Diagnostic yield and safety of diagnostic techniques for pulmonary lesions: systematic review, meta-analysis and network meta-analysis

Abstract

Background: With recent advancements in bronchoscopic procedures, data on the best modality to sample peripheral pulmonary lesions (PPLs) is lacking, especially comparing bronchoscopy with computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA).

Methods: We performed a meta-analysis, pairwise meta-analysis and network meta-analysis on studies reporting diagnostic yield and complications with the use of CT-TBNA, radial endobronchial ultrasound (rEBUS), virtual bronchoscopy (VB), electromagnetic navigation (EMN) or robot-assisted bronchoscopy (RAB) to sample PPLs. The primary outcome was diagnostic yield and the secondary outcome was complications. We estimated the relative risk ratios using a random-effects model and used the frequentist approach for the network meta-analysis. We performed extensive analysis to assess the heterogeneity including reporting bias, publication bias, subgroup and meta-regressional analysis. We assessed the quality of the studies using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) and QUADAS-Comparative (QUADAS-C).

Results: We included 363 studies. The overall pooled diagnostic yield was 78.1%, the highest with CT-TBNA (88.9%), followed by RAB (84.8%) and the least with rEBUS (72%). In the pairwise meta-analysis, only rEBUS showed inferiority to CT-TBNA. The network meta-analysis ranked CT-TBNA as likely the most effective approach followed by VB, EMN and RAB, while rEBUS was the least effective, with a low-GRADE certainty. CT-TBNA had the highest rate of complications.

Conclusion: Although CT-TBNA is the most effective approach to sample PPLs, RAB has a comparable diagnostic yield with a lesser complication rate. Further prospective studies are needed comparing CT-TBNA and RAB.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

FIGURE 2

Forest plots representing the diagnostic yield of individual and overall studies by a) computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA), b) radial endobronchial ultrasound with no additional techniques (rEBUS only), c) virtual bronchoscopy, d) electromagnetic navigation and e) robot-assisted bronchoscopy. Citation details for individual studies are included in Supplement 2.

FIGURE 2

Forest plots representing the diagnostic yield of individual and overall studies by a) computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA), b) radial endobronchial ultrasound with no additional techniques (rEBUS only), c) virtual bronchoscopy, d) electromagnetic navigation and e) robot-assisted bronchoscopy. Citation details for individual studies are included in Supplement 2.

FIGURE 3

a) Network geometry displaying a network of studies comparing the diagnostic yield with different modalities for sampling pulmonary lesions (the size of the nodes is proportionate to the total number of nodules sampled and the thickness of the lines is the proportion to the number of studies). b) Forest plot showing the relative risk of different diagnostic techniques in the network model with computed tomography-guided transthoracic biopsy or needle aspiration (CT-TBNA) as a reference. EMN: electromagnetic navigation; RAB: robot-assisted bronchoscopy; rEBUS: radial endobronchial ultrasound; VB: virtual bronchoscopy.