Purpose of review: The most efficient and cost-effective approach to pleural exudates not diagnosed by means of thoracocentesis remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. This review will focus on the developments in image guidance of closed pleural biopsy.
Recent findings: Recent studies suggest that computed tomography and ultrasound guidance improve the yield and safety of closed pleural biopsy. Imaging is best suited to reduce the rate of false-negative biopsy in malignant pleural disease by enhanced targeting of localized pleural changes typically situated dorsolaterally close to the diaphragm. Pleural tuberculosis causes effusions with discrete and uniformly distributed pleural thickening, and evidence suggests that the utilization of imaging has little advantage in this setting apart from decreasing the risk associated with blind biopsy. Imaging also facilitates a directed repeat thoracocentesis in the same session. The cumulative yield of image-assisted repeat thoracocentesis and pleural biopsy has been reported to approach that of thoracoscopy, particularly in cases with pleural thickening, nodularity or pleural-based mass lesions.
Summary: Image-guided pleural biopsy combined with repeat thoracocentesis is a safe, inexpensive, accessible and sensitive method for further examination of patients with pleural exudates not diagnosed by initial thoracocentesis.