Fluoroscopy-Guided Percutaneous Transthoracic Pleural Forceps Biopsy in Patients With Exudative Pleural Effusion

Abstract

Objective: This study aimed to evaluate the diagnostic performance and procedural characteristics of fluoroscopy-guided percutaneous transthoracic pleural forceps biopsy (PTPFB) in patients with exudative pleural effusion.

Materials and methods: Patients with exudative pleural effusion who underwent PTPFB between May 1, 2014, and February 28, 2023, were included in this retrospective study. The interval between percutaneous catheter drainage (PCD) and PTPFB, number of biopsies, procedural time, and procedure-related complications were evaluated. The sensitivity, specificity, and accuracy of diagnosing malignancy were computed for pleural cytology using PCD drainage, PTPFB, and combined PTPFB and pleural cytology.

Results: Seventy-one patients, comprising 50 male and 21 female (mean age, 69.5 ± 15.3 years), were included in this study. The final diagnoses were benign lesions in 48 patients (67.6%) and malignant in 23 patients (32.4%). The overall interval between PCD and biopsy was 2.4 ± 3.7 days. The interval between PCD and biopsy in the group that underwent delayed PTPFB was 5.2 ± 3.9 days. The mean number of biopsies was 4.5 ± 1.3. The mean procedural time was 4.4 ± 2.1 minutes. Minor bleeding complications were reported in one patient (1.4%). The sensitivity, specificity, and accuracy for pleural cytology, PTPFB, and combined PTPFB and pleural cytology were 47.8% (11/23), 100% (48/48), and 83.1% (59/71), respectively; 65.2% (15/23), 100% (48/48), and 88.7% (63/71), respectively; and 78.3% (18/23), 100% (48/48), and 93.0% (66/71), respectively. The sensitivity and accuracy of cytology combined with PTPFB were significantly higher than those of cytological testing alone (P = 0.008 and 0.001, respectively).

Conclusion: Fluoroscopy-guided PTPFB is an accurate and safe diagnostic technique for patients with exudative pleural effusion, with acceptable diagnostic performance, low complication rates, and reasonable procedural times.

Keywords: Biopsy; Exudate; Fluoroscopy; Forceps; Percutaneous; Pleura.

Fig. 1. Study flowchart of the patients. EBUS-TBNA = endobronchial ultrasound guided transbronchial needle aspiration

Fig. 2. An 82-years-old male presenting with dyspnea and a history of end-stage renal disease, diabetes mellitus, and hypertension admitted to the emergency department. A: The right lower hemithorax is punctured, followed by the insertion of an 8Fr sheath. Subsequently, biopsy forceps are inserted. B: When the tip of the biopsy forceps is in contact with the pleura and resistance is felt, pushing the biopsy forceps slightly further allows for the observation of forceps shaft bending (arrow). The tip of the forceps is open while being fixed to the pleura (arrowhead). C: With the tip anchoring and shaft bending, the biopsy forceps are manipulated to grasp the pleura and retract the pleural tissue. The tip of the forceps is grasping the pleura while being fixed to it (arrowhead). D: The biopsy forceps are gently pushed until resistance is felt while performing the pleural biopsy in the upper hemithorax. E: Once the tip contacts and fixes to the pleura, it is pushed slightly further to bend the shaft (arrow). The tip of the forceps is open while being fixed to the pleura (asterisk). F: In this position, biopsy forceps are manipulated to grasp and retract the pleural tissue to obtain pleural tissue. Note that the tip of the forceps grasping the pleura is fixed to it (asterisk). G: The photograph shows four pieces of pleural tissue obtained.