Pleuroscopy offers physicians a unique opportunity for the

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1 STATE OF THE ART: CONCISE REVIEW State of the Art: Pleuroscopy Pyng Lee, MD,* and Henri G. Colt, MD, FCCP The terms pleuroscopy, thoracoscopy, medical thoracoscopy, and video-assisted thoracic surgery are often used interchangeably to describe a minimally invasive procedure that provides access to the pleural space, parietal pleura, lung, and other structures within the thoracic cavity. Pleuroscopy is a more exact term for describing visualization of the pleura and contents of the pleural cavity using an endoscope. This procedure provides physicians a window into the pleural space, to perform biopsy of the parietal pleura under direct visual guidance, particularly for biopsies in cases of exudative effusions with unclear origin, chest tube placement, and pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. In this state-of-the-art review, we discuss the indications, contraindications, and complications of pleuroscopy, and its role in thoracic oncology. Key Words: Pleuroscopy, Flex-rigid, Thoracoscopy, Pleura. (J Thorac Oncol. 2007;2: ) Pleuroscopy offers physicians a unique opportunity for the evaluation of the pleural space and can be carried out in an endoscopy room or in the operating room. 1,2 Its fascinating history has bridged continents and specialties and is intimately related to the history of optics and optical technologies. 3 During the last decade, advances in video technology and improved endoscopic instrumentation have prompted a resurgence of interest in minimally invasive chest procedures among thoracic surgeons and interventional pulmonologists, and today, there is renewed enthusiasm for pleural investigations to manage both simple and complex pleural diseases. VIDEO-ASSISTED THORACIC SURGERY VERSUS PLEUROSCOPY Video-assisted thoracic surgery (VATS) refers to a thoracoscopic procedure performed in the operating room using single-lung ventilation with double-lumen endotracheal intubation and various disposable instruments (Table 1). From the *Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore; and Division of Pulmonary and Critical Care Medicine, University of California, Irvine Medical Center, Irvine, California. Disclosure: The authors declare no conflict of interest. Address for correspondence: Henri Colt, MD, Pulmonary and Critical Medicine, University of California, Irvine, Orange CA hcolt@uci.edu Copyright 2007 by the International Association for the Study of Lung Cancer ISSN: /07/ Technically, any procedure that includes parietal pleural biopsy, drainage of pleural effusion or empyema, and pleurodesis performed with the patient under general anesthesia could be termed VATS. Nevertheless, VATS usually refers to stapled lung biopsy, resection of pulmonary nodules, lobectomy, pneumonectomy, pericardial window, or other standard thoracic surgical procedures performed in a minimally invasive manner. 2,4 Pleuroscopy, on the other hand, refers to thoracoscopy that is performed in an endoscopy suite or operating room with the patient under conscious sedation and local anesthesia (although it can also be done using general anesthesia with intubation). This term is confined to interventions targeted at diagnosing pleural pathology, such as pleural effusions or pleural carcinomatosis by parietal pleural biopsy; chest tube placement under visual guidance; and talcage for recurrent malignant effusion or pneumothorax. 5 PRELIMINARY CONSIDERATIONS Patient Evaluation A detailed medical and drug history and a physical examination are essential in any preoperative evaluation, and imaging, such as chest x-ray (posteroanterior, lateral, and decubitus views), ultrasonography, and computed tomography scan, aids in the selection of an appropriate site for the insertion of the pleuroscope. The patient s health and respiratory status are assessed by complete blood count, coagulation studies, electrocardiogram, arterial blood-gas analysis, percutaneous oximetry, and pulmonary function test. Contraindications The only absolute contraindication to pleuroscopy is a lack of pleural space attributable to adhesions, although technically, this can be overcome by enlarging the skin incision or digitally dissecting the lung from the chest wall. Because pleuroscopy is performed under conscious sedation in a spontaneously breathing patient with partial or near-total lung collapse, these patients must not have severe hypoxemia unrelated to pleural effusion or requiring ventilatory support; they also may not have unstable cardiovascular status, bleeding diathesis, refractory cough, or allergy to the medications used. Equipment Pleuroscopy is performed using a variety of disposable and reusable instruments that are introduced through one or two ports of entry into the pleural cavity. Pleuroscopy is usually performed with the single-puncture technique, allow- Journal of Thoracic Oncology Volume 2, Number 7, July

2 Lee and Colt Journal of Thoracic Oncology Volume 2, Number 7, July 2007 TABLE 1. Comparison between Video-Assisted Thoracic Surgery and Pleuroscopy Procedure Video-Assisted Thoracic Surgery Pleuroscopy Facility Operating room Endoscopy suite Operator Surgeon Pulmonologist Anesthesia General Local Indications Stapled lung biopsy, pulmonary nodule resection, lobectomy, pneumonectomy, pericardial window, parietal pleural biopsy, pleural effusion or empyema drainage, invasive procedures Pleural cavity exploration, parietal pleura biopsy, pleurodesis, chest tube placement under direct visualization ing the operator to visualize the contents of the pleural space and insert accessory instruments through the working channel of a rigid or flex-rigid pleuroscope; a double-puncture technique, whereby a small, second incision is made along another intercostal space, allows insertion of another 3- to 10-mm pleural trocar for accessory instruments. This technique is often used to control bleeding, sever adhesions, suction large amounts of pleural fluid, or perform pleural biopsies. Rigid Instruments: Historically, rigid endoscopic equipment included a cold (xenon) light source, an endoscopic camera attached to the eyepiece of telescope, a video monitor, a recorder, and a printer for still photography (Figure 1). Trocars used for pleuroscopy come in different sizes (diameter, 3 13 mm) and are made of disposable plastic or reusable, stainless steel. Rigid telescopes have different angles of vision for direct (0 degrees) and oblique (30 or 50 degrees) viewing. Biopsy of the parietal pleura can be performed with 5-mm optical or coagulating tooth forceps. 2 Smaller telescopes and instruments also have been developed to enhance patient comfort during the procedure. Tassi and Marchetti 6 have reported an excellent view of the pleural space using a 3.3-mm telescope for a group of patients with small, loculated, pleural effusions that otherwise would be inaccessible using standard-sized instruments. The diagnostic yield obtained with 3-mm biopsy forceps was more than 90%, which was comparable with the yield from conventional forceps. Semirigid Pleuroscope The semirigid pleuroscope (model LTF 160 or 240, Olympus, Japan) is similar in design and handling to a videobronchoscope; it allows the performance of pleuroscopy in a fashion analogous to flexible bronchoscopy. The pleuroscope consists of a handle and a shaft that measures 7 mm in outer diameter and 27 cm in length. The shaft is made up of two sections: a 22-cm, proximal, rigid portion; and a 5-cm, flexible, distal end (Figure 2a), which can be moved using a lever on the handle. It also has a 2.8-mm working channel that accommodates biopsy forceps (Figure 2b), needles, and other accessories and that is compatible with various electrosurgical and laser procedures. The pleuroscope is inserted through a 10-mm disposable plastic trocar (Olympus, Japan) and allows autoclaving (model LTF 160), thereby obviating important issues related to asepsis. It also interfaces easily with existing processors (CV-160, CLV-U40) and light sources (CV-240, EVIS-100 or 140, EVIS EXERA-145 or 160) made by the manufacturer for flexible bronchoscopy or gastrointestinal endoscopy and FIGURE 1. Instruments used for rigid thoracoscopy. FIGURE 2. Semrigid pleuroscope with flexible tip and working channel for standard accessories. 664 Copyright 2007 by the International Association for the Study of Lung Cancer

3 Journal of Thoracic Oncology Volume 2, Number 7, July 2007 State of the Art: Pleuroscopy TABLE 2. Indications for Rigid or Semirigid Pleuroscopy Patient, Radiological, Endoscopic Characteristics Type of Procedure and Instrument Diagnostic pleuroscopy for indeterminate, uncomplicated pleural effusion, where suspicion of mesothelioma is not high Trapped lung, radiological thickened pleura, endoscopic infiltrated pleura Mesothelioma is suspected Pleuropulmonary adhesions Empyema, split pleural sign, loculated pleural effusion Pneumothorax with bulla or blebs Semirigid pleuroscopy (better tolerated) or with rigid telescopes under local anesthesia Rigid optical biopsy forceps or with flexible forceps performing multiple bites over the same area to obtain specimens of sufficient depth Rigid optical biopsy forceps Fibrous: rigid optical biopsy forceps* or semirigid pleuroscopy with electrocautery accessories Fibrinous (good alternative): flexible forceps Rigid instruments or converting to thoracotomy for decortication Rigid instruments (VATS) for staple bullectomy available in most endoscopy units without additional costs. 7,8 Table 2 describes the types of patients suitable for rigid and semirigid pleuroscopy. TECHNIQUE Before pleuroscopy, the operator may remove up to 500 ml of fluid from the pleural space and induce pneumothorax to facilitate collapse of the lung away from the chest wall for trocar insertion. Alternatively, the procedure can be performed directly through an intercostal incision that allows fluid to be freely aspirated or guided by ultrasonography. 9 Traditionally, the patient is placed in a lateral decubitus position, with the affected side facing upward. If malignancy is suspected, the trocar should be inserted over the sixth intercostal space at the midaxillary line, whereas the fourth space is preferred for better visualization of the lung apex for blebs and bullae in the case of pneumothorax. Continuous electrocardiograph, blood pressure, and oxygenation by means of pulse oximetry are monitored. Intravenous benzodiazepine (midazolam) and narcotic (fentanyl, demerol, or morphine) are administered and titrated according to the patient s comfort, without compromising respiration. A single-puncture technique involves making a 1- to 2-cm incision in the midaxillary line between the fourth and seventh intercostal spaces of the chest wall. This technique is used commonly for diagnostic pleuroscopy and talc poudrage; the double punctures are indicated for adhesiolysis, drainage of complex loculated fluid collections, and lung biopsy. A chest tube or small-bore catheter is usually inserted at the end of the procedure and can be removed once the lung is fully expanded without air leak. 10,11 COMPLICATIONS Mortality from conventional pleuroscopy using rigid instruments ranges between 0.09 and 0.24%, 12,13 which is comparable with the mortality rates associated with bronchoscopic transbronchial lung biopsy; complications associated with conventional pleuroscopy using rigid instruments are listed in Table 3. Complications with the semirigid pleuroscope, on the other hand, are rare. In fact, it has been shown to be very safe when performed by pulmonologists trained in conventional pleuroscopy. No morbidity or mortality was observed during its evaluation at two separate centers, in North America 7 and in the United Kingdom. 8 This observation is shared by the authors experience of 100 cases during 24 months (P. Lee and H.G. Colt, unpublished data, 2005 and 2006). Nevertheless, many safety outcome studies involve procedures performed by specialists and may not reflect actual circumstances with less experienced physicians; thus, the need for adequate, satisfactory training cannot be overemphasized. CLINICAL APPLICATIONS FOR PLEUROSCOPY Pleural Effusion of Unknown Origin The first step toward investigating pleural effusion of unknown origin is thoracentesis. Pleural fluid is analyzed for chemistry, microbiology, and cytology. More than half of exudative effusions are attributable to malignancy, and pleural fluid cytology is the simplest definitive method; nevertheless, its diagnostic yield depends on the extent of disease and the nature of the primary malignancy. 14 Cytological examination of pleural fluid is diagnostic in 62% of patients with metastatic pleural involvement, 15 but it has a yield 20% when mesothelioma is encountered. 16 Repetitive large-volume thoracentesis establishes the diagnosis of malignancy with 65% from the first specimen, a further 27% from the second, and 5% from the third. Closed-needle biopsy may be successful in 50% of metastatic pleural ma- TABLE 3. Complications of Pleuroscopy Prolonged air leak Hemorrhage Subcutaneous emphysema Postoperative fever Empyema Wound infection Cardiac arrhythmias Hypotension Seeding of chest wall from mesothelioma Copyright 2007 by the International Association for the Study of Lung Cancer 665

4 Lee and Colt Journal of Thoracic Oncology Volume 2, Number 7, July 2007 FIGURE 3. Polypoid lesions of the parietal pleura, suggestive of malignancy. FIGURE 4. poudrage. Optimal chest tube placement after talc lignancies, 17 and the addition of pleural biopsy to pleural fluid cytology merely increases the yield by 10%; moreover, it is of little value for tumors confined to the diaphragmatic, visceral, or mediastinal pleura. Therefore, pleuroscopy for undiagnosed pleural effusion aids in establishing the diagnosis of malignancy in more than 85% of patients 18,19 (especially if polypoid lesions, localized tumoral masses, thickened pleura, or candle wax drops are observed [Figure 3]), in guided biopsy of these pleural abnormalities for histologic confirmation and hormone receptor analysis, 20 for the removal of any adhesions to improve drainage of fluid, and in the assessment of lung expandability or the presence of trapped lung during fluid aspiration, without additional imaging studies. Moreover, pleurodesis with a sclerosing agent can be performed at the same time to prevent recurrence in selected cases and for optimal chest tube placement under visual guidance (Figure 4). Pleuroscopic biopsy results might be falsely negative in a very small percentage of patients in whom cancer is ultimately diagnosed; these false-negative results are attributable to adhesions that limit inspection, very early malignant mesothelioma with focal abnormalities and grossly normalappearing parietal pleura, and physician inexperience. Malignant Pleural Effusion Malignant pleural effusions affect 660 patients per million population per year and account for 150,000 and 40,000 new cases per year in the United States and the United Kingdom, respectively. 21 When malignant cells are detected in the pleural fluid or in pleural tissue, they denote dissemination. Carcinoma of any organ can metastasize to the pleura. In males, lung cancer is the most common malignancy that invades the pleura; in females, it is breast cancer. 22,23 Together, they account for 50 to 65% of malignant effusions. Lymphomas and tumors of the genitourinary and gastrointestinal tracts account for 25%, and in the remaining 7 to 15%, the primary site remains unknown. 24,25 Median survival of patients with malignant pleural effusions ranges between 3 and 12 months and is related to the type of neoplasm, with the shortest survival observed in lung cancer and the longest in ovarian cancer. 26,27 The primary goal in the management of patients with malignant pleural effusions is symptom palliation, and several pleural fluid parameters have been studied to determine prognosis of these patients and to assist physicians in selecting suitable treatment options. A meta-analysis of more than 400 patients with malignant effusions has shown that pleural fluid with a ph 7.28 accurately identified patients with poor survival and helped predict, to a moderate degree, those likely to fail pleurodesis. 28,29 Although pleural fluid ph was an independent predictor of survival, only 55% of patients with ph 7.28 died within 3 months. 28 It is arguable, therefore, that other factors such as patient s health and functional status, 30 response of tumor to therapy, and lung reexpandability should be considered in the overall management strategy. Observation is indicated only in asymptomatic patients with small pleural effusions or in those diagnosed with chemosensitive malignancy such as small-cell lung cancer, lymphoma, and breast cancer. 31 In the majority, if left untreated, they will increase in size as the malignancy progresses. Patients with symptomatic effusions should undergo therapeutic thoracentesis because it assesses the effect of intervention on dyspnea and provides a baseline to assess the time to recurrence. 32 Nevertheless, if the patient s dyspnea is not improved by thoracentesis, lymphangitis carcinomatosis, pericardial effusion, pulmonary or tumor embolism, atelectasis from bronchial obstruction, or trapped lung from extensive pleural involvement may be contributory. If the patient s underlying health status is good, instead of therapeutic thoracentesis that might have to be repeated daily until all pleural fluid is withdrawn, one can perform pleuroscopy early on in the disease course. This allows removal of all fluid in a single session and assesses the extent of pleural carcinomatosis, lung expandability, and pleurodesis, all at the same sitting. Subsequently, informed and educated management decisions can be made regarding followup, prognosis, referral for systemic therapy, or initiation of comfort care and supportive measures. 666 Copyright 2007 by the International Association for the Study of Lung Cancer

5 Journal of Thoracic Oncology Volume 2, Number 7, July 2007 State of the Art: Pleuroscopy Chemical pleurodesis when lung reexpandability is demonstrated should be considered in all patients, although many experts advocate its use only if patients survive for 3 months or more. We believe that the adoption of this stance is consequent to the perceived complexity of pleurodesis procedures and the need for hospitalization. Pleurodesis can be performed with similar success by the instillation of sclerosant via intercostal tubes or small-bore catheters (10-14F) into the pleural space Moreover, Saffran and coworkers 36 have demonstrated that outpatient pleurodesis was feasible for patients with malignant effusions who declined hospitalization using 14F pigtail catheters connected to closed gravity drainage bags followed by talc slurry. With new technology such as flex-rigid pleuroscopy, which allows complete fluid removal and talc poudrage at the same time, ambulatory talc or bleomycin pleurodesis with small-bore catheters, and novel methods of intrapleural staphylococcal superantigen therapy for patients who are otherwise unsuitable for systemic chemotherapy, 37 pleurodesis should be offered as similar procedures such as laser bronchoscopy for airway obstruction are performed in other areas of pulmonary medicine for patients where the estimated survival is extremely short (Table 4). Lung Cancer Cancer-related pleural effusions occur as a result of direct tumor invasion, tumor emboli to visceral pleura with secondary seeding of parietal pleura, hematogenous spread, or lymphatic involvement. 21 It is rare to find resectable lung cancer in the setting of pleural effusion despite negative cytologic examination. 38 Pleuroscopy, therefore, establishes operative eligibility by determining whether the pleural effusion is paramalignant or attributable to metastases. If pleural metastases are found, thereby making the cancer inoperable, talc poudrage can be performed at the same sitting to prevent recurrence. 39 Malignant Mesothelioma The average survival for a patient diagnosed with malignant mesothelioma is 6 to 18 months, with death resulting from respiratory failure. 40 During the last 30 years, the incidence of mesothelioma has been increasing steadily, and the 1940s male birth cohort is particularly affected, with the disease accounting for 1% of all deaths. 41 Malignant mesothelioma is suspected in a patient with a history of asbestos exposure and characteristic radiographic findings of a pleural effusion without contralateral mediastinal shift. Diagnosis by pleural fluid cytology and closedneedle biopsy is difficult 20 ; this has prompted some physicians to advocate open biopsy by mini- or lateral thoracotomy to obtain specimens of sufficient size and quantity for immunohistochemical stains and electron microscopy. 42 Today, conventional pleuroscopy is favored over thoracotomy, not only because the pleural specimens obtained with the 5- or TABLE 4. Treatment Options for Malignant Pleural Effusion Treatment Option Indication Comment Observation Therapeutic thoracentesis Chest tube and intrapleural installation of sclerosant (Table 3) Talc poudrage via pleuroscopy Long-term indwelling catheter Pleuroperitoneal shunt Pleural abrasion and pleurectomy Radiotherapy Chemotherapy Asymptomatic small effusion Small-cell lung cancer, lymphoma, breast cancer, cancers readily and quickly responsive to systemic therapy Recurrent effusion and poor performance status; short expected ( 2 mo) survival Performed in outpatient setting, obviating hospitalization Symptomatic large effusions Recurrent effusions Majority of effusions will recur during course of treatment, but time to recurrence is difficult, if not impossible, to predict High recurrence rate Complicated by iatrogenic pneumothorax and pleural space infection liters per session; multiple sessions usually necessary to remove all fluid 60% success rate Poor alternative to talc poudrage Alternative to pleurodesis via pleuroscopy Recurrent symptomatic effusions Success rate 90% Available expertise Intractable effusion Catheter-related infection and obstruction Recurrent effusion with poor performance status Tumor seeding in mesothelioma Trapped lung Intractable effusion Trapped lung Failed pleurodesis, in good health with long survival Failed pleurodesis, in good health with long survival Mediastinal lymph node metastasis from lymphoma and small-cell lung carcinoma Lymphoma, breast cancer, small-cell lung carcinoma Shunt-related complications: infection and occlusion Major surgical procedure with significant mortality Usually 100% effective Contraindicated in non-small cell lung cancer as adverse effects of radiation pneumonitis outweigh benefit Receptor analysis in breast cancer allows hormonal manipulation. Tissue chemosensitivity studies can be performed as indicated Copyright 2007 by the International Association for the Study of Lung Cancer 667

6 Lee and Colt Journal of Thoracic Oncology Volume 2, Number 7, July mm rigid forceps are comparable with open biopsies, 43 but because this method allows staging to be achieved in a minimally invasive manner. Pleuroscopy with semirigid instruments, on the other hand, raises valid concerns about the adequacy of pleural biopsies obtained with the small, flexible forceps. Because these issues are still unresolved at the time of writing, pending future studies, we would recommend the use of rigid 5-mm optical forceps in cases where mesothelioma is suspected. Mesothelioma is notorious for seeding biopsy and chest tube sites; thus, pleuroscopy and chest tube incisions should be placed so that if subsequent therapeutic resection is performed, these sites can be easily excised or prophylactically irradiated. 44 Estimates have suggested that only 1 to 5% of patients are suitable for curative surgery. 45 In the majority, who have advanced disease even at first presentation, aggressive palliation of dyspnea via pleuroscopic guided drainage and talc pleurodesis, improved pain control, and prophylactic irradiation of incision sites have resulted in effective symptom control. 46 Tuberculous Pleural Effusion The average diagnostic yield from closed-needle biopsy in tuberculous (TB) pleural effusion is 69%, although a wide range of 28 to 88% has been reported. In a prospective study of 100 TB effusions in Germany, immediate histological diagnosis was established by pleuroscopy in 94% compared with 38% by closed-needle biopsy. Positive yield from histology and bacteriological cultures was also found to be higher with pleuroscopic guided biopsies than with closedneedle biopsy and pleural fluid combined. 47 These results were reproduced in a study conducted in a country with high TB prevalence where diagnostic yield from pleuroscopic guided biopsy was 98% compared with 80% by the Abram needle. 48 Many experts, therefore, recommend that if TB pleuritis is strongly suspected in a patient residing in a highly TB-prevalent area, thoracentesis and closed-needle biopsy should suffice, and pleuroscopy should be reserved for special circumstances where lysis of adhesions is indicated for more effective drainage of loculated effusions or when larger quantities of tissue are required for culture in suspected drug-resistant cases. Recurrent Pleural Effusions of Benign Origin These effusions are usually caused by congestive heart failure, cardiac surgery, nephrotic syndrome, liver cirrhosis, uremia, connective tissue disease, and other inflammatory disorders, and pleuroscopy may indicated for evaluation of the pleural space, guided parietal pleural biopsy to exclude neoplastic or infectious origins, drainage, and talc poudrage, which confers success up to 90% in recurrence control. 49 Chylothorax Chylothorax occurs after trauma to the thoracic duct or as a result of neoplastic involvement by lymphoma, and initial treatment consists of drainage, nutritional support, and measures to diminish chyle flow. Delay in surgical intervention often leads to metabolic, nutritional, and immunologic deficiencies from the loss of chyle, but, more importantly, prolonged conservative treatment increases the risk of adhesion formation, loculation, organization, and infection of the chylothorax, making subsequent surgery difficult and increasing postoperative morbidity and mortality. VATS provides a minimally invasive approach for the repair of torn thoracic duct by clipping, and pleuroscopy under local anesthesia for talc pleurodesis in lymphoma-related chylothorax refractory to chemotherapy and radiation therapy or for recurrent chylothoraces attributable to lymphangioleiomyomatosis. 50,51 Diffuse Lung Disease Thoracoscopic lung biopsy not only provides adequate specimens for the diagnosis of diffuse interstitial lung disease and for mineralogic studies of pneumoconiosis; it also provides material for microbiological cultures in pulmonary infections. 52 These biopsies are usually obtained with an endoscopic stapling device, although some pulmonologists have used the coagulating forceps. Endoscopic staplers cut and staple the lung parenchyma; these are easier to obtain vessels with, and they also introduce less air leak than the coagulating forceps. For these reasons, most thoracoscopic lung biopsies involve stapled wedge resection, and the procedure is usually performed in the operating room, with the patient under general anesthesia and selectively intubated. Coagulating forceps, set at 60 to 100 W, can coagulate and seal the cut surface. In this technique, which is performed under local anesthesia, the physician grasps the lesion with forceps for 1 to 2 seconds and pulls toward the trocar while applying current with a foot pedal. Both techniques preserve the histologic features of biopsy specimens, 53 and an average of one to eight biopsy specimens are obtained during any given session. In cases where diffuse infiltrates are evident on a computed tomography scan, samples should be taken from healthy as well as abnormal areas. After lung biopsy, a chest tube is inserted and left in place until the air leak stops. In a patient with honeycomb lungs, any necessary random biopsy specimens should be taken from the mid- and upper lung, where emphysematous bullae and cysts are relatively sparse. In removing pulmonary nodules, principles of oncologic surgery must be strictly adhered to for prevention of seeding of tumor cells. 54 Postoperative stay in the intensive care unit is rarely necessary, and patients can be discharged from the hospital with minimal morbidity. 55 The safety of thoracoscopic lung biopsy has prompted physicians to consider the procedure earlier in the management of patients with parenchymal disease of uncertain cause, especially when bronchoscopic lung biopsies have been nondiagnostic. Nevertheless, patients with advanced lung disease who cannot tolerate single-lung ventilation or who are receiving mechanical ventilation should undergo open thoracotomy if lung biopsy is felt to be absolutely necessary. Empyema and Complicated Parapneumonic Effusions Pleuroscopy is useful in the management of empyema 56,57 and should be performed early in the course of disease, when fluid can be easily evacuated, with lysis of thin fibrinopurulent adhesions to facilitate pleural drainage and 668 Copyright 2007 by the International Association for the Study of Lung Cancer

7 Journal of Thoracic Oncology Volume 2, Number 7, July 2007 State of the Art: Pleuroscopy allow lung expandability. Chest tubes can be placed under direct guidance, even in a complicated pleural space with adhesions; this may aid drainage and hasten clinical resolution of symptoms. Nevertheless, in some cases, the finding of a thick pleural peel, trapped lung, or a complicated, multiloculated pleural space during pleuroscopy may prompt immediate referral for early decortication. Pneumothorax In spontaneous pneumothorax, pleuroscopy can reveal blebs and bullae, allow coagulation of blebs, and prevent recurrence by methods such as pleural abrasion or talc pleurodesis. Detection of blebs and bullae may be higher with VATS or thoracotomy than with pleuroscopy, 58 but several investigators have independently shown that specific treatment of these bullae associated with primary or secondary spontaneous pneumothoraces has not improved the outcome of pleurodesis. 59,60 This is particularly relevant for a selected group of patients with advanced lung disease and comorbidity who are at higher risk for general anesthesia, VATS, or thoracotomy. In these instances, air leaks can be repaired, and recurrent pneumothoraces can be prevented effectively by thoracoscopic talc poudrage. 60 OTHER APPLICATIONS FOR VATS VATS also could be indicated for the sampling of nonsurgical mediastinal tumors such as lymphoma, and as a complementary procedure to mediastinoscopy in the staging of mediastinal lymphadenopathy associated with bronchogenic and esophageal carcinomas. Nevertheless, these indications would decline in time with increasing use of percutaneous needle aspiration, endoscopic ultrasound biopsy techniques, 61 and positron emission tomography scanning. 62 CONCLUSION Pleuroscopy is effective in the evaluation of pleural and pulmonary diseases when routine cytology and closed-needle biopsy fail. In many institutions where facilities for pleuroscopy are available, it replaces second-attempt thoracentesis and closed-needle biopsy for patients with exudative effusions of unclear origin. Pleuroscopy also offers therapeutic intervention to break down loculations in early empyemas and to perform pleurodesis for recurrent malignant effusions and pneumothoraces, perhaps providing earlier referrals for VATS or open thoracic surgery if warranted. With the introduction of the semirigid pleuroscope, which is similar in design and handling to the flexible bronchoscope and compatible with standard light sources and video processors available in most bronchoscopy suites, pleuroscopy likely will be the object of expanded interest as both a diagnostic and therapeutic tool for pulmonary and critical care specialists experienced in flexible bronchoscopy. Although pleuroscopy is generally safe, it is, after all, an invasive procedure, and consultative collaboration between the pleuroscopist, primary care physician, chest radiologist, and thoracic surgeons is necessary to ensure that patients undergoing these procedures are assessed from all perspectives. 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