Percutaneous needle biopsy of the mediastinum: review of 94 procedures

Percutaneous core needle biopsy in the diagnosis of mediastinal tumors

OBJECTIVE

to determine the contribution of percutaneous core cutting needle biopsy (PCNB) in the diagnosis of mediastinal tumors.

DESIGN

retrospective review of 70 patients with mediastinal lesions who underwent CT-guided PCNB between 1988 and 1996.

RESULTS

PCNB provided adequate material in 62/70 cases, giving a total sample rate of 88.6%. Of these 62 patients, 57 were diagnosed correctly by PCNB whereas 5/62 were misdiagnosed as nonspecific inflammation, providing an overall sensitivity of 91.9%. PCNB established a specific histologic diagnosis in 90.3% of the patients, mainly in cases of lymphoma, bronchogenic carcinoma, and thymoma. Pneumothorax was the most commonly encountered complication (11%). Hemoptysis (30-50 ml) occurred in only one (1.6%) of the patients.

CONCLUSION

CT guided PCNB is an easy and safe procedure which can provide a precise diagnosis in the majority of mediastinal tumors and can obviate the need for exploratory thoracic surgery in cases which are medically treatable or non-resectable.

A comparison of biopsy through a parasternal anterior mediastinotomy under local anesthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors

The various methods of treating the numerous types of anterior mediastinal neoplasms are undergoing refinements; however, prior to the commencement of any treatment, an accurate histologic diagnosis must be established. We conducted a retrospective analysis of biopsies performed through a parasternal anterior mediastinotomy (PAM) on 21 patients with an anterior mediastial mass suspected of being malignant by computed tomography (CT) and other clinical information. Patients with possible localized thymomas were excluded. Mediastinotomy, which enables relatively large tissue samples to be taken, was performed through the bed of the second or third costal cartilage under local anesthesia. In 19 of the 21 patients (90%), the histologic diagnosis made from the mediastinotomy biopsy was identical to the final diagnosis. Conversely, although the tissue obtained from needle biopsy was sufficient for a histologic diagnosis in 11 of 12 patients, the histologic diagnosis made from the needle biopsy was the same as the final diagnosis in only 5 of 10 patients (50%). Thus, diagnostic accuracy was significantly higher in the mediastinotomy biopsies than in the needle biopsies (P = 0.0318). Moreover, the mediastinotomy biopsy specimens revealed subtypes of lymphomas and germ cell tumors. All of the patients from whom a mediastinotomy biopsy had been taken began appropriate therapy without delay according to the histologic diagnosis. These results suggest that the PAM approach should be chosen as the preferred method of biopsy for suspected malignant anterior mediastinal tumors.

Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients

BACKGROUND

The authors attempted to determine the utility of percutaneous core needle biopsy (PCNB) compared with fine-needle aspiration (FNA) in the diagnosis of peripheral lung carcinoma.

METHODS

A retrospective review was undertaken of 156 computed tomography (CT)-guided PCNBs and FNAs of malignant lung lesions between 1988-1996. Both CT-guided FNA and PCNB biopsies were performed sequentially at the same visit for each subject.

RESULTS

The authors reviewed 156 malignant lesions whose specific diagnosis was obtained by FNA in 133 cases (85.3%) and by PCNB in 121 cases (77.6%) (P < 0.05). PCNB confirmed the FNA diagnosis in 90 patients (57.7%), provided additional information in 17 patients (10.9%), and was less informative than FNA in 35 patients (22.4%), mostly those with nonsmall cell carcinoma. The PCNB was marginally superior to FNA only in cases of metastatic carcinoma. The only significant complication encountered was a 24% rate of pneumothorax, which is comparable to the reported rate for FNA alone-induced complications.

CONCLUSIONS

PCNB offers no substantial advantage over FNA in the evaluation of peripheral malignant lung lesions. Therefore, the authors recommend the use of FNA biopsy as the initial diagnostic procedure in all cases of suspected malignancy. The use of the PCNB technique is recommended when the diagnosis of malignancy by FNA is uncertain, or when a more detailed characterization of the lesion is required.

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions

OBJECTIVE

To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions.

DESIGN

A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients.

RESULTS

A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization.

CONCLUSION

PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.

Transthoracic needle biopsy for suspected thoracic malignancy in elderly patients using CT guidance

There are few reports of transthoracic needle biopsy (TNB) in elderly (>70 years) patients although there is some evidence that age may be a risk factor in developing pneumothorax. We report our experience of 38 patients, age range 70-90 years, who underwent computed tomography (CT)-guided TNB for suspected malignancy of the chest, with particular reference to sensitivity and complication rate following the procedure. The biopsy was obtained using either a spinal needle or, if appropriate, a core of tissue was obtained using a cutting needle. The biopsy showed evidence of malignancy in 27 patients. Pneumothorax occurred in 10 of 40 biopsies. Two patients with pneumothorax required pleural drains; one was discharged the following day and the other required drainage for 3 days. Haemoptysis was not a problem but occurred as a transient postbiopsy event in three patients. In 26 of 40 (65%) episodes the patients were sent home within 24 h of the diagnostic procedure. It is thus quite possible to undertake the procedure on a day case basis. CT-guided TNB is a safe and reliable procedure in elderly patients with suspected chest malignancy and is well tolerated.

Spindle-cell lesions of the mediastinum: diagnosis by fine-needle aspiration biopsy

Spindle cells seen in fine-needle aspiration biopsy (FNAB) of the mediastinal lesions can be a component of a wide variety of benign and malignant conditions. Few of these conditions, however, are described in the FNA cytopathology literature. This review discusses the cytopathologic features, differential diagnoses, and potential pitfalls of a variety of lesions with a significant component of spindle cells encountered in mediastinal FNAB. The cytopathology files from four institutions were searched for cases of mediastinal FNAB containing a spindle-cell component that was a key or predominant cytologic feature of the diagnostic specimen. The cytomorphologic features of these cases were analyzed, and their differential features are discussed. Of 196 mediastinal FNABs, 22 (11%) were lesions with significant spindle-cell component: granulomatous inflammation (four); benign nerve sheath tumor (four); thymic cyst (two); spindle-cell thymoma (two); large-cell non-Hodgkin's lymphoma with sclerosis (two); nodular sclerosing Hodgkin's disease (two); liposarcoma (two); spindle-cell squamous carcinoma possibly arising in a teratoma (one); unspecified high-grade sarcoma (one); spindle-cell malignant melanoma (one); and nonspecific fibrous tissue (one). The cytologic features of each lesion were analyzed as an aid for accurate classification. These findings were correlated with radiologic and clinical information when available. The value of ancillary studies performed on aspirated material in selected cases was also reviewed. FNA of mediastinal lesions with significant spindle-cell morphology represents an infrequent and heterogeneous group of entities that may pose significant diagnostic challenges. This review presents the salient cytopathologic features of various spindle-cell lesions of the mediastinum with particular emphasis on differential diagnosis and pitfalls. The pathologist must use caution when interpreting these lesions and ancillary studies may be of significant value in selected cases.

Mediastinal needle biopsy. A 15-year experience with 139 cases

BACKGROUND

Radiologically guided needle biopsy and cytologic evaluation provide a reliable method of diagnosis for planning definitive therapy of patients with mediastinal lesions.

MATERIALS AND METHODS

In this retrospective study of one of the largest series from a single institution, 141 consecutive mediastinal needle biopsies from 139 patients were reviewed during a 15-year period.

RESULTS

Adequate material was obtained with a diagnosis achieved in 128 cases (92%). Of these, 33 cases (26%) had benign diagnoses; the remaining 95 (74%) had malignant diagnoses, including 81 carcinomas, 3 sarcomas, 8 lymphoproliferative lesions, 2 malignant germ cell tumors, and 1 malignant thymoma. All benign cases were diagnostically confirmed, and 94 of 95 malignant cases were classified correctly. The only discrepancy that occurred involved a malignant lymphoma diagnosed as a malignant germ cell tumor. Of the 13 inadequate samples, the major category included a nodular sclerosis variant of Hodgkin's disease (4 cases), 1 case of thymoma, 1 case of tuberculous lymphadenitis, and 7 cases for which no follow-up data were available.

CONCLUSION

Needle biopsy is reaffirmed as a reliable and sensitive diagnostic tool for mediastinal lesions, with an overall cytologic diagnostic accuracy of 99% with adequate material. Sclerotic lesions may pose a limitation to this technique and require generous sampling before a more invasive diagnostic procedure is undertaken.