Multiple myeloma is a malignant plasma cell disorder primarily involving the bone marrow and skeleton, leading to anemia, renal dysfunction, and lytic bone lesions. Extramedullary disease, seen in about 9% of cases, reflects aggressive disease biology with poor prognosis. Common sites include the pleura, liver, and gastrointestinal tract, while pericardial involvement is exceedingly rare and often detected postmortem. Fewer than 25 cases of pericardial effusion or cardiac tamponade due to multiple myeloma have been reported, usually in advanced disease. The mechanism likely involves hematogenous spread or direct extension from adjacent lesions, often associated with high-risk cytogenetic abnormalities. This case presents an unusual first manifestation of multiple myeloma as pericardial effusion with tamponade physiology, emphasizing the need to consider hematologic malignancy in unexplained pericardial effusion, especially in resource-limited settings. A 60-year-old Ethiopian man presented with a 6-month history of progressive dry cough, dull chest pain, and worsening shortness of breath. He had been repeatedly treated for pneumonia and pulmonary tuberculosis without improvement. Chest computed tomography revealed a large pericardial effusion with features of cardiac tamponade. Echocardiography confirmed pericardial fluid causing right atrial and ventricular collapse. Pericardiocentesis drained 800mL of hemorrhagic fluid, and cytology showed atypical plasma cells. Further evaluation, including serum protein electrophoresis and bone marrow biopsy, confirmed multiple myeloma. The patient was managed with Pericardiocentesis and systemic chemotherapy, showing clinical and radiologic improvement, highlighting the rarity of pericardial involvement as an initial presentation of multiple myeloma. Pericardial involvement in multiple myeloma is an extremely rare and serious manifestation, usually signifying advanced or aggressive disease. While malignant pericardial effusions are commonly due to solid tumors, multiple myeloma should also be considered when no other cause is identified. Early echocardiography-guided pericardiocentesis is lifesaving, and definitive procedures such as a pericardial window may prevent recurrence. This case highlights the importance of suspecting hematologic malignancy in patients with unexplained pericardial effusion or cardiac tamponade. Early recognition and prompt initiation of systemic therapy can improve survival, particularly in resource-limited settings where diagnostic challenges are common.

The Role of Clinical Characteristics, Thoracic Ultrasonography and Pleural Fluid Parameters in Differentiating Malignant from Benign Pleural Effusion.

Pericardial effusion leading to cardiac tamponade can result from a wide range of underlying causes and may develop either acutely or sub acutely. Because of this variability in presentation, timely recognition and prompt intervention are essential, especially in the emergency department where delays can significantly impact patient outcomes. We describe the case of a 54-year-old woman with advanced lung cancer who presented with progressive respiratory distress. Although her initial vital signs, including blood pressure, appeared relatively stable, further evaluation revealed subtle but important features of early cardiac tamponade. An initial misinterpretation of her electrocardiogram (ECG), along with her seemingly preserved hemodynamics, contributed to a delay in initiating definitive management. Point-of-care ultrasound (POCUS) ultimately played a pivotal role in clarifying her condition.

Introduction: Malignant pericardial effusion (MPE) represents a relatively rare complication in various types of solid tumors. Its management is often challenging. One solution can be represented by surgical approaches, including a pericardio-peritoneal window (PPW), which allows draining the fluid into the abdominal cavity. The aim of this study is to investigate the efficacy and long-term outcomes of the PPW procedure as a definitive therapeutic strategy for MPE. Materials and methods: We retrospectively and prospectively observed pre-, peri-, and postoperative data of patients undergoing pericardio-peritoneal window creation from 2010 to December 2023 at the European Institute of Oncology (IEO), including the surgical procedures needed, total and specific postoperative complications, 30-day mortality rate, relapse rate, and the treatment of possible relapses. Results: A total of 44 consecutive patients underwent a pericardio-peritoneal window. In 28 patients (63.8%) PPW was associated with mono or bilateral videothoracoscopy for pleural biopsies/talc poudrage. In 23 cases, pre-operative percutaneous pericardial drainage (usually 1–2 days before surgery) was performed. No intraoperative deaths were observed. The 30-day mortality was 9% (four patients). We observed pericardial effusion recurrence in three patients at two months and in five patients at six months. In only two cases we treated this condition because of a pre-tamponade condition, treated by percutaneous pericardial drainage. The success rate of the PPW regarding pericardial relapse requiring further procedures was 95.5%. Conclusions: Patients presenting with a favorable short-term prognosis benefit from the pericardio-peritoneal window as a safe and effective method for resolving malignant pericardial effusion. Conversely, pericardial drainage is recommended as the most appropriate therapy for those with a less favorable prognosis.

ObjectiveElevated levels of high-fluorescent cells (HFCs) in serous effusions often suggest the presence of tumor cells. The purpose of this study was to evaluate the diagnostic value of HFC detection in the differentiation between benign and malignant serous effusions using the Sysmex XN-10 automated hematology analyzer in body fluid mode (BF mode).MethodsSerous effusion specimens, including 702 pleural effusions, 255 ascitic fluid samples and 21 pericardial effusions, were collected from 978 patients at the First Affiliated Hospital with Nanjing Medical University between June 2023 and June 2024. The absolute number (HFC#) and percentage (HFC%) of HFCs were detected using the Sysmex XN-10 automated hematology analyzer. Meanwhile, levels of carcinoembryonic antigen (CEA), lactate dehydrogenase (LDH) and other biomarkers in serous effusions were measured. The diagnostic performance for malignant effusions was evaluated using receiver operating characteristic (ROC) curves.ResultsThe HFC#, HFC% and CEA levels in the malignant effusion group were significantly higher than those in the benign effusion group (all P < 0.001). Multivariate logistic regression analysis revealed that HFC#, HFC%, CEA, and LDH were independently associated with malignant effusion. Receiver operating characteristic (ROC) analysis showed that CEA had the best diagnostic performance (AUC = 0.817), followed by HFC% (AUC = 0.727) and HFC# (AUC = 0.703). The diagnostic performance of HFC in combination with CEA is significantly better than that of CEA alone. For malignant effusions associated with lung cancer, the diagnostic performance of CEA was better than HFC and cytokeratin 19 fragment (CYFRA21-1), but there was no significant difference between HFC and CYFRA21-1.ConclusionHFC demonstrates high diagnostic value in identifying malignant serous effusions, especially when used in combination with CEA. As a rapid laboratory parameter based on cellular nucleic acid characteristics, HFC can serve as a useful auxiliary tool for screening malignant effusions.

IntroductionMalignant pericardial effusion (MPE) is uncommon in advanced-stage cancer. However, MPE can result in a life-threatening condition such as cardiac tamponade. Surgical drainage is routinely recommended as a rapid and effective treatment for this disease. This study aims to investigate the overall outcome after pleuropericardial window surgery in patients with MPE.MethodThis study enrolled 148 patients with MPE who underwent pleuropericardial window surgery from 1990 to 2020. The patients were grouped based on their history of lung cancer or nonlung cancer. A Kaplan-Meier survival analysis was performed to compare the two groups of patients. Depending on the variable type, the chi-square test, t test, or the Mann-Whitney U test was used to compare the two groups in terms of intraoperative and postoperative outcomes. Cox regression analysis was performed to demonstrate the mortality risk.ResultsA total of 148 patients underwent pleuropericardial window surgery during the study period; 92 patients had lung cancer, and 56 patients had nonlung cancer. In the subgroup analysis, there was no difference in age, underlying disease, or surgical approach. With regard to intraoperative outcomes, no differences were observed in hospital stay or postoperative complications. The Kaplan-Meier survival analysis revealed that patients with nonlung cancer survived longer than those with lung cancer did (p = .001).ConclusionPleuropericardial window surgery is a safe and effective procedure with acceptable postoperative outcomes. Among patients who have undergone this surgery, the presence of lung cancer, as compared with nonlung cancer, worsened their survival rate.

The Incremental Diagnostic Value of Computed Tomography Attenuation in the Differential Diagnosis of Malignant Pericardial Effusion: A Retrospective Observational Study.

Raman spectroscopy is a powerful method in the field of cancer diagnosis, for which various sample types and measurement modalities can be used. In this study, pleural effusion samples from twenty patients with suspected malignancies were analyzed. After fluid samples were fixed with ethanol and dried, high-quality spectra were taken at three different points using two laser lines. Principal Component Analysis showed clustering of spectra from malignant samples. The results show that despite a strong fluorescence signal from blood with the 532 nm laser line, spectra collected with both 532 nm and 785 nm laser lines are complementary, as they produce different high-intensity bands; e.g., breast cancer and adenocarcinoma signals are stronger with 785 nm. The main change in cancer specimens is an increase in amino acids. In addition, in small-cell carcinoma of the lung and mesothelioma, elevated nucleic acids and lipids were observed, respectively. Raman spectroscopy shows distinct profiles for control and malignant effusions. Further investigation of the utility of spectral markers in personalized treatment could improve survival.

Introduction: Chest drainage is central to thoracic surgery, pleural medicine, and emergency care, yet practice remains heterogeneous in tube caliber, access, suction, device selection, and removal thresholds. This narrative review aims to synthesize evidence and translate it into guidance. Materials and Methods: We performed a narrative review with PRISMA-modeled transparency. Using backward citation from recent comprehensive overviews, we included randomized trials, meta-analyses, guidelines/consensus statements, and high-quality observational studies. We extracted data on indications, technique, tube size, analog versus digital drainage, suction versus water-seal drainage, removal criteria, and key pleural conditions. Due to heterogeneity in device generations, suction targets, and outcomes, we synthesized the findings qualitatively according to converged evidence. Results: After lung resection, single-drain strategies, early use of water-seal, and standardized removal at ≤300–500 mL/day reduce pain and length of stay without increasing the need for reintervention; digital systems support objective removal using sustained low-flow thresholds (approximately 20–40 mL/min). Small-bore (≤14 Fr) Seldinger catheters perform comparably to larger tubes for secondary and primary pneumothorax and enable ambulatory pathways. In trauma, small-bore approaches can match large-bore drainage in stable patients when paired with surveillance and early escalation of care. For pleural infection, image-guided drainage, combined with fibrinolytics or surgery, is key. Indwelling pleural catheters provide relief comparable to talc in dyspnea associated with malignant effusions in patients with non-expandable lungs. Complications are mitigated by ultrasound guidance and avoiding abrupt high suction after chronic collapse; however, these strategies must be balanced against risks of malposition, occlusion or retained collections, prolonged air leaks, and device complexity, which demand protocolized escalation and team training. Conclusions: Practice coalesces around three pillars—right tube, right system, proper criteria. Adopt standardized pathways, device-agnostic thresholds, and volume or airflow criteria. Trials should harmonize “seal” definitions and validate telemetry-informed removal strategies.

Reply to the Letter to the Editor: 'Incremental Diagnostic Value of Computed Tomography Attenuation in Differentiating Malignant Pericardial Effusion'.

BackgroundPleural infection remains a significant clinical challenge, requiring hospitalisation, intravenous antibiotics and early chest drain insertion. Medical thoracoscopy (MT), a minimally invasive procedure used electively in the UK for malignant effusions, has demonstrated good outcomes when applied to acute pleural infection in retrospective case series. However, it has not been evaluated as a first-line intervention in the UK in a randomised controlled trial (RCT).ObjectivesThe Studying Pleuroscopy in Routine Pleural Infection Treatment (SPIRIT) trial assessed the feasibility of conducting a full-scale RCT comparing MT with chest drain insertion for acute pleural infection within UK National Health Service (NHS) hospitals.MethodsSPIRIT was an open-label, randomised feasibility trial conducted across seven NHS centres between 2017 and 2019. Adults with suspected pleural infection were prescreened; eligible patients were randomised to either chest drain insertion (control) or MT (performed the same or following day) with 90-day follow-up. The primary outcome was feasibility, assessed through a composite of prescreen, screen and allocation failure rates. Secondary outcomes included inpatient-stay duration, mortality, radiological and microbiological outcomes, second-line interventions, patient-reported outcomes and adverse events.ResultsOf 193 patients prescreened, 181 (93.8%) were excluded due to at least one criterion. Key factors included lack of MT deliverability (49.2%), a not truly infected effusion (45.1%) and contraindications to drainage or study involvement (44.0%). Consequently, the primary feasibility endpoint was not met. All 12 eligible patients were randomised with no attrition. MT lasted 15 min longer than drain insertion, but chest drains remained in situ over 3 days longer (p=0.17) with a longer hospital stay (p=0.57). Radiological improvement, microbiological yield and symptom scores were similar. Adverse events occurred in one control and three MT patients.ConclusionA full-scale RCT is not likely to be feasible in an NHS setting on the proposed protocol. Targeted recruitment from centres equipped for emergency MT may enhance feasibility.Trial registration numberISRCTN98460319.

BackgroundThe recurrence rate of malignant pericardial effusion after pericardiocentesis is 62%. For this reason, intrapericardial instillation of therapeutic agents is performed after pericardial evacuation to improve the treatment. Cisplatin has proved to be a useful and safe agent. ObjectiveTo present our experience with intrapericardial instillation of cisplatin for the management of malignant pericardial disease. Material and MethodsWe included patients admitted to the Instituto Alexander Fleming between January 2005 and May 2009 with cardiac tamponade or severe pericardial effusion treated with pericardial drainage and instillation of cisplatin (10 mg in 20 ml of physiological solution for 5 days). Malignant pericardial effusion had to be confirmed by cytological examination or by echocardiographic evidence of malignant disease involving the pericardial space. Low treatment expectation was another requirement for inclusion. A total of 9 patients (6 men and 3 women) were included; mean age was 60 years (51-69). The primary tumors were lung cancer (n=4); breast cancer (n=1); bladder cancer (n=1); esophageal cancer (n=1), and prostate cancer (n=1). The cytological examination was positive in 6 cases. Thecatheter was removed after 7 days. Three patients presented adverse events: pain, fever and atrial fibrillation. One patient had a recurrence one month later. Eight patients died [mean time to death: 50 days (7-83)] and one is alive. Conclusion Intrapericardial instillation of cisplatin is a feasible and well-tolerated procedure. The incidence of recurrences is low.

Primary mediastinal embryonal carcinoma is an exceptionally rare and aggressive extragonadal germ cell tumor, comprising less than 2% of mediastinal germ cell neoplasms. Cardiovascular complications, including pericardial effusion and tamponade physiology, are even more infrequent, with only isolated cases reported. We present the case of a 35-year-old male with no significant medical history who presented with progressive dyspnea, pleuritic chest pain, and right shoulder discomfort. Imaging revealed a massive anterior mediastinal mass (21.2 × 14.3 × 20.3 cm) compressing the left lung and shifting mediastinal structures rightward, with direct extension into the left atrium and pulmonary veins (Image 1 and 2). Echocardiography demonstrated a moderate-to-large pericardial effusion with right atrial inversion and respiratory variation in mitral inflow, suggestive of early tamponade (Image 3). However, due to stable hemodynamics and significant distortion of normal anatomy from the tumor mass, pericardiocentesis was deferred as high-risk. Multidisciplinary teams opted for conservative management, and the patient was initiated on systemic chemotherapy with ifosfamide, etoposide, and cisplatin. Serial imaging demonstrated stabilization of the pericardial effusion and early signs of tumor response. Pathology confirmed embryonal carcinoma with elevated tumor markers (AFP 514 ng/mL, β-hCG 158 mIU/mL, LDH 3,078 U/L). Neurological evaluation for multifocal infarcts revealed a brain metastasis and suspected embolic phenomena; vascular imaging showed a left popliteal artery thrombus. The case illustrates a rare instance where both malignant pericardial effusion and external tumor compression contributed to tamponade physiology without overt clinical collapse. It highlights the complexity of managing cardiac involvement in malignancy, where anatomy, mass effect, and clinical stability guide intervention. This case reinforces the need for individualized cardiovascular decision-making and interdisciplinary coordination in rare oncologic presentations involving pericardial pathology.

Background: Acute cardiac tamponade occurs when rising intrapericardial pressure compresses the heart, most commonly affecting right-sided chambers. However, in postoperative or malignant settings, pericardial adhesions or loculated effusions may produce regional tamponade, a variant where localized pressure causes isolated chamber compression. Left ventricular (LV) diastolic collapse, though rare, is a hallmark of this phenomenon when localized intrapericardial pressure exceeds LV diastolic pressure. Case Presentation: A 63-year-old man with metastatic EGFR-positive non–small-cell lung cancer and recent pulmonary embolism on rivaroxaban was admitted following elective pleural-peritoneal shunt placement for recurrent malignant pleural effusions. Transthoracic echocardiography (TTE) was notable for a small pericardial effusion on post-operative day 1. On post-operative day 2, he developed hypotension (BP 86/56 mmHg), tachycardia (HR 115 bpm), and elevated lactate (2.9 mmol/L; normal range 0.5 – 2.0 mmol/L). Exam revealed distant heart sounds and jugular venous distension. Repeat TTE demonstrated a large, loculated pericardial effusion with diastolic collapse of the lateral and apical LV ( Figure 1 ), right ventricle, and atria, along with respirophasic mitral/tricuspid inflow variation and expiratory hepatic vein flow reversal. Emergent subxiphoid surgical pericardial window revealed dense adhesions and evacuated 500cc bloody effusion, with immediate hemodynamic improvement. Histopathology confirmed malignant pericardial involvement with clusters of malignant adenocarcinoma cells ( Figure 2 ). Discussion: Here we highlight a visually compelling example of tamponade with LV diastolic collapse secondary to a loculated malignant pericardial effusion. LV diastolic collapse is a hallmark sign of regional cardiac tamponade, especially in malignancy or postsurgical states. Prior studies utilizing canine models of regional cardiac tamponade demonstrated that LV diastolic collapse correlated with significant reductions in cardiac output and mean arterial pressure prior to decompensated tamponade. Early recognition of regional tamponade and hallmark signs including LV diastolic collapse is critical to guide interventions and avoid hemodynamic deterioration.

Background: Hydropneumopericardium is a term used to describe accumulation of fluid as well as air in the pericardial space. Air or microbubbles in the pericardial space are rare findings typically associated with trauma, invasive procedures, or mechanical ventilation. Less common causes include malignancy, infection, and spontaneous erosion of adjacent structures. Early identification is important, as pneumopericardium can lead to tamponade and have a high mortality rate. Case Description: A 79-year-old woman with asthma presented with dyspnea, orthopnea, weight loss, and a right chest wall mass for 7 years. CT image revealed bilateral pleural effusions, a large pericardial effusion, and a right upper lobe soft tissue mass. Transthoracic echocardiography revealed a large pericardial effusion with unusual bright echo densities suggestive of microbubbles, raising concern for potential pneumopericardium. Pericardiocentesis was performed, yielding 400 mL of serous fluid. The drain remained in the place for approximately a week with persistent drainage that tapered slowly. The patient opted against getting a prophylactic pericardial window. Cytology reports came back positive for malignant effusion with suspected primary as malignant breast cancer, that is Estrogen Receptor and Progesterone Receptor positive. She was then started on Anastrozole and discharged to rehab with close follow up with oncology. Discussion: Pneumopericardium is most often related to trauma, barotrauma, or procedures such as pericardiocentesis, pacemaker placement, or esophagectomy. Less common causes include malignancy, tuberculosis, aspergillosis, and gastropericardial fistulae. Microbubbles in the pericardial space may be an early sign of air leakage, often preceding overt pneumopericardium. In our case, no communication with airways or gastrointestinal tract was identified on imaging, and no mechanical ventilation was used, ruling out barotrauma or fistulization. The presence of microbubbles may reflect localized necrosis or vascular invasion by tumor, leading to micro-air leak. Given the high mortality of unrecognized pneumopericardium and its potential for tamponade, early recognition of intrapericardial bubbles is critical. This case expands the differential diagnosis of this rare echocardiographic finding and highlights the importance of malignancy as an underlying etiology.

Academic advantage without survival benefit? a national cancer database analysis of primary effusion lymphoma

Introduction Ischemic stroke in the setting of advanced malignancy poses unique challenges due to competing risks of hypercoagulability and hemorrhage. We present a case of tandem occlusion caused by a free‐floating internal carotid artery (ICA) thrombus in a patient with metastatic adenocarcinoma, highlighting individualized decision‐making in reperfusion therapy. Materials/Methods A 59‐year‐old Mandarin‐speaking woman with stage IV lung adenocarcinoma, malignant pleural effusions (with PleurX catheter), malignant ascites, recent chemotherapy (amivantamab, pemetrexed, carboplatin) and left parietal AVM presented with sudden‐onset aphasia (last known well 3 hours). On arrival, she was awake but non‐verbal, not following commands despite interpreter assistance, with subtle left gaze preference and evolving right‐sided weakness (NIHSS 16). Non‐contrast CT showed subtle left MCA ischemic changes. CTA revealed a proximal free‐floating left ICA thrombus with tandem left M2 occlusion. Given prohibitive hemorrhagic risk from malignant effusions, ascites and AVM, IV thrombolysis was withheld. She underwent urgent mechanical thrombectomy with neuro‐ICU admission. Results Reperfusion was successfully achieved, with significant improvement in language function toward her baseline. The combination of proximal free‐floating ICA thrombus and distal MCA occlusion illustrated malignancy‐associated tandem pathology within a hypercoagulable milieu. Conclusion This case underscores several key points: free‐floating ICA thrombus is a rare but important malignancy‐associated cause of tandem occlusion; cancer‐related coagulopathy can present with atypical clot morphology and recurrence risk; and reperfusion strategies must balance guideline‐based therapies against individualized bleeding risks. Mechanical thrombectomy provided safe and effective treatment where IV thrombolysis was contraindicated. Recognition of stroke in oncology patients may be delayed by language barriers, treatment effects, and overlapping symptoms. This report contributes to the limited literature on thrombectomy outcomes in cancer patients with concurrent extracranial bleeding risks and cerebrovascular anomalies. image Image 1: L ICA free‐floating thrombus (donut sign) image Image 2: L M2 LVO (tandem occlusion)

Transcriptomic profiling of organoids derived from malignant effusions uncovers lncRNA MEG3 and target genes potentially involved in platinum resistance in serous ovarian carcinoma.

BackgroundMalignant pleural effusion (MPE), a grave complication in advanced malignant tumors, indicates poor clinical outcomes. Timely diagnosis of MPE is of great significance, yet presents a clinical challenge. This study aimed to develop a scoring system based on a nomogram to distinguish MPE from benign pleural effusion (BPE).MethodsThis single-center, retrospective study enrolled 382 patients with pleural effusion (PE) who underwent diagnostic thoracic puncture in Peking Union Medical College Hospital from December 2012 to May 2022. All participants were randomly divided into a training set (n=268) and a validation set (n=114) at a 7:3 ratio for predictive model development and internal validation. The nomogram model was established using the informative indexes screened by the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression. A scoring system based on this nomogram model was constructed to distinguish MPE from BPE.ResultsThe scoring system included: no fever (7 points), age/effusion adenosine deaminase (ADA) >2.5 (5 points), effusion/serum total protein (TP) ratio >0.5 (6 points), serum lactate dehydrogenase (LDH)/effusion ADA ratio [cancer ratio (CR)] >11.8 (8 points), effusion carcinoembryonic antigen (CEA) >3.6 ng/mL (10 points), and effusion LDH >154 U/L (7 points). The score showed favorable diagnostic performance in the training set [area under the curve (AUC) =0.961; 95% confidence interval (CI): 0.941–0.981], and the internal validation set (AUC =0.872; 95% CI: 0.803–0.942). At the optimal cutoff value of 28 points, the specificity and sensitivity for identifying MPE in the training set were 85.3% and 93.2%. In the internal verification set, they were 87.5% and 80.0%, respectively. The score also showed good diagnostic accuracy in differentiating MPE caused by lung cancer from BPE (training set: AUC =0.984; 95% CI: 0.971–0.998; validation set: AUC =0.914; 95% CI: 0.845–0.984). Besides, this scoring system outperformed conventional single tumor biomarkers in identifying cytologically suspected or negative malignant effusions (AUC =0.879; 95% CI: 0.812–0.945).ConclusionsThe combination of multiple tumor markers demonstrated potential diagnostic value for MPE identification. To further improve the cost-effectiveness and applicability, we developed a simple scoring system involving six easily accessible clinical variables, which exhibited good diagnostic performance and clinical applicability for identifying MPE.

Background: Exudative pleural effusion is a common clinical problem with diverse etiologies, often requiring invasive procedures for definitive diagnosis. While conventional cytology is widely used, its diagnostic yield remains limited. Ancillary methods such as cell block (CB) preparation, pleural brushing, and thoracoscopic pleural biopsy may enhance diagnostic accuracy.Objectives: This study aimed to evaluate and compare the diagnostic utility of pleural fluid cell cytology (CC), CB, pleural brushing, and pleural biopsy in patients with exudative pleural effusion.Methods: This prospective observational study was conducted at a tertiary care hospital and included 49 patients with exudative pleural effusion. All patients underwent pleural fluid analysis, cytology, CB preparation, and medical thoracoscopy with pleural brushing and biopsy. Diagnostic yields, sensitivity, specificity, positive predictive value, and negative predictive value of each modality were calculated using pleural biopsy as the reference standard.Results: The study population had a mean age of 52.4 ± 15.2 years, with 59% of male participants. Malignancy was the most frequent etiology (55%), followed by tuberculosis (28.5%) and nonspecific pleuritis (14.2%). Diagnostic yield was highest for pleural biopsy (83.6%), followed by pleural brushing (80.9%), CB (61.9%), and CC (38.1%). Sensitivity and specificity were 44.4% and 100% for cytology, 59.2% and 100% for CB, and 80.9% and 100% for pleural brushing, respectively. The combination of cytology and CB improved diagnostic yield compared to cytology alone.Conclusion: Conventional cytology alone has limited sensitivity in diagnosing exudative pleural effusions. CB and pleural brushing significantly improve diagnostic yield, while pleural biopsy remains the gold standard. Incorporating CB and pleural brushing into routine practice may enable earlier and more accurate diagnosis, particularly in suspected malignant effusions.