Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study

Lung. 2022 Dec;200(6):807-815. doi: 10.1007/s00408-022-00573-8. Epub 2022 Sep 29.


Purpose: The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers.

Methods: This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy.

Results: The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%).

Conclusion: The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Keywords: Benign pleural effusion; Cytological diagnostic sensitivity; Exudative pleural effusion; Image-guided pleural biopsy; Malignant pleural effusion.

Publication types

  • Observational Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Exudates and Transudates
  • Female
  • Humans
  • Male
  • Pleura / pathology
  • Pleural Effusion* / diagnosis
  • Pleural Effusion* / etiology
  • Pleural Effusion* / pathology
  • Pleural Effusion, Malignant* / diagnosis
  • Pleural Effusion, Malignant* / etiology
  • Pleural Effusion, Malignant* / pathology
  • Prospective Studies