The Accuracy of Video-Assisted Thoracic Surgery Pleural Biopsy in Patients with Suspected Diffuse Pleural Mesothelioma: A Real-Life Study

Our plain-English summary of The Accuracy of Video-Assisted Thoracic Surgery Pleural Biopsy in Patients with Suspected Diffuse Pleural Mesothelioma: A Real-Life Study, by L. Balsamo, E. Migliore, E. Della Beffa, et al (Journal of Clinical Medicine, 2025).

The study

• Authors: L. Balsamo, E. Migliore, E. Della Beffa, L. Delsedime, P.O. Lausi, D. Di Cuonzo, F. Lococo, P. Lyberis, D. Mirabelli, M.G. Papotti, E. Ruffini, F. Guerrera
• Journal: Journal of Clinical Medicine
• Published: 2025;15(1)
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The heritage of occupational and environmental asbestos exposure in Piedmont, Italy, has resulted in an enduring diffuse pleural mesothelioma (DPM) epidemic. Our study aimed to investigate the accuracy of Pleural biopsy (PB) via thoracoscopy (or video-assisted thoracic surgery-VATS) and analyze the diagnostic path of patients who experienced an initial DPM misdiagnosis. Methods: Patients who underwent PB by VATS for suspected DPM from 2004 to 2013 were analyzed. The Registry of Malignant Mesothelioma (RMM) records were examined to cross-check incident cases and identify misdiagnosed DPM. The sensitivity and specificity of the initial PB assessment versus the final classification of cases by RMM were evaluated. Results: Data from 552 patients were analyzed, and DPM was diagnosed in 178 cases (32%). Sensitivity and specificity were 93% and 100%, respectively. The number of false-negative PBs was 14 (2%). Of those, 10 (71%) had an initial diagnosis of chronic pleuritis, 3 (28.5%) were initially classified as mesothelial proliferation, and 1 had reactive mesothelial proliferation. All of them reported a history of asbestos exposure, and the correct diagnosis was reached after a median of 160 days. One- and four-year survival rates were 52% and 10% in DPM PB-positive cases and 50% and 19% in false-negative cases. Conclusions: When a strong clinical suspicion after a negative PB remains, iterative biopsy attempts should be considered, especially if a history of asbestos exposure is reported. In high-volume centers, the DPM misdiagnosis rate remains low, and future advancements in diagnostic technologies could further increase the accuracy and efficacy of histologic diagnosis.

In plain English

This single-center retrospective study reviewed 552 patients who had a video-assisted thoracic surgery (VATS) pleural biopsy for suspected diffuse pleural mesothelioma at a hospital in Turin, Italy, between 2004 and 2013. First biopsy results were checked against final diagnoses in the Piedmont Registry of Malignant Mesothelioma. The first biopsy found mesothelioma in 178 patients, with no false positives. Sensitivity was 93% and specificity 100%. In 14 patients the first biopsy missed the disease; 10 of them were first reported as chronic pleuritis. All 14 had a history of asbestos exposure, as did 148 (83%) of the 178 correctly diagnosed patients. The correct diagnosis came after a median of 160 days, most often from a second VATS biopsy. One-year survival was 52.2% (95% confidence interval 44.7 to 59.3) in correctly diagnosed patients and 50.0% (22.9 to 72.2) in missed cases. A log-rank test comparing the two groups' survival curves found no statistically significant difference (p = 0.813). The authors concluded that repeat biopsy should be strongly considered when suspicion persists after a negative biopsy, particularly with documented asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Observational, single-center (monocentric) retrospective study of prospectively recorded cases. It assessed the diagnostic accuracy (sensitivity and specificity) of the first VATS pleural biopsy against the final registry classification.
• Who was studied: 552 consecutive patients who underwent VATS pleural biopsy for suspected diffuse pleural mesothelioma at the Thoracic Surgery Department of S. Giovanni Battista Hospital, Città della Salute e della Scienza di Torino (Turin, Piedmont, Italy), January 2004 to December 2013. 386 (69.9%) were male and the median age was 69.0 years. Vital status was confirmed to 31 December 2023.
• Exposure: Reported history of asbestos exposure (occupational or environmental); fiber types were not reported. In the whole cohort, 319 (57.8%) reported asbestos exposure, 221 (40.0%) did not, and 12 (2.2%) had no information. The diagnostic procedure studied was VATS pleural biopsy.
• Main results:
  • The first biopsy diagnosed diffuse pleural mesothelioma in 178 of 552 patients (32%), and no false-positive biopsies were seen.
  • Sensitivity of the first VATS pleural biopsy was 93% and specificity was 100%.
  • 14 first biopsies were false negatives (reported as 2%). Of these 14, 10 (71%) were first diagnosed as chronic pleuritis, 3 (printed as 28.5%) as atypical mesothelial proliferation, and 1 as reactive mesothelial proliferation.
  • A history of asbestos exposure was reported in all 14 false-negative patients and in 148 (83%) of the 178 true-positive patients.
  • In the 14 false-negative patients, the correct diagnosis was reached after a median of 160 days (interquartile range 86 to 243). The text states that 9 (64%) were diagnosed by a further VATS biopsy, 3 (22%) by pleural fluid cytology, 1 (7%) by fine-needle biopsy and 1 (7%) by open surgery.
  • Median survival among patients eventually diagnosed with diffuse pleural mesothelioma was 13.8 months (95% CI 10.3 to 16.6).
  • In biopsy-positive (true-positive) cases, 1-year survival was 52.2% (95% CI 44.7 to 59.3) and 4-year survival was 10.1% (95% CI 6.2 to 15.1). In false-negative cases, 1-year survival was 50.0% (95% CI 22.9 to 72.2) and 4-year survival was 14.3% (95% CI 2.3 to 36.6). A log-rank test comparing the survival curves gave p = 0.813, and the authors described the survival analysis as exploratory.
  • Epithelioid mesothelioma was the most frequent histotype among true-positive cases (72.5%).
• The authors' conclusion: The authors concluded that when suspicion of diffuse pleural mesothelioma persists despite a negative pleural biopsy, further evaluation including repeat biopsy should be strongly considered, particularly in patients with documented asbestos exposure. They also concluded that the misdiagnosis rate remains relatively low in high-volume tertiary referral centers.
• Limitations the authors state:
  • The single-center, retrospective design limits generalizability and introduces selection and spectrum/referral bias.
  • With only 14 false negatives, no multivariable adjustment for confounders was done. Comparisons are unadjusted and exploratory.
  • Patients were at various stages of disease, so clinical presentation, disease burden and biopsy complexity varied.
  • Biopsies were done by different surgeons with varying expertise, which may have introduced variability between operators.
  • Survival was not a predefined endpoint, and the study was not designed or powered to compare prognosis.
  • Perioperative complications were not collected systematically.

Topics

Medical terms in this study, explained in our Lexicon: Thoracic Surgery, Pleural Biopsy, Pleural Mesothelioma, Asbestos Exposure, Thoracoscopy, Video-Assisted Thoracoscopic Surgery (VATS), Misdiagnosis, Mesothelioma.

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