Thesis (PhD)--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Although transthoracic ultrasonography is a well established modality, it is still
underutilised by chest physicians. The aim of this research project was to
investigate the feasibility, diagnostic yield and safety of ultrasound(US)-assisted
transthoracic biopsies performed by clinicians in various settings relevant to daily
practice of respiratory medicine. We conducted four clinical trials which are
summarised below: 1. In a prospective study on the feasibility of US-assisted transthoracic fine
needle aspiration (TTFNA) of drowned lung secondary to a proximal mass
lesion, a novel indication for US-assisted TTFNA was described. TTFNA
passes >20mm from the visceral pleura had a sensitivity of 74.2% and
were also more likely to contain malignant cells than more superficial
passes. The surprisingly high yield and the fact that no serious
complications were observed validated this approach, which may be an
alternative to bronchoscopy.
2. In the largest single-centre study on US-assisted TTFNA with rapid on-site
evaluation (ROSE) and cutting needle biopsy (CNB) in the setting of
superior vena cava (SVC) syndrome ever reported, we were able to
accurately diagnose 96% of all patients who presented with an associated
mass lesion that abutted or infiltrated the chest wall. No pneumothoraces
or major haemorrhage was caused. We also validated the single-session approach, and were able to conclude that US-assisted TTFNA (with
ROSE) is the initial investigation of choice in suspected bronchogenic
carcinoma, whereas both TTFNA and CNB need to be performed in all
other cases. 3. We continued to validate the novel single-session sequential approach in
a study on anterosuperior mediastinal masses. US-assisted TTFNA with
ROSE was performed on 45 consecutive patients, immediately followed
by CNB where a provisional diagnosis of epithelial carcinoma or probable
tuberculosis (TB) could not be established. An accurate cytological
diagnosis was made in 73.3%, and was more likely to be diagnostic in
epithelial carcinoma and TB than all other pathology (p<0.001). CNB
yielded a diagnosis in 88.2%. Overall 93.3% of patients were diagnosed
by the single-session approach. No pneumothorax or major haemorrhage
was observed. 4. In a prospective study, we compared US-assisted Abrams and Tru-Cut
needle biopsies with regard to their yield for pleural TB. Pleural biopsy
specimens obtained with Abrams needles contained pleural tissue in
91.0% of cases and were diagnostic in 81.8%, whereas Tru-Cut needle
biopsy specimens only contained pleural tissue in 78.7% (p=0.015) and
were diagnostic in 65.2% (p=0.022). In conclusion, we investigated the feasibility of US-assisted biopsies performed
by respiratory physicians in various settings, and consistently found acceptable
to very high diagnostic yields with minimal complications. Furthermore, we were
able to validate a novel indication for US-assisted TTFNA (US-assisted TTFNA of
drowned lung), validate the use of a single-session sequential approach (USassisted
TTFNA with ROSE followed by CNB where indicated) in at least two
clinical settings (SVC syndrome and anterosuperior mediastinal masses) and we
were able to show that US-assisted Abrams needle biopsy is superior to Tru-Cut
needles biopsy when histological confirmation of TB pleuritis is required. / AFRIKAANSE OPSOMMING: Alhoewel transtorakale ultrasonografie ‘n gevestigde modaliteit is, word dit
onderbenut deur pulmonoloë. Die doel van hierdie navorsingsprojek was om die
praktiese uitvoerbaarheid, diagnostiese opbrengs en veiligheid van sonargerigte
transtorakale biopsies uitgevoer deur klinici in verskeie situasies relevant tot die
alledaagse praktyk te ontleed. Ons het vier kliniese proewe uitgevoer wat
hieronder opgesom word:
1. In ‘n prospektiewe studie oor die praktiese uitvoerbaarheid van
sonargerigte transtorakale fyn naald aspirasie (TTFNA) van areas van
obstruktiewe pneumonitis sekondêr tot proksimale massa letsels, is ‘n
nuwe indikasie vir sonargerigte TTFNA beskryf. TTFNA aspirasies wat >20mm van die visserale pleura geneem is, het ‘n sensitiwiteit van 74.2%
gehad en was meer geneig om maligne selle op te lewer as meer
oppervlakkige aspirasies. Die verbasende hoë diagnostiese sensitiwiteit
en afwesigheid van ernstige komplikasies het die praktiese waarde van
hierdie benadering bevestig.
2. In die grootste studie nog oor sonargerigte TTFNA met spoedige in-teater
evalusies (SITE) en sny-naald biopsie (SNB) in die teenwoordigheid van
superior vena cava (SVC) sindroom, kon ons 96% van pasiënte wat
presenteer het met ‘n geassosieerde massa letsel wat die borskaswand betrek, akkuraat diagnoseer. Geen pneumotoraks of major bloeding is
waargeneem nie. Ons kon ook die praktiese uitvoerbaarheid van ‘n enkelsessie
benadering bevestig en kon tot die gevolgtrekking kom dat
sonargerigte TTFNA (met SITE) die aanvanklike ondersoek van keuse is
waar bronguskarsinoom vermoed word, maar dat beide TTFNA en SNB
noodsaaklik is in ander gevalle.
3. Ons het voortgegaan om die waarde van die nuwe enkel-sessie
benadering te bevestig in ‘n studie oor antero-superior mediastinale
massas. Sonargerigte TTFNA met SITE is uitgevoer op 45 pasiënte en in
gevalle waar ‘n voorlopige diagnose van epiteliale karsinoom of
waarskynlike tuberkulose (TB) nie bevestig kon word nie, is dit onmiddelik
gevolg deur SNB. ‘n Akkurate sitologiese diagnose is gemaak in 73.3%
van gevalle en meer algemeen in epiteliale karsinoom en TB as ander
patologie (p<001). SNB was diagnosties in 88.2%. In 93.3% kon ‘n
diagnose verkry word met die enkel-sessie benadering. Geen
pneumotoraks of major bloeding is waargeneem nie.
4. In ‘n prospektiewe studie is sonargerigte Abrams naald en Tru-Cut naald
biopsies se opbrengs vir pleurale TB met mekaar vergelyk. Pleurale
biopsie monsters wat met ‘n Abrams naalde geneem is, het pleurale
weefsel in 91.0% gevalle getoon en was diagnosties in 81.8%, vergeleke met Tru-Cut naalde wat slegs in 87.7% pleurale weefsel opgelewer het
(p=0.015) en wat net in in 65.2% diagnosties was (p=0.022).
Opsommend het ons die praktiese uitvoerbaarheid van sonargerigte biopsies
uitgevoer deur pulmonoloë in veskeie kliniese situasies nagevors, en het
deurlopend aanvaarbare tot hoë diagnostiese opbrengste gevind met minimale
komplikasies. Verder kon ons ‘n nuwe indikasie vir sonargerigte TTFNA beskryf
en evalueer (sonargerigte TTFNA van obstruktiewe pneumonitis); ‘n enkel-sessie
sekwensiële benadering se waarde bevestig (sonargerigte TTFNA met SITE,
gevolg deur SNB waar aangedui) in ten minste twee kliniese situasies (SVC
sindroom en anterosuperior mediastinale massas); en was dit moontlik om te
bewys dat UK-geleide Abrams naald biopsies superior tot Tru-cut naald biopsies
is in die histologiese bevestiging van TB pleuritis.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:sun/oai:scholar.sun.ac.za:10019.1/18054 |
| Date | 12 1900 |
| Creators | Koegelenberg, Coenraad Frederik Nicolaas |
| Contributors | Bolliger, Chris T., Diacon, Andreas H., Wright, Colleen A., University of Stellenbosch. Faculty of Health Sciences. Dept. of Medicine. Internal Medicine. |
| Publisher | Stellenbosch : University of Stellenbosch |
| Source Sets | South African National ETD Portal |
| Language | en_ZA |
| Detected Language | Unknown |
| Type | Thesis |
| Format | 129, 10 p. : ill. |
| Rights | Stellenbosch University |
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