Comparing a straight-to-biopsy versus pleural aspiration-first approach in malignant and tuberculous pleural effusions.

BackgroundPleural aspiration has limited diagnostic yield in malignant (MPE) and tuberculous pleural effusions (TPE), more so when requiring molecular profiling in MPE and due to the paucibacillary nature of TPE. In our institution, patients with suspected MPE or TPE are offered a straight-to-biopsy approach with pleural biopsy as the initial diagnostic procedure, or a pleural aspiration-first approach, through shared decision-making.ObjectivesTo compare clinical outcomes between a straight-to-biopsy strategy and a pleural aspiration-first approach in patients diagnosed with MPE or TPE.DesignWe performed a retrospective study of patients who underwent pleural procedures for unilateral effusions between January 2022 and February 2025 and were diagnosed with MPE or TPE. We excluded patients with an Eastern Cooperative Oncology Group status ≥ 3 and patients with a pre-existing, established diagnosis of metastatic cancer who had pleural procedures performed for non-diagnostic intent.MethodsClinical outcomes were compared between a straight-to-biopsy versus pleural aspiration-first approach.Results271 patients were included (mean age 67 years, SD 15); 74.9% had MPE and 25.1% had TPE. Straight-to-biopsy and pleural aspiration-first approaches were undertaken in 44.3% and 55.7% of patients, respectively. Most patients in the straight-to-biopsy group underwent medical thoracoscopy (92.5%, 111/120), with concurrent talc pleurodesis performed in 55 patients. Compared with pleural aspiration-first, a straight-to-biopsy approach was associated with a shorter time to actionable diagnosis (16 (IQR:9-21) vs 23 (IQR:16-40) days; p<0.001), earlier treatment initiation (22 (IQR:16-33) vs 27 (IQR:18-43) days; p=0.023), shorter hospitalisation for diagnostic evaluation (4 (IQR:3-5) vs 8 (IQR:5-13) days; p<0.001), and were less likely to require ≥2 diagnostic (3.3% vs 42.4%; p<0.001) or therapeutic pleural procedures (21.1% vs 50.0%; p<0.001).ConclusionIn patients with MPE or TPE, a straight-to-biopsy approach was associated with earlier diagnosis and treatment initiation, fewer repeat procedures, and shorter hospitalisation. Prospective studies are needed to establish its safety, clinical utility, and cost-effectiveness.