Video of the procedure


A pleural biopsy should be considered in exudative effusions. It is not indicated in transudative effusions. Even in exudative effusions, the role of a pleural biopsy is being challenged.

I think we can place the role of a pleural biopsy in the correct perspective after reviewing the diseases diagnosable by pleural biopsy. There is a long list of diseases known to give exudative pleural effusions, only some of which are diagnosable by pleural biopsy. Exudative effusions can be caused by malignancy, TB, SLE, rheumatoid arthritis, pneumonia, pulmonary embolism, viral infections, asbestosis, myxedema, uremia, drugs, idiopathic, etc.

A large majority of etiologies have no specific findings in the pleural biopsy. They are diagnosed by circumstantial evidence by association and exclusion of malignancy and tuberculosis.

The three main groups of disorders that can be diagnosed by a pleural biopsy are as follows:

  1. Malignancy (secondary, mesothelioma and lymphoma)
  2. Granulomatous (TB, sarcoidosis, fungus)
  3. Lupus (drug induced, denovo lupus)

I will present my modus operandi. The following lists criteria for selecting a patient with pleural effusion for biopsy.

I see pleural effusion in three clinical settings:

  1. Part of anasarca:
    In patients with anasarca, all we need to decide on is whether the effusion is a transudate or an exudate and a biopsy is not indicated.
  2. Occurring with a disease known to cause pleural effusion:
    In the clinical setting with a disease known to cause pleural effusion, our first task is to consider tests which will confirm that disease (RA, pancreatitis, pneumonia, lupus, another primary, etc). A pleural biopsy will be indicated only in patients with lupus and when another malignancy exists.
  3. As a presenting problem:
    When pleural effusion is the presenting problem, my initial procedure is a pleural biopsy. The main working diagnosis is malignancy in this clinical setting. I favor a pleural biopsy in this setting since 60% of diseases I have encountered are diagnosable by biopsy. Most important, I do not want to miss the opportunity to diagnose a granulomatous pleuritis secondary tuberculosis.

Are you aware that there is a controversy about the value of pleural biopsy? With increased sophistication, pathologists are able to make a definitive diagnosis of malignancy by pleural fluid cytology. The yield of three independent pleural fluid cytology may be just as sensitive, without a pleural biopsy. Another concern is that physicians are poorly trained in pleural biopsy and usually do not obtain adequate tissue.

I think there is a role for pleural biopsy. While the necessity of pleural biopsy for the diagnosis of malignancy has decreased, certainly there is a need for the biopsy in tuberculous effusions. I also think it is extremely valuable in confirming the diagnosis of lupus. I have had extensive past experience with pleural biopsies and my complication rate is negligible. I almost always obtain pleura.