Pleural Biopsy

There are many causes for fluid build up or thickening of the pleura. Some are minor, others are more serious. Coping with not knowing what is wrong can be really difficult; Lung Cancer Specialist Nurses can provide support so ask your doctor if you would like to be referred.

Causes of pleural abnormalities include:

Inflammation

The lining of the lung can become irritated, thickened and make fluid. Asbestos or certain types of dusts at work may cause irritation. Some medical conditions can also cause irritation, such as rheumatoid arthritis.

Previous severe chest infection

Severe chest infections can cause infected fluid to build up around the lung. If the body fights off the infection scar tissue and fluid may remain. Tuberculosis (TB) infection can cause the fluid or thickening.

Previous bleeding in the chest

For example, after breaking ribs in an accident there may be a small amount of bleeding that heals on its own but leaves fluid or thickening behind.

Cancer

Mesothelioma is a cancer that starts in the pleura. It is much more common in people who have worked with asbestos but can occur in people who don’t remember being around asbestos. Lung cancer or spread of cancer from elsewhere in the body can cause a pleural effusion.

Heart problems

If the heart is not pumping properly fluid can build up but this is diagnosed and treated without the need for any surgery.

A pleural biopsy involves taking samples from the pleura lining the chest wall. The sample is sent to the laboratory for tests. Before taking the biopsy we drain all the fluid in the pleural space. Part of the fluid is also sent for analysis. Draining the fluid helps with breathlessness. Usually a biopsy is taken using keyhole surgery with you fully asleep, the surgery takes about 45 to 60 minutes. The surgery can sometimes be done with local anaesthetic so you are awake but this is much less common.

Sometimes it is impossible to get a biopsy using the keyhole method. In this case we make one of the keyhole incisions bigger to get a biopsy.

Talc pleurodesis is procedure that causes the two layers of pleura to become inflamed so that they stick together. This helps prevent fluid from building up again. It will only work if the lung expands well after draining fluid and the 2 layers of pleura are touching.

During surgery sterile talc powder is sprayed inside the chest to evenly coat the pleura.

A pleural catheter (IPC) is a thin flexible tube put in the pleural space. It is a small chest drain that is secure and can stay in for as long as it is needed.

After draining the fluid during surgery, the lung may still be compressed by thickened pleura. This leaves a space between the 2 layers of pleura; talc will not work in this case. Fluid would build up again. The IPC allows the fluid to be drained intermittently and relieve the breathlessness. You (and a close friend/relative) can be trained how to drain fluid from the IPC at home. You will learn how to do this before you go home after surgery. Support from your district nurse will be arranged too. An IPC allows you to control your breathlessness, you may feel that it is time to drain the fluid off by your breathing. Drainage is usually needed every other day.

Without pain relief you would have chest pain after surgery. There are plenty of options for pain relief, most people are comfortable with intercostal blocks done in theatre and a PCA on the ward. As the pain settles you can take tablets instead, these should be continued at home and only reduced slowly.

Recovery follows the general recovery after thoracic surgery. Biopsies are shorter operations and do not remove lung tissue so you may find your recovery is ahead of the timelines. You may find you are much less breathless straight after surgery. Listen to your body, do what you feel able to and stop if you are in pain.

General risks apply to pleural biopsies and talc/pleural catheter insertion.

In addition, the following risks apply:

• Not getting a diagnosis from the biopsies
• Build-up of fluid again despite surgery
• Damage to organs in the abdomen

It normally takes approximately 2 weeks for the laboratory to test the samples. Testing for TB may take 6 weeks. If we receive results before you are due to come to a clinic appointment for follow up we may call you.

Having a diagnosis can guide which treatments would be best for you. It can also give you an idea of what to expect from the disease, including symptoms or whether the disease may shorten your life.

If you do not want to have an operation to get a diagnosis other options may include:

• Relying on existing tests (such as scans) to judge which disease is most likely
• Repeating a previous test
• Continuing close observation

If you do not want an operation to improve your symptoms other options may include:

• Palliative care

We can use talc via chest drain in certain cases. This means you would still need a chest drain but can be done with you awake. Sterile talc powder is mixed with sterile water and flushed up the chest drain instead of being sprayed over the pleura. Surgical talc has a higher success rate than talc via a drain. Talc via a drain may be more painful that talc via surgery.

Samples may be taken and a pleural catheter may be inserted using local anaesthetic instead of a general anaesthetic in some cases.

It is your choice whether to go ahead with surgery or choose another kind of treatment. We will respect your wishes and support you in choosing the treatment that suits you. You are always welcome to seek a second opinion.