Surgical pleural biopsy, also referred to as “open” pleural biopsy, is the “gold standard” for diagnosis of pleural diseases, but thoracotomy is associated with substantial morbidity [17–20]. Minimally invasive surgical approaches to pleural biopsy, including video-assisted thoracoscopic surgery (VATS) and physician-based thoracoscopy, have also demonstrated a high diagnostic yield (>90 %) [21–26]. However, VATS and thoracoscopy require a safe separation of the visceral and parietal pleura, and medical thoracoscopy requires the presence of a moderate effusion [27], whereas image-guided pleural biopsy is not limited by these factors.

Nonsurgical percutaneous pleural biopsy, also known as “blind” or “closed” pleural biopsy, was first described in patients with pleural effusion in the 1950s by Abrams and Cope [28, 29]. In this technique, a reverse-beveled needle is advanced into the pleural cavity and pulled back to “hook” the pleura and obtain a biopsy sample (Fig. 12.4). Four to six passes are usually necessary to obtain an adequate diagnostic specimen [8]. Although blind pleural biopsy can be performed at the bedside and is relatively simple, the diagnostic yield is suboptimal and the complication rates are higher than those for image-guided biopsy [30]. Simultaneous fluid analysis with blind pleural biopsy has demonstrated better diagnostic value than blind biopsy alone [31].

Over the last two decades, the trend has been away from blind pleural biopsy and toward image-guided pleural biopsy, using either ultrasonography or computed tomography (CT) [32].

Both CT and ultrasonography can be used to guide pleural biopsies. Initially, a diagnostic imaging study, usually a CT (Fig. 12.5) scan or a PET-CT (Fig. 12.3) scan, identifies areas of nodular, patchy, or diffuse pleural thickening. Subsequently, the choice between CT and ultrasound depends on personal preference, local expertise, and equipment availability. Ultrasonography provides real-time imaging, is widely available, and is relatively inexpensive. However, pleural lesions near or behind the ribs or along the paravertebral or medial surfaces may be difficult to image with ultrasound, and small pleural nodules in the absence of pleural effusion may be challenging to localize with ultrasound (Fig. 12.6). CT can help identify and target virtually any nodule or area of pleural thickening in the thoracic cavity.

For blind pleural biopsy, Abrams or Cope needles are used. These needles range in size from 11 to 8 gauge (up to 4 mm in diameter). Each needle is fitted with a “cutting window” to trap and extract a sample of the pleura. Safe application of these devices requires the presence of a moderate-sized pleural effusion (Fig. 12.4).

For image-guided biopsies, both fine-needle aspiration (FNA) biopsy (Fig. 12.7) and automated tissue-cutting biopsy guns (Fig. 12.2) have been used. Cutting-needle biopsy has been shown to be more sensitive than FNA biopsy in diagnosing pleural malignancies [14, 33]. The size of the needle (14 vs. 18 gauge) used in cutting-needle biopsy does not influence diagnostic sensitivity [14, 34]. The use of FNA biopsy and core biopsy together may help increase the diagnostic yield for malignant disease [14, 35].

In ultrasonography, patients can be positioned in a sitting or a recumbent position. A sitting position is advantageous in patients with large pleural effusions to avoid worsening of respiratory symptoms such as shortness of breath, which is frequently encountered in these patients. Positioning of the patient for CT-guided biopsy depends on the location of the target tissue. Patients can be placed in a supine, prone, lateral decubitus, or oblique position. Tilting the CT gantry helps target lesions located behind a rib. To biopsy areas of minimal pleural thickening, the needle should be aligned almost parallel to the pleural surface that is to be biopsied to allow the longest interface of the needle with the area of abnormality (Fig. 12.2). This is important for both FNA and tissue-cutting biopsies.