What is an open pleural biopsy?

Open Pleural Biopsy: Surgical Diagnostic Procedure for Pleural Disease

An open pleural biopsy is a surgical procedure performed to obtain pleural tissue samples when less invasive methods are not possible or have failed to provide a diagnosis, particularly in cases of suspected malignant pleural disease.

Definition and Indications

Open pleural biopsy involves making a small muscle-sparing incision within an intercostal space (with or without partial rib resection) to directly access and sample pleural tissue. It is indicated in several clinical scenarios:

• When thoracoscopy (VATS or medical thoracoscopy) is not feasible due to an obliterated pleural space from locally advanced disease 1
• For patients without an effusion or patent pleural space that would allow safe thoracoscopy 1
• When less invasive diagnostic methods have failed to provide a definitive diagnosis
• In cases of suspected malignant pleural mesothelioma (MPM) variants that may evade diagnosis with other techniques 1

Diagnostic Value

Open pleural biopsy has excellent diagnostic yield:

• Studies show a diagnostic rate of 100% in patients with malignant pleural mesothelioma 2
• It is considered a gold standard diagnostic method for MPM with nearly perfect accuracy for determining the presence of disease 2
• Provides sufficient tissue depth to confirm invasion, which is crucial for distinguishing malignant mesothelioma from benign mesothelial proliferation 1

Comparison with Other Diagnostic Methods

Open pleural biopsy offers advantages over other techniques in specific situations:

1. Versus Pleural Fluid Cytology:

   • Cytology has limited sensitivity (58-62%) for diagnosing mesothelioma 1
   • Cannot reliably distinguish between reactive mesothelial cells and malignant cells 1

2. Versus Closed Pleural Needle Biopsy:

   • Closed biopsies have lower diagnostic yield (40-75%) 1
   • Higher risk of sampling error with closed techniques 1

3. Versus Thoracoscopy:

   • Medical thoracoscopy and VATS are preferred when feasible (diagnostic yield >92%) 1
   • Open biopsy becomes necessary when thoracoscopy cannot be performed due to pleural adhesions or obliterated pleural space 1

Procedure Details

The procedure typically involves:

• A small muscle-sparing incision in an intercostal space
• Sometimes partial rib resection to improve access
• Direct visualization and sampling of abnormal pleural tissue
• Collection of multiple biopsies of sufficient size and depth for comprehensive pathological analysis
• Biopsies should be obtained from both abnormal and normal-appearing tissue 1

Clinical Considerations

• Tissue adequacy: Samples must be sufficient for immunohistochemical staining and to assess invasion 1
• Subtyping limitations: While excellent for diagnosing MPM, open pleural biopsy has limitations in determining histologic subtypes (particularly non-epithelial subtypes) 2
• Surgical planning: When malignancy is suspected, incisions should be placed in line with possible future thoracotomy incisions to allow resection of biopsy tracts during definitive surgery 1

Complications

Complications are generally infrequent but may include:

• Bleeding
• Infection
• Pain at the incision site
• Pneumothorax
• Potential for tumor seeding along the biopsy tract in cases of malignancy

Key Advantages

• Provides adequate tissue for definitive diagnosis when less invasive methods are not feasible
• Allows direct visualization of the pleura
• Higher diagnostic yield than needle-based techniques
• Can be performed as a relatively limited and generally low-risk surgical procedure 1

Open pleural biopsy remains an important diagnostic tool in the armamentarium for evaluating pleural disease, particularly when thoracoscopic approaches are not possible due to technical limitations or patient factors.