Medical Thoracoscopy

Rigid Thoracoscopy or Flexi-rigid Pleuroscopy?

Kim Hoong Yap; Martin J. Phillips; Y.C. Gary Lee


Curr Opin Pulm Med. 2014;20(4):358-365. 

In This Article

Future Directions

Thoracoscopy has played a significant role in the workup of pleural effusions in the last 100 years since its first introduction. However, the need for pleuroscopy is likely to decrease as other less-invasive alternatives advance (see our other review[31]). For example, modern cytological assessment (with better immunohistochemical and molecular markers) has high sensitivity for most metastatic carcinomas and even for mesothelioma, reducing the need for tissue biopsy. In a recent study of 815 mesothelioma patients, pleural fluid cytology was positive in 68% and verified as accurate against postmortem findings.[32]

Imaging-guided biopsies are attractive alternatives. Ultrasound-guided bedside pleural biopsy has a high yield in suitable patients[33] and is growing in popularity. Maskell et al.[34] showed that CT-guided pleural biopsy was useful in over 80% of patients presented with pleural thickening. Although not formally proven, the sensitivity of imaging-guided biopsy can be further improved with fluorodeoxyglucose positron emission tomography (FDG-PET), especially in patients with diffuse pleural thickening. Targeting FDG-avid areas with imaging-guided biopsy is useful in selected cases (Fig. 8).

Figure 8.

(Left) FDG-avid area demonstrated on PET. (Right) CT-guided pleural biopsy of FDG-avid region. CT, computed tomography; FDG, fluorodeoxyglucose.

Conversely, the usefulness of thoracoscopy as a diagnostic tool has likely reached its peak; attempts to improve the diagnostic yield with thoracoscopy have been disappointing. Autofluorescence[35] and narrow band imaging[36,37] have been evaluated as an adjunct for diagnostic thoracoscopy but have failed to show significant additional advantages.