Chest · 2026
Thoracentesis with pleural fluid cytology versus thoracoscopy with pleural biopsy for the diagnosis of malignant pleural effusion: a cost-effectiveness study.
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Bridwell Greta J, Xiao David, Grosu Horiana B, Chaddha Udit, Agrawal Abhinav, Gesthalter Yaron B, Godfrey Caroline M, Leonard Kaele, Ratwani Ankush P, Paez Rafael, Duke Jennifer D, Pichiarello Christina, Kammer Michael N, Ost David, Grogan Eric L, Lentz Robert J, Maldonado Fabien, Shojaee Samira
Аннотация
BACKGROUND: Thoracentesis with pleural fluid (PF) cytology has a sensitivity of ∼60% to diagnose malignant pleural effusion (MPE). Medical thoracoscopy with pleural biopsy has a higher diagnostic sensitivity. This study evaluates the cost-effectiveness of thoracentesis versus thoracoscopy for diagnosis of MPE in patients with prior or active malignancy.
RESEARCH QUESTION: When is thoracentesis or thoracoscopy cost-effective for the diagnosis of malignant pleural effusion in patients with prior or active malignancy?
STUDY DESIGN AND METHODS: A cost-effectiveness model was developed comparing thoracentesis with PF-cytology to medical thoracoscopy with pleural biopsy for the diagnosis of MPE in two scenarios: 1) initial evaluation of unilateral pleural effusion in patients with prior or active malignancy, 2) evaluation of a recurrent effusion following a cytology-negative thoracentesis. The primary outcome was cost per complication avoided with willingness-to-pay threshold of $10,000. One-way deterministic sensitivity analyses were conducted on all parameters. Model assumptions were established by consensus among a multicenter panel of pleural disease experts.
RESULTS: In unilateral pleural effusion and prior or active malignancy, a thoracoscopy-first diagnostic strategy resulted in 0.0311 fewer complications and cost an additional $1,890 compared to a thoracentesis-first strategy. Thoracoscopy-first strategy was more cost-effective when PF-cytology sensitivity was ≤27%. In recurrent effusion following a cytology-negative thoracentesis in patients with prior or active malignancy, a thoracoscopy-next strategy resulted in 0.0278 fewer complications and cost an additional $19 compared to the thoracentesis-next strategy. Thoracoscopy-next strategy was more cost-effective unless the second-thoracentesis PF-cytology sensitivity was above 29%.
INTERPRETATION: In patients with prior or active malignancy, thoracentesis is a more cost-effective initial diagnostic strategy for malignant pleural effusion in cancers that have a PF-cytology diagnostic sensitivity of >27%. In recurrent effusion following a cytology-negative thoracentesis, thoracoscopy with pleural biopsy is more cost-effective than a second thoracentesis.
RESEARCH QUESTION: When is thoracentesis or thoracoscopy cost-effective for the diagnosis of malignant pleural effusion in patients with prior or active malignancy?
STUDY DESIGN AND METHODS: A cost-effectiveness model was developed comparing thoracentesis with PF-cytology to medical thoracoscopy with pleural biopsy for the diagnosis of MPE in two scenarios: 1) initial evaluation of unilateral pleural effusion in patients with prior or active malignancy, 2) evaluation of a recurrent effusion following a cytology-negative thoracentesis. The primary outcome was cost per complication avoided with willingness-to-pay threshold of $10,000. One-way deterministic sensitivity analyses were conducted on all parameters. Model assumptions were established by consensus among a multicenter panel of pleural disease experts.
RESULTS: In unilateral pleural effusion and prior or active malignancy, a thoracoscopy-first diagnostic strategy resulted in 0.0311 fewer complications and cost an additional $1,890 compared to a thoracentesis-first strategy. Thoracoscopy-first strategy was more cost-effective when PF-cytology sensitivity was ≤27%. In recurrent effusion following a cytology-negative thoracentesis in patients with prior or active malignancy, a thoracoscopy-next strategy resulted in 0.0278 fewer complications and cost an additional $19 compared to the thoracentesis-next strategy. Thoracoscopy-next strategy was more cost-effective unless the second-thoracentesis PF-cytology sensitivity was above 29%.
INTERPRETATION: In patients with prior or active malignancy, thoracentesis is a more cost-effective initial diagnostic strategy for malignant pleural effusion in cancers that have a PF-cytology diagnostic sensitivity of >27%. In recurrent effusion following a cytology-negative thoracentesis, thoracoscopy with pleural biopsy is more cost-effective than a second thoracentesis.