Combined Ultrasound-Guided Thoracentesis, Percutaneous Pleural Biopsy, and Indwelling Pleural Catheter Insertion as the First Intervention in Patients With High Likelihood of Malignant Pleural Effusion

CHEST Pulmonary 2025 July 30 [Link]

Michael V Brown, Jelena Solujic, Sarah Yeo, Julia Kim, Phan Nguyen, Arash Badiei

Abstract

Background: Malignant pleural effusion (MPE) indicates advanced disease and imposes a significant symptomatic burden to patients. Current guidelines recommend stepwise investigation and management.

Research question: Is it feasible and safe to combine ultrasound (US)-guided pleural biopsy and indwelling pleural catheter (IPC) insertion as the initial diagnostic and therapeutic procedure for patients with high preprocedural probability of MPE?

Study design and methods: We retrospectively analyzed patients who underwent pleural procedures between March 1, 2021, and September 30, 2022. Sixteen patients with symptomatic unilateral pleural effusion and clinical or radiologic features suggestive of malignancy underwent combined US-guided pleural biopsy and IPC insertion as their first management step. Feasibility was determined by the number of patients requiring repeat diagnostic and therapeutic procedures, and time to diagnosis. Safety was determined by complication rates.

Results: Of 258 patients who received 384 pleural procedures, 16 patients (11 male; mean age ± SD, 77 ± 9.5 years) underwent the combined procedure. All patients had high preprocedural probability of MPE as evidenced by appropriate history, a unilateral pleural effusion (93.7%), and pleural nodularity or thickening on CT chest scan or US (87.5%). Mean time to diagnostic procedure was 9.3 days. Malignancy was confirmed in 100% of cases, with mesothelioma being the most common (50%). Pleural fluid cytology was diagnostic in 3 cases (18.8%), whereas 13 US-guided pleural biopsies (81.3%) were diagnostic. Nine patients (56.25%) had their IPC removed because of autopleurodesis or treatment response, with a mean removal time of 55.8 days. At 12 months, 5 patients (31.25%) had a documented complication, with pain and catheter blockage being the most common. One patient (6.25%) developed pleural infection. Over one-half (56.2%) received antineoplastic treatment with their IPC in situ. No patient required a repeat pleural procedure on follow-up.

Interpretation: A combined approach of closed, percutaneous US-guided pleural biopsy and IPC insertion as initial pleural intervention was shown to be feasible in patients with high preprocedural probability for MPE with no unexpected safety signals.