Who performs a pleural biopsy on an adult patient with a suspected pleural-based condition?

Who Performs Pleural Biopsy

Pleural biopsies are performed by different specialists depending on the technique: interventional radiologists perform image-guided needle biopsies, interventional pulmonologists perform medical thoracoscopy (pleuroscopy), and thoracic surgeons perform video-assisted thoracoscopic surgery (VATS). 1, 2

Blind Percutaneous Pleural Biopsy

• Any trained physician (typically pulmonologists or general internists) can perform blind percutaneous pleural biopsy using an Abrams or Cope needle at the bedside or in an outpatient setting 1
• This technique is most commonly used when clinical suspicion of tuberculosis is high, as it has a diagnostic rate of 75% for tuberculosis 1
• However, blind biopsies should never be performed in current practice according to contemporary guidelines, as they have been superseded by image-guided techniques 3

Image-Guided Cutting Needle Biopsy

• Interventional radiologists perform image-guided cutting needle pleural biopsies using ultrasound, CT, or fluoroscopic guidance 1, 4
• This approach is indicated when contrast-enhanced CT shows focal pleural nodularity or thickening 1
• Image-guided biopsy has a sensitivity of 84% (76-88%) for malignancy, significantly superior to blind Abrams needle biopsy (47% sensitivity) 1
• Ultrasound-assisted selection for biopsy site increases diagnostic yield by >17% in malignant pleural effusion compared to blind techniques 5

Medical Thoracoscopy (Pleuroscopy)

• Interventional pulmonologists perform medical thoracoscopy in the bronchoscopy suite or at the bedside under local anesthesia with conscious sedation 2, 6
• This procedure is performed on spontaneously breathing patients, often as an outpatient procedure 2
• Medical thoracoscopy has a diagnostic sensitivity of 95-99% for malignancy and is indicated when less invasive tests (thoracentesis and percutaneous biopsy) have failed to provide a diagnosis 1
• In intensive care unit settings, interventional pulmonologists can perform bedside medical thoracoscopy in critically ill patients who cannot be transported to the operating room 6

Video-Assisted Thoracoscopic Surgery (VATS)

• Thoracic surgeons perform VATS in the operating room under general anesthesia with single-lung ventilation 2
• VATS is reserved for patients who require more extensive pleural evaluation or when medical thoracoscopy is not available or has failed 2
• The diagnostic yield is comparable to medical thoracoscopy (>90%), but VATS is more invasive and requires general anesthesia 2, 6

Clinical Decision Algorithm

For patients with pleural effusion only (no pleural thickening or masses on CT):

• Medical thoracoscopy by interventional pulmonologist is preferred, with sensitivity of 96.9% versus 69.7% for image-assisted needle biopsy 7
• The false-negative rate is significantly lower with medical thoracoscopy (3.1%) compared to image-assisted needle biopsy (30.3%) 7

For patients with pleural thickening or discrete pleural lesions on CT:

• Image-guided needle biopsy by interventional radiologist is acceptable as first-line approach, with sensitivity of 88.1% versus 95.4% for medical thoracoscopy (not statistically different) 7
• This approach is particularly useful in patients unsuitable for thoracoscopy 1

For patients requiring therapeutic intervention (pleurodesis, drainage of loculated effusions):

• Medical thoracoscopy by interventional pulmonologist or VATS by thoracic surgeon is preferred, as both allow simultaneous diagnosis and treatment 1, 6

Important Caveats

• All cases should be discussed within a multidisciplinary "pleural team" that includes interventional pulmonologists, thoracic surgeons, and interventional radiologists to determine the optimal approach 2
• Biopsy sites must be marked with Indian ink if mesothelioma is suspected, as these sites require local radiotherapy within 1 month if mesothelioma is diagnosed 1
• Cases diagnosed as "non-specific pleuritis" on thoracoscopy require at least one year of follow-up, as 10-15% will eventually be diagnosed with cancer, typically malignant pleural mesothelioma 2