1. MEDICAL THORACOSCOPY IN THE DIAGNOSIS OF PLEURAL DISEASE “ …a minimum invasive technique which allows the examination of the pleural space in a spontaneously breathing patient, offering great solutions …” Dimitrios G Oikonomou Interventional Pulmonologist Interbalcan Medical Center, Thessaloniki, Greece.

2. MEDICAL THORACOSCOSPY Definition Medical thoracoscopy/pleuroscopy is a minimally invasive procedure that allows access to the pleural space using a combination of viewing and working instruments. It also allows for basic diagnostic (undiagnosed pleural fluid or pleural thickening ) and therapeutic (pleurodesis) procedures to be performed safely. Interventional Pulmonary Procedures: Guidelines from ACCP Chest 2003;123:1693-1717

3. Thoracoscopy is not a new technique; H.C.Jacobeus, the Swedish internist, was the first to perform thoracoscopy in 1910, as a diagnostic procedure for exudative pleuritis Thoracoscopy was “reinvented” at around 1980.

4. VATS vs Medical thoracoscopy Medical thoracoscopy is generally characterised as thoracoscopy performed under local anaesthesia in the endoscopy suite with the use of nondisposable instruments, and is generally for diagnostic purposes. VATS is as a keyhole surgical procedure in the operating room, under general anaesthesia with one-lung ventilation using disposable instruments, generally for therapeutic purposes

5. VATS vs Medical Thoracoscopy Feature Medical Thoracoscopy/ VATS pleuroscopy Purpose Diagnosis/Pleurodesis Minimally invasive thoracic surgery Location Endoscope suite/operating room Operating room Anesthesia Local with moderate sedation Single lung ventilation Technique Single puncture/Double puncture Multiple punctures Instruments Nondisposable Disposable Simple Complex

6. VATS vs Medical Thoracoscopy MT/P MT/P or VATS VATS Pleural effusions Spontaneous pneumothorax Lung procedures Pleural effusions Staging Lung biopsy of unknown etiology Staging of lung cancer Pleurodesis by talc poudrage Lobectomy Staging of diffuse Empyema (stage I/II) Pneumonectomy malignant mesothelioma Pleurodesis by talc poudrage Drainage Decortication or any other agent Diffuse pulmonary diseases Lung volume reduction surgery Localised lesions Pleura procedures Chest wall/diaphragm Pleurectomy(pneumothorax) Sympathectomy/splachnicectomy Drainage/decortication(empyema stage III) Esophageal procedures Excision of cyst,benign tumors, esophagectomy,anti-reflux procedures, mediastinal procedures. Resection of mediastinal mass Thoracic duct ligation Pericardial window Sympathectomy

7. INDICATIONS FOR MEDICAL THORACOSCOPY Diagnosis of pleural effusion Pleural biopsy Spontaneous pneumothorax Empyema (early stage) Chemical pleurodesis

8. INDICATIONS FOR MEDICAL THORACOSCOPY Thoracoscopy is the gold standard for the diagnosis and treatment of pleural diseases. Its diagnostic yield is 95% in patients with malignant pleural disease, with approximately 90% successful pleurodesis for malignant pleural effusion and 95% for pneumothorax. Pleural effusion of unknown origin remains the commonest indication of pleuroscopy and is considered to be one of the techniques with the highest diagnostic yield in “aspiration cytology negative exudative effusions”.

9. PLEURAL EFFUSION: THE FIRST STEPS Diagnostic thoracocenthesis Thoracocenthesis is indicated as the first step in the work-up of practically every pleural effusion of unknown origin Total and differential cell counts, biochemical study (including total proteins, lactate dehydrogenase (LDH), glucose, adenosinedeaminase (ADA) Cytology analysis should also be included in the initial work-up. Thoracocenthesis provides information allowing classification of the effusion in 90% of patients. A definite diagnosis is obtained in 20% of the patients after initial thoracentesis After the first analysis, the effusion has to be classified into either transudate or exudate following the criteria of LIGHT The cause remains unclear in 25% of the pleural effusions, and about half of those will later on be diagnosed with a MPE

11. Should thoracoscopy always be performed in non-specific pleuritis? The alternative to thoracoscopy is a wait-and-see approach. In patients with no diagnosis at the end of 8-15 days, thoracoscopy should be carried out.

12. MALIGNANT PLEURAL EFFUSIONS One of the leading causes of exudative effusions; 42-77% of exudative effusions are secondary to malignancy Nearly all neoplasms can involve the pleura Lung cancer is the most common Breast carcinoma is the second most common Lymphomas (Hodgkin and non-Hodgkin) are also important cause of MPE

13. SENSITIVITY (%) OF DIFFERENT BIOPSY METHODS IN MALIGNANT PLEURAL EFFUSIONS (Loddenkemper et al, 1983b)

14. Eventual results in 709 patients with exudative pleuritis after thoracoscopy ( Janssen 2003)

15. Final diagnosis in 31 patients with false-negative thoracoscopy. Mesothelioma 10 Non-Hodgkin lymphoma 5 Adenocarcinoma 4 Non small cell lung cancer 4 Small cell lung cancer 1 Breast cancer 3 Other cancer 4

16. KEY POINTS Medical thoracoscopy has an overall diagnostic yield above 85% for MPE Patients who after undergoing diagnostic thoracoscopy are not found to have a MPE are highly unlikely to develop one during at least the following 3 years ( Mouchantaf F, Villanueva AG, J Bronchol Intervent Pulmonol 2009; 16:25–27 ) Thoracoscopic findings result in important changes in treatment in patients with MPE;clinical management is influenced by thoracoscopy (Harris et al, Chest 1995; 107: 845–852 ) Thoracoscopy is the procedure of choice to differentiate between resectable and unresectable cancer if there is also pleural effusion; in case of pleural metastasis, the stage of disease migrates to IIIB, with a prognosis of stage IV

17. EQUIPMENT FOR THORACOSCOPY Flexible bronchoscope Semi-rigid thoracoscope Minithoracoscopy (2&3mm, 2 points of entry) The standard equipment for thoracoscopy (as developed by Boutin) is the 7mm rigid thoracoscope

21. Complications of medical thoracoscopy: one of the safest procedures Subcutaneous emphysema 0.6–4.9% Air leak 0.5–8.1% Air embolism 0.2% Empyema 0.5–2.7% Hemorrhage (major)% Shock 0.2% Cardiac arrhythmias 2% Chest wall seeding by malignancy 0.5–4%

22. CONTRAINDICATIONS OF MEDICAL THORACOSCOPY Absolute contraindication: Absence of potential pleural space ( 6-10 cm usually due to extensive adhesions). Relative contraindications: Uncorrectable coaggulopathy Multiple pleural adhesions Unstable cardio-respiratory status Uncontrollable cough Inability to lie flat for an hour

23. Summary: advantages of medical thoracoscopy in the diagnosis of pleural effusions. Fast and definate biopsy diagnosis including TB culture and hormone receptor assay Biopsies not only from chest wall pleura but also from diaphragm Staging in lung cancer and diffuse mesothelioma Exclusion of malignancy and tuberculosis with high probability Gold standard for scientific studies

24. Summary: advantages of medical thoracoscopy in the treatment of pleural effusions. Complete and immediate fluid removal Evaluation of loculations Evaluation of the reexpansion potential of the lung Early start to drug treatment In addition better diagnosis+staging Talc poudrage for pleurodesis with uniform distribution of talc, under visual control.