blinded randomized controlled trial (first clinical trial in Mansoura University Thoracic Medicine Department) was conducted on forty two patients with exudative pleural effusion based on Light criteria, 2011 [15]. They were assembled from out-patient clinic of Thoracic Medicine department, Mansoura University Hospitals during the period from July 2014 to December 2015. Patients signed their written consents after detailed explanation of the study protocol. Local ethical approval had been obtained.

Inclusion criteria: Patients with exudative pleural effusion

Exclusion criteria:

1- Previously known etiology of pleural effusion.

2- Transudative pleural effusion.

3- Frozen chest due to organized empyema or pleurodesis.

4- Patients with bleeding tendency or blood coagulation defects.

5- Obese patients

6- Severely disabled patients

7- Patient with skeletal deformities and kyphoscoliosis.

Procedure

Pleural echography: - The patients were evaluated with the following echographic signs during the TTU procedure using ultrasound apparatus (Philips HD 5 , Japan, with superficial two dimensional probe 7-11MHz) ; pleural sonomorphology

1- Shape of pleural based lesion.

2- Pleural layer involved.

3- Echogenecity

4- Secondary changes (necrosis and degenerations)

5- Doppler study (decreased vascularity or increased with neovasculatrization).

6- Echoinvasion of surrounding structures.

7- Borders of the pleural lesion (ill defined / well defined) [16].

Forceps biopsy: - Patients were submitted for the procedure once. The study was conducted via an ultrasound apparatus (Philips HD 5, Japan, with superficial two dimensional probe 7-11MHz), biopsy forceps (Douay cervical biopsy forceps - 20 cm), trocar and cannula of Anderson needle and closing the inlet by rubber seal. The Procedure was carried out using the two-hand technique under US observation. The desired skin site for instrument insertion was determined according to the site of the pleural lesion which was identified by US. The patient was then received analgesic (biprofenid 150 mg) in a sitting position. The skin at the biopsy site was sterilized and anesthetized with 5–10 ml of 2% xylocaine followed by making a stab incision with size 11 scalpel blade alongside the intended biopsy track. The skin incision was followed by introduction of the trocar and cannula into the pleural space. The trocar was then withdrawn and the mouth of the cannula occluded with the finger pressure simultaneously with closure of the cannula valve to prevent leaking of any air into the pleural cavity. Rubber inlet seal was then fixed at the mouth of the cannula to ensure that no fluid or air could pass during introduction of the forceps. During forceps introduction through the cannula; the valve was opened and simultaneously the US probe was applied to the chest wall enveloped in sterile gloves with enclosed gel. The operator held the cannula and the biopsy forceps while the assistant held the US probe in order to direct the operator to the pleural lesion to take biopsy. Following biopsy, the forceps withdrawn gradually and the cannula valve closed. Further biopsy from different sites was achieved by the reintroduction of the forceps and changing the angle of the cannula at the skin simultaneously with the changing position of the probe. The incision was then sutured by 2 zero stitches silk. All biopsies were placed in 10% formalin and sent to the pathologist for histopathological examination. Medical thoracoscopy was done for cases with nonspecific pleurisy that confirmed the diagnosis of chronic fibrinous pleurisy. Assurance of the results exceeded those procedures by following up these patients either with neoplastic and nonneoplastic disorders.

Statistical analysis

Data was analyzed using SPSS (Statistical Package for Social Sciences) version 21. Qualitative data was presented as number and percentage. Quantitative data was presented for normality by Kolmogrov-Smirnov test. Normally distributed data was presented as mean and standard deviation. Comparison between groups was done using one way ANOVA test. Student t-test was used to compare between two groups. P value < 0.05 was considered significant.

Results

Table 1 showed that this study was conducted on forty two patients with mean age of studied cases was 53.71 with standard deviation 18.072 with median 53. Their sex was matched (50% male and 50% females) with higher median age in metastatic adenocarcinoma and nonspecific pleurisy than other pathological pleural lesions.