Computed tomography of the chest in unilateral pleural effusions: Outcome of the british thoracic society guideline

Simon Reuter*, Dennis Lindgaard, Christian Laursen, Barbara Malene Fischer, Paul Frost Clementsen, Uffe Bodtger

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review

Abstract

Background: The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines’ recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods: The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013–2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light’s criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results: In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light’s criteria not assessed: n=111; 67%). 18 F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. Conclusions: Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.

Original languageEnglish
JournalJournal of Thoracic Disease
Volume11
Issue number4
Pages (from-to)1336-1346
ISSN2072-1439
DOIs
Publication statusPublished - 1. Apr 2019

Fingerprint

Pleural Effusion
Guidelines
Exudates and Transudates
Delayed Diagnosis

Keywords

  • Radiography
  • Thoracentesis
  • Thoracic
  • Tomography
  • X-ray computed and sensitivity and specificity

Cite this

Reuter, Simon ; Lindgaard, Dennis ; Laursen, Christian ; Fischer, Barbara Malene ; Clementsen, Paul Frost ; Bodtger, Uffe. / Computed tomography of the chest in unilateral pleural effusions : Outcome of the british thoracic society guideline. In: Journal of Thoracic Disease. 2019 ; Vol. 11, No. 4. pp. 1336-1346.
@article{9749917d7c1f4a959e1616dcf16ac8ef,
title = "Computed tomography of the chest in unilateral pleural effusions: Outcome of the british thoracic society guideline",
abstract = "Background: The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines’ recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods: The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013–2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light’s criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results: In total, 323 of the 465 included patients underwent CT (69{\%}). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54{\%}; Light’s criteria not assessed: n=111; 67{\%}). 18 F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58{\%}). The sensitivity of a non-guideline supported CT (70{\%}) was significantly higher compared to a guideline supported CT (47{\%}), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25{\%} to 52{\%}. A negative CT (LR negative 0.62) decreased the probability to 17{\%}. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53{\%} and (LR negative 0.38) 11{\%}, respectively. Conclusions: Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.",
keywords = "Radiography, Thoracentesis, Thoracic, Tomography, X-ray computed and sensitivity and specificity",
author = "Simon Reuter and Dennis Lindgaard and Christian Laursen and Fischer, {Barbara Malene} and Clementsen, {Paul Frost} and Uffe Bodtger",
year = "2019",
month = "4",
day = "1",
doi = "10.21037/jtd.2019.03.75",
language = "English",
volume = "11",
pages = "1336--1346",
journal = "Journal of Thoracic Disease",
issn = "2072-1439",
publisher = "Pioneer Bioscience Publishing Company",
number = "4",

}

Computed tomography of the chest in unilateral pleural effusions : Outcome of the british thoracic society guideline. / Reuter, Simon; Lindgaard, Dennis; Laursen, Christian; Fischer, Barbara Malene; Clementsen, Paul Frost; Bodtger, Uffe.

In: Journal of Thoracic Disease, Vol. 11, No. 4, 01.04.2019, p. 1336-1346.

Research output: Contribution to journalJournal articleResearchpeer-review

TY - JOUR

T1 - Computed tomography of the chest in unilateral pleural effusions

T2 - Outcome of the british thoracic society guideline

AU - Reuter, Simon

AU - Lindgaard, Dennis

AU - Laursen, Christian

AU - Fischer, Barbara Malene

AU - Clementsen, Paul Frost

AU - Bodtger, Uffe

PY - 2019/4/1

Y1 - 2019/4/1

N2 - Background: The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines’ recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods: The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013–2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light’s criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results: In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light’s criteria not assessed: n=111; 67%). 18 F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. Conclusions: Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.

AB - Background: The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines’ recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation. Methods: The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013–2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light’s criteria, if applicable. We registered use of CT, and calculated diagnostic values. Results: In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light’s criteria not assessed: n=111; 67%). 18 F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively. Conclusions: Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.

KW - Radiography

KW - Thoracentesis

KW - Thoracic

KW - Tomography

KW - X-ray computed and sensitivity and specificity

U2 - 10.21037/jtd.2019.03.75

DO - 10.21037/jtd.2019.03.75

M3 - Journal article

C2 - 31179075

AN - SCOPUS:85065390560

VL - 11

SP - 1336

EP - 1346

JO - Journal of Thoracic Disease

JF - Journal of Thoracic Disease

SN - 2072-1439

IS - 4

ER -