Combined PET-CT and VATS biopsy in pleural effusion: diagnostic accuracy, surgical factors, and prognosis-a...

To clarify the combined contribution of positron emission tomography-computed tomography (PET-CT) and video-assisted thoracoscopic surgery (VATS) pleural biopsy to diagnostic accuracy, perioperative outcomes, and long-term prognosis in patients with unexplained pleural effusion.

We retrospectively reviewed 29 consecutive patients who underwent both PET-CT and VATS biopsy for unexplained pleural effusion between 2009 and 2024. Imaging findings and pathological diagnosis, operative variables, complications, and overall survival were analyzed.

Among 13 PET-negative patients, 4 (30.8%) had malignancy on VATS biopsy. Among 16 PET-positive patients, 5 (31.3%) had benign pathology. PET-CT findings were not associated with operative time, blood loss, or duration of chest tube. Postoperative complications occurred in 4 patients (13.8%), with no difference between PET-positive and negative groups. Complications included prolonged air leak, difficult-to-control pain, and thromboembolic events. Survival was significantly worse in malignant than benign cases (5-year overall survival: 29% vs. 56%, p = 0.02). When patients were grouped into four combined PET-CT/VATS biopsy categories, survival did not significantly differ among the groups (p = 0.11).

PET-CT and VATS biopsy were not always concordant, reinforcing the role of VATS biopsy for definitive diagnosis even when PET-CT is negative. Prognosis was more associated with VATS biopsy pathology than with PET-CT. Perioperative complications after VATS biopsy were not uncommon, particularly in patients with multiple comorbidities.