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Pleural diseases are a common and increasing clinical problem. Establishing accurate diagnosis is an essential step in management of these patients, and approximately 40% of pleural effusions will remain undiagnosed after initial diagnostic thoracocentesis. Obtaining pleural tissue (by blind, image-guided or thoracoscopic pleural biopsy) is therefore a key procedure. Recent evidence provides important information on the relative value of each of these techniques.For the diagnosis of malignant pleural disease, both thoracoscopic and image-guided biopsy have a far higher diagnostic yield than blind pleural biopsy. Cutting needle biopsies have a higher diagnostic yield in malignancy (and especially mesothelioma) compared with fine needle aspiration. The complication rate of image-guided biopsy is low. Rates of biopsy site tract invasion by mesothelioma may be lower using smaller biopsy ports, as used for image-guided pleural biopsy.Blind pleural biopsy should no longer be conducted for the study of malignant pleural disease if facilities for other techniques are available. Image-guided and thoracoscopic biopsies have similarly high diagnostic rates, and are complementary techniques used in different clinical situations. Further studies assessing biopsy tract site invasion from mesothelioma with different biopsy techniques are required.