• Anand Sundaralingam, Avinash Aujayeb, Baki Akca, Clare Tiedeman, Vineeth George, Michael Carling, Jennifer Brown, Radhika Banka, Dinesh Addala, Eihab O Bedawi, Rob J Hallifax, Beenish Iqbal, Poppy Denniston, Maria T Tsakok, Nikolaos I Kanellakis, Florian Vafai-Tabrizi, Michael Bergman, Georg-Christian Funk, Rachel E Benamore, John M Wrightson, and Najib M Rahman.
• Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK. Electronic address: Anand.Sundaralingam@ndm.ox.ac.uk.
• Chest. 2023 May 1; 163 (5): 132813391328-1339.

BackgroundPleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation.Research QuestionWhat is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions?Study Design And MethodsThis study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis.ResultsThe median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highest yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P < .03).InterpretationAlthough previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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