Optimal Number of Pleural Biopsies During Pleuroscopy (OPTIBIOP)

BACKGROUND: There is currently no evidence-based standard for the number of pleural biopsies required during pleuroscopy to achieve diagnostic adequacy. This study evaluated the cumulative diagnostic yield of sequential pleural biopsy aliquots obtained during rigid pleuroscopy. METHODS: We conducted a prospective, single-center observational pilot study of adult patients undergoing pleuroscopy. Biopsy specimens were obtained according to routine practice and submitted in sequential aliquots: aliquot 1 (biopsies 1 to 3), aliquot 2 (4 to 6), aliquot 3 (7 to 9), and aliquot 4 (≥10). Pathologic evaluation was performed sequentially to determine the earliest aliquot yielding a definitive diagnosis. Cumulative diagnostic yield, the need for additional aliquots for comprehensive biomarker testing, and complications were evaluated. RESULTS: A definitive diagnosis was achieved in all 104 patients. The median number of biopsies performed was 10 (IQR 6 to 14). The diagnostic yield for aliquot 1 (≤3 biopsies) was 93%. Among the 7% of cases requiring subsequent aliquots for diagnosis, 6 had diffuse parietal pleural abnormalities on pleuroscopy, while 1 had discrete lesions. Of the 17 patients who required comprehensive biomarker testing, 10 (59%) needed samples beyond the first aliquot. No major complications were reported. CONCLUSION: While most diagnoses can be established with 3 or fewer biopsies, cases requiring additional biopsies were more frequently associated with diffuse pleural disease. These findings support tailoring the biopsy strategy to pleural morphology: lesion-directed sampling for focal disease and broader sampling for diffusely abnormal or benign-appearing pleura, especially when malignancy is suspected, or comprehensive biomarker testing is required.