Sensitivity and complications of thoracentesis and thoracoscopy: a meta-analysis

Our plain-English summary of Sensitivity and complications of thoracentesis and thoracoscopy: a meta-analysis, by G. Martinez-Zayas, S. Molina, D.E. Ost (European Respiratory Review, 2022).

The study

• Authors: G. Martinez-Zayas, S. Molina, D.E. Ost
• Journal: European Respiratory Review
• Published: 2022;31(166)
• Type of article: Systematic review, Meta-analysis
• Cited by: 32 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Thoracentesis and thoracoscopy are used to diagnose malignant pleural effusions (MPE). Data on how sensitivity varies with tumour type is limited.

Methods: Systematic review using PubMed was performed through August 2020 to determine the sensitivity of thoracentesis and thoracoscopy for MPE secondary to malignancy, by cancer type, and complication rates. Tests to identify sources of heterogeneity were performed. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and National Institutes of Health quality assessment tools. Publication bias was tested using funnel plots.

Results: Meta-analyses for sensitivity of thoracentesis for MPE secondary to malignancy, mesothelioma and lung and breast cancer included 29, eight, 12 and nine studies, respectively. Pooled sensitivities were 0.643 (95% CI 0.592-0.692), 0.451 (95% CI 0.249-0.661), 0.738 (95% CI 0.659-0.836) and 0.820 (95% CI 0.700-0.917), respectively. For sensitivity of thoracoscopy for MPE secondary to malignancy and mesothelioma, 41 and 15 studies were included, respectively. Pooled sensitivities were 0.929 (95% CI 0.905-0.95) and 0.915 (95% CI 0.871-0.952), respectively. Pooled complication rates of thoracentesis and thoracoscopy were 0.041 (95% CI 0.025-0.051) and 0.040 (95% CI 0.029-0.052), respectively. Heterogeneity was significant for all meta-analyses. Funnel plots were asymmetric.

Interpretation: Sensitivity of thoracentesis varied significantly per cancer type. Pooled complication rates were low. Awareness of how sensitivity of thoracentesis changes across cancers can improve decision-making when MPE is suspected.

Copyright ©The authors 2022.

In plain English

This was a systematic review and meta-analysis of studies on two tests for diagnosing cancer-related fluid around the lung (malignant pleural effusion): thoracentesis, testing drawn-off fluid for cancer cells, and thoracoscopy with pleural biopsy. It included 71 thoracentesis and 90 thoracoscopy studies. Sensitivity meant the share of confirmed malignant pleural effusions a test detected. For thoracentesis, pooled sensitivity (95% confidence interval) was 0.643 (0.592–0.692) for effusions from any cancer (29 studies, 5444 patients), 0.451 (0.249–0.661) for mesothelioma (8 studies, 1133 patients), 0.738 (0.648–0.819) for lung cancer and 0.820 (0.700–0.917) for breast cancer. For thoracoscopy it was 0.929 (0.905–0.95) for any cancer (41 studies) and 0.915 (0.871–0.952) for mesothelioma (15 studies, 453 patients). Per procedure, pooled complication rates were 0.041 (0.025–0.061) for ultrasound-guided thoracentesis and 0.040 (0.029–0.052) for thoracoscopy. Results differed significantly between studies. The authors concluded that thoracentesis sensitivity was lowest for mesothelioma and highest for breast cancer, and that complication rates were low. They noted most mesothelioma studies predated reports that BAP1 and CDKN2A tests improve detection. The review did not study asbestos, mentioning asbestos exposure only as one sign suggesting 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 randomised controlled trials and cohort studies
• Who was studied: Published English-language randomised controlled trials and cohort studies found in PubMed (searched July 2020). Each study had at least 10 patients whose pleural effusions proved to be due to cancer. 71 thoracentesis studies and 90 thoracoscopy studies were included.
• Exposure: No asbestos exposure was studied. The review compared two diagnostic procedures: thoracentesis with pleural fluid cytology, and thoracoscopy with pleural biopsy. Asbestos exposure was mentioned only in the discussion, as an example of a feature giving a high pre-test probability of mesothelioma.
• Main results:
  • Thoracentesis, malignant pleural effusion from any cancer: pooled sensitivity 0.643 (95% CI 0.592–0.692), from 29 studies covering 5444 patients
  • Thoracentesis, malignant pleural effusion from mesothelioma: pooled sensitivity 0.451 (95% CI 0.249–0.661), from 8 studies covering 1133 patients
  • Thoracentesis, malignant pleural effusion from lung cancer: pooled sensitivity 0.738 (95% CI 0.648–0.819 per table and forest plot), from 12 studies covering 1184 patients
  • Thoracentesis, malignant pleural effusion from breast cancer: pooled sensitivity 0.820 (95% CI 0.700–0.917), from 532 patients
  • Thoracoscopy, malignant pleural effusion from any cancer: pooled sensitivity 0.929 (95% CI 0.905–0.95), from 41 studies covering 2963 patients
  • Thoracoscopy, malignant pleural effusion from mesothelioma: pooled sensitivity 0.915 (95% CI 0.871–0.952), from 15 studies covering 453 patients
  • Thoracentesis complications, pooled only from studies of ultrasound-guided thoracentesis and calculated per procedure: 0.041 (95% CI 0.025–0.061), from 23 studies
  • Thoracentesis pneumothorax: pooled rate 0.025 (95% CI 0.017–0.034), from 36 studies
  • Thoracoscopy complications, calculated per procedure: pooled rate 0.040 (95% CI 0.029–0.052), from 79 studies
  • Heterogeneity between studies was significant in all the thoracentesis sensitivity meta-analyses
• The authors' conclusion: The authors concluded that thoracentesis sensitivity was lowest for mesothelioma, intermediate for lung cancer and highest for breast cancer. They also concluded that pooled complication rates for both procedures were low.
• Limitations the authors state:
  • Too few studies reported thoracoscopy sensitivity for lung or breast cancer, so no cancer-specific thoracoscopy estimates could be made for those cancers.
  • Very few studies reported thoracentesis sensitivity for cancers other than mesothelioma, lung or breast cancer.
  • Most mesothelioma studies were published before reports that BAP1 immunostaining and CDKN2A increase sensitivity, so pooled mesothelioma sensitivities may change.
  • No subgroup analysis was done for thoracentesis sensitivity for mesothelioma using cell block techniques.
  • Heterogeneity between studies was significant, and the small number of studies limited the search for its causes. The stratified and meta-regression results should be seen as exploratory.
  • Publication bias should not be ruled out even though the Begg and Egger tests were not significant.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

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

Related studies

• Outcomes and complications following medical thoracoscopy — F.J. Brims, M. Arif, et al. (2012)
• Medical thoracoscopy, results and complications in 146 patients: a retrospective study — M. Hansen, P. Faurschou, et al. (1998)
• Diagnostic value of medical thoracoscopy in malignant pleural effusion — Y.B. Wu, L.L. Xu, et al. (2017)
• Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single-centre experience — J. Leemans, C. Dooms, et al. (2018)
• The safety of medical thoracoscopy in a group at high risk for complications — M. Metintas, G. Ak, et al. (2013)
• Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom — M. Turner, F. Craighead, et al. (2023)

Browse more research in European Respiratory Review, or return to medical research.