Pleural disease in lung cancer can be benign or malignant with the latter carrying a grave prognosis. In this review, we describe and discuss the advances in pleural imaging, procedures, and biomarkers for the diagnosis of pleural diseases in lung cancer. Ultrasound and computed tomography are increasingly applied in the planning of pleural procedures to enhance diagnostic accuracy and safety whilst pleuroscopy gives excellent yield in excess of 93% in the evaluation of cytology negative pleural effusions. Invasion beyond the elastic layer of the visceral pleura upstages lung cancer, and may indicate a need for adjuvant chemotherapy. Biomarkers isolated from pleural fluid or tissue may aid in diagnosis and guide treatment in the future. Magnetic resonance imaging, positron emission tomography, narrow band imaging of the pleura and autofluorescence thoracoscopy are technologies that require further evaluation to better define their respective roles in the diagnostic algorithms of pleural diseases in lung cancer.