Chest
Volume 147, Issue 2, February 2015, Pages 502-512
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Original Research: Disorders of the Pleura
Accuracy of Fluorodeoxyglucose-PET Imaging for Differentiating Benign From Malignant Pleural Effusions: A Meta-analysis

https://doi.org/10.1378/chest.14-0820Get rights and content

BACKGROUND

The role of fluorodeoxyglucose (FDG)-PET imaging for diagnosing malignant pleural effusions is not well defined. The aim of this study was to summarize the evidence for its use in ruling in or out the malignant origin of a pleural effusion or thickening.

METHODS

A meta-analysis was conducted of diagnostic accuracy studies published in the Cochrane Library, PubMed, and Embase (inception to June 2013) without language restrictions. Two investigators selected studies that had evaluated the performance of FDG-PET imaging in patients with pleural effusions or thickening, using pleural cytopathology or histopathology as the reference standard for malignancy. Subgroup analyses were conducted according to FDG-PET imaging interpretation (qualitative or semiquantitative), PET imaging equipment (PET vs integrated PET-CT imaging), and/or target population (known lung cancer or malignant pleural mesothelioma). Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. We used a bivariate random-effects model for the analysis and pooling of diagnostic performance measures across studies.

RESULTS

Fourteen non-high risk of bias studies, comprising 407 patients with malignant and 232 with benign pleural conditions, met the inclusion criteria. Semiquantitative PET imaging readings had a significantly lower sensitivity for diagnosing malignant effusions than visual assessments (82% vs 91%; P = .026). The pooled test characteristics of integrated PET-CT imaging systems using semiquantitative interpretations for identifying malignant effusions were: sensitivity, 81%; specificity, 74%; positive likelihood ratio (LR), 3.22; negative LR, 0.26; and area under the curve, 0.838. Resultant data were heterogeneous, and spectrum bias should be considered when appraising FDG-PET imaging operating characteristics.

CONCLUSIONS

The moderate accuracy of PET-CT imaging using semiquantitative readings precludes its routine recommendation for discriminating malignant from benign pleural effusions.

Section snippets

Search Strategy and Study Selection

The systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.5 This study was registered with the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO) as CRD42011001392 (“Accuracy of FDG-PET for diagnosing malignant pleural effusions: a systematic review and meta-analysis”). We searched the Cochrane Library, PubMed/MEDLINE, and EMBASE from inception to June 2013 to identify

Characteristics of the Included Studies

A total of 619 studies were identified, of which 45 were retrieved for full-text review. Only 27 of those, published between 1997 and 2012, met the inclusion criteria.6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 Table 2 summarizes the design, participants, and findings of the initially selected studies. Subsequently, 12 studies with a high risk of bias based on the QUADAS-2 tool9, 12, 14, 17, 18, 19, 22, 23, 24, 26, 28, 31 and another,

Summary of Evidence

This meta-analysis summarizes 14 non-high risk of bias studies that assessed the diagnostic usefulness of FDG-PET imaging in patients with pleural effusions (or thickening). According to the data, in the best-case scenario, the yield of stand-alone PET imaging systems for labeling the malignant nature of pleural fluid accumulation, when qualitative criteria were applied, was sensitivity of 96%; specificity of 76%; LR positive, 4.09; LR negative, 0.06; and AUC, 0.95.

However, the stand-alone PET

Conclusions

The results of the present meta-analysis, based on 14 studies with > 600 patients spanning the last 16 years, suggest that, although of some value, FDG-PET imaging does not seem to change the probability of pleural malignancy sufficiently as to be recommended in the routine workup of effusions of undetermined cause. The FDG-PET imaging technique warrants broader prospective evaluations using: (1) gating acquisition techniques to reduce motion artifacts, (2) VOI analyses to enhance quantitative

Acknowledgments

Author contributions: J. M. P. had full access to all of the data in the study, takes responsibility for the integrity of the data and the accuracy of the data analysis, is guarantor for the entire manuscript, contributed to the study concept and design and to drafting the manuscript, and served as principal author. J. M. P. and P. H. contributed to the systematic review. M. M.-A. contributed to the statistical analysis. S. B. and A. S. contributed to revision of the manuscript. J. M. P., P.

References (36)

  • JM Porcel

    Pearls and myths in pleural fluid analysis

    Respirology

    (2011)
  • D Moher et al.

    PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

    Ann Intern Med

    (2009)
  • R Liao et al.

    Clinical role of F-18 FDG PET/CT in differentiating malignant and benign pleural effusion in patients with lung cancer [in Chinese]

    Zhongguo Fei Ai Za Zhi

    (2012)
  • PF Whiting et al.

    QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies

    Ann Intern Med

    (2011)
  • T Bury et al.

    Evaluation of pleural diseases with FDG-PET imaging: preliminary report

    Thorax

    (1997)
  • I Buchmann et al.

    F-18-FDG PET for differential diagnosis of pleural processes [in German]

    Nucl Med (Stuttg)

    (1999)
  • A Carretta et al.

    18-FDG positron emission tomography in the evaluation of malignant pleural diseases - a pilot study

    Eur J Cardiothorac Surg

    (2000)
  • JJ Erasmus et al.

    FDG PET of pleural effusions in patients with non-small cell lung cancer

    AJR Am J Roentgenol

    (2000)
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    FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

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