Image-assisted pleural needle biopsy or medical thoracoscopy: which method for which patient? a randomized controlled trial

BACKGROUND Image-guided or assisted needle biopsies and the increasing use of medical thoracoscopy (MT) have significantly increased the diagnostic accuracy of pleural diseases. However, there is no consensus on which patients should undergo medical thoracoscopy (MT) and which patient should undergo image-guided or assisted needle biopsy as the first procedure to ensure greater diagnostic accuracy in patients with pleural effusion. RESEARCH QUESTION Which biopsy method is more appropriate for which patient to provide the highest diagnostic accuracy in the diagnosis of pleural effusion? METHODS This prospective, randomized, parallel study included two hundred twenty-eight patients with undiagnosed exudative pleural effusion. Patients were divided into two groups based on computed tomography (CT) findings. Group 1: patients with pleural effusion only; Group 2: patients with pleural thickening or lesion in addition to pleural effusion. Patients in each group were randomly assigned to an image- assisted Abrams needle biopsy (IA-ANPB) or MT arm. The diagnostic sensitivity, reliability, and safety were determined for both groups. RESULTS The false negativity rate was 30.3% for the IA-ANPB arm and 3.1% for the MT arm in Group 1. The same rates were 11.9% for IA-ANPB and 4.7% for MT in Group 2. In Group 1, the sensitivity for the IA-ANPB arm was 69.7%, negative likelihood ratio of 0.30. The same rates for the MT arm were 96.9% and 0.03 (p=0.009). In Group 2, these values were 88.1% and 0.12 for the IA-ANPB arm and 95.4% and 0.05 for the MT arm (p=0.207). The rate of complications between the two biopsy methods was not different (8.5% and 15.8%, respectively; p=0.107). INTERPRETATION MT showed a high diagnostic success in all patients with pleural fluid. On the other hand, IA-ANPB showed similar diagnostic success as MT in patients with pleural effusion and associated pleural thickening/lesions. Therefore, in the latter case, IA-ANPB could be preferable before MT.