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IntroductionPleural fluid characteristics may be complimentary in diagnosing pleural disease but tissue histopathology remains the gold-standard for diagnosis, particularly in malignancy. We sought to understand how practice has changed over time with the incorporation of novel techniques in a high-volume centre.MethodsA retrospective study of all local anaesthetic thoracoscopies (LAT) and physician performed image guided pleural biopsies (IGPBx) with ultrasound at a single centre from 2014–2019.Results510 procedures were performed over this period; 67% were LATs (343/510) the remainder were IGPBx (167/510).The proportion of IGPBx rose from 31% of procedures per year in 2014 (26) to 45% of procedures per year in 2018 (44). The number of talc poudrages performed decreased from 46% in 2015 (29) to 9% in 2018 (5).IGPBx was used preferentially in cases of benign pleural disease with 61.2% (98) resulting in a benign diagnosis compared to 46.8% (153) in the LAT group (c2 1df = 8.9, p=0.003).A higher proportion of complications were seen in LATs overall (c2 1df = 8.0, p=0.005) with complications seen in 15% of case (53). The majority were related to pain control (17), followed by vasovagal episodes (8). IGPBx were associated with complications in 6.6% of cases (11) and were largely related to bleeding (7).The sensitivity of LAT biopsies for malignant pleural disease was 87%, compared to 78% for IGPBx. The negative predictive value of both were comparable at 90% for LAT and 87% for IGPBx (figure 1). The majority of false negative biopsies in both groups were seen in Mesothelioma; 11/18 (61.1%) in the LAT group and 9/14 (64.2%) in the IGPBx group.Abstract P203 Table 1Sensitivity/Specificity/PPV/NPV analysis LAT and IGPBx LAT +ve Malignant Pleural Disease -ve Malignant Pleural Disease IGPBX +ve Malignant Pleural Disease -ve Malignant Pleural Disease Biopsy +ve 123 1 PPV 0.99 Biopsy +ve 49 0 PPV 1.00 Biopsy -ve 18 160 NPV 0.90 Biopsy -ve 14 95 NPV 0.87 Sens 0.87 Spec 0.99 Sens 0.78 Spec 1.00 DiscussionPhysician performed IGPBx offers an alternative choice of procedure to LAT with comparable negative predictive values although direct comparison is limited due to the heterogenous patient groups they were performed in. IGPBx were associated with fewer complications and therefore may be suited to a frailer patient cohort. LAT biopsies have a higher diagnostic yield and therefore thoracoscopic biopsies remain the gold-standard for diagnosing malignant pleural disease.

A 57-year-old woman presented with several weeks of headache associated with neck stiffness, drowsiness and nausea. She developed diplopia with right-sided 6th nerve palsy and subsequently developed a complex ophthalmoplegia and right-sided ptosis.Repeated lumbar punctures showed high opening pressures of up to 60 cm H2O and high protein levels up to 2.48 g/L. She developed episodes of marked loss of responsiveness but EEGs showed only generalised slowing. Brain imaging was essentially normal. An MRI Spine showed an enhancing intramedullary hyperintensity T8-T10 with overlying meningeal enhancement. A CT-PET scan revealed uptake along the cord consistent with diffuse infiltration or a meningitis – biopsy was inconclusive but macroscopically the dura was thickened with calcification observed on the spinal cord surface. A brain biopsy did not aid diagnosis and unfortunately the patient deteriorated with increasing severity of headaches and drowsiness. She died after a number of cardiorespiratory arrests.At post-mortem, thickened meninges showed a glioneuronal cell infiltrate and a diagnosis of diffuse leptomeningeal glioneuronal tumour (DL-GNT). WHO recently described DL-GNT in the 2016 update of CNS tumour classification. Previous case reports of this rare disease have concerned adults and children. DL-GNT should be considered in cases of radiological leptomeningeal enhancement and high CSF protein levels.

A 50-year-old female was admitted following a subacute and increasing headache, numbness in both hands and feet, generalised weakness and confusion.An MRI brain revealed an acute left temporal infarct with multi-focal established infarcts. MR angiography demonstrated marked occlusive disease affecting terminal internal carotid artery and both middle cerebral and posterior cerebral arteries, in a potential Moyamoya pattern.Lumbar puncture, extensive blood tests and echocardiography were unremarkable. A skin biopsy showed intimal thickening of the deep dermal arteries compatible with a diagnosis of Sneddon Syndrome. Livedo reticularis was absent and antiphospholipid antibodies negative. Antiplatelet therapy only was commenced given her seronegativity and Moyamoya.DiscussionSneddon syndrome is an uncommon disorder, characterised as generalised livedo reticularis with stroke (Sneddon, 1965). It is an increasingly recognised cause of ischaemic stroke in young adults, however, its clinical course remains poorly defined in the literature (Boesch et al. 2003). It is increasingly associated with Moyamoya syndrome, posing a challenge in terms of anticoagulation in these patients (Fierini et al. 2015). To our knowledge, this is only the second reported case without livedo reticularis (Marianetti et al. 2011) - highlighting the importance of skin biopsy - and the first with this clinical and radiological combination.