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Needle biopsy of the pleura 1 was first used after it was shown by Small 2 and others 3 that open biopsy of the pleura was often a good indicator of underlying pulmonary disease. In expert hands the use of the Vim-Silverman needle has produced some very gratifying results. It has, however, two disadvantages: 1. A pleural specimen is often not obtained. 2. There is a danger of boring out a core of lung, especially when there is only a very thin cushion of pleural fluid. In an attempt to overcome these difficulties, I have designed an instrument. Its most important unit is a curet-like needle, which has a side slot shaped as in figure 1 C and is set 2 to 3 mm. from the terminal blunt end; the blunt tip is closed except for a small central hole which allows, if necessary, a small needle to push out

Summary Pleural biopsy by the Vim-Silverman needle was done in 35 cases of pleural effusion without radiographic evidence of lung disease or bacteriological evidence of tuberculosis; 3 cases of empyema; 4 of effusion secondary to malignant disease of the lung and pleura; and 4 cases of effusion secondary to pulmonary tuberculosis. Four biopsies of the group with pleural effusions without apparent cause and one of the effusions secondary to known pulmonary tuberculosis showed tuberculous tissue. One of the cases of malignant effusion showed evidence of malignancy. There were no complications in any case.

Summary A new pleural biopsy needle is hollow with a movable stylet. Three millimeters away from the tip of the needle, there is a hook-like notch for holding the biopsied pleural tissue. Its tip is not sharp enough to damage the lung tissue. As the tip is closed by solder, the specimen does not slip easily. Compared with the Cope needle, biopsy with this needle is easier to perform, and the size of the specimen is much larger. There were no complications in 21 patients.

The Ballestero needle features an oval shaft with eccentric stylette, allowing 90° rotation of the cutting tip after pleural penetration. On withdrawal, the misaligned tip produces easily palpable hooking on the pleura. The tip is held against the pleura; the shaft-cutting jaw is rotated to alignment; the jaws are closed and the instrument is withdrawn.

A case of subcutaneous implantation and growth of mammary cancer following needle biopsy of the parietal pleura is reported. This is a rare complication which does not affect the prognosis of patients with malignant pleural effusions. Fear of such local spread of tumor should not serve as a contraindication to pleural biopsy.

• To evaluate the diagnostic merit of fiberoptic bronchoscopy in pleural effusions, we performed fiberoptic bronchoscopy in addition to thoracocentesis and closed pleural biopsy in 140 patients who were admitted for diagnostic investigation of the causes of pleural effusions. The patients were divided into subgroups based on clinical features and roentgenographic findings of chest x-ray films. In 39 patients, the pleural effusions were due to various nonneoplastic disorders and in 95 patients it was caused by malignancy. In six patients, the causes of the pleural effusions remained undetermined. A final diagnosis was made by pleural examination in 68 patients, by fiberoptic bronchoscopy in 58 patients, and by either one or both in 100 patients. In 82 patients who had no hemoptysis, a final diagnosis was made by pleural examination in 57 cases and by fiberoptic bronchoscopy in 11 cases only. The diagnostic yield of fiberoptic bronchoscopy (47/58) was superior to that of pleural examination (11/58) in 58 patients presenting with hemoptysis. In 74 patients who had pleural effusions as the sole roentgenographic abnormality, the final entity was established by pleural examination in 45 and by fiberoptic bronchoscopy in 12. The diagnostic merit of fiberoptic bronchoscopy was significantly higher in 59 patients who had concurrent pulmonary abnormalities on their chest roentgenograms. A final diagnosis was made in 43 cases by fiberoptic bronchoscopy in comparison with 21 cases by pleural examination. For patients with unknown pleural effusions, fiberoptic bronchoscopy was more likely to yield a diagnosis than thoracocentesis with closed pleural biopsy in those who had hemoptysis or pulmonary abnormality on chest x-ray films, whereas the reverse applied when these features were absent. ( Arch Intern Med 1989;149:855-857)

• To determine the clinical value of a nonspecific pleural biopsy specimen and fluid in malignant neoplasm and tuberculosis, we retrospectively reviewed records of all patients with pleural effusions undergoing the procedure at three community hospitals over six years. Two hundred eleven patients underwent biopsies. Adequate tissue was obtained in 207. The results were compared with the ultimate clinical and pathologic outcome by follow-up for 12 to 72 months. The initial procedure was diagnostic of malignant neoplasm in 54 patients and granulomatous disease in ten. A nonspecific or normal result was found in 143 (68%). Malignant neoplasms or tuberculosis was eventually established in 30 and excluded in 101 of the 143 patients. In 12 patients, no diagnosis was made. The procedure's sensitivities were 65% (malignant neoplasm) and 90% (tuberculosis). One false-positive result occurred in a patient with nontuberculous granulomatous pleuritis. The specificity and positive predictive value were 99% and 98%, respectively. The negative predictive value was 77%. Closed pleural biopsy with simultaneous fluid analysis is a valuable diagnostic procedure in community hospital patients, but a nonspecific result does not exclude malignant disease. (Arch Intern Med1984;144:325-328)

Inspired oxygen concentrations below 55% generally do not injure a patient's lungs. According to Fedullo, the injury increases exponentially as the patient's inspired oxygen concentration rises above 60%. It is the oxygen in the patient's inspired air and not the oxygen dissolved in his blood that damages his lungs. In a similar manner, the other 16 contributors to Poe and Israel's book give their readers a lot of useful and sometimes hard-to-come-by information about managing their patients' pulmonary diseases. When they first visit their physicians, about 95% of the men and women with lung cancer have symptoms. A change in the pattern of an elderly or middle-aged smoker's cough, Quazi warns, should alert the smoker's physician to the probability of a tumor. Finding pleural fluid in a patient with bronchogenic carcinoma, he notes, does not necessarily imply metastatic seeding and inoperability. Thoracentesis and pleural biopsy will help distinguish between malignant

To the Editor.— The importance of a careful and complete history in the evaluation of patients with possible environmental lung disease is illustrated by the following case. A 56-year-old retired army sergeant was seen at the Madigan Army Medical Center in 1969 with right pleuritic chest pain and low-grade fever of three days' duration and was found to have a right-sided pleural effusion. Complete evaluation including thoracentesis and pleural biopsy examination did not show a cause for the effusion. He subsequently has been followed up as an outpatient and has developed bilateral pleural thickening (Figure) compatible with asbestos exposure. When initially queried about occupations generally considered pertinent to asbestosis, eg, asbestos-weaving and steam-pipe lagging, he denied any such occupation. However, when asked to go through his occupational history month-by-month including part-time jobs, he recalled working for nine months at age 16 as a fire-eater in a carnival. This entailed using

To the Editor.— I was interested in the article by Strober et al, "Malignant Pleural Disease: A Radiotherapeutic Approach to the Problem" (226:296, 1973), that emphasized a simple, safe, and effective means of controlling malignant pleural disease. All of their patients had pleural disease as a result of metastases from another primary source, either lung or breast. May I comment briefly on another malignant pleural process that we treated recently with radiotherapy with equally satisfactory results. A 29-year-old man with an unexplained pleural effusion was ultimately found, by an open pleural biopsy (a previous needle biopsy was inconclusive), to have a diffuse malignant pleural mesothelioma. He had been subject to recurrent pleural effusions that had required multiple thoracenteses. There was no known exposure to asbestos. The therapy for this disease is not well established. Surgical excision has been replaced by intrapleural agents such as mechlorethamine hydrochloride and gold Au 198.

Chronic pleural effusion occurred in three patients, one of whom also developed acute pericarditis. A fourth patient developed both pleural and pericardial effusions. All patients had been receiving dantrolene sodium for at least two months. The pleural fluid was a sterile exudate with pleural and peripheral blood eosinophilia in all patients. No pulmonary parenchymal involvement was apparent. Pleural biopsy specimens showed nonspecific inflammation. Resolution of the pleural process was prolonged after dantrolene therapy was discontinued. Although a causal relationship between dantrolene and serosal inflammation remains unproved, this association in four patients warrants careful observation of others receiving long-term dantrolene therapy. (JAMA242:2772-2774, 1979)

Pleural biopsy cultures for tubercle bacilli, performed on specimens from 63 consecutive patients with exudative pleural effusions, grew out Mycobacterium tuberculosis from the tissue of 16 patients. Twenty-one of the patients in the study were eventually proved to have tuberculous pleurisy. The rate of positive pleural biopsy cultures in proved cases was, therefore, 76%. When culture results of the

Rheumatoid pleuritis characteristically occurs in middle-aged male rheumatoid patients and may antedate the arthritis. The pleural fluid is an exudate, frequently turbid, and may be milky. The glucose content of the fluid is less than 30 mg/100 ml in 70% to 80% of effusions. A low glucose level in pleural fluid that is nonpurulent, negative for bacteria on smear and culture, and negative for malignant cells on cytologic examination almost invariably indicates that the effusion is due to rheumatoid pleuritis unless pleural biopsy reveals tuberculosis.

Excerpt INTRODUCTION The inability of the physician to establish rapidly and accurately the etiology of pleurisy with effusion has been recognized for many years. As a result of experience, based m...

Excerpt The study was designed to evaluate the usefulness of performing pleural biopsy in every patient with pleural disease, regardless of the presence of fluid. A total of 211 biopsies were perfo...

The value of pleural biopsy in the differential diagnosis of pleural effusion is well established.1,6However, the frequency with which acid-fast bacilli have been reported in stained sections of needle biopsy specimens has been unimpressive. All too frequently the report of a granulomatous reaction which is compatible with tuberculosis must be accepted as a basis for treatment, with stains for acid-fast bacilli being either negative or even omitted. In this hospital we have recently used the Harefield needle, which was developed in England.3It is the increased frequency with which acid-fast bacilli have been demonstrated in these needle biopsy specimens of the pleura which prompts this brief report at this time. Methods and Patient Material Previous reports have dealt with both open surgical biopsy and closed needle biopsy.1,6Of the needle biopsies, the majority have been done with a Vim-Silverman aspiration needle, although Cope2has reported

To the Editor:— Dr. Cope's comments are a welcome supplement to our report on pleural biopsy. Space limitations precluded considerations of the physical characteristics of the biopsy needle, and acknowledgement of Dr. Cope's pioneering work with this device. We have had some difficulty due to backward bending of the hook and because of catching of the hook on the cannula. We agree that such difficulties are always ascribable to errors of technique. Such complications do not occur when the procedure is performed properly. It is true, however, that the sturdiness of the instrument has varied depending on the manner of manufacture. We are pleased to learn that henceforth this instrument will be stronger than in the past and thus no longer subject to the difficulties we have encountered.

For almost 100 years pleurisy has been considered clinically to be one of the systemic manifestations of rheumatoid arthritis. 13,18, 22,29 Although this impression was supported by postmortem evidence, 2,3,12,14 it was not until the recent development of the technique of pleural biopsy that the diagnosis was confirmed during life. 7,17 The incidence of rheumatoid pleuritis and pleural effusion is difficult to estimate from the reports in the literature because of the difficulty of confirming this diagnosis prior to the development of the pleural biopsy technique. McCrae, 22 in 1915, reported 7 cases of acute pleurisy (one had tuberculosis) in 319 patients with rheumatoid arthritis, an incidence of approximately 2%. In a group of 510 rheumatoid arthritic patients studied by Lewis-Faning, 18 approximately 2% were found to have had pleurisy. There were 5 patients with pleurisy (1 accompanied by an effusion) in the 293 patients with rheumatoid arthritis recently reported by Short, Bauer, and Reynolds. 29 In