THE IMPACT OF THORACOSCOPY ON THE MANAGEMENT OF PLEURAL DISEASE

Study objective: To describe the diagnostic efficacy, morbidity, and p atient outcome of thoracoscopy; to quantify the direct impact of thora coscopy on clinical management; and to determine preoperative variable s associated with finding malignancy at thoracoscopy to aid patient se lection. Design: Retrospective chart review of consecutive cases of th oracoscopy for pleural disease. Setting: Single tertiary medical cente r. Patients: One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 thro ugh 1992). Measurements and results: Final diagnoses were 98 (54%) mal ignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a d iagnostic sensitivity of 95% for malignancy and 100% for benign diseas e. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cyt ologic specimens. Chart review by preestablished criteria showed infor mation obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least on e perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was perfo rmed, although none died within 48 h. There was one thoracoscopy-relat ed death. Sixty-two (34% patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathorac ic malignancy present at thoracoscopy died within 6 months. Patients f ound to have malignant pleural disease by thoracoscopy were more likel y to have a preoperative history of a malignancy (p=0.001). Age more t han 50 years was associated with finding malignancy at thoracoscopy (p =0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy(p=0.004). Preoperative pleural data showed that idiop athic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions. Conclusions: (1) Thoracoscopy increases yield for malignan t and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management i n 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignan t pleural disease, thoracoscopy has its greatest diagnostic yield in o lder patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.