Diagnostic value of ultrasound-guided needle biopsy in undiagnosed pleural effusions

Abstract

Background and Objective: Undiagnosed pleural effusions (UPEs) are a common problem of respiratory medicine, leading to an increased diagnostic burden globally. However, the most efficient and cost-effective approaches to UPEs remain controversial. This study aimed to assess the diagnostic value of ultrasound-guided needle biopsy (UGNB) in UPEs. Methods: We conducted a search of PubMed, Embase, the Cochrane Library and reference lists of retrieved studies with no publication data limitation. Articles that investigated the diagnostic accuracy of UGNB in UPEs were included. The quality of eligible studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. The diagnostic value of UGNB was evaluated by calculating the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds rate, and the area under the curve for the summary receiver operating characteristic curve using a random effects model. Results: Seven studies comprising 165 patients with UPEs met the inclusion criteria. UGNB had a pooled sensitivity of 83% (95% confidence intervals [CI], 75% - 89%), a specificity of 100% (95% CI, 90% - 100%), a positive likelihood ratio of 8.89 (95% CI, 3.29 - 24.02), a negative likelihood ratio of 0.23 (95% CI, 0.16 - 0.33), a diagnostic odds rate of 51.47 (95% CI, 14.70 - 180.16), and an area under the curve of 0.94. Six pneumothorax cases (3.6%), 5 local wound infections (3.0%), and 1 empyema case (less than 1%) were observed. There was no significant heterogeneity or publication bias in this study. Conclusions: Based on current evidence, UGNB is a safe and convenient procedure with a high accuracy for diagnosing UPEs. However, physicians should still be cautious in interpreting negative UGNB results.

Diagnostics in Pleural Disease

“…The literature comparing ultrasound-guided to CT-guided biopsies is sparse. A recent meta-analysis across seven studies and 165 patients with US-guided pleural biopsies across both cutting needles and reverse-bevel needles suggested a pooled sensitivity of 83% (95% CI 75-89%) with rates of pneumothorax at 3.6%, wound infection 3%, and empyema < 1% [65]. This is similar to the sensitivity suggested by Metintas et al for their CT-guided Abrams needle technique.…”

Sonography of the pleura

“…In pleural tumors, a biopsy is usually necessary so that histologic diagnosis and appropriate therapy can be initiated. Ultrasound-guided biopsy has a very high diagnostic accuracy and a low complication rate [49], as a puncture route can be chosen to avoid the interposition of ribs and intercostal vessels. It is best to biopsy a parietal pleural lesion at a site where pleural effusion is present to reduce the risk of pneumothorax (▶ Fig.…”

Ultrasound-guided pleural biopsy

“…The Abrams and Tru-Cut biopsy needles are the most commonly used devices for closed pleural biopsy. [15,16] The Abrams needle [Fig. 3] consists of 3 individual components: 2 concentric tubes and a stylet.…”

“…Recently, a systematic review and metanalysis reported that direct USguided closed pleural biopsy had a pooled sensitivity and specificity for undiagnosed exudates of 83% and 100%, respectively. [16] Alternatively, "ultrasound-assistance" describes a free-hand technique in which the pleural target is marked on the skin after noting the angle, depth, and location of the diaphragm and neurovascular bundle. The procedure is then performed during a breath hold without changing the patient's position.…”

“…Other common complications are site pain (up to 15%), vasovagal syncope (up to 5%), local wound infection (up to 5%), hemothorax (<2%), site hematoma (<1%), fever (<1%), and empyema and minor bleeding. [11,15,16,18] Life threatening hemorrhage is the most feared complication, but it is exceedingly rare. Although it could arise from a puncture of the viscera, it usually originates from the intercostal arteries.…”