Comparison between closed pleural biopsy and medical thoracoscopy for the diagnosis of undiagnosed exudative pleural effusions: a systematic review and meta-analysis

Our plain-English summary of Comparison between closed pleural biopsy and medical thoracoscopy for the diagnosis of undiagnosed exudative pleural effusions: a systematic review and meta-analysis, by Y. Wei, K. Shen, T. Lv, et al (Translational Lung Cancer Research, 2020).

The study

• Authors: Y. Wei, K. Shen, T. Lv, H. Liu, Z. Wang, J. Wu, H. Zhang, S. Colella, F.Z. Wu, M.T. Milano, P. Zhan, Y. Song, Z. Lu, written
• Journal: Translational Lung Cancer Research
• Published: 2020;9(3):446-458
• Cited by: 31 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Exudative pleural effusion (EPE) is a common diagnostic challenge. The utility of medical thoracoscopy (MT) and closed pleural biopsy (CPB) to aid in the diagnosis of EPE has been reported in many published studies. Herein, we perform a systematic review and meta-analysis to compare the diagnostic yield and safety of CPB and MT in EPE.

Methods: Four databases were searched for studies reporting the diagnostic yield of CPB and MT for EPE. The quality of the included studies was evaluated according to the quality assessment of diagnostic accuracy studies (QUADAS) tool. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and complication risks were compared between the two groups.

Results: Ten studies dealing with CPB and twenty-three studies dealing with MT for the diagnosis of EPE were included in this meta-analysis. Pooled sensitivity, specificity, PLR, NLR and DOR of CPB group was 77%, 99%, 32.55, 0.22, 165.71, respectively, while pooled sensitivity, specificity, PLR, NLR and DOR of MT group was 93%, 100%, 10.82, 0.08, 162.81, respectively. The area under the summary receiver operating characteristic (SROC) curve of CPB and MT were both 0.97. The ability of CPB to diagnose non-malignant diseases was like MT (69% vs. 68%), while the ability was lower than that of MT to diagnose malignant diseases (72% vs. 92%). The pooled diagnostic accuracy of CPB and MT for mesothelioma was 26% (95% CI, 14-38%) and 42% (95% CI, 22-62%) (P<0.001), respectively. The rate of complications with CBP was lower than that reported for MT.

Conclusions: CBP is a relatively accurate tool with a lower complication rate compared to MT in the diagnosis of EPE, especially in diagnosing non-malignant diseases. We confirm the utility of MT in the diagnostic workup of malignancy (especially mesothelioma); however, in selected cases, CPB could be used as the first diagnostic approach with a favorable safety profile.

2020 Translational Lung Cancer Research. All rights reserved.

In plain English

This was a systematic review and meta-analysis of published studies, not new patients. The authors searched four databases (January 2000 to July 2018) for studies of two ways to sample pleural tissue in undiagnosed exudative pleural effusion (abnormal fluid around the lung): closed pleural biopsy and medical thoracoscopy. They included 10 closed-biopsy studies (1,747 subjects) and 23 thoracoscopy studies (1,783 subjects). Pooled sensitivity was 77% (95% CI, 75–80%) for closed biopsy and 93% (95% CI, 91–94%) for thoracoscopy; pooled specificity was 99% and 100%. Pooled diagnostic accuracy, closed biopsy versus thoracoscopy, was 69% (95% CI, 51–88%) versus 68% (95% CI, 48–87%) for non-malignant diseases, 72% (95% CI, 62–82%) versus 92% (95% CI, 88–95%) for malignant diseases, and 26% (95% CI, 14–38%) versus 42% (95% CI, 22–62%) for mesothelioma (P less than 0.001). Pooled complication rates were 5% (95% CI, 3–7%) for closed biopsy and 8% (95% CI, 6–11%) for thoracoscopy. The article did not study asbestos exposure. The authors concluded that closed biopsy was relatively accurate with fewer complications, while thoracoscopy was paramount to exclude malignancy, especially mesothelioma.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Systematic review and meta-analysis of published studies of diagnostic accuracy
• Who was studied: Published studies, January 2000 to July 2018, of patients with undiagnosed exudative pleural effusion: 10 studies (1,747 subjects) on closed pleural biopsy and 23 studies (1,783 subjects) on medical thoracoscopy, from many countries
• Exposure: No asbestos or other environmental exposure was studied. The comparison was between two diagnostic procedures: closed pleural biopsy (CPB) and medical thoracoscopy (MT).
• Main results:
  • Closed pleural biopsy: pooled sensitivity 77% (95% CI, 75–80%); pooled specificity 99%
  • Medical thoracoscopy: pooled sensitivity 93% (95% CI, 91–94%); pooled specificity 100%
  • The area under the summary receiver operating characteristic curve was 0.97 for both procedures
  • Non-malignant diseases: pooled diagnostic accuracy 69% (95% CI, 51–88%) for closed pleural biopsy and 68% (95% CI, 48–87%) for medical thoracoscopy
  • Malignant diseases: pooled diagnostic accuracy 72% (95% CI, 62–82%) for closed pleural biopsy and 92% (95% CI, 88–95%) for medical thoracoscopy
  • Mesothelioma: pooled diagnostic accuracy 26% (95% CI, 14–38%) for closed pleural biopsy and 42% (95% CI, 22–62%) for medical thoracoscopy (P less than 0.001)
  • Pooled complication rate was 8% (95% CI, 6–11%) for medical thoracoscopy, significantly higher (P less than 0.001) than 5% (95% CI, 3–7%) for closed pleural biopsy
  • The most common complication of closed pleural biopsy was pneumothorax; for medical thoracoscopy the most common were subcutaneous emphysema and fever
  • The test for publication bias was significant for the thoracoscopy studies but not for the closed-biopsy studies (P=0.74)
• The authors' conclusion: The authors concluded that closed pleural biopsy is a relatively accurate tool with a lower complication rate than medical thoracoscopy, especially for non-malignant diseases. In their view, medical thoracoscopy is paramount to exclude malignancy (especially mesothelioma) or infections.
• Limitations the authors state:
  • Differences between studies in design, sample size and patients' baseline disease status limit interpretation of the pooled data
  • Factors affecting performance, such as operator experience, number of biopsies and type of thoracoscope, need further exploration
  • Only studies published in English were included, which may cause language bias

Topics

Medical terms in this study, explained in our Lexicon: Pleural Biopsy, Medical Thoracoscopy, Pleural Effusion, Systematic Review, Meta-Analysis, Odds Ratio, Mesothelioma.

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• Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial — M. Metintas, G. Ak, et al. (2010)
• Investigation of pleural effusion: comparison between fibreoptic thoracoscopy, needle biopsy and cytology — W.M. Edmondstone (1990)
• Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark — F. Willendrup, U. Bodtger, et al. (2014)
• Medical thoracoscopy in the diagnosis of unexplained pleural effusion — M.L. Wilsher, A.G. Veale (1998)
• Intrapleural Urokinase Directly Under Medical Thoracoscopy for the Diagnosis of Malignant Pleural Mesothelioma With Severe Multiloculated Pleural Effusions — S. Terashita, H. Kawachi, et al. (2019)

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