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A3157 - Make the Definitive Diagnosis: The Importance of Pleural Biopsy in Diagnosing Nonmalignant Pleural Effusions in Cancer Patients
Author Block: K. Bakhsh1, A. Borah2, E. Abramian3; 1Pulmonary and Critical Care Medicine, Drexel University, Philadelphia, PA, United States, 2Pulmonary and Critical Care, Philadelphia, PA, United States, 3Drexel University, Philadelphia, PA, United States.
A 53 year old female with a history of left breast ductal carcinoma in situ status post double mastectomy presented with back pain and osseous metastatic disease. She was started on palliative chemotherapy that included Taxotere. Taxotere is a chemotherapeutic agent with a well documented side effect of fluid retention that can present as exudative effusions with mesothelial cells. A few months later the patient presented with dyspnea associated to bilateral pleural effusions. Repeated thoracentesis revealed exudative effusions with no malignant or infectious etiology. Upon follow up, pulmonary was consulted and a pleuroscopic biopsy was performed; the pathology of which was negative for malignant tissue. Thorascopy with pleural biopsy has a sensitivity of 95% in revealing pleural malignancy. In our patient, it was the lack of malignancy on pleural biopsy that definitively removed the etiology of her pleural effusions being malignancy related and more likely a side effect of Taxotere. This case reveals the important role thorascopy with pleural biopsy has in management of pleural effusions for cancer patients. Malignant cells residing in pleural fluid signifies disseminated disease and in many cases a reduced life expectancy with the shortest survival time being associated with malignant effusions secondary to lung cancer. In cancer patients, the etiology of pleural effusions has a great impact in treatment planning and overall quality of life. Current recommendations agree that initial thoracentesis with cytology should reveal malignant cells in about 60% of cases. If malignant cells are not revealed, a repeat thoracentesis may be done. When thoracentesis has not demonstrated malignancy and suspicion is still high the next definitive step in management is pleural biopsy. Blind percutaneous biopsies were performed using a closed needle but with low sensitivity and high complication risks have fallen out of favor. For many cancer patients, percutaneous biopsy is not even an option secondary to minimal access due to anatomy or minimal pleural thickening and these patients depend on thorascopy to obtain biopsies. Thorascopy has a diagnostic sensitivity of over 90%. In addition, as per the British Thoracic Society, complications only occur in 2.3% of patients and death is rare at 0.40%. With such high diagnostic yields, thorascopic pleural biopsies can be considered definitive. The ability of medical pleuroscopy with pleural biopsy to allow us to exclude pleural malignancy ensured proper staging and treatment for this patient.