Background. To compare the diagnostic value of thoracoscopic biopsy, fluid cytology, and Abrams needle biopsy, the authors analyzed prospectively the records of 188 patients with malignant pleural mesothelioma examined between 1973 and 1990. Symptoms were pleural effusion in 173 patients, empyema in 1, spontaneous pneumothorax in 1, and radiologic tumor without effusion in 13.
Methods. Thoracoscopy was performed using a rigid thoracoscope under local anesthesia with neuroleptanalgesia. A total of 10–20 biopsies were taken from the parietal, diaphragmatic, and visceral pleura. Each diagnosis was confirmed by the French panel of mesothelioma pathologists. To prevent parietal seeding, radiation therapy at a dose of 21 Gy was administered during a period of 3 days to all points of entry.
Results. Tolerance to thoracoscopy was good. The only complications were subcutaneous emphysema (1 patient), local pleural infection (4 patients), hemorrhage of less than 100 ml (3 patients), and temperature of 38–38.5°C (26 patients). In 137 patients, the cavity was free, and complete endoscopic inspection was achieved. In 51 patients, inspection was limited by adhesions that were severed to obtain biopsy. Nonspecific inflammation was observed in 12 patients (6.5%), nodules in 92 (49%), thickening in 21 (11%), and mixed lesions in 63 (33.5%). Diagnosis was achieved by thoracoscopy in 98% of patients, by fluid cytology in 26%, and by needle biopsy in 21%.
Conclusion. In most patients, thoracoscopy allows complete visualization of the pleural cavity and provides high‐quality biopsy samples. The diagnostic accuracy of thoracoscopy is similar to open thoracotomy, but the procedure is far less invasive, usually requiring that the patient remain in the hospital only 1 day.
Epidemiologic and pathologic data demonstrate that malignant mesothelioma occurs preferentially after exposure to long amphibole asbestos fibers. However, mineralogic studies have rarely detected such fibers in the parietal pleura. We hypothesized that the distribution of asbestos fibers in the pleura was heterogeneous and that they might concentrate in certain areas, as does coal dust in patients showing anthracotic "black spots" of the parietal pleura during thoracoscopy. We collected thoracoscopic biopsy samples from these black spots and from normal areas of the parietal pleura and lung from 14 subjects (eight with and six without asbestos exposure). Asbestos content was determined by transmission electron microscopy. In exposed subjects, mean fiber concentrations were 12.4 +/- 9.8 x 10(6) fibers/g of dry tissue in lung, 4.1 +/- 1.9 in black spots, and 0.5 +/- 0.2 in normal pleura. In unexposed patients, concentrations were 0, 0.3 +/- 0.1, and 0, respectively. Amphiboles outnumbered chrysotile in all samples. A total of 22.5% of fibers were > or = 5 microns in length in black spots. A histologic similarity of these black spots with milky spots is suggested by conventional and electron microscopy. We conclude that the distribution of asbestos fibers is heterogeneous in the parietal pleura. Indeed, the fibers concentrate in black spots, where they can reach high concentrations. These findings could explain why the parietal pleura is the target organ for mesothelioma and plaques.
Background. Thoracoscopy appears to be essential in identifying tumors at the beginning of pleural disease.
Methods. Between 1973 and 1990, diagnostic thoracoscopy was carried out in a prospective series of 188 patients with malignant pleural mesothelioma (MPM). Biopsy samples were obtained in all cases, and diagnosis was confirmed by the French panel of mesothelioma specialists. In all patients we noted the degree of involvement of the parietal, diaphragmatic, or visceral pleura, and classified patients according to the Butchart system: Stage I (66 patients), II (110 patients), III (4 patients), and IV (8 patients). To assess prognostic factors, a multivariate analysis of clinical and endoscopic findings was performed according to the Cox model.
Results. The most favorable factors were absence of weight loss at the time of diagnosis, absence of involvement of the visceral pleura, Butchart Stage I, and epithelial histopathologic type. When Stage I patients were subdivided into two groups according to whether or not they displayed involvement of the visceral pleura, a significant difference in survival was noted (32.7 months versus 7 months, respectively; P < 0.001).
Conclusions. Based on these findings, we propose to divide Butchart or Mattson Stage I into two subgroups, i.e., Stage IA in which only the parietal or diaphragmatic pleura is involved and Stage IB in which the visceral pleura is invaded. In the International Union Against Cancer (UICC) classification, T1 should be used for tumors restricted to the parietal or diaphragmatic pleura and T2 for tumors with additional involvement of the visceral pleura.
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