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Peer-reviewedCC BY-NC-NDTranslational cancer research

Cancer ratio plus and malignant pleural effusion: a systematic review and meta-analysis of diagnostic test accuracy study.

  • Wen-Jie Hou1,2,3
  • Xu-Lei Hao1,2,3
  • Yue Gao2,3
  • Rui Niu2,3
  • Qiu-Fen Tian2,3
  • Ran-Tong Bao1
  • Lu Tong1
  • Ya-Ning Shi1
  • Ya-Nan Xu1
  • Li Yan2,4
  • Wen-Qi Zheng2,3
  • Zhi-De Hu1,2,3
1 more authors
  • Mei-Ying Wang2,3
4 affiliations
  1. 1Center for Clinical Epidemiology Research, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.
  2. 2Department of Laboratory Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.
  3. 3Key Laboratory for Biomarkers, Inner Mongolia Medical University, Hohhot, China.
  4. 4Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China.
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Abstract

The current reference standards for diagnosing malignant pleural effusion (MPE) are effusion cytology and pleural biopsy, which have limitations in invasiveness and subjectivity. Effusion or serum chemistries offer minimal invasiveness, low cost, and objectivity. They are therefore usually used to support the diagnosis of MPE in patients with undiagnosed pleural effusion. Multiple studies have shown that the cancer ratio (CR) plus has diagnostic value for MPE, but findings have varied. This study aimed to ascertain the diagnostic accuracy of CR plus for MPE using meta-analysis. We searched the PubMed and Web of Science databases through May 2026 to identify diagnostic studies that used CR plus to diagnose MPE in undiagnosed pleural effusion and reported sensitivity, specificity, and sample sizes. The study design and reference standard for MPE were not restricted. We used the revised Quality Assessment of Diagnostic Accuracy Studies-Version 2 (QUADAS-2) tool for quality assessment. We used a bivariate random-effects model to pool sensitivity and specificity. A summary receiver operating characteristic (sROC) curve was constructed. We also used likelihood ratios, diagnostic odds ratio (DOR), heterogeneity (I2), and a Fagan plot to depict the diagnostic accuracy of CR plus for MPE. Deeks' test was used to evaluate publication bias. A total of seven studies (eight cohorts) comprising 1,171 participants (507 with MPEs and 601 with benign pleural effusions) were included. The area under the sROC curve of CR plus for diagnosing MPE ranged from 0.58 to 0.98 across eligible studies. The pooled sensitivity was 0.87 [95% confidence interval (CI): 0.80-0.92], and the pooled specificity was 0.78 (95% CI: 0.60-0.90). CR plus had a pooled positive likelihood ratio of 4.0 (95% CI: 1.9-8.4), a negative likelihood ratio of 0.16 (95% CI: 0.09-0.30), and a DOR of 24 (95% CI: 7-86). The area under the curve of the sROC curve was 0.90 (95% CI: 0.88-0.93). Deeks' test revealed no significant publication bias (P=0.11). Subgroup analysis and meta-regression were not performed due to the limited number of included studies. According to the QUADAS-2 assessment, the main methodological weaknesses of the included studies lay in patient selection, index test conduct, and index test interpretation. CR plus can help pulmonologists to estimate the probability of MPE. It cannot be used alone to confirm or rule out MPE. Its diagnostic value should be interpreted with clinical context.

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Cite

BibTeXRIS
BibTeX
@article{hou2026cancer,
  title = {{Cancer ratio plus and malignant pleural effusion: a systematic review and meta-analysis of diagnostic test accuracy study.}},
  author = {Wen-Jie Hou and Xu-Lei Hao and Yue Gao and Rui Niu and Qiu-Fen Tian and Ran-Tong Bao and Lu Tong and Ya-Ning Shi and Ya-Nan Xu and Li Yan and Wen-Qi Zheng and Zhi-De Hu and Mei-Ying Wang},
  journal = {Translational cancer research},
  year = {2026},
  month = oct,
  doi = {10.21037/tcr-2026-1587},
  url = {https://europepmc.org/article/MED/42997697},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Cancer ratio plus and malignant pleural effusion: a systematic review and meta-analysis of diagnostic test accuracy study.
AU  - Wen-Jie Hou
AU  - Xu-Lei Hao
AU  - Yue Gao
AU  - Rui Niu
AU  - Qiu-Fen Tian
AU  - Ran-Tong Bao
AU  - Lu Tong
AU  - Ya-Ning Shi
AU  - Ya-Nan Xu
AU  - Li Yan
AU  - Wen-Qi Zheng
AU  - Zhi-De Hu
AU  - Mei-Ying Wang
PY  - 2026
DA  - 2026/10/26
JO  - Translational cancer research
DO  - 10.21037/tcr-2026-1587
UR  - https://europepmc.org/article/MED/42997697
AB  - The current reference standards for diagnosing malignant pleural effusion (MPE) are effusion cytology and pleural biopsy, which have limitations in invasiveness and subjectivity. Effusion or serum chemistries offer minimal invasiveness, low cost, and objectivity. They are therefore usually used to support the diagnosis of MPE in patients with undiagnosed pleural effusion. Multiple studies have shown that the cancer ratio (CR) plus has diagnostic value for MPE, but findings have varied. This study aimed to ascertain the diagnostic accuracy of CR plus for MPE using meta-analysis. We searched the PubMed and Web of Science databases through May 2026 to identify diagnostic studies that used CR plus to diagnose MPE in undiagnosed pleural effusion and reported sensitivity, specificity, and sample sizes. The study design and reference standard for MPE were not restricted. We used the revised Quality Assessment of Diagnostic Accuracy Studies-Version 2 (QUADAS-2) tool for quality assessment. We used a bivariate random-effects model to pool sensitivity and specificity. A summary receiver operating characteristic (sROC) curve was constructed. We also used likelihood ratios, diagnostic odds ratio (DOR), heterogeneity (I2), and a Fagan plot to depict the diagnostic accuracy of CR plus for MPE. Deeks' test was used to evaluate publication bias. A total of seven studies (eight cohorts) comprising 1,171 participants (507 with MPEs and 601 with benign pleural effusions) were included. The area under the sROC curve of CR plus for diagnosing MPE ranged from 0.58 to 0.98 across eligible studies. The pooled sensitivity was 0.87 [95% confidence interval (CI): 0.80-0.92], and the pooled specificity was 0.78 (95% CI: 0.60-0.90). CR plus had a pooled positive likelihood ratio of 4.0 (95% CI: 1.9-8.4), a negative likelihood ratio of 0.16 (95% CI: 0.09-0.30), and a DOR of 24 (95% CI: 7-86). The area under the curve of the sROC curve was 0.90 (95% CI: 0.88-0.93). Deeks' test revealed no significant publication bias (P=0.11). Subgroup analysis and meta-regression were not performed due to the limited number of included studies. According to the QUADAS-2 assessment, the main methodological weaknesses of the included studies lay in patient selection, index test conduct, and index test interpretation. CR plus can help pulmonologists to estimate the probability of MPE. It cannot be used alone to confirm or rule out MPE. Its diagnostic value should be interpreted with clinical context.
SN  - 2218-676X
SN  - 2219-6803
ER  -