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. 1999 Oct;54(10):884–893. doi: 10.1136/thx.54.10.884

Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis

Y Lacasse 1, E Wong 1, G Guyatt 1, D Cook 1
PMCID: PMC1745381  PMID: 10491450

Abstract

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.
METHODS—Searches 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.
RESULTS—A 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%.
CONCLUSIONS—Given 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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Selected References

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  1. Allison D. J., Hemingway A. P. Percutaneous needle biopsy of the lung. Br Med J (Clin Res Ed) 1981 Mar 14;282(6267):875–878. doi: 10.1136/bmj.282.6267.875. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Austin J. H., Cohen M. B. Value of having a cytopathologist present during percutaneous fine-needle aspiration biopsy of lung: report of 55 cancer patients and metaanalysis of the literature. AJR Am J Roentgenol. 1993 Jan;160(1):175–177. doi: 10.2214/ajr.160.1.8416620. [DOI] [PubMed] [Google Scholar]
  3. Baker R. R., Stitik F. P., Marsh B. R. The clinical assessment of selected patients with bronchogenic carcinoma. Ann Thorac Surg. 1975 Nov;20(5):520–528. doi: 10.1016/s0003-4975(10)64251-8. [DOI] [PubMed] [Google Scholar]
  4. Balsløv S., Vestbo J., Viskum K. A. Value of Tru-cut lung biopsy in focal and diffuse lung disease. Thorax. 1988 Feb;43(2):147–150. doi: 10.1136/thx.43.2.147. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Begg C. B., McNeil B. J. Assessment of radiologic tests: control of bias and other design considerations. Radiology. 1988 May;167(2):565–569. doi: 10.1148/radiology.167.2.3357976. [DOI] [PubMed] [Google Scholar]
  6. Boiselle P. M., Shepard J. A., Mark E. J., Szyfelbein W. M., Fan C. M., Slanetz P. J., Trotman-Dickenson B., Halpern E. F., Miller S. W., McLoud T. C. Routine addition of an automated biopsy device to fine-needle aspiration of the lung: a prospective assessment. AJR Am J Roentgenol. 1997 Sep;169(3):661–666. doi: 10.2214/ajr.169.3.9275873. [DOI] [PubMed] [Google Scholar]
  7. Burbank F., Kaye K., Belville J., Ekuan J., Blumenfeld M. Image-guided automated core biopsies of the breast, chest, abdomen, and pelvis. Radiology. 1994 Apr;191(1):165–171. doi: 10.1148/radiology.191.1.8134564. [DOI] [PubMed] [Google Scholar]
  8. Charboneau J. W., Reading C. C., Welch T. J. CT and sonographically guided needle biopsy: current techniques and new innovations. AJR Am J Roentgenol. 1990 Jan;154(1):1–10. doi: 10.2214/ajr.154.1.2104689. [DOI] [PubMed] [Google Scholar]
  9. Collins C. D., Breatnach E., Nath P. H. Percutaneous needle biopsy of lung nodules following failed bronchoscopic biopsy. Eur J Radiol. 1992 Jul-Aug;15(1):49–53. doi: 10.1016/0720-048x(92)90203-l. [DOI] [PubMed] [Google Scholar]
  10. Costrini A. M. Transthoracic needle aspiration biopsy of focal pulmonary lesions: a community hospital experience. South Med J. 1986 Jan;79(1):21–23. doi: 10.1097/00007611-198601000-00007. [DOI] [PubMed] [Google Scholar]
  11. Crosby J. H., Hager B., Høeg K. Transthoracic fine-needle aspiration. Experience in a cancer center. Cancer. 1985 Nov 15;56(10):2504–2507. doi: 10.1002/1097-0142(19851115)56:10<2504::aid-cncr2820561030>3.0.co;2-a. [DOI] [PubMed] [Google Scholar]
  12. Cummings S. R., Lillington G. A., Richard R. J. Estimating the probability of malignancy in solitary pulmonary nodules. A Bayesian approach. Am Rev Respir Dis. 1986 Sep;134(3):449–452. doi: 10.1164/arrd.1986.134.3.449. [DOI] [PubMed] [Google Scholar]
  13. Dewan N. A., Reeb S. D., Gupta N. C., Gobar L. S., Scott W. J. PET-FDG imaging and transthoracic needle lung aspiration biopsy in evaluation of pulmonary lesions. A comparative risk-benefit analysis. Chest. 1995 Aug;108(2):441–446. doi: 10.1378/chest.108.2.441. [DOI] [PubMed] [Google Scholar]
  14. Fagan T. J. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975 Jul 31;293(5):257–257. doi: 10.1056/NEJM197507312930513. [DOI] [PubMed] [Google Scholar]
  15. Fleiss J. L. The statistical basis of meta-analysis. Stat Methods Med Res. 1993;2(2):121–145. doi: 10.1177/096228029300200202. [DOI] [PubMed] [Google Scholar]
  16. Flower C. D., Verney G. I. Percutaneous needle biopsy of thoracic lesions--an evaluation of 300 biopsies. Clin Radiol. 1979 Mar;30(2):215–218. doi: 10.1016/s0009-9260(79)80166-x. [DOI] [PubMed] [Google Scholar]
  17. Francis D. Aspiration biopsies from diagnostically difficult pulmonary lesions. A consecutive case material. Acta Pathol Microbiol Scand A. 1977 Mar;85A(2):235–239. doi: 10.1111/j.1699-0463.1977.tb00421.x. [DOI] [PubMed] [Google Scholar]
  18. García Río F., Díaz Lobato S., Pino J. M., Atienza M., Viguer J. M., Villasante C., Villamor J. Value of CT-guided fine needle aspiration in solitary pulmonary nodules with negative fiberoptic bronchoscopy. Acta Radiol. 1994 Sep;35(5):478–480. [PubMed] [Google Scholar]
  19. Gasparini S., Ferretti M., Secchi E. B., Baldelli S., Zuccatosta L., Gusella P. Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses. Experience with 1,027 consecutive cases. Chest. 1995 Jul;108(1):131–137. doi: 10.1378/chest.108.1.131. [DOI] [PubMed] [Google Scholar]
  20. Gazelle G. S., Haaga J. R. Biopsy needle characteristics. Cardiovasc Intervent Radiol. 1991 Jan-Feb;14(1):13–16. doi: 10.1007/BF02635525. [DOI] [PubMed] [Google Scholar]
  21. Greene R., Szyfelbein W. M., Isler R. J., Stark P., Janstsch H. Supplementary tissue-core histology from fine-needle transthoracic aspiration biopsy. AJR Am J Roentgenol. 1985 Apr;144(4):787–792. doi: 10.2214/ajr.144.4.787. [DOI] [PubMed] [Google Scholar]
  22. Gurney J. W. Determining the likelihood of malignancy in solitary pulmonary nodules with Bayesian analysis. Part I. Theory. Radiology. 1993 Feb;186(2):405–413. doi: 10.1148/radiology.186.2.8421743. [DOI] [PubMed] [Google Scholar]
  23. Harrison B. D., Thorpe R. S., Kitchener P. G., McCann B. G., Pilling J. R. Percutaneous Trucut lung biopsy in the diagnosis of localised pulmonary lesions. Thorax. 1984 Jul;39(7):493–499. doi: 10.1136/thx.39.7.493. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hasselblad V., Hedges L. V. Meta-analysis of screening and diagnostic tests. Psychol Bull. 1995 Jan;117(1):167–178. doi: 10.1037/0033-2909.117.1.167. [DOI] [PubMed] [Google Scholar]
  25. House A. J., Thomson K. R. Evaluation of a new transthoracic needle for biopsy of benign and malignant lung lesions. AJR Am J Roentgenol. 1977 Aug;129(2):215–220. doi: 10.2214/ajr.129.2.215. [DOI] [PubMed] [Google Scholar]
  26. Hughes J. M. 18F-fluorodeoxyglucose PET scans in lung cancer. Thorax. 1996 Aug;51 (Suppl 2):S16–S22. doi: 10.1136/thx.51.suppl_2.s16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Irwig L., Tosteson A. N., Gatsonis C., Lau J., Colditz G., Chalmers T. C., Mosteller F. Guidelines for meta-analyses evaluating diagnostic tests. Ann Intern Med. 1994 Apr 15;120(8):667–676. doi: 10.7326/0003-4819-120-8-199404150-00008. [DOI] [PubMed] [Google Scholar]
  28. Jaeschke R., Guyatt G., Sackett D. L. Users' guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 1994 Feb 2;271(5):389–391. doi: 10.1001/jama.271.5.389. [DOI] [PubMed] [Google Scholar]
  29. Jamieson W. R., Suen K. C., Hicken P., Martin A. L., Burr L. H., Munro A. I. Reliability of percutaneous needle aspiration biopsy for diagnosis of bronchogenic carcinoma. Cancer Detect Prev. 1981;4(1-4):331–336. [PubMed] [Google Scholar]
  30. Jamplis R. W., Stevens G. M., Lillington G. A. Percutaneous needle aspiration biopsy of the lung. Am J Surg. 1968 Aug;116(2):243–250. doi: 10.1016/0002-9610(68)90500-x. [DOI] [PubMed] [Google Scholar]
  31. Johnson R. D., Gobien R. P., Valicenti J. F., Jr Current status of radiologically directed pulmonary thin needle aspiration biopsy. An analysis of 200 consecutive biopsies and review of the literature. Ann Clin Lab Sci. 1983 May-Jun;13(3):225–239. [PubMed] [Google Scholar]
  32. King E. B., Russell W. M. Needle aspiration biopsy of the lung--technique and cytologic morphology. Acta Cytol. 1967 Jul-Aug;11(4):319–324. [PubMed] [Google Scholar]
  33. Klein J. S., Schultz S. Interventional chest radiology. Curr Probl Diagn Radiol. 1992 Nov-Dec;21(6):219–277. doi: 10.1016/0363-0188(92)90005-z. [DOI] [PubMed] [Google Scholar]
  34. Knudsen D. U., Nielsen S. M., Hariri J., Christensen J., Kristensen S. Ultrasonographically guided fine-needle aspiration biopsy of intrathoracic tumors. Acta Radiol. 1996 May;37(3 Pt 1):327–331. doi: 10.1177/02841851960371P169. [DOI] [PubMed] [Google Scholar]
  35. Kramer M. S., Feinstein A. R. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther. 1981 Jan;29(1):111–123. doi: 10.1038/clpt.1981.18. [DOI] [PubMed] [Google Scholar]
  36. Lalli A. F., McCormack L. J., Zelch M., Reich N. E., Belovich D. Aspiration biopsies of chest lesions. Radiology. 1978 Apr;127(1):35–40. doi: 10.1148/127.1.35. [DOI] [PubMed] [Google Scholar]
  37. Lees W. R., Hall-Craggs M. A., Manhire A. Five years' experience of fine-needle aspiration biopsy: 454 consecutive cases. Clin Radiol. 1985 Sep;36(5):517–520. doi: 10.1016/s0009-9260(85)80204-x. [DOI] [PubMed] [Google Scholar]
  38. Levine M. S., Weiss J. M., Harrell J. H., Cameron T. J., Moser K. M. Transthoracic needle aspiration biopsy following negative fiberoptic bronchoscopy in solitary pulmonary nodules. Chest. 1988 Jun;93(6):1152–1155. doi: 10.1378/chest.93.6.1152. [DOI] [PubMed] [Google Scholar]
  39. Lieberman R. P., Hafez G. R., Crummy A. B. Histology from aspiration biopsy: Turner needle experience. AJR Am J Roentgenol. 1982 Mar;138(3):561–564. doi: 10.2214/ajr.138.3.561. [DOI] [PubMed] [Google Scholar]
  40. Lillington G. A. Management of solitary pulmonary nodules. Dis Mon. 1991 May;37(5):271–318. doi: 10.1016/s0011-5029(05)80012-4. [DOI] [PubMed] [Google Scholar]
  41. Lovett J. V., Manalo P. B., Barcia T. C., Bomberger R. A., McGregor D. B. Diagnosis of pulmonary masses by fine-needle aspiration. Am J Surg. 1988 Dec;156(6):441–445. doi: 10.1016/s0002-9610(88)80523-3. [DOI] [PubMed] [Google Scholar]
  42. McEvoy R. D., Begley M. D., Antic R. Percutaneous biopsy of intrapulmonary mass lesions. Experience with a disposable cutting needle. Cancer. 1983 Jun 15;51(12):2321–2326. doi: 10.1002/1097-0142(19830615)51:12<2321::aid-cncr2820511226>3.0.co;2-s. [DOI] [PubMed] [Google Scholar]
  43. Meyer J. E., Gandbhir L. H., Milner L. B., McLaughlin M. M. Percutaneous aspiration biopsy of nodular lung lesions. J Thorac Cardiovasc Surg. 1977 May;73(5):787–791. [PubMed] [Google Scholar]
  44. Midgette A. S., Stukel T. A., Littenberg B. A meta-analytic method for summarizing diagnostic test performances: receiver-operating-characteristic-summary point estimates. Med Decis Making. 1993 Jul-Sep;13(3):253–257. doi: 10.1177/0272989X9301300313. [DOI] [PubMed] [Google Scholar]
  45. Nahman B. J., Van Aman M. E., McLemore W. E., O'Toole R. V. Use of the Rotex needle in percutaneous biopsy of pulmonary malignancy. AJR Am J Roentgenol. 1985 Jul;145(1):97–99. doi: 10.2214/ajr.145.1.97. [DOI] [PubMed] [Google Scholar]
  46. Nasiell M. Diagnosis of lung cancer by aspiration biopsy and a comparison between this method and exfoliative cytology. Acta Cytol. 1967 Mar-Apr;11(2):114–119. [PubMed] [Google Scholar]
  47. Pak H. Y., Yokota S., Teplitz R. L., Shaw S. L., Werner J. L. Rapid staining techniques employed in fine needle aspirations of the lung. Acta Cytol. 1981 Mar-Apr;25(2):178–184. [PubMed] [Google Scholar]
  48. Pavy R. D., Antic R., Begley M. Percutaneous aspiration biopsy of discrete lung lesions. Cancer. 1974 Dec;34(6):2109–2117. doi: 10.1002/1097-0142(197412)34:6<2109::aid-cncr2820340635>3.0.co;2-u. [DOI] [PubMed] [Google Scholar]
  49. Perlmutt L. M., Johnston W. W., Dunnick N. R. Percutaneous transthoracic needle aspiration: a review. AJR Am J Roentgenol. 1989 Mar;152(3):451–455. doi: 10.2214/ajr.152.3.451. [DOI] [PubMed] [Google Scholar]
  50. Pilotti S., Rilke F., Gribaudi G., Damascelli B. Fine needle aspiration biopsy cytology of primary and metastatic pulmonary tumors. Acta Cytol. 1982 Sep-Oct;26(5):661–666. [PubMed] [Google Scholar]
  51. Poe R. H., Tobin R. E. Sensitivity and specificity of needle biopsy in lung malignancy. Am Rev Respir Dis. 1980 Nov;122(5):725–729. doi: 10.1164/arrd.1980.122.5.725. [DOI] [PubMed] [Google Scholar]
  52. Sagel S. S., Ferguson T. B., Forrest J. V., Roper C. L., Weldon C. S., Clark R. E. Percutaneous transthoracic aspiration needle biopsy. Ann Thorac Surg. 1978 Nov;26(5):399–405. doi: 10.1016/s0003-4975(10)62917-7. [DOI] [PubMed] [Google Scholar]
  53. Samuelsson L., Albrechtsson U., Tylén U. Fine-needle biopsy of chest lesions. Radiologe. 1982 Nov;22(11):493–496. [PubMed] [Google Scholar]
  54. Sanders C. Transthoracic needle aspiration. Clin Chest Med. 1992 Mar;13(1):11–16. [PubMed] [Google Scholar]
  55. Simpson R. W., Johnson D. A., Wold L. E., Goellner J. R. Transthoracic needle aspiration biopsy. Review of 233 cases. Acta Cytol. 1988 Jan-Feb;32(1):101–104. [PubMed] [Google Scholar]
  56. Sokolowski J. W., Jr, Burgher L. W., Jones F. L., Jr, Patterson J. R., Selecky P. A. Guidelines for percutaneous transthoracic needle biopsy. This position paper of the American Thoracic Society was adopted by the ATS Board of Directors, June 1988. Am Rev Respir Dis. 1989 Jul;140(1):255–256. doi: 10.1164/ajrccm/140.1.255. [DOI] [PubMed] [Google Scholar]
  57. Stanley J. H., Fish G. D., Andriole J. G., Gobien R. P., Betsill W. L., Laden S. A., Schabel S. I. Lung lesions: cytologic diagnosis by fine-needle biopsy. Radiology. 1987 Feb;162(2):389–391. doi: 10.1148/radiology.162.2.3797651. [DOI] [PubMed] [Google Scholar]
  58. Stevens G. M., Jackman R. J. Outpatient needle biopsy of the lung: its safety and utility. Radiology. 1984 May;151(2):301–304. doi: 10.1148/radiology.151.2.6709896. [DOI] [PubMed] [Google Scholar]
  59. Stevens G. M., Weigen J. F., Lillington G. A. Needle aspiration biopsy of localized pulmonary lesions with amplified fluoroscopic guidance. Am J Roentgenol Radium Ther Nucl Med. 1968 Jul;103(3):561–571. doi: 10.2214/ajr.103.3.561. [DOI] [PubMed] [Google Scholar]
  60. Swensen S. J., Silverstein M. D., Ilstrup D. M., Schleck C. D., Edell E. S. The probability of malignancy in solitary pulmonary nodules. Application to small radiologically indeterminate nodules. Arch Intern Med. 1997 Apr 28;157(8):849–855. [PubMed] [Google Scholar]
  61. Taft P. D., Szyfelbein W. M., Greene R. A study of variability in cytologic diagnoses based on pulmonary aspiration specimens. Am J Clin Pathol. 1980 Jan;73(1):36–40. doi: 10.1093/ajcp/73.1.36. [DOI] [PubMed] [Google Scholar]
  62. Targhetta R., Bourgeois J. M., Marty-Double C., Coste E., Proust A., Balmes P., Pourcelot L. Peripheral pulmonary lesions: ultrasonic features and ultrasonically guided fine needle aspiration biopsy. J Ultrasound Med. 1993 Jul;12(7):369–374. doi: 10.7863/jum.1993.12.7.369. [DOI] [PubMed] [Google Scholar]
  63. Veale D., Gilmartin J. J., Sumerling M. D., Wadehra V., Gibson G. J. Prospective evaluation of fine needle aspiration in the diagnosis of lung cancer. Thorax. 1988 Jul;43(7):540–544. doi: 10.1136/thx.43.7.540. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Vine H. S., Kasdon E. J., Simon M. Percutaneous lung biopsy using the Lee needle and a track-obliterating technique. Radiology. 1982 Sep;144(4):921–922. doi: 10.1148/radiology.144.4.7111747. [DOI] [PubMed] [Google Scholar]
  65. Weisbrod G. L., Herman S. J., Tao L. C. Preliminary experience with a dual cutting edge needle in thoracic percutaneous fine-needle aspiration biopsy. Radiology. 1987 Apr;163(1):75–78. doi: 10.1148/radiology.163.1.3823460. [DOI] [PubMed] [Google Scholar]
  66. Weisbrod G. L. Transthoracic needle biopsy. World J Surg. 1993 Nov-Dec;17(6):705–711. doi: 10.1007/BF01659079. [DOI] [PubMed] [Google Scholar]
  67. Westcott J. L. Direct percutaneous needle aspiration of localized pulmonary lesions: result in 422 patients. Radiology. 1980 Oct;137(1 Pt 1):31–35. doi: 10.1148/radiology.137.1.7422857. [DOI] [PubMed] [Google Scholar]
  68. Williams A. J., Santiago S., Lehrman S., Popper R. Transcutaneous needle aspiration of solitary pulmonary masses: how many passes? Am Rev Respir Dis. 1987 Aug;136(2):452–454. doi: 10.1164/ajrccm/136.2.452. [DOI] [PubMed] [Google Scholar]
  69. Winning A. J., McIvor J., Seed W. A., Husain O. A., Metaxas N. Interpretation of negative results in fine needle aspiration of discrete pulmonary lesions. Thorax. 1986 Nov;41(11):875–879. doi: 10.1136/thx.41.11.875. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Yazdi H. M., MacDonald L. L., Hickey N. M. Thoracic fine needle aspiration biopsy versus fine needle cutting biopsy. A comparative study of 40 patients. Acta Cytol. 1988 Sep-Oct;32(5):635–640. [PubMed] [Google Scholar]
  71. Yuan A., Yang P. C., Chang D. B., Yu C. J., Lee Y. C., Kuo S. H., Luh K. T. Ultrasound-guided aspiration biopsy of small peripheral pulmonary nodules. Chest. 1992 Apr;101(4):926–930. doi: 10.1378/chest.101.4.926. [DOI] [PubMed] [Google Scholar]

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