For and Against
The case for performing pleural biopsies for the aetiological diagnosis of exudates. Yes
¿Se debe realizar una biopsia pleural para el diagnóstico etiológico de los exudados? Sí
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Yes" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "420" "paginaFinal" => "422" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "F. Rodriguez-Panadero" "autores" => array:1 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Rodriguez-Panadero" "email" => array:1 [ 0 => "frodriguezpan@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Médico-Quirúrgica de Enfermedades Respiratorias (UMQER), Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Laboratorio de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Se debe realizar una biopsia pleural para el diagnóstico etiológico de los exudados? Sí" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">When faced with pleural effusion (PE) of unknown origin after a clinical evaluation and a pleural fluid (PF) analysis, most guidelines recommend a pleural biopsy (PB) to rule out a tumor and tuberculosis.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Pleural biopsy when faced with suspected tuberculosis</span><p id="par0010" class="elsevierStylePara elsevierViewall">The definitive diagnosis of pleural tuberculosis should be based on the detection of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> in sputum, PF or tissue obtained by PB,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> the latter of which is indicated in the four circumstances listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Thoracoscopy is recommended when we need to differentiate between tuberculous pleurisy (especially in PE with neutrophilia and multiloculated PE) and complicated parapneumonic PE. Thoracoscopy allows for a debridement and taking biopsies under visual control.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The coexistence of malignant PE and tuberculosis is not exceptional,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> especially in cases of mesothelioma. Thoracoscopy is therefore recommended if pleural nodules are observed and adenosine-deaminase (ADA) levels in the PF are high.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pleural biopsy in effusions suspected of neoplasia</span><p id="par0020" class="elsevierStylePara elsevierViewall">Malignant PE constitutes the main cause of pleural exudate (excluding the parapneumonic type), although pleural neoplasia can occur without PE. A study conducted on autopsies found metastatic involvement of the pleura in 29% of 191 cases with malignant tumors in some organ; however, there was PE in only 15% of these patients.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> More than a third of malignant PEs are produced by lung cancer, followed by breast cancer.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">6,7</span></a> Depending on the prevalence of asbestos-related diseases, mesothelioma can be the third leading cause of malignant PE; however, we should also consider lymphoma, ovarian tumors and others.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The yield of cytology is approximately 60% and depends on the extent of the tumor in the pleura and the nature of the primary neoplasm. In general, the positivity of cytology is higher in breast and ovarian cancer and lower in lymphomas, sarcomas and mesotheliomas.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> If lymphoma is suspected, flow cytometry in the PF can be very useful.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">PE can be observed with a malignant tumor in an organ, without actual direct tumor involvement of the pleura (“paramalignant” PE). A necropsy study found this type of PE in 17% of patients with neoplasia<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>; the main causes are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. To establish as paramalignant, the PE must rule out tumor involvement of the pleura with certainty; however, neither cytology nor needle PB are sufficiently sensitive to achieve this certainty. Thoracoscopy would therefore be the better option.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">If malignant PE is suspected, PB is especially indicated in three circumstances (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>): (1) PE coexisting with lung cancer and with negative PF cytology, (2) suspected mesothelioma and (3) a need to implement retreatment for relapsing patients after chemotherapy.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pleural effusion coexisting with lung cancer and with negative pleural cytology</span><p id="par0040" class="elsevierStylePara elsevierViewall">A series of 971 consecutive patients with lung cancer found PE in the chest radiography in 72 patients (7%). The pleural cytology was positive in only 40% of those patients.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> However, there was pleural metastasis in 75% of these cases.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> As a result, a thoracoscopy is advisable to rule out unsuspected pleural metastases or invasion of the mediastinum before attempting surgical resection in these patients.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pleural biopsy when faced with suspected mesothelioma</span><p id="par0045" class="elsevierStylePara elsevierViewall">Needle PB is seldom worthwhile in these cases due to the small size of the samples obtained<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a>; however, its performance can improve significantly if performed with real-time ultrasonography<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> or computed tomography.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14,15</span></a> Medical thoracoscopy, however, facilitates taking more and larger samples. Video-assisted thoracoscopic surgery (VATS) also enables better tumor staging and can even perform pleurectomy/decortication in selected cases, although it requires general anesthesia and tracheal intubation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pleural biopsy for retreatments in relapsing patients after chemotherapy</span><p id="par0050" class="elsevierStylePara elsevierViewall">In these cases, “personalized therapy” needs to be applied, which is adapted to the heterogeneity and the potential mutations of the primary tumor or of its metastases.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> It is likely that the analysis of the circulating tumor cells (the so-called “liquid biopsy”) will resolve this problem in the future,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> but at this time we need sufficient tissue with which to investigate those factors related to better treatment response.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Thoracoscopy has high diagnostic performance, can be performed with local anesthesia and mild sedation and presents no greater complications than with needle BP.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> However, needle BP can be performed in an outpatient regimen, while thoracoscopy is more complex and, especially when combined with pleurodesis, requires hospitalization.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> The technique selection depends in considerable measure on the availability and degree of training, as well as the clinical aggressiveness of the PE.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author declares that he has no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres907027" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec887311" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres907028" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec887310" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Pleural biopsy when faced with suspected tuberculosis" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Pleural biopsy in effusions suspected of neoplasia" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Pleural effusion coexisting with lung cancer and with negative pleural cytology" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Pleural biopsy when faced with suspected mesothelioma" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Pleural biopsy for retreatments in relapsing patients after chemotherapy" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-10" "fechaAceptado" => "2017-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec887311" "palabras" => array:4 [ 0 => "Pleural biopsy" 1 => "Malignant pleural effusion" 2 => "Tuberculous pleurisy" 3 => "Thoracoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec887310" "palabras" => array:4 [ 0 => "Biopsia pleural" 1 => "Derrame pleural maligno" 2 => "Pleuritis tuberculosa" 3 => "Toracoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pleural biopsies are especially indicated in the following circumstances: (a) inconclusive pleural fluid analysis and negative sputum study, if adenosine deaminase (ADA) levels are unavailable; (b) suspected multi-resistant tuberculosis; (c) a need for differentiating tuberculous pleurisy (if it progresses with neutrophilia) and complicated parapneumonic effusion; (d) malignant pleural effusion coexisting with very high ADA levels; (e) effusion coexisting with lung cancer and negative pleural cytology; (f) suspected mesothelioma; and (g) need for implementing re-treatment for patients with relapse after chemotherapy. Image-guided needle biopsy is recommended for cases a and b, while thoracoscopy is preferable for the other cases.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La biopsia pleural está especialmente indicada en las siguientes circunstancias: a) análisis del líquido pleural no concluyente y estudio de esputos negativo, si no se dispone de adenosina-desaminasa (ADA); b) sospecha de tuberculosis multirresistente; c) necesidad de distinguir entre pleuritis tuberculosa (si cursa con neutrofilia) y derrame paraneumónico complicado; d) derrame pleural maligno coexistiendo con ADA muy elevada; e) derrame coexistiendo con cáncer de pulmón y con citología pleural negativa; f) sospecha de mesotelioma, y g) necesidad de aplicar retratamiento en pacientes con recaída tras quimioterapia. Es recomendable hacer biopsia con aguja guiada por técnicas de imagen en a) y b), y sería preferible hacer toracoscopia en el resto de las situaciones.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodriguez-Panadero F. ¿Se debe realizar una biopsia pleural para el diagnóstico etiológico de los exudados? Sí. Rev Clin Esp. 2017;217:420–422.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviation</span>: ADA, adenosine-deaminase.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indications for pleural biopsy \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Suspected tuberculous pleurisy</td><td class="td" title="table-entry " align="left" valign="top">Inconclusive pleural fluid analysis and negative sputum, if ADA is not available \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspected multiresistant tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difference between tuberculous pleurisy (with pleural fluid neutrophilia) and complicated parapneumonic effusion <span class="elsevierStyleItalic">(thoracoscopy preferable)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malignant pleural effusion coexisting with very high ADA <span class="elsevierStyleItalic">(thoracoscopy preferable)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Suspected neoplastic effusion</td><td class="td" title="table-entry " align="left" valign="top">Pleural effusion of unknown origin, coexisting with lung cancer (<span class="elsevierStyleItalic">thoracoscopy preferable</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suspected mesothelioma (<span class="elsevierStyleItalic">thoracoscopy preferable</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need to implement retreatment in patients with relapse after chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525558.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Indications for pleural biopsy with suspected tuberculous or malignant effusion.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstructive pneumonitis or atelectasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmonary embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphatic obstruction in the mediastinum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoracic duct obstruction (with or without chylothorax) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-radiation/chemotherapy syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypoalbuminemia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525557.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Possible causes of paramalignant pleural effusion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "BTS Pleural Guideline Group" "etal" => false "autores" => array:3 [ 0 => "C. 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|---|---|---|---|
| 2024 April | 1 | 0 | 1 |
| 2023 March | 8 | 4 | 12 |
| 2017 October | 4 | 2 | 6 |
| 2017 September | 0 | 1 | 1 |
