Division of Pulmonology, Department of Medicine, Stellenbosch University, Tygerberg Academic Hospital, Cape Town, South Africa.
Curr Opin Pulm Med. 2013 Jul;19(4):368-73. doi: 10.1097/MCP.0b013e32835f4c23.
The most efficient and cost-effective approach to pleural exudates not diagnosed by means of thoracocentesis remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. This review will focus on the developments in image guidance of closed pleural biopsy.
Recent studies suggest that computed tomography and ultrasound guidance improve the yield and safety of closed pleural biopsy. Imaging is best suited to reduce the rate of false-negative biopsy in malignant pleural disease by enhanced targeting of localized pleural changes typically situated dorsolaterally close to the diaphragm. Pleural tuberculosis causes effusions with discrete and uniformly distributed pleural thickening, and evidence suggests that the utilization of imaging has little advantage in this setting apart from decreasing the risk associated with blind biopsy. Imaging also facilitates a directed repeat thoracocentesis in the same session. The cumulative yield of image-assisted repeat thoracocentesis and pleural biopsy has been reported to approach that of thoracoscopy, particularly in cases with pleural thickening, nodularity or pleural-based mass lesions.
Image-guided pleural biopsy combined with repeat thoracocentesis is a safe, inexpensive, accessible and sensitive method for further examination of patients with pleural exudates not diagnosed by initial thoracocentesis.
对于经胸腔穿刺术仍无法明确诊断的胸腔渗出液，目前最有效且最具成本效益的方法仍不明确。经胸腔镜或闭式胸膜活检均可获取胸膜组织。本综述重点介绍了闭式胸膜活检的影像学引导技术的发展。
近期研究表明，CT 和超声引导可提高闭式胸膜活检的阳性率和安全性。影像学检查最适合通过增强对典型位于背外侧靠近膈肌的局灶性胸膜改变的靶向定位，从而降低恶性胸膜疾病中假阴性活检的发生率。结核性胸腔积液引起的胸腔积液具有离散且均匀分布的胸膜增厚，有证据表明，除了降低盲目活检相关风险外，影像学在这种情况下并没有太大优势。影像学还可方便在同一次操作中进行有针对性的重复胸腔穿刺术。有研究报道，在胸膜增厚、结节或基于胸膜的肿块病变患者中，影像学引导重复胸腔穿刺术和胸膜活检的累积阳性率接近胸腔镜检查。
对于经初次胸腔穿刺术仍无法明确诊断的胸腔渗出液患者，影像学引导下的胸膜活检联合重复胸腔穿刺术是一种安全、经济、便捷且敏感的进一步检查方法。
