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a Centre de
Pneumologie, Hôpital Laval, Ste-Foy, Québec, Canada, b Department of Medicine, University of
Alberta, Edmonton, Alberta, Canada, c Department of Clinical Epidemiology and
Biostatistics and Department of Medicine, McMaster University,
Hamilton, Ontario, Canada
Correspondence to: Dr Y Lacasse, Centre de Pneumologie, Hôpital Laval, 2725 Chemin Ste-Foy, Ste-Foy, P. Quebec, G1V 4G5, Canada.
Received 23 October 1998; Returned to authors 12 January 1999; Revised version received 1 April 1999; Accepted for publication 10 June 1999
BACKGROUND
Persisting
controversy surrounds the use of transthoracic needle aspiration biopsy
(TNAB) stemming from its uncertain diagnostic accuracy. A systematic
review and meta-analysis was therefore conducted to evaluate the
accuracy of TNAB for the diagnosis of solitary or multiple localised
pulmonary lesions.
METHODSSearches for English
literature papers in Index Medicus (1963-1965) and Medline
(1966-1996) were performed and the bibliographies of the retrieved
articles were systematically reviewed. Articles evaluating the accuracy
of TNAB in series of consecutive patients presenting with solitary or
multiple pulmonary lesions were considered. Only papers in which
90% of patients were given a final diagnosis according to an
appropriate reference standard were included in the meta-analysis.
RESULTSA total of 48 studies were included and five meta-analyses were conducted according
to four diagnostic thresholds. From the pooled sensitivity and
specificity corresponding to each diagnostic threshold, associated
likelihood ratios (LRs) were derived for malignant disease as follows:
(1) malignant versus all other categories, LR = 72; (2) malignant or
suspicious versus all others, LR = 49; (3) suspicious versus all
categories but malignant, LR = 15; (4) benign versus all others, LR = 0.07; and (5) specific benign diagnosis versus all others, LR = 0.005. Differences in methodological quality of the studies, needle types, or
whether a cytopathologist participated in the procedure failed to
explain the heterogeneity of the results found in almost every
meta-analysis. Given a 50% probability of malignancy prior to the
TNAB, post-test probabilities of malignancy upon receiving the results
would be malignant, 99%; suspicious, 94%; non-specific benign, 7%;
and benign with a specific diagnosis, 0.6%.
CONCLUSIONSGiven the
intermediate pre-test probabilities that would probably lead to
performing TNAB, findings of "malignant" or of a specific diagnosis
of a benign condition provide definitive results. Findings of
"suspicious" markedly increase the probability of malignancy, and
"benign" markedly decreases it but may not be considered definitive.
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