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Rapid Responses: Rapid Responses published:
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Don't forget surgical techniques
- michael poullis (27 January 2007)
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tuberculous pleural effusion can simulate malignant pleural effusion
- oscar,m jolobe (27 January 2007)
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VATS remains the gold standard for investigation of malignant pleural effusion
- Loic Lang-Lazdunski, John E Pilling (31 January 2007)
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michael poullis, consultant cardiothoracic surgeon ctc liverpool l14 3pe
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Rahman et al in their article on Investigating suspected malignant pleural effusion, unfortunately mentions medical thoracopcopy as the only diagnostic and therapeutic intervention should needle aspiration or closed pleural biopsy fail. This unfortunately may not be best practice for all patients, and certainly does not constitute a comprehensive assessment review on how to manage this often difficult condition. Unfortunately medical thoracoscopy is only useful for simple non loculated effusions with minimal visceral lung involvement, an important fact that the authors failed to mention. Failure to appreciate this could result in a failed procedure at best, but unfortunately could also result in significant pulmonary parenchymal damage. In addition pleurodesis will not work in cases with significant visceral lung involvement. Surgical thoracoscopy enables pleural loculations to be broken down, and allows assessment of the advisability of talc instillation. Unnecessary talc instillation in a case that will clearly never work unfortunately can lead to formation of an empyema. In summary these sometimes seemingly simple, but often complicated cases should be discussed with a thoracic surgeon. In addition unaudited “I’ve been trained so I’ll have a go at medical thorascopcopy” should be discouraged for the sake of putting the patient first. Competing interests: None declared |
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oscar,m jolobe, retired geriatrician 1 The Lodge, 842 Wilmslow Road, didsbury, manchester, M20 2RN
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A blood stained pleural effusion falls into the category cited in the title, namely, suspected malignant pleural effusion(1). In a study dealing with "clinical implications of appearance of pleural fluid at thoracentesis" 47% of 59 "bloody"(ie dark red, similar to blood)pleural effusions were attributable to malignancy, and, among the rest of the bloody pleural effusions were two instances of tuberculous pleural effusion(2). In countries with a high prevalence of tuberculosis malignancy is still the commonest cause of bloody pleural effusion but the next most common causes are tuberculosis and trauma(3). Accordingly in the absence of associated stigmata of malignancy, even pleural effusion whose outward apparance is highly suggestive of malignancy should be considered to be of potentially tuberculous aetilogy, and appropriate tests should be instigated if initial investigations are not confirmatory of malignancy. In this context appropriate tests for a tuberculous aetiology include, not only closed biopsy(with histology and culture), as mentioned by the authors(1), but also quantification of interferon gamma in the pleural fluid(4). In the context of tuberculous pleural effusion the latter parameter is associated with sensitivities and specificities of the order of 90-100%(4)(5), highly comparable results being also generated by the adenosine deaminase(ADA) content of the pleural fluid(4)(5). Given these opportunities to make a rapid diagnosis of tuberculous pleural effusion, whenever the diagnosis of suspected malignant effusion remains in doubt, especially if the patient is from a high-risk population, there should be minimum delay in initiating tests for a tuberculous aetiology, and these tests should include interferon gamma and ADA. References (1) Rahman NM., Davies RJO., Gleeson FV Investigating suspected maliganant pleural effusion BMJ 2007:334:206-7 (2)Villena V., Lopez-Encuentra A., Garcia-Lujan R et al Clinical implications of appearance of pleural fluid at thoracocentesis Chest 2004:125:156-9 (3)Onadeko BO Haemorrhagic pleural effusion in Nigerians Trop Geogr Med 1979:31:57-61 (4)Aoe K., Hiraki A., Murakami T et al Diagnostic significance of interferon-gamma in tuberculous pleural effusions Chest 2003:123:740-44 (5)Gupta UA., Chhabra SK Diagnosing tubercular pleural effusions Chest 2005:127:1078-9 References Competing interests: None declared |
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Loic Lang-Lazdunski, consultant thoracic surgeon Guy's hospital, London, John E Pilling
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We read with interest the article by Rahman and colleagues from Oxford. We were surprised that video-assisted thoracoscopic surgery (VATS) is not mentioned in the article. For more than 15 years VATS has been the cornerstone of investigation and palliation of malignant pleural effusion in those fit for general anaesthetic: Complex loculated effusions can be evacuated and the pleural cavity debrided appropriately. The systematic examination of the mediastinum, pericardium and diaphragm as well as the visceral pleura and underlying lung is easily and safely performed. Multiple targeted pleural biopsies can be performed as well as biopsies of mediastinal nodes as required. The expansion of the lung in response to positive pressure ventilation determines the appropriate method of palliation. If there is apposition of the visceral and parietal pleura talc pleurodesis is the method of choice, where this does not occur talc is detrimental and potentially leads to empyema. In the vast majority of series surgical talc insufflation has been shown to provide superior palliation to talc slurry. Lastly, as a thoracic surgeon operating on a large volume of patients with malignant mesothelioma, VATS represents an excellent staging tool and determinant of the best surgical option for those patients (palliative talc pleurodesis, pleurectomy/decortication or extrapleural pneumonectomy). Competing interests: none |
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