Diagnostic performance and safety of image-guided pleural biopsy and medical thoracoscopy for undiagnosed exudative pleural effusion: a systematic review and network meta-analysis

Our plain-English summary of Diagnostic performance and safety of image-guided pleural biopsy and medical thoracoscopy for undiagnosed exudative pleural effusion: a systematic review and network meta-analysis, by S. Lyu, Z. Zheng, L. Liao, et al (European Respiratory Review, 2026).

The study

• Authors: S. Lyu, Z. Zheng, L. Liao, X. Feng, M. Deng, J. Li, J.M. Porcel, G. Hou
• Journal: European Respiratory Review
• Published: 2026;35(180)
• Type of article: Systematic review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: Undiagnosed exudative pleural effusions often require pleural biopsy for a definitive diagnosis. The optimal sampling method, particularly when medical thoracoscopy is compared with image-guided pleural biopsy, remains uncertain.

Methods: This systematic review and network meta-analysis included studies that reported on the diagnostic performance and safety of medical thoracoscopy and image-guided pleural biopsy approaches. The primary outcome of this study was diagnostic yield, and the secondary outcomes included other diagnostic parameters (e.g. sensitivity, negative likelihood ratio, and negative predictive value), post-procedure complications, and biopsy quality and number. A frequentist network meta-analysis was performed to compare and rank the diagnostic performance and safety of various pleural biopsy methods using a random-effects model. A subgroup analysis was performed according to the presence of pleural nodules or thickness and the type of biopsy needles used.

Results: An analysis of 64 studies involving 8744 patients revealed that rigid medical thoracoscopy had the highest diagnostic yield (95.0%), followed by cryobiopsy (93.1%), semirigid medical thoracoscopy (92.3%), and ultrasound elastography (UE)-guided biopsy (92.3%). Closed pleural biopsy had the lowest yield (75.1%). The current evidence is insufficient to establish the superiority of any biopsy method in terms of complications. The network meta-analysis ranked rigid medical thoracoscopy as having the highest overall diagnostic yield, closely followed by UE-guided biopsy, with no statistically significant differences between image-guided biopsy and rigid medical thoracoscopy.

Conclusion: Closed pleural biopsy consistently has a low diagnostic yield and is not recommended as a first-line biopsy method for patients with undiagnosed exudative pleural effusions. Rigid medical thoracoscopy offers distinct clinical value for a complete visual inspection, large biopsies, and potential pleurodesis, particularly in suspected mesothelioma cases. The currently available evidence does not support the routine replacement of semirigid medical thoracoscopy with cryobiopsy. Computed tomography-guided biopsy may be preferred in cases involving thickening ≥10 mm or small target lesions. Conversely, ultrasound-guided biopsy may be appropriate for lesions measuring ≥3 mm with a clear acoustic window. UE-guided pleural biopsy shows promise as an emerging option, although the evidence is limited. In tuberculous pleurisy, medical thoracoscopy may offer higher diagnostic sensitivity in certain settings, particularly in high-prevalence areas. The current evidence is insufficient to establish a clear advantage for any biopsy method regarding the overall complication risk.

Copyright ©The authors 2026.

In plain English

This was a systematic review and network meta-analysis, a statistical pooling of earlier studies. It compared ways of taking tissue samples (biopsies) of the lung lining in patients with exudative pleural effusion (fluid around the lung) of unknown cause. The authors combined 64 studies with 8744 patients, published between 1988 and 2025. Diagnostic yield is the share of patients who received a specific diagnosis. It was 95.0% (95% confidence interval 92.3–97.1%) for rigid medical thoracoscopy, 93.1% (85.3–98.4%) for cryobiopsy, 92.3% (90.1–94.3%) for semirigid medical thoracoscopy, 92.3% (88.2–95.6%) for ultrasound elastography-guided biopsy (from only two studies), and 75.1% (61.7–86.6%) for closed pleural biopsy. For mesothelioma, sensitivity was 94.5% (83.0–100.0%) for rigid and 94.1% (87.4–100.0%) for semirigid thoracoscopy. In the network analysis of 11 randomised trials, rigid thoracoscopy ranked first for diagnostic yield, but no differences between methods were statistically significant. The authors concluded that closed pleural biopsy is not recommended as a first-line method. They also concluded that the evidence was insufficient to show that any method had fewer complications. They noted differences between the included studies and between the biopsy devices used. The study did not examine asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Systematic review and network meta-analysis of published studies (randomised controlled trials, prospective, cross-sectional and retrospective studies)
• Who was studied: 64 studies involving 8744 patients with undiagnosed exudative pleural effusion who underwent pleural biopsy. The studies were published between 1988 and 2025 and found by searching PubMed, Embase and Web of Science up to 1 November 2025. They comprised 16 randomised controlled trials, 20 prospective, two cross-sectional and 26 retrospective studies.
• Exposure: The study did not examine asbestos or any fiber exposure. It compared pleural biopsy methods: rigid and semirigid medical thoracoscopy, cryobiopsy, image-guided biopsy (CT-guided, ultrasound-guided, ultrasound-assisted, ultrasound elastography-guided, PET/CT-guided) and closed pleural biopsy.
• Main results:
  • Rigid medical thoracoscopy had the highest overall diagnostic yield: 95.0% (95% CI 92.3–97.1%), in 21 studies with 1217 patients.
  • Cryobiopsy had a diagnostic yield of 93.1% (95% CI 85.3–98.4%) in six studies with 359 patients. Semirigid medical thoracoscopy had 92.3% (95% CI 90.1–94.3%) in 28 studies with 3111 patients.
  • Ultrasound elastography-guided biopsy had a diagnostic yield of 92.3% (95% CI 88.2–95.6%), from only two studies with 208 patients. CT-guided biopsy had 88.9%, ultrasound-guided biopsy 84.4% and ultrasound-assisted biopsy 80.8%.
  • Closed pleural biopsy had the lowest diagnostic yield: 75.1% (95% CI 61.7–86.6%), across 10 studies with 1702 patients.
  • Sensitivity for diagnosing mesothelioma was 94.5% (95% CI 83.0–100.0%) for rigid medical thoracoscopy, 94.1% (95% CI 87.4–100.0%) for semirigid medical thoracoscopy and 87.5% (95% CI 46.7–99.3%) for CT-guided biopsy.
  • In direct head-to-head comparisons, semirigid medical thoracoscopy had a significantly lower diagnostic yield than rigid medical thoracoscopy (OR 0.284, 95% CI 0.111–0.731; p=0.009). No significant difference was found between image-guided biopsy and rigid medical thoracoscopy (5 studies).
  • In the network meta-analysis of 11 randomised trials, rigid medical thoracoscopy ranked first for overall diagnostic yield (SUCRA 68.8) and closed pleural biopsy ranked last (SUCRA 33.0). No differences between any of the methods were statistically significant.
  • The overall complication rate was 15.8% for rigid medical thoracoscopy and 13.5% for semirigid medical thoracoscopy. The text reports that closed pleural biopsy had the highest incidence of major haemorrhage (0.8%, 95% CI 0–5.8%) and of pneumothorax requiring a chest tube (2.4%, 95% CI 0.6–4.8%).
  • Ultrasound-guided biopsy had a significantly higher diagnostic yield in patients with pleural thickening than in those without (OR 3.612, 95% CI 2.10–6.22). The same was true for CT-guided biopsy (OR 4.84, 95% CI 2.09–11.23).
• The authors' conclusion: The authors concluded that closed pleural biopsy consistently has a low diagnostic yield and is not recommended as a first-line method. They concluded that rigid medical thoracoscopy offers distinct value, particularly in suspected mesothelioma. They also concluded that the evidence is insufficient to show a clear advantage for any method in overall complication risk.
• Limitations the authors state:
  • Pooled results should be interpreted with caution because studies differed in their procedures, including periprocedural management and operator experience.
  • Missing data in retrospective studies may have introduced bias. Analysis of rare events carries statistical uncertainty.
  • Differences in biopsy devices were a potential source of bias and limited the reliability of the network meta-analysis.
  • Findings for ultrasound elastography-guided biopsy rest on few trials and may be affected by small-study effects.
  • The funnel plot of complications was asymmetric, suggesting possible publication bias.
  • Excluding video-assisted thoracoscopic surgery (VATS) limits the breadth of the comparisons.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Pleural Biopsy, Medical Thoracoscopy, Pleural Effusion, Systematic Review, Meta-Analysis, Biopsy, Ultrasound, Pleurodesis.

Related studies

• Comparison between closed pleural biopsy and medical thoracoscopy for the diagnosis of undiagnosed exudative pleural effusions: a systematic review and meta-analysis — Y. Wei, K. Shen, et al. (2020)
• Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark — F. Willendrup, U. Bodtger, et al. (2014)
• Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial — M. Metintas, G. Ak, et al. (2010)
• Physician-based ultrasound-guided biopsy for diagnosing pleural disease — R.J. Hallifax, J.P. Corcoran, et al. (2014)
• Advantages of thoracic ultrasound-guided fine-needle aspiration biopsy in lung cancer and mesothelioma — M. Sperandeo, L. Dimitri, et al. (2014)
• The safety of medical thoracoscopy in a group at high risk for complications — M. Metintas, G. Ak, et al. (2013)

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