Predicting malignant pleural effusion during diagnostic pleuroscopy with biopsy: A prospective multicentre study

Abstract

Background and objective: Pleuroscopy with pleural biopsy has a high sensitivity for malignant pleural effusion (MPE). Because MPEs tend to recur, concurrent diagnosis and treatment of MPE during pleuroscopy is desired. However, proceeding directly to treatment at the time of pleuroscopy requires confidence in the on-site diagnosis. The study's primary objective was to create a predictive model to estimate the probability of MPE during pleuroscopy. Methods: A prospective observational multicentre cohort study of consecutive patients undergoing pleuroscopy was conducted. We used a logistic regression model to evaluate the probability of MPE with relation to visual assessment, rapid on-site evaluation (ROSE) of touch preparation and presence of pleural nodules/masses on computed tomography (CT). To assess the model's prediction accuracy, a bootstrapped training/testing approach was utilized to estimate the cross-validated area under the receiver operating characteristic curve. Results: Of the 201 patients included in the study, 103 had MPE. Logistic regression showed that higher level of malignancy on visual assessment is associated with higher odds of MPE (OR = 34.68, 95% CI = 9.17-131.14, p < 0.001). The logistic regression also showed that higher level of malignancy on ROSE of touch preparation is associated with higher odds of MPE (OR = 11.63, 95% CI = 3.85-35.16, p < 0.001). Presence of pleural nodules/masses on CT is associated with higher odds of MPE (OR = 6.61, 95% CI = 1.97-22.1, p = 0.002). A multivariable logistic regression model of final pathologic status with relation to visual assessment, ROSE of touch preparation and presence of pleural nodules/masses on CT had a cross-validated AUC of 0.94 (95% CI = 0.91-0.97). Conclusion: A prediction model using visual assessment, ROSE of touch preparation and CT scan findings demonstrated excellent predictive accuracy for MPE. Further validation studies are needed to confirm our findings.

Local Anaesthetic Thoracoscopy for Pleural Effusion—A Narrative Review

“…Firstly, rapid onsite evaluation (ROSE) of the specimens by histopathologists in real time at the time of LAT is an option, notwithstanding the limitations in assessing some cancers such as mesothelioma where differentiation between benign fibrinous material, atypical mesothelial cells and tumour with ROSE might prove impossible. ROSE has not been tested in large multi-centre trials, but monocentric observational data would suggest that combining radiological imaging and ROSE findings would increase diagnostic yield [ 50 ]. However, widespread applicability is challenging, as having a histopathologist or a cytotechnologist presents at all LAT would not be possible given that, for example, in the United Kingdom at least, there is a lack of histopathologists or cytotechnologists [ 51 ].…”

Increasing diagnostic yield at medical thoracoscopy

“…To the Editors: I congratulate Grosu et al for their impressive work on combining visual assessment of the pleura, rapid on-site evaluation (ROSE) of touch preparation of any pleural biopsies and the presence of pleural nodules/masses on computed tomography. 1 This has not been done together before. I agree with the authors that to know what is being biopsied to prevent further procedures is a valid point but the main reason would be to have a clear answer for the patient, and not have to resort to other modalities such as image-guided biopsies or surgical approaches.…”

“…3 This is currently being tested in a United Kingdom nationwide trial. 4 What would be fascinating for Grosu et al 1 is to describe the set up for ROSE of touch preparation in greater detail as well as evaluate the extra costs and resources associated with this, as the big question which the authors attest to is generalizability of the findings. Furthermore, outdated guidance from international societies (new ones are eagerly awaited this year) would suggest that multiple (in our centre, we encourage 10) thoracoscopic biopsies should be taken, and they should be deep enough and consist of adipose and muscle tissue from multiple sites.…”

“…Furthermore, outdated guidance from international societies (new ones are eagerly awaited this year) would suggest that multiple (in our centre, we encourage 10) thoracoscopic biopsies should be taken, and they should be deep enough and consist of adipose and muscle tissue from multiple sites. Perusing the data, this is not available for Grosu et al, 1 and it would also be good for the authors to speculate on the adequacy of the biopsies they obtained. Notwithstanding these points, I commend the authors again on this study and would value their answers to these questions.…”

Reply

“…From the Authors: We thank Dr Avinash Aujayeb for his thoughtful review and observations on our article in Respirology, which showed excellent predictive accuracy for malignant pleural effusion (MPE) using an algorithm incorporating visual assessment, rapid on-site evaluation (ROSE) of touch preparations (touch preps) and computer tomography scan. 1 Dr Aujayeb correctly points out that in patients with MPE, a variety of treatment modalities are used in clinical practice for relief of dyspnoea. Some MPE treatments, such as thoracentesis, achieve only temporary relief, while placement of an indwelling pleural catheter (IPC), placement of a chest tube with chemical pleurodesis and pleuroscopy with chemical pleurodesis provide more definitive relief.…”