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Performance Characteristics of Different Modalities for Diagnosis of Suspected Lung Cancer*: Summary of Published Evidence FREE TO VIEW

Gilbert Schreiber, MD, FCCP; Douglas C. McCrory, MD, MHS
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*From the Department of Medicine, Duke University Medical Center, Durham, NC.

Correspondence to: Gilbert Schreiber, MD, FCCP, Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Box 403, 1515 Holcombe Blvd, Houston, TX 77030; e-mail: egschreib@mdanderson.org



Chest. 2003;123(1_suppl):115S-128S. doi:10.1378/chest.123.1_suppl.115S
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Study objectives: To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

Design, setting, and participants: A systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer.

Measurement and results: For sputum cytology, the pooled specificity was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central lesions than for peripheral lesions (0.71 vs 0.49, respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69. Peripheral lesions < 2 cm or > 2 cm in diameter showed sensitivities of 0.33 and 0.62, respectively. Updating a previous meta-analysis with 19 studies revealed a pooled sensitivity of 0.90 for TTNA. A trend toward lower sensitivity was noted for lesions that were < 2 cm in diameter. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive and false-negative rates were 0.09 and 0.02, respectively.

Conclusions: The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions that are < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease. The distinction between small cell lung cancer and non-small cell lung cancer by cytology appears to be accurate.

Figures in this Article

This article summarizes and critically examines the performance characteristics of the various modalities for the accurate histopathologic diagnosis of suspected lung cancer. It provides the background evidence for the Clinical Practice Guidelines on Lung Cancer that are outlined in this supplement. A joint panel from the American College of Chest Physicians assisted in the design, conduct, and development of this article.

Lung cancer is usually suspected on the basis of an abnormal radiographic imaging study, often in conjunction with symptoms caused by either local or systemic effects of the tumor. The modality selected to diagnose a suspected lung cancer is based on the size and location of the primary tumor in the lung, the presence of potential metastatic spread, and the anticipated treatment plan.

The main goals in selecting a specific diagnostic modality are as follows: (1) to maximize the yield of the selected procedure for both diagnosis and staging; and (2) to avoid unnecessary invasive tests for the patient, with special attention to the projected treatment plan.

Sputum cytology, bronchoscopic techniques, transthoracic needle biopsies, and surgical biopsy (resection) define the main modalities employed in the diagnosis of bronchogenic carcinoma. Positron emission tomography has emerged as a helpful adjunct in both the diagnosis and staging of lung cancer.

In this article, we focus on techniques for the histologic and cytologic diagnosis of lung lesions. The noninvasive evaluation of pulmonary nodules will be covered elsewhere in this supplement in the article reporting on single pulmonary nodules. Definitive diagnostic procedures that are aimed at mediastinal lymph nodes or extrathoracic tumors will be covered in the articles on staging.

In several panel discussions, the American College of Chest Physicians Committee on Clinical Practice Guidelines for Lung Cancer formulated the following four key questions on the diagnostic workup of lung cancer that were to be answered by a comprehensive critical review of the published evidence:

  1. What are the performance characteristics (sensitivity and specificity) for sputum cytology for the diagnosis of lung cancer with special consideration for the location of the tumor (central vs peripheral)?

  2. What are the performance characteristics (sensitivity and specificity) of flexible bronchoscopy and its ancillary procedures (biopsy, cytobrushing, washing, transbronchial needle aspiration [TBNA], and BAL) for the diagnosis of central (endobronchial), as opposed to peripheral, tumors and for peripheral lesions < 2 cm and > 2 cm in diameter?

  3. What are the performance characteristics (sensitivity and specificity) for transthoracic needle aspiration (TTNA) as a diagnostic modality with particular emphasis on the size and the location of the suspected cancer?

  4. What is the diagnostic error rate when differentiating between non-small cell lung cancer and small cell lung cancer that is generated by various diagnostic techniques (bronchoscopy and sputum cytology)?

To address these questions, we conducted a computerized search of the MEDLINE bibliographic database from 1966 to July 2001, HealthStar, and the Cochrane Library. We searched using the terms lung neoplasm, bronchial neoplasm, bronchoscopy, biopsy, needle, sputum, cytodiagnosis, yield, predictive value of tests, and sensitivity and specificity. In addition, we searched the reference lists of included studies, practice guidelines, systematic reviews, and meta-analyses.

We selected studies of at least 50 patients with suspected lung cancer that compared test results with a reference standard consisting of pathology/histology, definitive cytologic diagnosis, or radiographic follow-up of at least 1 year. We considered the following diagnostic tests: sputum cytologic examination (expectorated or aspirated, spontaneous or induced); flexible bronchoscopy (including any of biopsy, brushing, washing, TBNA, or BAL); and TTNA. Studies were required to report sufficient data to permit completion of a 2 × 2 table comparing test results with a reference standard diagnosis. If too few studies met this criterion, then we identified studies that described the diagnostic yield (sensitivity) among patients with lung cancer. When possible, diagnostic performance was estimated separately for patients with central (endobronchial) lesions, peripheral lesions > 2 cm in diameter, and peripheral lesions < 2 cm in diameter.

Key Question 1: What Are the Performance Characteristics for Sputum Cytology for the Diagnosis of Lung Cancer With Special Consideration for the Location of the Tumor (Central vs Peripheral)?

We found few studies describing the accuracy of sputum cytology as a result of our computerized bibliographic literature search, but we identified many among the citations of four review articles.14

Problems With the Published Literature on Sputum Cytology:

Studies describing the sensitivity and specificity of sputum cytology are described in Table 1 . Most of the studies involved the identification of patients from cytology laboratory samples without regard to the indication for sputum cytology testing. Several studies described the study population indications as including the evaluation of suspected lung cancer and screening in patients with COPD. Few studies have evaluated both the sensitivity and specificity of sputum cytology in patients with suspected lung cancer.5 Some studies of patients undergoing bronchoscopy have reported the results of prebronchoscopy or postbronchoscopy sputum testing; however, all of these studies (reviewed for key question 1) were limited to patients with proven lung malignancies and thus could not describe the test specificity.

Studies of sputum cytology that did attempt to verify test-negative subjects are reviewed, with the exception of screening trials of healthy or high-risk individuals. (These studies are to be covered in the article on screening elsewhere in this supplement.)

Performance Characteristics of Sputum Cytology for the Diagnosis of Suspected Lung Cancer:

Table 1 shows 16 studies.2,519 Sensitivity ranges from 0.42 to 0.97, and specificity ranges from 0.68 to 1.0. The pooled sensitivity is 0.66, and the pooled specificity is 0.99. The single study conducted in patients who were evaluated for suspected lung cancer5 had a sensitivity of 0.87 and a specificity of 0.90. After pooling all studies, regardless of the indication for sputum testing, the false- positive test result rate was 0.09, and the false-negative test result rate was 0.06.

Some of the bronchoscopy studies included under key question 1 described the sensitivity of prebronchoscopy sputum examination. These studies have the advantage that all patients were suspected of having lung cancer and, thus, more closely approximate the population of interest. Table 2 describes the sensitivity of prebronchoscopy sputum examination in eight studies.4,2026 The sensitivity ranges from 0.10 to 0.74, with an average value of 0.22.

Effect of Location on the Sensitivity of Sputum Cytology:

The effect of location (central vs peripheral) of lung nodules or masses on the sensitivity of sputum cytology has been described in 17 studies (Table 3 ).2,5,1012,18,22,2736 Most studies showed decreased sensitivity for peripherally located masses, but a few showed no such difference. On average, sensitivity was 0.71 for central lesions and 0.49 for peripheral lesions.

Böcking et al2 have shown that the sensitivity of sputum cytology for detecting lung cancer is highly dependent on the number of sputum specimens collected per patient, ranging from approximately 0.68 for a single specimen, to 0.78 for two specimens, to 0.85 to 0.86 for three or more specimens.

Sputum Cytology and Associated Clinical Findings:

Another approach to association with a positive sputum diagnosis was described by predictive modeling in a large cohort of patients tested with sputum cytology.37 Patient characteristics associated with positive cytologic diagnosis using sputum were the following: bloody sputum; low FEV1 values; large lung tumors (ie, > 2.4 cm); centrally located tumors; and squamous cell cancers.

Difficulties in Summarizing the Evidence on Sputum Cytology:

Studies of the accuracy of sputum cytology for the diagnosis of lung cancer are difficult to summarize because of a variety of methodological problems. The studies show highly variable estimates of sensitivity and no clear reasons for the variation. There is evidence to suggest that the number of sputum samples and the specimen adequacy are strongly related to the sensitivity of the technique. We have insufficient detail about these features to determine whether these factors explain the heterogeneity of the test accuracy results.

Furthermore, between-study differences in the threshold for considering cytology “positive” with regard to the category of “suspicious,” and whether insufficient specimens were excluded or classified as negative, also may have a profound influence on calculated sensitivity. These details are likewise unavailable for most studies.

Key Question 2: What Are the Performance Characteristics (Sensitivity and Specificity) of Flexible Bronchoscopy and Its Ancillary Procedures (Biopsy, Cytobrushing, Washing, TBNA, and BAL) for the Diagnosis of Central (Endobronchial), as Opposed to Peripheral, Tumors and for Peripheral Lesions < 2 cm and > 2 cm in Diameter?

A comprehensive literature search on studies published since 1970 was performed to determine the sensitivity of flexible bronchoscopy for the diagnosis of bronchogenic carcinoma. Studies with < 50 patients and those that reported exclusively on interoperator performance variabilities or focused on technical aspects (eg, needle size or cytology preparation) were excluded. Forty-four studies met our inclusion criteria. Only six of these included both disease-positive and disease-negative patients, and provided data on test accuracy, positive predictive value, and negative predictive value. Most of the studies identified were limited to patients with pathologically confirmed bronchogenic carcinoma and provided data only on the diagnostic yield (test sensitivity). The data were analyzed further with respect to the diagnosis of central disease with an endobronchial component and peripheral disease beyond the segmental level.

Bronchoscopy Sensitivity for Central Disease (Endobronchial Disease):

Thirty studies of patients with central disease were identified (Table 4 ).4,2024,26,3860 Endobronchial biopsies provided the highest sensitivity (0.74; 20 studies), followed by brushings (0.59; 18 studies) and washings (0.48; 12 studies). The interpretation of the sensitivity for bronchoscopic needle aspirates (range, 0.23 to 0.90; average, 0.56; 8 studies) was limited to fewer studies with large differences in sample size and inconsistencies in technique (ie, endobronchial vs transbronchial biopsy). The overall sensitivity for all bronchoscopic modalities combined, where reported, was 0.88 for centrally located, endobronchial disease (14 studies).

Bronchoscopy Sensitivity for Peripheral Disease (Beyond the Segmental Bronchus):

Thirty studies reported on the sensitivity of flexible bronchoscopy beyond the visual segmental bronchi (Table 5 ).4,22,2526,38,45,4750,5253,5673 Brushings provided the highest sensitivity (0.52; 15 studies), followed by transbronchial biopsies (0.46; 18 studies) and BAL/washings (0.43; 13 studies). Although TBNA showed a high sensitivity (0.67; five studies), the data deserve cautious interpretation because of the limited number of studies and the large differences in sample size. The overall sensitivity for all modalities in the diagnosis of peripheral disease was 0.69 (12 studies).

Bronchoscopic Sensitivity for the Peripheral Lesions < 2 cm vs > 2 cm in Diameter:

Eight studies were identified that reported on the sensitivity of bronchoscopy (brush and/or biopsy) for peripheral lesions with a size < 2 cm or > 2 cm in diameter (Table 6 ).25,38,5658,7274 The sensitivity for peripheral lesions < 2 cm in diameter was 0.33. Peripheral tumors with a diameter > 2 cm resulted in a sensitivity of 0.62. Six studies2324,59,65,67,71 reported on the sensitivity of postbronchoscopy sputa as an adjunct to the previously mentioned bronchoscopic techniques, which was 0.35 (Table 7 ).

Key Question 3: What Are the Performance Characteristics (Sensitivity and Specificity) for TTNA as Diagnostic Modality, With Particular Emphasis on the Size and the Location of the Suspected Cancer?

A meta-analysis by Lacasse et al75 focused on the performance characteristics of TBNA or biopsy for the diagnosis of localized pulmonary lesions. The study encompassed a comprehensive search (up to 1995) of English-language reports on the use of needle aspiration or biopsy for the evaluation of solitary or multiple pulmonary lesions.

At least 90% of the study populations had to have parenchymal pulmonary lesions as opposed to mediastinal, hilar, or pleural lesions. All diagnoses were verified by surgical biopsy, biopsy of an adjacent site with tumor involvement, culture results, or clinical follow-up for at least 1 year. Cytology alone, even when confirmed by another site, was not accepted as a reference standard. At least 90% of patients in each study had a histologic reference standard diagnosis. Diagnostic accuracy data were abstracted in a 2 × 6 table and were analyzed according to predefined thresholds.

We updated the literature search and metaanalysis using the same inclusion criteria, except that we required each study to have a minimum of 50 subjects. In our reanalysis, we considered only the following cut point: definite malignancy or suspicion for malignancy as test-positive, and all other test results, including nondiagnostic, benign, nonspecific, and specific benign diagnoses, as test-negative (this corresponds to cut point “b” in the published meta-analysis).

We identified 19 studies that had not been included in the previously published meta-analysis. Seven studies7682 were published in 1996 or before and had been considered and excluded by Lacasse et al75 Twelve reports had not been considered by Lacasse et al,75 11 published since 1996,8393 and one published in 1995.94We excluded five studies9599 with < 50 subjects that were included in the published meta-analysis.

Performance Characteristics of TTNA:

We analyzed the additional 19 reports, compared our these results with those of the published meta-analysis, and reanalyzed all the studies74,7694,100139 with particular attention to lesion size, location, and imaging technology (Table 8 ). The pooled sensitivity was 0.90 (95% confidence interval [CI], 0.88 to 0.92). Individual study estimates ranged from 0.62 to 0.99 (Fig 1 ). The pooled estimate was not importantly different, regardless of whether it was based on the 19 additional studies that had not been reviewed by Lacasse et al,,75 which included > 50 subjects, or the combination of these two categories. There was little difference in specificity for any group of studies analyzed.

Performance Characteristics for TTNA by Lesion Size:

A total of seven studies described a lower boundary or gave results limited to large lesions; however, the boundary varied. Studies described the accuracy in lesions > 1.5 cm in diameter,76,139 > 2 cm in diameter,80,84,100,136 and > 3 cm in diameter.87 These studies range in date from 1967 to 2000 and used varied imaging technologies for the localization of lung nodules. A total of five studies reported results for small lesions, which were defined as < 1.5 cm in diameter,76,91 < 2 cm in diameter,84,100 and < 3 cm in diameter.92 Because of the great differences in date and technique, we believe that the most valid data come from two studies76,84 in which biopsy specimens from small and large lesions were obtained and that described results separately for each type of lesion. In another study of this type,100 the rate of inadequate specimens was > 10% and was significantly greater than the rate for large lesions. Furthermore, these patients were not subject to the reference standard; therefore, this study was not used for this analysis.100

In one of the included studies,84 the sensitivity was 0.95 (95% CI, 0.89 to 0.98) for lesions > 2 cm in diameter, and 0.91 (95% CI, 0.79 to 0.97) for lesions < 2 cm in diameter. In the other study,76 sensitivity was 0.94 (95% CI, 0.84 to 0.98) for lesions > 1.5 cm, and 0.78 (95% CI, 0.56 to 0.92) for lesions < 1.5 cm. In neither study was the difference between sensitivity in small and large lesions statistically significant. However, both studies, each of which used CT guidance, suggested a trend toward lower sensitivity.

Performance Characteristics for TTNA by Location of the Lesion:

Overall, only a few studies described the test performance data (sensitivity and specificity) according to location of lesion, so that we had limited data with which to address the question of differences in test performance based on lesion location. It is possible that some studies describing only the yield (sensitivity) would provide data by location of lesion.

Performance Characteristics for TTNA by Imaging Technique (CT Scan vs Fluoroscopy):

We compared the pooled sensitivity and specificity for studies using CT guidance vs those using fluoroscopy guidance in order to investigate the potential reasons for the between-study differences in accuracy. Most of the new studies used CT scanning to guide TTNA, and, although initially hypothesized, Lacasse et al75 did not find any differences in test operating characteristics between CT and fluoroscopic guidance of TTNA in their original meta-analysis. However, with substantially more data from CT-guided TTNA studies in our analysis, we found that studies using CT guidance showed higher sensitivity than those using fluoroscopy guidance. Using a random-effects model, the pooled sensitivities were 0.92 (95% CI, 0.90 to 0.94) and 0.88 (95% CI, 0.85 to 0.90) for studies of CT-guided and fluoroscopy-guided TTNA, respectively. Significant differences in sensitivity based on imaging technology may relate to the issue of lesion size. As CT scanning has been used to guide TTNA, the size of the nodules for which biopsy has been attempted has decreased, with the lower limit of the size of the lesion for some recently published studies as low as 0.5 cm. Pooled specificity was identical for the two technologies (0.97; 95% CI, 0.96 to 0.98).

Performance Characteristics by Needle Type (Aspiration, Aspiration Biopsy, or Cutting Needle):

Twenty studies used cutting-type needles that were designed to remove a tissue sample for histologic analysis, and in 12 studies this was the only sample on which the diagnosis was based (Table 8). The remaining studies used either fine-needle aspiration cytology exclusively (n = 19) or fine-needle aspiration with cytologic analysis of the aspirate and histologic analysis of the tissue aspirated (n = 21). In one study, the needle type was not described. Controlling for needle type did not decrease heterogeneity among studies in the meta-analysis by Lacasse et al,75 nor did sensitivity or specificity estimates vary by needle type in this analysis.

Two studies77,94 reported direct comparisons between aspiration cytology and cutting needle biopsy histologic diagnoses. Both studies found that transthoracic needle core biopsy compared with fine-needle aspirate showed similar sensitivity for malignancy (86% vs 92%, respectively77; and 98% vs 98.4%, respectively94) and better ability to determine a specific diagnosis for nonmalignant lesions (100% vs 44%, respectively77; and 100% vs 50%, respectively94).

Key Question 4: What Is the Diagnostic Error Rate When Differentiating Between Non-small Cell Lung Cancer and Small Cell Lung Cancer Generated by Various Diagnostic Techniques (Bronchoscopy and Sputum Cytology)?

We systematically reviewed the studies that we selected for reviews of the diagnostic accuracy of TTNA and bronchoscopy to find data on the differences in diagnosis between small cell and non-small cell lung cancer based on the cytologic vs histologic diagnoses. We also included studies describing series of patients with lung cancer, and correlating cytologic and histologic diagnoses that had been identified through previous reviews.12,4,140 We considered sputum cytology, TTNA cytology, bronchoscopic washings, BAL, and brushings.

We attempted to construct a 2 × 2 table correlating cytologic diagnosis of small cell lung cancer or non-small cell lung cancer with a histologic diagnosis based on the same categories. All histologic types of non-small cell lung cancer were considered to be the same. We limited consideration only to patients with lung cancer who had both a cytologic and histologic diagnosis.

Table 9 summarizes 21 studies,7,20,22,26,89,91,101,105,109,113,122,128,131,136,141147 some addressing several diagnostic modalities (TTNA, 14 studies; expectorated sputum, 5 studies; bronchoscopy brush sample, 2 studies; and bronchoscopy TBNA, 4 studies). These studies showed that the overall accuracy of diagnosing small cell lung cancer vs non-small cell lung cancer is 0.98, with individual studies ranging from 0.94 to 1.0. The proportion of small cell lung cancer ranged from 0.03 to 0.25 among these studies. When small cell lung cancer was diagnosed based on cytology, the true diagnosis was non-small cell lung cancer in about 9% of such cases (the false-positive test rate for cytologic diagnosis of small cell lung cancer, on average, was 0.09, with individual studies ranging from 0 to 0.33). When non-small cell lung cancer was diagnosed based on cytology, the true diagnosis was small cell lung cancer in about 2% of cases. (The false-negative test rate for diagnosing non-small cell lung cancer was 0.02, with individual studies ranging from 0 to 0.07.)

The available techniques for diagnosing lung cancer are well-supported in the medical literature. The majority of the data on flexible bronchoscopy for the diagnosis of suspected lung cancer defines only the diagnostic yield (sensitivity). The sensitivity for endobronchial disease is high, especially for biopsies and brushings. The sensitivity is lower for peripheral lesions, with cytobrushing showing the highest sensitivity, followed by transbronchial biopsies and BAL/washing. Flexible bronchoscopy has a poor sensitivity for peripheral lesions < 2 cm in diameter.

The sensitivity of TTNA is excellent, and our expanded analyses did not reveal significant differences from a recently published meta-analysis. There is a trend toward lower sensitivity for smaller lesions (ie, < 2 cm in diameter). Studies using CT guidance had a significantly higher sensitivity than those using fluoroscopy guidance.

Studies on the accuracy of sputum cytology for the diagnosis of lung cancer are difficult to summarize because of a variety of methodological problems, and suggest that the number of sputum samples and the specimen adequacy are strongly related to the sensitivity of the technique.

The distinction between small cell lung cancer and non-small cell lung cancer on the basis of cytology appears to be highly accurate, although a cytologic diagnosis of non-small cell lung cancer is more reliable than a cytologic diagnosis of small cell lung cancer, with average misclassification rates of 2% and 9%, respectively.

Important limitations of the literature include the fact that few studies describe the outcomes of evaluation in all patients who are suspected of having lung cancer. This problem is particularly apparent in studies of flexible bronchoscopy. Although false-positive diagnoses are rare, nondiagnostic results are not uncommon and lead to the use of other techniques or procedures for diagnosis.

Abbreviations: CI = confidence interval; TBNA = transbronchial needle aspiration; TTNA = transthoracic needle aspiration

This research was supported by a contract from the American College of Chest Physicians.

Table Graphic Jump Location
Table 1. Sensitivity and Specificity of Sputum Cytology for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 2. Sensitivity of Prebronchoscopy Sputum for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 3. Sensitivity of Sputum Cytology for Diagnosis of Bronchogenic Carcinoma by Location of Lesion (Central vs Peripheral)*
* 

Adapted from Table X in Sing et al, 1997.4

Table Graphic Jump Location
Table 4. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Central Bronchogenic Carcinoma*
* 

EBNA = endobronchial needle aspiration.

 

No. of patients represents the maximum number included in sensitivity calculations for any one method.

Table Graphic Jump Location
Table 5. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Peripheral Bronchogenic Carcinoma
* 

No. of patients represents the maximum number included in sensitivity calculations for any one method.

Table Graphic Jump Location
Table 6. Sensitivity of Flexible Bronchoscopic Diagnosis of Bronchogenic Carcinoma by Size of Lesion*
* 

Neg = negatives; Pos = positives; Sens = sensitivity.

Table Graphic Jump Location
Table 7. Sensitivity of Postbronchoscopy Sputum for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 8. Sensitivity and Specificity of Transthoracic Needle Aspiration and/or Biopsy for Diagnosis of Peripheral Bronchogenic Carcinoma*
* 

A = aspiration needle; B = aspiration biopsy needle; C = cutting biopsy needle; Fluo = fluoroscopy; NR = not reported; US = ultrasound.

 

False-positive rate is 1 minus the positive predictive value of the test. It is highly dependent on the prevalence of disease.

 

False-negative rate is defined here as 1 minus the negative predictive value of the test. It is highly dependent on the prevalence of disease.

Figure Jump LinkFigure 1. Summary receiver operating characteristic curve for studies of TTNA or biopsy for the diagnosis of peripheral bronchogenic carcinoma. Gray ovals indicate sensitivity and specificity estimates from individual studies. The black curve indicates the summary receiver operating characteristic curve. A black “X” indicates an estimate of sensitivity and specificity from separate meta-analyses of sensitivity and specificity using a random-effects model (upper) or a fixed-effects model (lower). Reprinted with permission by Sing et al.4Grahic Jump Location
Table Graphic Jump Location
Table 9. Accuracy of Cytology for Distinguishing Between Small Cell Lung Cancer and Non-small Cell Lung Cancer (Histology “Gold Standard”)
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Figures

Figure Jump LinkFigure 1. Summary receiver operating characteristic curve for studies of TTNA or biopsy for the diagnosis of peripheral bronchogenic carcinoma. Gray ovals indicate sensitivity and specificity estimates from individual studies. The black curve indicates the summary receiver operating characteristic curve. A black “X” indicates an estimate of sensitivity and specificity from separate meta-analyses of sensitivity and specificity using a random-effects model (upper) or a fixed-effects model (lower). Reprinted with permission by Sing et al.4Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Sensitivity and Specificity of Sputum Cytology for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 2. Sensitivity of Prebronchoscopy Sputum for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 3. Sensitivity of Sputum Cytology for Diagnosis of Bronchogenic Carcinoma by Location of Lesion (Central vs Peripheral)*
* 

Adapted from Table X in Sing et al, 1997.4

Table Graphic Jump Location
Table 4. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Central Bronchogenic Carcinoma*
* 

EBNA = endobronchial needle aspiration.

 

No. of patients represents the maximum number included in sensitivity calculations for any one method.

Table Graphic Jump Location
Table 5. Sensitivity of Flexible Bronchoscopic Diagnostic Procedures for Peripheral Bronchogenic Carcinoma
* 

No. of patients represents the maximum number included in sensitivity calculations for any one method.

Table Graphic Jump Location
Table 6. Sensitivity of Flexible Bronchoscopic Diagnosis of Bronchogenic Carcinoma by Size of Lesion*
* 

Neg = negatives; Pos = positives; Sens = sensitivity.

Table Graphic Jump Location
Table 7. Sensitivity of Postbronchoscopy Sputum for Diagnosis of Bronchogenic Carcinoma
Table Graphic Jump Location
Table 8. Sensitivity and Specificity of Transthoracic Needle Aspiration and/or Biopsy for Diagnosis of Peripheral Bronchogenic Carcinoma*
* 

A = aspiration needle; B = aspiration biopsy needle; C = cutting biopsy needle; Fluo = fluoroscopy; NR = not reported; US = ultrasound.

 

False-positive rate is 1 minus the positive predictive value of the test. It is highly dependent on the prevalence of disease.

 

False-negative rate is defined here as 1 minus the negative predictive value of the test. It is highly dependent on the prevalence of disease.

Table Graphic Jump Location
Table 9. Accuracy of Cytology for Distinguishing Between Small Cell Lung Cancer and Non-small Cell Lung Cancer (Histology “Gold Standard”)

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