Pleural Biopsy

Indications for pleural biopsy include the following:

• Undiagnosed exudative lymphocytic pleural effusions, including exudative lymphocytic pleural effusions, recurrent pleural effusions of unknown etiology, and cytologically negative pleural effusions.
• Pleural mass, thickening, or nodularity
• Recurrent pleural effusion of unknown etiology

Cope needles and Abrams needles, as shown in the images below, are most commonly used for blind or closed needle biopsy. This procedure generally is performed in the setting of a large pleural effusion without any imaging other than chest radiography.

The Cope needle contains an outer needle 11G (B) with an adjustable needle stop (A). The inner 13G biopsy trocar (C) has a hook shape for pleural biopsy sample collection. The inner needle (D) has a fitted stylet. (Image used with permission, courtesy of Dyna Medical Corporation.)

View Media Gallery

The Cope needle assembly contains outer needle 11G with an adjustable needle stop and inner 13G biopsy snare (A). The inner needle has a fitted stylet (B). (Image used with permission, courtesy of Dyna Medical Corporation.)

View Media Gallery

Abrams needle (A) outer cannula with trocar point and cutting window, which can be closed with a turning action of the inner tube (B) inner stylet. (Image used with permission, courtesy of Dyna Medical Corporation.)

View Media Gallery

Complete Abrams needle assembly with stylet needle. The needle is in the closed position. (Image used with permission, courtesy of Dyna Medical Corporation.)

View Media Gallery

Procedure

After positioning the patient, the biopsy site is selected following a thorough physical examination and imaging review. Under strict aseptic conditions, local anesthesia is administered at the chosen site. A small skin incision is made using a scalpel blade. 

A Cope needle with a stylet is then introduced through the skin incision at the upper surface of the rib, minimizing the risk of damage to the neurovascular bundle. The needle is advanced until pleural fluid is aspirated. Once fluid is obtained, the stylet is removed, and the biopsy trocar is introduced. A 50-ml syringe is attached to the biopsy needle, creating a closed system that allows for the withdrawal of pleural fluid, thus confirming that the biopsy needle is correctly positioned within the pleural space. 

The biopsy needle is then rotated so that the right-angled projection faces downward. The outer cannula and the biopsy trocar are partially withdrawn until the parietal pleura is engaged. One hand applies Gentle traction to the biopsy trocar, while the outer cannula is advanced using a rotary motion. This maneuver facilitates the dissection of pleural tissue and intercostal muscle. 

As the biopsy needle is withdrawn, the patient is instructed to make an "EEEEE" sound to minimize the risk of air entry into the pleural space. The biopsy specimen is collected using the attached syringe while applying positive pressure. The needle site is carefully monitored for any bleeding complications, and a pressure dressing is applied to prevent the subcutaneous accumulation of pleural fluid. 

The Abrams pleural biopsy needle consists of three components: two concentric tubes and a stylet. The outer tube features a trocar point and a deep notch positioned behind it. The inner tube can be closed with a rotary movement, allowing for the precise cutting of pleural tissue. The general technique for performing a pleural biopsy with the Abrams needle is akin to that described for the Cope needle. 

In moderate to large pleural effusions, a blind pleural biopsy can also be conducted using a Tru-cut needle. The results obtained with this method are comparable to those achieved with the Abrams and Cope needles. ^{[11, 12]}  However, the Tru-cut needle is typically utilized with image guidance, such as ultrasonography or CT scanning. 

A newer approach involving retrograde biopsy forceps (Retroforceps, Karl Storz, Tuttlingen, Germany) has been proposed by Wiewiorski et al. This technique was evaluated in a thoracoscopic cadaver study to assess its feasibility and pleural yield. During the study, the surgeon was blinded to the thoracoscopic view while performing 20 closed pleural biopsies (10 on the left hemithorax and 10 on the right). 19 of the 20 biopsy attempts successfully obtained parietal pleural samples, confirmed via thoracoscopy. The authors suggest that this technique may reduce complications associated with closed pleural biopsies, such as pneumothorax and bleeding, by employing a closed system with suction, an optional syringe attachment, and a blunt-tipped design. 

One limitation of this proposed technique is that the biopsy forceps must be removed after each biopsy. Further evaluation of this closed technique and its ultrasonography-assisted counterpart is warranted in clinical settings, particularly compared to other established pleural biopsy methods. ^[13]

Complications and precautions

During pleural biopsy, injury to adjacent organs, such as the liver, kidney, and spleen, is uncommon. However, conducting a chest radiography post-procedure is essential to rule out immediate complications, including pneumothorax. The incidence of pneumothorax associated with closed needle biopsy ranges from approximately 8% to 18%. ^[14]

Hemorrhagic states are regarded as a relative contraindication for pleural biopsy. Correcting any coagulation abnormalities prior to the procedure is crucial to minimize the risk of bleeding complications, including chest wall hematoma and hemothorax. 

Diagnostic yield

Needle biopsy of the pleura is a valuable tool for establishing the diagnosis of malignant or tuberculous pleural effusion. ^[15]  Multiple pleural biopsies are often performed to increase the diagnostic yield. Combining pleural biopsy with pleural fluid cytology further enhances diagnostic accuracy. ^[7]  Notably, needle biopsy of the parietal pleura is more effective in patients with suspected tuberculous effusion than those with malignant effusion, with the initial biopsy demonstrating granulomas in 50-80% of cases. ^[16]  

Historically, the sensitivity of Abrams biopsies for detecting malignancy has ranged from 27% to 60%. In the most extensive review, which included 2,893 Abrams samples, the diagnostic yield for malignancy was reported at 57%. ^[17]  The sensitivity for diagnosing tuberculosis with Abrams biopsies is notably higher, ranging from 67% to 92%, partly due to the diffuse pleural involvement seen in tuberculous pleuritis. ^[17]  

In a 2010 study by Pandit et al, the use of the Abrams needle resulted in a diagnosis of tuberculosis and malignancy in 90.9% and 63.2% of cases, respectively, with tubercular granulomas noted on histopathology in all cases of tuberculosis. ^[18]  It is important to note that granulomatous pleuritis is not specific to tuberculosis; it can also be associated with other conditions, such as fungal infections, sarcoidosis, and rheumatoid disease. 

Several studies have compared the diagnostic sensitivity of the Cope needle with that of the Abrams needle. In a 2006 study involving 57 patients with pleural tuberculosis, the diagnostic yield for the Cope needle was 85%, compared with 57% for the Abrams needle; however, this difference did not reach statistical significance. The incidence of pneumothorax was higher with the Cope needle than with the Abrams needle. ^[14]  Additionally, the Cope needle requires more patient cooperation to achieve maximal exhalation, which helps reduce negative intrapleural pressure and the risk of pneumothorax. 

One innovative study employed a cytological brush to enhance the closed pleural biopsy procedure yield with the Cope needle. This technique yielded a diagnostic success rate of 91%, surpassing the yields achieved with pleural fluid cytology (67%) or pleural biopsy alone (58%) in cases of malignant pleural effusions. ^[20]  

In a 2010 study by James et al., closed pleural biopsy using a Tru-cut needle resulted in a diagnostic yield of 62.2% for all exudative pleural effusions, 76.2% for tuberculous pleural effusions, and 85.7% for malignant pleural effusions. ^[12]  

An 8-year prospective study published in 2017 evaluated 1,034 closed pleural biopsies (using either Cope or Abrams needles) performed on patients with lymphocytic exudative effusions of unknown etiology at a tertiary referral center in Mexico City. The sensitivity and specificity of closed pleural biopsy for any malignancy were 77% and 98%, respectively, whereas for mesothelioma, these figures were 81% and 100%. Among the samples collected, 378 (36.56%) displayed nonspecific findings, with 137 (23.34%) corresponding to false-negative results for malignancy. The complication rate was lower than previously reported, at 4.4%, comprising 30 pneumothoraces (11 of which required chest tube placement), 6 hematomas, 2 vasovagal episodes, and 3 cases of subcutaneous emphysema.

Although the needle selection was not specified in the accuracy analysis, the overall sensitivity exceeded previous reports, which noted sensitivities of up to 68%. ^[21]  The sensitivity for any malignancy was comparable to the lower end of sensitivity reported for image-guided pleural biopsies (77%). ^{[22, 23]}  

Closed pleural biopsy can be considered in patients with suspected diffuse pleural involvement and undiagnosed exudative lymphocytic pleural effusions, mainly when image-guided techniques are unavailable or when the patient cannot tolerate thoracoscopy. It may also serve as a first-line diagnostic tool in resource-limited settings with a high prevalence of tuberculosis. ^{[6, 17, 24]}  However, due to the inability to target areas of abnormal pleural thickening or nodularity, the risk of adjacent organ injury, and the frequent complications associated with closed pleural biopsy—such as pneumothorax ^[14] —this procedure is generally reserved for patients with significant pleural effusion and has largely been supplanted by image-guided pleural biopsy techniques. 

The procedural yield of pleural biopsy is significantly improved when utilizing ultrasonography or CT guidance, primarily due to the ability to accurately target abnormal areas of the pleura. ^{[17, 25, 26]}  Ultrasonography is particularly sensitive in detecting loculated pleural effusions, outperforming CT scanning in this regard. ^[6]  Additionally, ultrasonography offers the advantage of a real-time approach to the biopsy procedure without exposing patients to radiation. 

CT guidance, on the other hand, provides superior visualization of the extent of focal pleural masses and offers a clearer delineation of parenchymal pathology. Furthermore, contrast-enhanced CT scanning, particularly with "pleural phase" imaging, can effectively highlight areas of pleural involvement and nodularity, aiding clinicians in the selection of optimal biopsy sites. ^[17]  

Procedure

An area of pleural abnormality is identified using ultrasonography or CT imaging. The patient is then positioned according to the pleural lesions to be biopsied—prone for paravertebral lesions and supine for lateral or anterior lesions. Automated cutting needle devices, as shown in the images below, provide better histological samples than fine-needle aspiration. Three or more samples are generally obtained to ensure adequate pleural tissue for histopathological diagnosis.

Tru-cut needle before activation, placed proximal to the lesion under imaging guidance.

View Media Gallery

Tru-cut needle (activated) showing the site for the collection of biopsy tissue.

View Media Gallery

Utilizing a sterile technique, a local anesthetic agent is administered. The large coaxial needle with stylet is then advanced under ultrasound or CT guidance into the pleural lesion, as depicted in the images below.

Thoracic CT performed in the prone position demonstrates a right-sided irregular pleural-based lesion.

View Media Gallery

CT-guided pleural biopsy and Tru-cut needle.

View Media Gallery

The stylet is then removed manually, and the cutting needle device is placed with a tip proximal to the biopsy site to allow the “throw” of device. The tissue is obtained with the activation of the biopsy device (see image below). Multiple pleural biopsies can be collected while keeping the coaxial outer needle in place.

Tru-cut needle with pleural tissue sample obtained following CT-guided pleural biopsy.

View Media Gallery

A 2015 prospective study by Koegelenberg et al involving 100 patients outlined a sequential approach that utilized ultrasonography to assess pleural involvement, assist with site selection, and determine biopsy technique. If a pleural mass was identified, fine-needle aspiration was performed with rapid on-site evaluation. If the findings were negative, a cutting needle was used. In the setting of pleural thickening, needle selection was determined by thickness (10-24 mm for Abrams and >25 mm for a cutting needle). If no thickening was noted, an Abrams needle was used. This method increased diagnostic yield from 31% to 89.7% for malignancy and up to 90% for all diagnoses. ^[27]

Selection between needles and image-guided techniques depend on the feasibility of each technique considered for the individual patient. Variable effusion sizes, pleural thickening, patient cooperation, positioning, and visibility under ultrasonographic guidance influence selection of the appropriate technique. If no pleural effusion is present, selection of the Abrams needle for ultrasonographic or CT guidance is eliminated.

Diagnostic advantages and limitations

Image-guided pleural biopsy is a safe and effective method that enables targeted sampling of abnormal pleural tissue, enhancing diagnostic yield regardless of pleural thickening. This technique allows for the collection of samples from areas closer to the midline and diaphragm, where malignant deposits are more likely to occur. ^{[28, 29]}  Cutting biopsy needles demonstrate a higher sensitivity for malignancy compared to fine-needle aspiration, with reported sensitivities as high as 91% for diagnosing mesothelioma ^[30] . Previous studies have indicated a sensitivity of up to 88% for image-guided cutting needle biopsies in malignancy diagnosis, ^{[17, 30, 22, 31, 32]}  and nearly 100% when lesions are at least 20 mm in any dimension. ^[27]  

Image guidance can also be effectively applied to the Abrams needle. Reports indicate sensitivities ranging from 60% to 77.4% with ultrasonography-assisted site selection, and up to 87.5% with CT-guided Abrams needle biopsies. ^{[33, 34, 35]}  Notably, Koegelenberg et al (2010 and 2015) documented diagnostic yields for ultrasonography-assisted Abrams needle biopsy of 80-90% for pleural tuberculosis and 83-90% for pleural malignancies. ^{[27, 36]}  The diagnostic yield of CT-guided pleural biopsies also is enhanced in cases where pleural thickening is 1 cm or greater, leading to a sensitivity of 87% for cutting needle biopsies and 95% for CT-guided Abrams needle biopsies. ^{[26, 31, 34]}  

Complication rates associated with image-guided biopsy are notably lower than those of blind pleural biopsies, particularly concerning pneumothorax. ^{[30, 37]}  This protective effect was corroborated in a comparison between ultrasonography- and CT-guided biopsies, revealing a reduced incidence of pneumothorax in the ultrasonography group (5.5% vs 14.7%), although the patients were not randomized. ^{[17, 25]}  Patients who are unable to hold their breath during the procedure—due to underlying lung pathology or positive pressure ventilation—are at a greater risk of developing complications such as pneumothorax and lung injury. 

In a study by Tekin et al., which analyzed 181 patients who underwent cutting-needle pleural biopsies (100 CT-guided and 81 ultrasonography-guided), both techniques demonstrated similar technical success rates (99.8% for ultrasonography-guided and 97% for CT-guided). There were no significant differences in pathological results, with malignancies accounting for 54.1% and benign cases for 43.6%, while 2.2% yielded insufficient material. Although complication rates did not differ significantly between groups, ultrasonography-guided procedures were completed in an average of 17 minutes compared to 35 minutes for CT-guided procedures. Additionally, ultrasonography-guided biopsies were performed more frequently on patients with higher comorbidities, were cost effective, and did not involve ionizing radiation. ^[38]  

Ultrasonography-assisted cutting-needle biopsies can be effectively performed by experienced pulmonologists without compromising diagnostic sensitivity. ^[39]  This approach remains a viable option for patients who are unable to tolerate thoracoscopy or in whom thoracoscopy has failed, achieving a diagnostic sensitivity of 94% for all diagnoses and 87% for malignancy in a small series of 50 patients. ^[40]  Recent studies indicate that image-guided pleural biopsy yields comparable diagnostic results to thoracoscopy, even though thoracoscopy is still considered the criterion standard. 

A 2024 study by Metintas et al. conducted a prospective, randomized trial involving 228 patients, who were divided into two groups based on CT scan findings: Group 1 had pleural effusion only, while Group 2 presented with both pleural effusion and pleural thickening or lesions. Patients in each group were randomly assigned to either an image-assisted Abrams needle pleural biopsy (IA-ANPB) or medical thoracoscopy (MT). The results revealed that MT had a significantly lower false-negative rate and higher sensitivity than IA-ANPB for patients with pleural effusion alone, with false-negative rates of 30.3% for IA-ANPB compared to 3.1% for MT, and sensitivities of 69.7% and 96.9%, respectively. In the second group, involving pleural thickening or lesions, the diagnostic sensitivity of IA-ANPB was similar to that of MT (88.1% vs. 95.4%), with false-negative rates of 11.9% for IA-ANPB and 4.7% for MT. The study concluded that while MT is highly effective for all patients with pleural fluid, IA-ANPB remains a viable alternative for those with pleural thickening or lesions. Furthermore, the complication rates between the two methods did not show significant differences. ^[66]

Thoracoscopy has been a key procedure for over a century, and has increasingly gained recognition as a gold standard for diagnosing pleural effusions, boasting a diagnostic yield of up to 95% in cases of malignant pleural disease. ^{[41, 42]} Unlike earlier biopsy techniques, thoracoscopy offers both diagnostic and therapeutic benefits, enabling direct visualization of pleural pathology, adhesiolysis, pleurodesis, and chest tube placement. This procedure is typically performed by a pulmonologist in an endoscopy suite or operating room, utilizing local anesthesia and/or moderate sedation, with appropriate cardiopulmonary monitoring. 

Instruments

Medical thoracoscopy can be executed using either rigid or semirigid instruments, employing one or two ports of entry. The semirigid thoracoscope is, similar in design to a bronchoscope, features a larger proximal rigid section and a flexible distal end that moves with the handle. This thoracoscope includes a working channel for biopsy forceps and other instruments. A trocar facilitates the passage of the scope through the chest wall, with varying instrument diameters: trocars (7-11 mm), optics (6-10 mm), biopsy forceps (2.8-6 mm), and cryoprobes (1.9-2.4 mm). ^{[42, 43]}  The advantages of a semirigid thoracoscope includes a design like bronchoscope, which provides a general familiarity to a pulmonologist and could equate to an easier skill to gain. This is not in production anymore and is vastly replaced by single port, rigid mini-thoracoscopy thoracoscope which allow passage of rigid instruments for diagnostic or therapeutic purposes. In skilled hands, this could equate to better specimen acquisition due to the ability to use rigid forceps.  

Procedure

Continous cardiopulmonary monitoring is performed throughout the procedure with electrocardiography and pulse oximetry.The procedure can be performed in either endoscopy or operative room, based on local policies. In addition to local anesthesia, the proceduralist may pursue moderate sedation, monitored anesthesia care without an advanced airway, or general anesthesia with endotracheal tube with selective lung ventilation. The patient is positioned in the lateral decubitus position, with the affected side facing upward. 

Ultrasound is often used to localize the site of entry and pre-operative marking. After positioning the patient, a small skin incision is made at the site of entry, followed by blunt dissection to the parietal pleural until gaining access to pleural space. If there is no significant pleural effusion, iatrogenic pneumothorax is pursued with insertion of flexible trocar. The collapse of lung allows it to move away from the chest wall and facilitate access to the pleural space and insertion of instruments The trocar is ideally advanced over the sixth intercostal space at the midaxillary line if malignancy is suspected; otherwise, the fourth space is preferred for better visualization of the lung apex. ^[44] For diagnostic purposes, a single-puncture technique is employed, creating a 1- to 2-cm incision in the midaxillary line between the fourth and seventh intercostal spaces. 

An initial systemic survey of parietal pleura and visceral structures is performed. If there is pleural effusion, samples are collected for additional analysis. If pleural lesions are visualized, targeted biopsies are performed. Multiple parietal pleural biopsies can be obtained through this single port using biopsy forceps. For more complex procedures such as adhesiolysis, lung biopsy, or drainage of loculated fluid, a double-puncture technique may be preferred. At the procedure's end, a small-bore catheter or chest tube is placed to correct the pneumothorax and can be removed in the procedure room or post operative recovery area if there is no airleak and once the lungs are fully inflated. 

Medical thoracoscopy guided biopsy of parietal pleura utilizing flexible forceps. After selecting a site for biopsy (A), a pleural peal is obtained for a larger sample (B, C). A defect in parietal pleura is noted with minimal residual bleeding (D)

View Media Gallery

A patient with mesothelioma with diffuse pleural abnormality and dark pleural effusion (A, B, C). The biopsy was performed with flexible forceps with difficulty due to thick pleura (D). Multiple specimens were obtained to improve diagnostic yield which was confirmatory of diagnosis.

View Media Gallery

Limitations

Samples obtained via the semirigid thoracoscope are often small, limiting the depth of pleural specimens due to the mechanical constraints of the biopsy forceps. To ensure adequate biopsy depth, obtaining multiple samples (5-10) from abnormal areas is recommended. ^[41]

To address the challenges of small biopsy samples, Thomas et al. conducted a safety and feasibility study of cryoprobe pleural biopsies, demonstrating no increased risk of complications and larger biopsy samples with less crush artifact, while maintaining comparable diagnostic yield. ^{[17, 42, 45]} Similar outcomes have been reported in subsequent studies. ^[46] A 2016 prospective study by Wurps et al. compared rigid forceps, semirigid forceps, and cryobiopsy techniques during medical thoracoscopy, revealing that rigid forceps yielded larger and deeper biopsy samples, with diagnostic yields of 98.7% for rigid, 92.5% for flexible, and 91.3% for cryobiopsies. ^{[43, 47]}  

In the context of malignant pleural mesothelioma, similar findings have been observed, with cryobiopsy techniques consistently yielding larger, deeper specimens and improved diagnostic sensitivity compared to conventional instruments. ^[48]

Complications

A comprehensive analysis of 47 studies involving 4,756 patients reported major complications in 1.8% of cases, minor complications in 7.8%, and a mortality rate of 0.34%. Major complications include hemorrhage, empyema, pneumonia, tumor seeding along the procedure tract, and bronchopleural fistula leading to postoperative pneumothorax or prolonged air leaks. Minor complications may encompass subcutaneous emphysema, minor bleeding, local wound infection, hypotension during the procedure, and transient fever. ^{[17, 41, 49]}  A meta-analysis by Agarwal et al. in 2013 confirmed similar rates, with pooled major and minor complication rates of 1.5% and 10.5%, respectively, and no reported mortality. ^{[49, 50]}

The primary concern during the procedure is pleural hemorrhage, which may arise from underlying intercostal blood vessels. Immediate control of bleeding can be achieved using forceps and gauze. In cases of significant bleeding, an additional incision may be necessary to access the pleural cavity for cauterization. Should bleeding persist despite pressure and cauterization, ligation of bleeding vessels with endoclips may be required, and ongoing hemorrhage could necessitate thoracotomy. 

Video-assisted thoracic surgery (VATS) allows additional access to lung tissue and operative interventions, including lung biopsies, lobectomy, pericardia! window placement, and empyema drainage. VATS is carried out by thoracic surgeons in an operating room under general anesthesia using single-lung ventilation. 

Instruments

VATS is performed with rigid endoscopic equipment, including a light source, an endoscopic camera with a video monitor, and a recording system (see images below). ^[51]

Rigid telescopes with different vision angles for direct and oblique viewing.

View Media Gallery

Rigid telescope attached with light source and endoscopic camera.

View Media Gallery

The different telescopes have various angles, from 0° for direct visualization to oblique (30° or 50°) and periscopic (90°) viewing. Various sizes of trocars are deployed as a means of introduction for the rigid telescope through the chest wall.

Insertion of the rigid telescope with trocars placement in chest wall.

View Media Gallery

Procedure

VATS is performed after placing a double-lumen endotracheal tube or a single-lumen tube with a bronchial blocker. The patient is usually placed in the lateral decubitus position with the affected area exposed. However, the procedure can also be performed in the supine position. 

 Using sterile techniques, 1-3 incisions, each 0.5-1 cm, are placed. The initial port site is created by incising the skin with the scalpel, then using a hemostat to bluntly spread the fascia and muscle layers until the pleural cavity is entered. The first incision placement should be at the maximum distance from the site of dissection or inspection to allow better visualization. Surgical interventions are made over the rib to prevent any injury to the neurovascular bundle. One of the incisions is usually performed at a site deemed to be suitable for a laterplacement of the chest tube at the conclusion of the procedure. The second incision is placed more cephalad in a more anterior or posterior position depending on area of interest to be biopsied. 

 A port is placed through the first incision and a camera is inserted. The second incision is created with direct visualization of the camera from the inside. The pleural space is then inspected, and areas of interest are biopsied at multiple sites after a thorough inspection is completed. Biopsy samples can be collected with biopsy forceps or other endoscopic instruments. After completion of the biopsy, the camera is rotated between port sites to check for hemostasis. A chest tube is then placed. The lung is then reinflated, and the remaining port site is closed with absorbable sutures. 

buffering

Replay

View all webmd.com videos.

CC

Captions

OFF

ON

Track :NonePresets :

Aa

Aa

Aa

Aa

Font :ArialTimes New RomanCourierGeorgiaHelveticaVerdanaImpactComic Sans SerifTimes New RomanEdge :noneDepressedLeft drop shadowRaisedRight drop shadowUniform

Size :SmallMediumLargeScroll :Pop outRoll onPaint on

Color :

Background :

Edge :

Window :

Lorem ipsum dolor sit amet

Apply

Cancel

Default

Show Advanced Settings

Opacity :

Video-assisted thoracic surgery (VATS) pleural biopsy.

View Media Gallery

Postprocedural care

Chest tubes are removed when air leaks have resolved and drainage is at acceptable levels. Chest X- Ray is performed post-procedure and after removal of the chest tube to assess for pneumothorax.

Limitations

Several factors can limit this diagnostic intervention, including marked coagulopathy, an inability to obtain unilateral lung ventilation, or patient’s inability to tolerate the procedure because of hypoxemia. Adhesions represent a relative contraindication depending on their location and density. 

Complications

The reported complications of VATS are similar to those seen with medical thoracoscopy, including mesothelioma tract metastasis. Mesothelioma has been reported to spread along the tracks of surgical biopsy incisions, chest tubes, and biopsy needles. The reported incidence of 22% for tract metastasis was higher with surgical biopsy compared to 4% with needle biopsy in one study of 100 patients. ^[52] Prophylactic radiation may be helpful, although this is controversial. ^{[53, 54]}

Closed pleural biopsy is best reserved for suspected diffuse processes in resource-limited settings, particularly where there is a high prevalence of tuberculosis and image-guided techniques are not available. It is essential that operators maintain a high level of procedural competency to ensure safety and effectiveness. Prior to conducting an image-guided biopsy or thoracoscopy, contrast-enhanced CT scans can be valuable in highlighting areas of pleural involvement and identifying any parenchymal abnormalities. 

When thoracoscopy is not an option for undiagnosed exudative pleural effusions, image-guided pleural biopsy should be the primary method of investigation. This approach offers a favorable diagnostic yield, low complication rates, and broad accessibility. However, thoracoscopy, whether performed as medical thoracoscopy or video-assisted thoracoscopic surgery (VATS), remains the gold standard for evaluating pleural disease. Its advantages include a consistent safety profile, high diagnostic yield, and the ability to perform therapeutic interventions. Nonetheless, it may not be suitable for all patients, necessitating careful consideration of individual circumstances.