Pleural Biopsy Research Articles

Defining pre-clinical models is of utmost importance for pleural mesothelioma (PM) to improve prognosis and predict therapeutic response. Using cells isolated from pleural fluid (PF) and diagnostic pleural biopsy (PB), we generated PM patient-derived organoids (PM-PDOs) and reactive-mesothelial (RM)-patient derived organoids (RM-PDO) aiming at assessing the proportion of successful cultures both from PF and PB. We also compared the architectural and immune-histochemical features of PM-PDOs to those of parental tissues and evaluated the PM-PDOs response to chemo-immunotherapy. We obtained 11 successful PM-PDOs from 15 PF/PB (73.3%). The rate of success was higher in epithelioid PM (88.8%) compared to biphasic PM (40.0%) (p=0.175), and when using PF (60.0%) compared to PB (20.0%) (p=0.001). We also obtained 3 RM effective cultures from 6 asbestos-exposed patients (50%) with non-specific pleuritis. Transcriptome analysis identified gene expression profile in PM-PDOs, which differentiate from RM-PDOs. PM-PDOs successfully maintained the histological architecture and molecular markers of their parental tumour tissues. The macrophagic component (CD68+ and CD163+) was an important component in RM-PDOs and was present in all three PM histotypes. Epithelioid PM-PDOs showed resistance to both Cis/PeMtx and pembrolizumab plus peripheral blood mononuclear cells (PBMCs), while both biphasic and sarcomatoid subtypes were sensitive to immunotherapy. Notably, immunotherapy induced an upregulation of PD-L1 expression and activated the STAT3/NF-κB signaling pathway, suggesting a mechanism of immune evasion. PF offers a valuable source of cancer and stromal cells to generate PDO, reinforcing its clinical utility for patients who cannot undergo invasive procedures.

Diagnostic Yield of Ultrasound-Guided Tru-Cut Pleural Biopsy in Undiagnosed Exudative Lymphocytic Pleural Effusion in a Tertiary Healthcare Setting

HIV, TB, and pleuropulmonary paragonimiasis co-infection is extremely rare and presents a significant diagnostic challenge due to superimposed clinical and radiological findings. Immunological suppression induced by HIV predisposes individuals to tuberculosis (TB) and concurrently suppresses the typical parasitic immune response, such as eosinophilia. Paragonimus westermani is the sole causative agent of human paragonimiasis, a disease endemic in Asia and Africa, predominantly transmitted through the consumption of raw or inadequately cooked freshwater crustaceans. We present the case of a 29-year-old Libyan male patient with a known history of HIV infection and established pulmonary TB. The patient is presented with chronic cough, weight loss, pyrexia, and pleuritic chest pain. Imaging showed chronic pleural effusion and thickening. While the patient was confirmed to have TB via GeneXpert, a VATS-guided pleural biopsy unexpectedly detected parasitic ova that are consistent with P. westermani. Histopathological diagnosis, utilizing special stains (Giesma), was essential as peripheral eosinophilia was not evident. The patient clinically improved following anti-tuberculous therapy, even though anti-parasitic therapy was not administered due to early discharge. This case highlights the importance of including parasitic infection in the differential diagnosis for unresponsive effusions in an immunocompromised host, particularly in endemic locations. Early histopathology and biopsy are valuable in unusual instances to prevent misdiagnosis and delayed treatment.

Comparative Diagnostic Utility of Cell Cytology, Cell Block, Pleural Brushing, and Pleural Biopsy in Exudative Pleural Effusions

Background: Infectious pleurisy, including Tuberculous Pleural Effusion (TPE) and Para Pneumonic Effusion (PPE), remains a diagnostic challenge in resource-limited settings. Biomarkers such as Adenosine Deaminase (ADA) and Lactate Dehydrogenase (LDH) are widely used, but the diagnostic performance of their ratio (LDH/ADA) is less explored. To determine the diagnostic accuracy of pleural fluid LDH/ADA ratio in identifying infectious pleurisy, using pleural fluid culture as the gold standard. Material and Methods: This descriptive study was conducted in the Department of Pulmonology, Ojha Institute of Chest Diseases, Dow University of Health Sciences (DUHS), Karachi, from February 2025 till July 2025. In this descriptive study, 80 patients aged 18–60 years with pleural effusion and ADA > 33 U/L were recruited at Ojha Institute of Chest Diseases, DUHS, Karachi. Pleural fluid samples were analyzed for biochemical markers and culture. LDH/ADA ratio > 10 was considered positive. Diagnostic accuracy parameters were calculated. Results: A total of 80 patients with pleural effusion were included (mean age 37.8 ± 11.3 years; 60% male). Infectious effusions showed significantly higher pleural LDH, ADA, LDH/ADA ratio, and protein, whereas glucose and pH were lower compared to non-infectious effusions (p < 0.05). An LDH/ADA ratio > 10 demonstrated excellent diagnostic performance with 93.3% sensitivity, 90.0% specificity, and 92.5% overall accuracy. Conclusion: The pleural fluid LDH/ADA ratio demonstrates high diagnostic accuracy for infectious pleurisy and may serve as a reliable, inexpensive tool in clinical settings where pleural biopsy is unavailable. Keywords: Infectious pleurisy, LDH/ADA ratio, Pleural effusion, Para pneumonic effusion, Tuberculous pleural effusion.

Objective: To compare diagnostic yield between pleural fluid cell block and pleural biopsy by Pleuroscopy. Methods: This prospective study was conducted at the Pulmonology Department, Mayo Hospital Lahore. Patients with exudative pleural effusion from December 2020 to December 2022 who underwent Pleuroscopy at the Pulmonology Department were included in the study. Pleuroscopy was performed under local anaesthesia; pleural fluid was collected for a cell block, and then multiple pleural biopsies were taken. Results: Thirty patients with exudative pleural effusion were enrolled in the study. Final diagnosis was 16 adenocarcinoma, 2 small cell carcinoma, 1 squamous cell carcinoma, 5 malignant pleural mesothelioma (MPM), 3 no malignancy, 2 metastatic carcinoma, 1 caseating granuloma. Diagnostic yield by pleural biopsy in comparison to cell block was found to be significantly higher [90% (27/30) vs. 70% (21/30); p = 0.008]. Nine patients with negative cell block had positive results on pleural biopsy (1 diffuse large B cell lymphoma,1 metastatic small cell carcinoma,1 mesothelioma,4 adenocarcinoma,1 metastasis malignancy). Three patients had inconclusive evidence for malignancy on both pleuroscopy and cell block. Conclusion: Cellblock can be used as an initial, less invasive diagnostic test for the workup of suspected pleural effusion. It can be easily performed on pleural fluid during thoracentesis, and treatment can be initiated in case of positive cell block reports without the need for pleuroscopy in every patient with suspected malignant pleural effusion. However, Pleuroscopy can be subsequently performed in patients with a negative cell block.

Background Pulmonary artery sarcoma (PAS) is a rare malignant tumor originating from the pulmonary arterial wall, often mimicking pulmonary thromboembolism. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET-CT) are crucial for early detection. Case Presentation A 35-year-old man presented with dyspnea, signs of pulmonary embolism, and right ventricular (RV) strain. Echocardiography suggested pulmonary embolism with a suspected mass in the right ventricular outflow tract (RVOT). Despite thrombectomy and thrombolysis, the filling defect persisted. The initial biopsy was negative for malignancy. Further imaging with CT, cardiac MRI, and PET-CT revealed a fluorodeoxyglucose (FDG)-avid mass extending from the RVOT into the main pulmonary artery, causing significant stenosis. Subsequent pleural and lung video-assisted thoracoscopic surgery (VATS) biopsies were also negative. After four months, a third CT-guided biopsy confirmed a high-grade spindle cell neoplasm. Retrospective examination of the thrombectomy specimen revealed a small focus of atypical spindle cells with an identical immunohistochemical profile. The tumor was inoperable, and chemotherapy was not initiated due to severe cardiac symptoms. The patient ultimately developed circulatory shock and succumbed to his illness. Conclusion This case highlights the importance of early diagnosis and intervention in PAS to prevent fatal outcomes. While histopathology remains the gold standard, initial negative biopsies delay treatment. In suspected cases, a thorough examination of thrombectomy specimens, along with ancillary studies, is critical. Advanced imaging techniques, including cardiac MRI and PET-CT, may provide sufficient diagnostic evidence to initiate treatment when biopsy results are delayed or inconclusive.

BackgroundTuberculous pleurisy (TP) presents persistent diagnostic challenges owing to the suboptimal sensitivity of conventional microbiological assays. This study aimed to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS) in diagnosing TP using formalin-fixed paraffin-embedded (FFPE) pleural biopsy tissues.MethodsThis retrospective study evaluated the diagnostic efficacy of mNGS in FFPE pleural samples of suspected TP patients at The First Affiliated Hospital of Soochow University between April 1, 2018 and February 1, 2023. Those patients with inadequate pleural specimens for mNGS analysis were excluded. Diagnosis of TP was established according to the WS 288-2017 Health Industry Standard of the People’s Republic of China.ResultsA total of 73 patients were enrolled in this study and divided into the TP group and non-tuberculous pleurisy (NTP) group. The TP group comprised 51 patients with a median age of 52 years, including 33 (64.7%) males. The NTP group consisted of 22 patients with a median age of 64 years, including 13 (59.1%) males. Our results showed that mNGS assay on FFPE in pleural biopsies had a sensitivity of 78.43% [95% confidence interval (CI): 0.667–0.901] and a specificity of 100% (95% CI: 1.000–1.000) in diagnosing TP. In the 51 TP cases, mNGS detected Mycobacterium tuberculosis complex (MTBC) in 40 (78.43%) cases and non-tuberculous mycobacteria (NTM) in 31 (60.78%) cases. Of these, 16 cases were MTBC infections alone and 7 cases were NTM infections alone, while 24 were mixed MTBC and NTM infections.ConclusionsmNGS of FFPE of pleural biopsy tissues not only improves the diagnostic efficiency of TP, but also potential accurately distinguishes between MTBC and NTM, providing molecular and microbial basis for the diagnosis of TP, which is helpful for the rapid diagnosis and precise treatment of TP.

ABSTRACTWe report the case of a 41‐year‐old woman who developed an epithelioid‐type pleural mesothelioma (PM) decades after treatment for childhood acute myeloid leukaemia (AML), who was treated with chemotherapy and total body irradiation (TBI). The diagnosis was confirmed by thoracoscopic pleural biopsy and immunohistochemical staining. Although PM is classically associated with asbestos exposure, the patient had no known history of exposure. This case report highlights the fact that PM can occur as a late‐onset secondary malignancy following radiation therapy in childhood cancer survivors. Although radiation‐induced PM has been reported primarily in survivors of Hodgkin lymphoma or breast cancer, incidences following treatment for leukaemia are exceptionally rare. This case report highlights the importance of considering prior therapeutic irradiation, including total‐body irradiation, as a potential etiological factor for non‐asbestos‐related PM. It also emphasises the need for the long‐term surveillance and monitoring of childhood cancer survivors, particularly those who have received radiation therapy.

Traditional thoracic ultrasound-guided pleural biopsy (TUSPB) is considered the initial method for histological diagnosis; however, its sensitivity for detecting malignant pleural effusion (MPE) is limited. Ultrasound elastography can be used to differentiate MPE from benign diseases by evaluating pleural stiffness. This study aimed to investigate whether ultrasonic elastography-guided pleural biopsy (UEPB) offers diagnostic accuracy superior to that of TUSPB for pleural effusions. In this multicentre, randomised trial (ClinicalTrials.gov ID: NCT05781659), patients with pleural effusion of unknown origin were enrolled and randomized (1:1) to undergo either UEPB or TUSPB. The primary outcome measured was the sensitivity of UEPB in diagnosing MPE; the secondary outcomes were the diagnostic rate of the two methods in patients with different pleural thicknesses, and the safety of UEPB. In total, 232 patients with pleural effusion were enrolled, 228 of whom were included in the analysis. The sensitivity for detecting MPE was significantly greater in the UEPB group than that in the TUSPB group (85.00% [51/60] versus 63.16% [36/57], p=0.007). Patients in the UEPB group had a significantly greater diagnostic yield than those in the TUSPB group did (87.83% [101/115] versus 76.99% [87/113], p=0.032). For patients with MPE and a pleural thickness ≤5 mm without who did not have pleural nodules, UEPB had a significantly greater sensitivity than did TUSPB (80.49% [33/41] versus 50.00% [15/30], p=0.007). The rates of procedure-related complications were similar between the UEPB and TUSPB groups (6.36% versus 8.33%, p=0.552). UEPB was superior to TUSPB in the diagnosis of MPE with a similar safety profile.

BackgroundPleural effusion is a common clinical problem with varied etiologies. Timely diagnosis is essential for appropriate treatment. This study aimed to compare the diagnostic performance of brush cytology and imprint cytology, with histopathology, in pleural biopsy specimens obtained via thoracoscopy.MethodsThis prospective observational study included 96 patients with undiagnosed exudative pleural effusion undergoing medical thoracoscopy. Biopsy samples were analyzed by histopathology, brush cytology, and imprint cytology. Diagnostic metrics, including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), McNemar’s test, receiver operating characteristic (ROC) analysis, and logistic regression, were computed.ResultsImprint cytology demonstrated higher sensitivity (73.17%) and NPV (76.60%) compared to brush cytology (65.85% and 72.00%, respectively). Logistic regression showed that a positive imprint result predicted biopsy positivity with an odds ratio of 5.17. ROC analysis confirmed superior diagnostic performance for imprint cytology.ConclusionImprint cytology is a reliable, rapid, and effective diagnostic tool in thoracoscopic pleural biopsy evaluation, with performance metrics approaching those of histopathology.

BackgroundPrevious studies have indicated that C-C class chemokine ligand 22 (CCL22) is involved in the pathogenesis of tuberculous pleural effusion and malignant pleural effusion. However, the diagnostic role of pleural fluid CCL22 levels in patients with undiagnosed pleural effusions remains to be elucidated.MethodsWe prospectively recruited patients with undiagnosed pleural effusion who visited two centres (Hohhot and Changshu) in China. Pleural biopsy, microbiological culture and effusion cytology were used to verify the cause of pleural effusion. Pleural fluid CCL22 levels were measured using an ELISA. The diagnostic accuracy of CCL22 for identifying heart failure (HF) was evaluated using a receiver operating characteristic (ROC) curve, and the net benefit of CCL22 was evaluated using decision curve analysis (DCA). Net benefit was defined as the benefit associated with true positives minus the harms associated with false positives at various threshold probabilities.ResultsWe enrolled 153 and 58 patients in the Hohhot and Changshu cohorts, respectively. The cohort included 28 patients with HF and 183 patients with non-HF. Patients with HF had significantly lower pleural fluid CCL22 levels than non-HF patients. The area under the ROC curve (AUC) of CCL22 was 0.85 (95% CI: 0.77 to 0.93) in the Hohhot cohort and 0.87 (95% CI: 0.75 to 0.98) in the Changshu cohort. The AUC in the combined cohort was 0.85 (95% CI: 0.79 to 0.92), with a sensitivity of 0.82 (95% CI: 0.68 to 0.93) and a specificity of 0.73 (95% CI: 0.67 to 0.79) at the threshold of 150 ng/mL. DCA revealed a potential net benefit of pleural CCL22 determination in patients with undiagnosed pleural effusions.ConclusionsPleural fluid CCL22 may be a potential diagnostic marker for HF-related pleural effusion. Owing to the small sample size of this study, further studies with larger sample sizes are needed to validate our findings.

Background/Objectives: Up to one third of pleural biopsies performed during medical thoracoscopy (MT) are labelled as non-specific pleuritis (NSP). The histological diagnosis of NSP has long been worrisome for pulmonologists, with the potential to evolve into a life-threatening condition. The aim of this study was to identify clinical and biological predictors for patients with a diagnosis of NSP to guide clinical decisions. Methods: Baseline, procedural and follow-up data of NSP patients were retrospectively analysed to identify potential outcome predictors. Results: Of the 272 patients who underwent MT, 192 (71%) were diagnosed with malignancies, 9 (3%) with benign diseases and 71 (26%) with NSP. At follow-up, 17% were diagnosed with malignant disease and 21% with a benign condition and 62% remained idiopathic. A thoracoscopist’s evaluation of the pleural appearance reported a PPV of 28% and an NPV of 91% to predict malignancy. Patients with a subsequent diagnosis of malignancy tended to have a higher volume of fluid drained than those with persistently idiopathic NSP [2.7 litres (L) vs. 1.6 L p = 0.06]. A lymphocytic pleural effusion was more common in the malignant and idiopathic groups (63% and 60%, respectively) than the benign group (16%; p = 0.06 and p = 0.01). The three groups had a similar rate of effusion recurrence. Overall survival was higher in patients with idiopathic pleural effusion than in those with malignant (p = 0.04) or benign disease (p = 0.008). Conclusions: NSP diagnosis hides a malignancy in one in five cases, underlying the importance of closely following up these patients. The volume of drained pleural fluid, cell count and thoracoscopist’s impression may guide clinicians in the challenging management of patients with NSP.

Background and objectivesRecurrent pleural effusion has always posed a challenge for definitive etiological diagnosis because it relies on nonspecific investigative methods like pleural fluid analysis.The basic nature of fluid, like transudate or exudate, can be differentiated by Light’s criteria. The common causes of exudative effusion are tuberculosis, malignancy, and pneumonia. The non-specific method of diagnosis mainly depends upon pleural fluid biochemical and cytological tests in order to decide an empirical treatment. The blind method of pleural biopsy by introducing a specialized pleural biopsy needle into the pleural cavity is also not promising for accurate histopathological study in order to reach a definitive etiological diagnosis in exudative pleural effusion patients. The aim and objectives of this study are to determine the role and efficacy of medical thoracoscopy for definitive diagnosis in patients having exudative pleural effusion.MethodsThe study was carried out by taking a sample size of 61 patients fulfilling the inclusion and exclusion criteria, having recurrent exudative pleural effusion as per Light's criteria, admitted in the pulmonary medicine department of Kalinga Institute of Medical Sciences over a period of two years (2023-2025). All cases were subjected to medical thoracoscopy in the designated procedural suite of this hospital after doing the required investigations. Multiple pleural biopsy samples were obtained in each patient and sent to the histopathology lab to obtain tissue diagnosis. All the data of the study were kept for critical analysis to reflect in the results and conclusion.ResultsThe mean age of cases was 58 years with a male-female ratio of 1.25:1. Shortness of breath was the most common symptom (56 cases, 91.8%) followed by cough (47 cases, 77.04%). Hypertension was the most common comorbidity found among the cases (16 cases, 26.2%). The most common radiology finding was gross pleural effusion (54 cases, 88.5%), followed by mass lesion (16 cases, 26.2%), thickened pleura (16 cases, 26.2%), and nodules (nine cases, 14.8%). Pleural tissue biopsy revealed malignancy in 41 patients (67.2%). Out of which adenocarcinoma was the most common subtype (30 patients, 49.2%), followed by squamous cell carcinoma (eight patients, 13.1%), and was inconclusive in four patients. Post-thoracoscopic minor complications were reported in only 8 patients; 6 patients (9.8%) had subcutaneous emphysema, and two patients (3.3%) developed persistent air leak. Those were resolved with conservative treatment.ConclusionThis study favored medical thoracoscopy as an ideal and effective tool to achieve a definitive diagnosis in recurrent exudative pleural effusion with very minimal and self-limited complications. Its role and efficacy are undisputed in all cases of recurrent exudative pleural effusion in order to achieve a highly promising diagnosis, so that an early treatment plan can be initiated accordingly.

Tuberculosis is an infectious disease that primarily affects the lungs and can pose diagnostic challenges to physicians. This case report discusses a 23-year-old male who initially presented with signs suggestive of lung carcinoma. A pleural biopsy done confirmed a TB-related right pleura necrotizing granuloma that responded well to anti-TB medications.

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor that develops from the mesothelial cells of the pleura, primarily caused by exposure to asbestos. The diagnosis is based on imaging (chest X-ray, CT scan), biopsy, and immunohistochemical analysis. Treatment relies on surgery, chemotherapy (cisplatin, pemetrexed), and radiotherapy. The prognosis is generally unfavorable, with a median survival of 12 to 18 months. We report the case of a 63-year-old patient who worked as a mason and had a history of chronic smoking (40 pack-years) and professional exposure to asbestos. Clinical signs of severe dyspnea, accompanied by chest pain and a productive cough, led to further examinations. The chest X-ray revealed a significant pleural effusion, and the CT scan showed diffuse pleural thickening. A pleural biopsy confirmed the diagnosis of mesothelioma. The prognosis for patients with mesothelioma is generally poor, with 5-year survival rates often below 10%. Management of this disease requires a multidisciplinary approach, including surgery, chemotherapy, and potentially radiotherapy, but outcomes remain limited. Prevention is crucial and relies on reducing exposure to asbestos, the primary identified risk factor. Laws prohibiting the use of asbestos have been enacted, and efforts to raise public awareness about the dangers of this substance are essential. Research is also ongoing to explore new therapies, including immunotherapy, to improve outcomes for patients with this disease.

Objective: To assess the efficacy of gene Xpert assay in comparison of Pleural biopsy to diagnose of pleural tuberculosis.Methodology: This study was conducted at PIMS/SZABMU, Islamabad, Adult population, both genders, aged between 14-70 years presented to hospital with complaints of fever, cough and exudative lymphocytic pleural effusion who were requested to enroll in the study. Included groups of positive and negative for Pleural tuberculosis underwent near neural biopsy using ABRAM's needle approach. SPSS (Statistical Package for Social Sciences) version 23, was used to analyze all of the data. For categorical variables such as gender, frequency and percentage were calculated. For continuous variables such as age, the mean +/- standard deviation was calculated.Results: A total of 190 patients were included in the study with mean age of 27.4 ± 4.8 years; The frequency of Pleural effusion site reported right sided effusion in 108 (56.8%) and left sided effusion in 82 (43.2%) of patients. The Gene xpert results were reported as positive in 55 (28.9%) and negative in 135 (71.1%) of patients; pleural biopsy was reported as positive in 77 (40.5%) and negative in 113 (59.5%) of patients. Correlation of pleural biopsy with gene Xpert results indicated 47 gene xpert patients with Pleural biopsy as positive and 8 as negative while gene xpert negative results were reported in 30 patients with pleural biopsy positive results and 105 negative results, p-value was estimated at 0.0007. Sensitivity was reported as 71.2%, specificity at 92.4%, PPV was 88.2%, NPV at 81.9% and Accuracy was 84.2% respectively.Conclusion: Mycobacterium TB can be accurately detected in patients with exudative pleural effusions using gene xpert analysis.Keywords: Myobacterium TB, Gene Xpert assay, Pleural effusion, Pleural Biopsy

Tuberculosis (TB) remains one of the leading causes of death from infectious agents worldwide. Pleural TB is one of its most common presentations, especially in regions with high endemicity. Its diagnosis is challenging due to clinical and radiological similarities with other conditions, such as malignant pleural mesothelioma. We report the case of a patient with fever, weight loss, dyspnea, fatigue, and asthenia, whose chest CT scan revealed diffuse pleural thickening associated with pleural effusion and lymphadenopathy, suggesting neoplastic involvement. The patient underwent lymph node and pleural biopsies, which revealed a granulomatous process with caseous necrosis. The histopathological findings, along with the high regional TB endemicity, justified the initiation of specific treatment. The patient showed progressive clinical and radiological improvement after therapy. Active TB should be considered in the differential diagnosis of diffuse pleural thickening, even in the absence of subjective symptoms. CT imaging can be useful in assessing disease activity, ruling out differential diagnoses, and monitoring treatment response in patients with pleural TB.

Given the growing incidence of pleural effusions and the limited availability of medical thoracoscopy (MT) in clinical practice, ultrasound (US)-guided pleural needle biopsies using Abrams or cutting needles are increasingly being used for the histopathological diagnosis of pleural diseases. To assessed the diagnostic yield and safety of US-guided Abrams and cutting needles to determine the optimal needle type for specific clinical situations. Prospective randomized study. The study included 174 patients with undiagnosed pleural effusion requiring histopathological evaluation. Patients were randomized into two arms: those who underwent US-guided cutting needle biopsy (US-CNPB) and those who underwent US-guided Abrams needle biopsy (US-ANPB). The US-CNPB group exhibited a false-negative rate of 36.9% and diagnostic accuracy of 63.0%. compared to 21.3% and 78.7% in the US-ANPB group, with significant differences between the groups (p = 0.036 and 0.045, respectively). In patients with pleural thickening < 1 cm or absent on US, US-CNPB exhibited 55.2% diagnostic accuracy and a negative likelihood ratio (-LR) of 0.57. For US-ANPB, the corresponding rates were 77.3% and 0.32. The difference in diagnostic accuracy between the two groups was significant (p = 0.009). In patients with pleural thickening ≥ 1 cm, the diagnostic accuracy of US-CNPB was 93.3% and 88.9% for US-ANPB, with no significant difference between the groups. The corresponding -LR values were 0.08 and 0.17. In patients with pleural thickening < 1 cm, four major bleeding events (6.9%) occurred in the US-CNPB group. No deaths were reported in this study. US-CNPB should be preferred in patients with pleural thickness ≥ 1 cm on US. MT is recommended for patients with pleural thickening < 1 cm or those presenting with pleural effusion without pleural thickening. However, in the absence of MT, US-ANPB is the preferred alternative because of its superior diagnostic accuracy and procedural safety.

Combined ultrasound-guided thoracentesis, percutaneous pleural biopsy, and indwelling pleural catheter insertion as the first intervention in patients with high likelihood of malignant pleural effusion