Abstract Rationale Malignant (MPE) and tuberculous pleural effusions (TPE) are top causes of unilateral exudative pleural effusions. The recommended first line diagnostic approach is a pleural aspiration. However, the low diagnostic yield of pleural fluid often leads to delayed diagnosis and many patients require repeated procedures for diagnostic and therapeutic purposes due to recurrence of symptomatic effusions. With good safety profiles of medical thoracoscopy (MT) and closed pleural biopsy, we sought to evaluate an upfront pleural biopsy approach in patients with suspected MPE or TPE. Methods We conducted a retrospective analysis of patients who underwent a diagnostic pleural procedure for a predominantly unilateral effusion eventually diagnosed as MPE or TPE, from January 2022 to December 2024. Clinical characteristics and outcomes were compared between patients who underwent upfront pleural biopsy via medical thoracoscopy or closed pleural biopsy versus pleural aspiration as the first diagnostic procedure. ‘Actionable’ diagnosis was defined as a cyto-histopathological diagnosis with adequate molecular profiling in cancers known to have targetable oncogenic mutations. Results We included 271 patients in our study, with a median age of 71 (interquartile range (IQR):59-78) years. MPE and TPE were diagnosed in 74.9% and 25.1% of patients respectively. Upfront pleural biopsy and pleural aspiration-first approach were adopted in 44.3% and 55.7% of patients respectively, with no significant differences in age, gender, size of pleural effusion on chest radiograph, or procedural complication rates between the two groups. In patients with an upfront pleural biopsy approach, 92.5% underwent medical thoracoscopy and about half (49.5%) had concurrent talc pleurodesis performed. Patients with upfront pleural biopsy had a significantly shorter time to ‘actionable’ diagnosis (16 (IQR:9-21) vs 23 (IQR:16-40) days, p0.001), treatment initiation (22 (IQR:16-33) vs 27 (IQR:18-43) days, p = 0.023), and fewer hospitalisation days for diagnostic evaluation (4 (IQR:3-5) vs 8 (IQR:5-13) days, p 0.001) or therapeutic intervention (4 (IQR:3-7) vs 12 (IQR:6-17) days, p 0.001). A significantly lower proportion of patients with upfront pleural biopsy required ≥2 diagnostic (3.3% vs 42.4%, p 0.001) or ≥ 2 therapeutic procedures (21.1% vs 50.0%, p 0.001) for symptomatic pleural effusions. Conclusions An upfront pleural biopsy approach for new onset unilateral pleural effusions was associated with a shorter time to diagnosis, fewer hospitalisation days and a reduced need for repeated invasive procedures. These findings support the consideration of upfront pleural biopsy in selected patients. Prospective trials are warranted to establish the utility and cost effectiveness of this approach in patients with suspected MPE and TPE. This abstract is funded by: None
Chia et al. (Fri,) studied this question.