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Pleural biopsy 

Pleural biopsy
Pleural biopsy

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

Page of

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date: 29 June 2022

General points

Several techniques can be used to obtain a pleural biopsy.

  • Using image guidance (either CT or USS), a cutting needle (e.g. 18G Temno® or Cook Quickcore®) takes several 1–2cm cores along the long axis of any parietal pleural pathology. FDG-PET CT may have a role guiding pleural biopsy in patients with diffuse pleural abnormality to increase sensitivity. Malignancy sensitivity >85%

  • Using thoracoscopic biopsy (medical thoracoscopy/VATS) (see Pleural biopsy p. [link]). Multiple biopsies are taken of visually abnormal parietal pleura. Malignancy sensitivity >92%

  • Using a pleural biopsy needle (e.g. Abrams’ or Cope) in a ‘blind’ percutaneous fashion to take multiple biopsies. Not advocated for diagnosing malignancy (sensitivity 47%—unsurprising, given patchy nature of pleural malignancy). May have utility in resource-limited settings for diffuse pleural diseases (e.g. TB pleuritis), but thoracoscopy still preferred (TB sensitivity ~100% vs ~80%).

Abrams’ pleural needle biopsy


  • Diagnosis of tuberculous pleural effusion when access to other biopsy techniques limited.


An assistant is required.

  • Discuss procedure with patient, and obtain written consent

  • Insert IV cannula

  • Consider sedation (e.g. midazolam 2–5mg IV, with O2 saturation monitoring)

  • Position patient sitting forward, leaning on a pillow over a table, with their arms folded in front of them

  • Double-check correct side from chest examination and CXR

  • Choose biopsy site using pleural USS to ensure an adequate volume of pleural fluid under proposed site. Use lateral approach to avoid neurovascular bundle, which lies mid-intercostal space posteriorly

  • Sterile skin preparation. Wear sterile gloves and gown

  • Infiltrate skin, intercostal muscle, and parietal pleura with 10–20mL (up to 3mg/kg) of 1% lidocaine. Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. Anaesthetize area behind rib below the insertion point. Verify that pleural fluid can be aspirated. If unable to aspirate, do not proceed

  • Whilst waiting for anaesthetic to work, assemble Abrams’ reverse bevel biopsy needle. The needle consists of an outer sheath with a triangular opening (biopsy port) that can be opened or closed by rotating an inner sheath

  • Make small (5mm) skin incision; dissect intercostal muscles with blunt forceps (e.g. Spencer–Wells)

  • Insert biopsy needle gently, with biopsy port closed. Do not apply force; the needle should slip into the pleural space without resistance. When in the pleural cavity, fluid can be withdrawn by attaching a syringe to the needle and opening the biopsy port

  • To take a biopsy, attach a syringe to the needle. Open the biopsy port and angle it downwards, and then pull the biopsy port firmly against the parietal pleura on the rib beneath the entry point (6 o’clock position relative to entry point). Close the biopsy port, thereby pulling a sample of parietal pleura into the needle

  • Remove the biopsy needle; open the biopsy port, and remove biopsy sample

  • Repeat procedure 4–6 times in positions 4–8 o’clock; always sampling below the insertion point (to avoid the neurovascular bundle beneath the rib above)

  • Send biopsy samples in saline for analysis for TB and in formalin for histological processing

  • Apply dressing to biopsy site. May require a single stitch

  • CXR to exclude pneumothorax.


include pain (up to 15%), pneumothorax (up to 15%), haemothorax (<2%), and empyema. Haemorrhage from trauma to an intercostal artery may necessitate emergency thoracotomy. Fatalities are well documented but rare.

Further information

Maskell NA et al. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003;361:1326–31.Find this resource:

Hooper C et al. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl. 2):ii4–17.Find this resource: