Percutaneous transthoracic needle aspiration biopsy: a comprehensive review of its current role in the diagnosis and treatment of lung tumors

Diagnostic performance of percutaneous core needle lung biopsy under multi-CT fluoroscopic guidance for ground-glass opacity pulmonary lesions

OBJECTIVE

The diagnostic performance of percutaneous core needle lung biopsy under multi-CT fluoroscopic guidance for ground-glass opacity (GGO) pulmonary lesions was evaluated.

MATERIALS AND METHODS

Out of 90 patients who underwent CT fluoroscopy-guided core needle biopsy of GGO lesions at our institution, the biopsy results and the final diagnoses were retrospectively compared in 67 patients with available data (one lesion per patient). Diagnostic performance was also compared according to the lesion size (≤ 10 mm (n=8) versus 11-20mm (n=42) versus >20mm (n=17)), the percentage of GGO component (50-90% (n=31) versus >90% (n=36)), and the length of needle path (≤ 7 cm (n=45) versus > 7 cm (n=22)). Finally, all 90 cases were reviewed for complications.

RESULTS

The overall sensitivity, specificity, and accuracy were 97%, 100%, and 97%, respectively. The diagnostic sensitivity and accuracy tended to be lower in smaller lesions (≤ 10 mm; 86 and 88%, 11-20mm; 97 and 98%, >20mm; 100 and 100%, respectively, p>0.05), and in lesions with lower percentage of GGO component (50-90%; 93 and 94%, >90%; 100 and 100%, respectively, p=0.21), but statistical significances were not reached. The sensitivity and accuracy were not significantly affected by the length of needle path (≤ 7 cm; 98 and 98%, > 7 cm; 95 and 96%, respectively, p=1.00). Fourteen patients (16%) developed pneumothoraces, and 13 patients (14%) experienced mild hemoptysis, all of which resolved conservatively.

CONCLUSION

The diagnostic performance was satisfactory, and it was considered that the procedure was appropriate for GGO lesions regardless of lesion size, the percentage of GGO component, or the length of needle path. The procedure was also feasible without any major complications.

C-arm cone-beam CT-guided percutaneous transthoracic lung biopsy: usefulness in evaluation of small pulmonary nodules

OBJECTIVE

The purpose of this study was to evaluate the usefulness of C-arm conebeam CT-guided percutaneous transthoracic lung biopsy of small (≤ 2 cm) lung nodules.

MATERIALS AND METHODS

Twenty-seven patients who underwent C-arm cone-beam CT-guided percutaneous transthoracic lung biopsy of small (≤ 2 cm) lung nodules were enrolled in the study. The mean nodule size was 13 ± 4 mm in diameter. These lesions were divided into two groups according to size: 10 lesions 1 cm or smaller and 17 lesions larger than 1 cm. The diagnostic accuracy, sensitivity, and specificity in the two groups were compared by use of Fisher's exact test. Radiation dose in a female humanoid phantom was measured with radiophotoluminescent glass dosimeters. The average patient dose was calculated.

RESULTS

Eighteen malignant (67%) and eight benign (30%) nodules and one (3%) indeterminate nodule were found. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 94%, 89%, 94%, 89%, and 92%. The sensitivity, specificity, and accuracy were 100%, 75%, and 90% for the lesions 1 cm or smaller and 91%, 100%, and 94% for the lesions larger than 1 cm. The accuracy, sensitivity, and specificity did not differ significantly between the groups (all p > 0.05, Fisher's exact test). The average radiation dose among 27 patients was 4.6 mSv (range, 2.19-9.37).

CONCLUSION

C-arm cone-beam CT-guided percutaneous transthoracic lung biopsy is a useful diagnostic technique in the evaluation of small lung nodules.

Computed tomography-guided fine needle aspiration cytology of solitary pulmonary nodules suspected to be bronchogenic carcinoma: Experience of a general hospital

BACKGROUND

Fine needle aspiration cytology (FNAC) may be diagnostic in candidates with indeterminate solitary pulmonary nodules (SPNs) suspicious of bronchogenic carcinoma.

AIMS

The study was performed to evaluate the usefulness of computed tomography (CT)-guided FNAC in our centre.

MATERIALS AND METHODS

All the cases had a strong clinical suspicion of lung cancer, negative bronchoscopy, negative sputum cytology for malignant cells and acid fast bacilli. A thorough radiological evaluation was made to rule out primary malignancy elsewhere.

RESULTS

A total of 94 patients were studied in one year. May-Grünwald-Giemsa stain was used for the smears. The cytological diagnosis was correlated with clinical-radiological follow-up and biopsy to arrive at a final diagnosis. The procedure had a high sensitivity and specificity. Chi-square test was used to calculate statistical significance. Tumor of more than three centimeter and immediate cytological assessment significantly increased the yield. Review of slides added two cases of malignancy that were missed initially. There were very few complications.

CONCLUSIONS

CT-guided FNAC was an accurate and safe procedure for SPNs.

[Ultrasound in chest disease]

In the past few years transthoracic ultrasound has been recognized as an important tool for chest physicians. At present, ultrasound devices are practical, portable, easy to use and reliable, which makes them suited for diagnostic investigations as well as for therapeutic procedures guidance. Basic ultrasound technical expertise is required to assess pleural effusions and perform ultrasound -guided thoracentesis. More complex procedures can be done with specific training and include assistance to chest drain insertion and identification with potential biopsy of thoracic lesions. The authors aim to review, in a practical approach, the technique and recent developments in this field. Clinical cases are presented in order to illustrate and guide the beginner in chest ultrasound.

Number of biopsies in diagnosing pulmonary nodules

Purpose:

To determine the number of specimens to be obtained from pulmonary lesions to get the highest possible accuracy in histological work-up.

Materials and methods:

A retrospective evaluation (January 1999 to April 2004) covered 260 patients with thoracic lesions who underwent computer tomography (CT)-guided core-cut biopsy in coaxial technique. All biopsies were performed utilizing a 19 gauge introducer needle and a 20 gauge core-cut biopsy needle. In all, 669 usable biopsies were taken (from 1–5 biopsies in each setting). The specimens were marked sequentially and each biopsy was worked up histologicaly. The biopsy results were correlated to histology after surgery, clinical follow-up or autopsy. The number of biopsies was determined that is necessary to achieve the highest possible accuracy in diagnosing pulmonary lesions.

Results:

In 591 of 669 biopsies (88.3%), there were correct positive results. The overall accuracy was 87.4%. In 193 of 260 (74.2%) patients, a suspected malignancy was confirmed. In 50 of 260 (19.2%) patients, a benign lesion was correctly diagnosed. Seventeen (6.5%) patients were lost to follow-up. The first, second and third biopsies had cumulative accuracies of 63.6%, 89.2% and 91.5%, respectively (P < 0.02). More biopsies did not show any higher impact on accuracy.

Conclusion:

For the highest possible accuracy in diagnosing pulmonary lesions by CT-guided core-cut biopsy, at least three usable specimens are recommended to be taken.

Clinical significance of non-diagnostic pathology results from percutaneous transthoracic needle lung biopsy: experience of a tertiary hospital without an on-site cytopathologist

BACKGROUND AND OBJECTIVE

More non-diagnostic pathology results may be reported following transthoracic needle lung biopsy (TTNB) when no on-site cytopathologist is available. This study was conducted to analyse the final outcomes in patients with non-diagnostic pathology results, and the factors related to the adequacy of specimens.

METHODS

The medical records of consecutive patients who had undergone TTNB from January 2004 to January 2005 were retrospectively analysed. Non-diagnostic pathology results were classified into three groups: (i) atypical cells, (ii) non-specific inflammation and (iii) inadequate specimen. The final diagnosis and clinical outcome for each patient were analysed after additional diagnostic studies and clinical follow up.

RESULTS

TTNB was performed on 291 patients. Specimens were adequate in 256 cases. The results were non-diagnostic for 103 patients, and the percentages of atypical cells, non-specific inflammation and inadequate specimen were 15.5% (16/103), 50.5% (52/103) and 40% (35/103), respectively. In 14 patients (87.5%) the diagnosis of atypical cells was confirmed, and in 10 (62.5%) these were due to malignancies. In two patients (3.8%) the lesions reported as non-specific inflammation were eventually confirmed as malignancies. After repeated attempts to confirm their diagnoses, 22 patients (62.9%) with initial reports of inadequate specimen were diagnosed with specific diseases. Specimen adequacy correlated with technical skill, size of the lesion, guidance method and biopsy method.

CONCLUSIONS

Non-diagnostic pathology results from TTNB, in the absence of an on-site cytopathologist, are of value in assessing the clinical probability of malignancy and can be useful in the management of lung lesions. However, many other factors should be considered in patients with inadequate specimens.

Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of CT fluoroscopy-guided percutaneous needle aspiration biopsy of ground-glass opacity (GGO) pulmonary lesions.

MATERIALS AND METHODS

Twenty-eight patients with GGO lesions who underwent CT fluoroscopy-guided needle aspiration biopsy were enrolled in this study. GGO lesions were divided into three groups according to their size: group 1, lesions < or = 10 mm (n = 10); group 2, lesions 11-20 mm (n = 10); and group 3, lesions > 20 mm (n = 8). Sensitivity, specificity, and diagnostic accuracy were calculated on the basis of 28 needle aspiration biopsy results and were compared among the three groups using Fisher's exact test. Diagnostic accuracy was also compared according to length of needle path (< 5 cm vs 5-9 cm vs > 9 cm) and GGO component (50-90% vs > 90%). Each case was reviewed for complications, which included pneumothorax, thoracostomy tube insertion, and hemoptysis.

RESULTS

There were 17 (61%) malignant and 11 (39%) benign lesions. Three (10%) biopsy results were nondiagnostic, all of which were confirmed as benign. The sensitivity, specificity, and accuracy of CT fluoroscopy-guided needle aspiration biopsy for diagnosing GGO were 67%, 100%, and 80% in group 1; 71%, 100%, and 80% in group 2; and 75%, 100%, and 88% in group 3. The diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy for diagnosing GGO was not significantly different among the three groups (p > 0.05). The diagnostic accuracy was not significantly different according to the length of the needle path (p > 0.05). However, diagnostic accuracy was significantly more accurate in mixed GGO lesions than in pure GGO lesions (p = 0.046). Five patients (18%) developed a pneumothorax, two of whom (7%) required placement of a thoracostomy tube. Mild hemoptysis occurred in three patients (11%).

CONCLUSION

CT fluoroscopy-guided needle aspiration biopsy is a useful diagnostic technique for GGO pulmonary lesions and has an acceptable complication rate, even for small and deeply located lesions. The diagnostic accuracy is influenced by the GGO component.

Variables affecting the risk of pneumothorax and intrapulmonal hemorrhage in CT-guided transthoracic biopsy

The influence of various variables on the rate of pneumothorax and intrapulmonal hemorrhage associated with computed tomography (CT)-guided transthoracic needle biopsy of the lung were evaluated retrospectively. One hundred and thirty-three patients underwent CT guided biopsy of a pulmonary lesion. Two patients were biopsied twice. Variables analyzed were lesion size, lesion location, number of pleural needle passes, lesion margin, length of intrapulmonal biopsy path and puncture time. Eighteen-gauge (18G) cutting needles (Trucut, Somatex, Teltow, Germany) were used for biopsy. Pneumothorax occurred in 23 of 135 biopsies (17%). Chest tube placement was required in three out of 23 cases of pneumothorax (2% of all biopsies). Pneumothorax rate was significantly higher when the lesions were located in the lung parenchyma compared with locations at the pleura or chest wall (P < 0.05), but all pneumothorax cases which required chest tube treatment occurred in lesions located less than 2 cm from the pleura. Longer puncture time led to an increase in pneumothorax rate (P < 0.05). Thirty-seven (27%) out of 135 biopsies showed perifocal hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage and pneumothorax (P < 0.05). Significantly more hemorrhage occurred when the pleura was penetrated twice during the puncture (P < 0.05). Lesion size <4 cm is strongly correlated with higher occurrence of perifocal hemorrhage (P < 0.05). Lesion margination showed no significant effect on complication rate. CT-guided biopsy of smaller lesions correlates with a higher bleeding rate. Puncture time should be minimized to reduce pneumothorax rate. Passing the pleura twice significantly increases the risk of hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage as well as pneumothorax.

Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases

Although numerous studies have been conducted on the use of ultrasonography (US) for the examination of thoracic structures, this procedure is not as widely accepted as abdominal US. The newer portable scanners can be used at the bedside to detect pleural malignancies and effusions, as well as peripheral lung nodules of the lung, even in seriously ill patients. Focal thickening of the pleura can be easily detected with US and further investigated with a US-guided biopsy. US guidance can also be used during percutaneous drainage of pleural effusion or transthoracic biopsy of peripheral lung lesions, thus reducing the incidence of procedure-related pneumothorax to almost zero. We review the current literature on thoracic US and present our clinical experience with the technique in large groups of patients with pleural and peripheral lung diseases.

Diagnostic accuracy of CT-guided core biopsy of ground-glass opacity pulmonary lesions

OBJECTIVE

The purpose of our study was to evaluate the accuracy of CT-guided percutaneous core biopsy of ground-glass opacity (GGO) pulmonary lesions.

MATERIALS AND METHODS

The study included 50 patients (24 men, 26 women; age range, 43-78 years) who had a GGO pulmonary lesion and underwent CT-guided core biopsy. Diagnostic accuracy was compared between two groups according to lesion size (< 2 cm vs > or = 2 cm) and GGO component (> 90% vs 50-90%). Each case was reviewed for complications, including pneumothorax, thoracostomy tube insertion, and hemoptysis.

RESULTS

Malignancy was finally diagnosed in 33 patients, including three who underwent repeated biopsies, with 33 true-positive and three false-negative findings for an overall sensitivity of 92% (33/36). A benign lesion was finally diagnosed in 10 patients with one false-positive result, for a specificity of 90%. Two benign lesions without confirmative diagnosis because of loss of follow-up and five nondiagnostic samples were excluded from the calculations of sensitivity, specificity, and diagnostic accuracy. The overall diagnostic accuracy was 91%, with a positive predictive value of 97% and a negative predictive value of 75%. Sensitivity and accuracy were not significantly different between the two groups of lesion size and GGO components (p = 0.0491). Ten (18%) patients had pneumothorax, with one (2%) requiring placement of a thoracostomy tube. Mild hemoptysis occurred in seven (13%) patients.

CONCLUSION

CT-guided core biopsy of GGO lesions can yield high diagnostic accuracy and acceptable complication rates approaching those of solid lesions.

Accuracy of CT-guided transthoracic needle biopsy of lung lesions: factors affecting diagnostic yield

PURPOSE

This study was performed to analyse the variables affecting the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions.

MATERIALS AND METHODS

A retrospective study of 612 consecutive procedures with confirmed final diagnoses was undertaken. Benign and malignant needle biopsy results were compared with final outcomes to determine diagnostic accuracy. A statistical analysis of factors related to patient characteristics, lung lesions and biopsy technique was performed to determine possible influences on diagnostic yield. A p value less than 0.05 was interpreted as statistically significant.

RESULTS

There were 508 (83%) malignant and 104 (17%) benign lesions. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for a diagnosis of malignancy were 90.2%, 99.0%, 99.8%, 67.3% and 91.7%, respectively. Overall diagnostic accuracy was 83.3%. Variables affecting diagnostic accuracy were the final diagnosis (benign 67%, malignant 92%; p<0.001) and lesion size (lesions<1.5 cm 68%, lesions 1.5-5.0 cm 87%, lesions>5 cm 78%; p<0.05).

CONCLUSIONS

In CT-guided transthoracic needle biopsy, the final diagnosis and lesion size affect diagnostic accuracy: benign lung lesions and lesions smaller than 1.5 cm or larger than 5.0 cm in diameter provide lower diagnostic yield.

Endobronchial Ultrasonography: Current Status and Future Directions

Endobronchial ultrasonography (EBUS) has emerged as a new diagnostic tool that allows the bronchoscopist to see beyond the airway. The radial probe EBUS was first introduced to evaluate the airway structure, which has been shown to be useful for identifying the extent of tumor invasion in the central airway. With advance in technology, smaller radial probes are now available that are capable of visualizing peripheral lung nodules. EBUS is also used as a tool to assist in a biopsy in respiratory diseases. The radial probe EBUS-guided transbronchial needle aspiration (TBNA) increases the yield of TBNA of mediastinal processes. By the use of the ultra-miniature probe EBUS along with the guide sheath, peripheral lung lesions can be accessed without the exposure to radiation. However, it is still not a real-time procedure with target visualization. The newest development is the convex probe EBUS (CP-EBUS) with a curvilinear electronic transducer on the tip of a flexible bronchovideoscope. CP-EBUS allows real-time EBUS-guided TBNA. Although the main indication for EBUS-TBNA is lymph node staging, it can also be used for diagnosis of intrapulmonary tumors, of unknown hilar and/or mediastinal lymphadenopathy, and of mediastinal tumors. To date, there are no reports of complications related to EBUS-guided TBNA. It is a novel approach that has a good diagnostic yield with excellent potential in assisting safe and accurate diagnostic interventional bronchoscopy. The aim of this review is to highlight the current status of the different EBUS techniques available and to discuss the future direction of EBUS.

Initial Diagnosis of Lung Cancer

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

Contrast-enhanced ultrasound (CEUS) for the study of peripheral lung lesions: a preliminary study

The use of contrast-enhanced ultrasound (CEUS) for the study of peripheral lung lesions has never been systematically investigated. We evaluated the CEUS patterns of 98 peripheral lung lesions before performing US-guided fine-needle biopsies (FNB). The examinations were done with an Esaote Technos MPX scanner in the harmonic mode with a mechanical index of 0.04 or less. Contrast enhancement was achieved with a 4.8 mL bolus of SonoVue (Bracco) administered via an antecubital vein. All FNBs performed under CEUS guidance were adequate for pathologic diagnosis. Seventy-eight lesions were malignant: 33 (41.9%) were adenocarcinomas, 29 (36.5%) were squamous-cell carcinomas, 13 (17.6%) were undifferentiated large-cell carcinomas and the remaining three (4.1%) were small-cell carcinomas. All presented intralesional enhancement consistent with tumor neovascularization. In some cases, there were unenhanced areas consistent with zones of necrosis and these areas were avoided during FNB. The other 20 lesions were benign (four lipomas, two fibrous lung tumor, two noncaseous granulomas, six abscesses, one rheumatoid nodule, one histiocytosis X, one chondroid hamartoma, one sclerosing hemangioma, two sarcoid nodules) and none presented intralesional enhancement. This initial and admittedly limited experience suggests that CEUS may provide diagnostically useful information on peripheral lung lesions and increase the diagnostic yield of transthoracic FNB by reducing the risk of inadequate tissue sampling.

Clinical impact of concomitant surgical diagnosis and subsequent lobectomy for preoperatively undiagnosed lung cancer

OBJECTIVES

We conducted a retrospective study of the clinical impact of a concomitant diagnostic and therapeutic procedure for patients with histologically unproven pulmonary nodules.

METHODS

Between January 2001 and December 2003, we performed 150 consecutive surgical biopsy procedures for histologically indeterminate pulmonary nodules. We compared the clinical impact of the concomitant diagnostic wedge resection followed by lobectomy (U group, n=50) with that of a scheduled standard lobectomy in those with preoperatively proven clinical stage I lung cancer during the same period (C group, n=60).

RESULTS

There were no significant differences in dichotomous variables, whereas we found significant differences in tumor size, operative time and blood loss between the 2 groups. Complication developed in 9 in the U group and 3 in the C group (p=0.030). Hospital mortality was 2% in the U group and 0% in the C group (p=0.11).

CONCLUSION

Morbidity and mortality following a concomitant diagnostic and therapeutic procedure in patients with preoperatively undiagnosed lung cancer was acceptable, however, staged operations should be indicated for patients with considerable co-morbidity.

Endobronchial Ultrasound-Driven Biopsy in the Diagnosis of Peripheral Lung Lesions

STUDY OBJECTIVES

The aim of our study was to compare the diagnostic yield of two bronchoscopic procedures: endobronchial ultrasound-driven transbronchial biopsy (EBUS-TBB) and transbronchial biopsy (TBB) in peripheral pulmonary lesions.

DESIGN

Prospective, randomized, blinded study.

SETTING

University Hospital of Rome, Italy.

PATIENTS AND METHODS

We examined 799 patients with peripheral lung lesions using bronchoscopy. Patients who could undergo a complete clinical diagnostic follow-up (n = 293) were enrolled in the study and randomly assigned to EBUS-TBB or TBB. We performed these two procedures on 221 patients (97 EBUS-TBB and 124 TBB). Patients in whom biopsies were not diagnostic underwent more invasive procedures to obtain a final diagnosis, and a complete follow-up was possible in 206 patients (87 EBUS-TBB and 119 TBB).

RESULTS

Lung cancer was diagnosed in 61 patients in the EBUS-TBB group and in 83 patients in the TBB group. Pulmonary diseases other than cancer were diagnosed in 26 patients and 36 patients, respectively. For patients with lung cancer, sensitivity was 0.79 in the EBUS group and 0.55 in the TBB group (p = 0.004), and accuracy was 0.85 and 0.69, respectively (p = 0.007). The analysis of a subset of patients with lesions > 3 cm showed no significant difference in diagnostic ability between the two procedures. In lesions < 3 cm, we found a considerable decline in TBB sensitivity and accuracy (0.31 and 0.50) while EBUS-TBB maintained their diagnostic yield (0.75 and 0.83) [p = 0.0002 and p = 0.001, respectively]. A similar difference was observed when we compared the sensitivity of the two procedures in lesions < 2 cm (0.23 vs 0.71, p < 0.001).

CONCLUSIONS

EBUS-TBB can be an important option in the early diagnosis of peripheral lung cancer, especially in small-sized lesions and in patients who are not eligible for surgery.

CT Fluoroscopy–guided Biopsy of the Lung or Upper Abdomen with a Breath-hold Monitoring and Feedback System: A Prospective Randomized Controlled Clinical Trial

PURPOSE

To prospectively determine the clinical effectiveness of a breath-hold monitoring and feedback system in computed tomographic (CT) fluoroscopy-guided biopsies in which respiratory motion is a problem.

MATERIALS AND METHODS

Institutional review board approval and oral and written informed consent were obtained. This study was HIPAA compliant. A bellows-based system was used to monitor respiration and provide patient feedback. A randomized controlled clinical trial compared intermittent mode CT fluoroscopy-guided biopsies of the lung or upper abdomen performed with (n = 56) and without (n = 57) the bellows system. Inclusion criteria for 113 patients were lesions 6 cm or smaller in maximum dimension that were not affixed to the chest or abdominal wall. Primary outcome measurements were CT fluoroscopy exposure time and patient dose. Wilcoxon rank sum, chi(2), and Fisher exact tests were used for statistical analysis.

RESULTS

Median CT fluoroscopy exposure time was 12.6 seconds (range, 2.4-44.4 seconds) for the bellows group and 18.0 seconds (range, 6.0-118.0 seconds) for the nonbellows group (P = .004). Patient dose was decreased in the bellows group (median dose, 29.5 mGy; range, 4.7-135.8 mGy) versus the nonbellows group (median, 41.3 mGy; range, 11.8-155.9 mGy) (P = .01). Lesions were accessed successfully with one needle puncture attempt in 43 of 56 patients (77%) in the bellows group and 30 of 57 patients (53%) in the nonbellows group (P = .007). Pneumothorax developed in 11 of 50 patients (22%) in the bellows group who underwent lung biopsy compared with 16 of 50 (32%) patients in the nonbellows group.

CONCLUSION

A breath-hold monitoring and feedback system allows depiction of mobile target lesions throughout CT fluoroscopy-guided biopsy of the lung and upper abdomen.

Usefulness of Core Roll Preparations in Immediate Assessment of Neoplastic Lung Lesions

INTRODUCTION

CT scan-guided fine-needle aspiration (FNA) of lung nodules is a well-established diagnostic technique. In our institution, both FNA and tissue core biopsy (using a 20-gauge needle) under CT scan guidance are routinely performed during the same procedure, and a preliminary diagnosis (an immediate assessment) is rendered. We compared core roll preparations (CRPs) with aspirate smears in the immediate assessment of pulmonary lesions and also assessed whether CRP resulted in the alteration of the histopathology of the core biopsy.

STUDY DESIGN

Twenty-five cases of neoplastic pulmonary lesions diagnosed in CT scan-guided lung FNA specimens, with core biopsies performed sequentially at the same visit for each patient, were evaluated. CRPs were made by lightly rolling the tissue core on a glass slide, followed by air-drying. Only stained slides (Diff-Quik; Mercedes Medical; Sarasota, FL) were reviewed, and were scored for cellularity and morphology.

RESULTS

CRPs in seven cases (28%) scored more diagnostic points than FNA smears, and were found to be better for cellularity and morphology compared to the corresponding FNA smears. The FNA smears scored more than CRPs in 10 cases (40%), while in 8 cases (32%) both CRPs and FNA smears scored equal diagnostic points. Using both CRP and FNA smears in the immediate assessment of lung biopsy specimens, we could assign a specific malignant histologic cell type in 23 of 25 cases (92%). In comparison, if the FNA smears were evaluated alone, we could assign a specific malignant histologic cell type in only 16 of 25 cases (64%). The CRP did not alter the histopathology of the core biopsy specimens in any of the above cases.

CONCLUSION

The CRP complements the CT scan-guided lung FNA procedure in the immediate assessment of neoplastic lung lesions without altering the histopathology of core biopsy specimens.

CT-Guided Transbronchial Biopsy Using an Ultrathin Bronchoscope With Virtual Bronchoscopic Navigation

STUDY OBJECTIVES

We evaluated the feasibility, safety, and efficacy of CT-guided transbronchial biopsy (TBB) using an ultrathin bronchoscope with navigation by virtual bronchoscopy (VB) for small peripheral pulmonary lesions of < 20 mm in diameter.

DESIGN

A pilot study.

SETTING

A national university hospital.

PATIENTS

We performed CT-guided TBB after VB navigation for 25 patients with 26 small peripheral pulmonary lesions (average diameter, 13.2 mm) between June 1, 2001, and October 31, 2002. Of the 26 lesions, 10 were in the right upper lobe, 2 were in the right middle lobe, 6 were in the right lower lobe, and 8 were in the left upper lobe. Nineteen lesions were not detected on chest radiographs.

INTERVENTIONS

VB images were reconstructed from helical CT scans. CT-guided TBB was performed using an ultrathin bronchoscope after studying the VB image.

RESULTS

CT-guided TBB was performed safely without any complications for all patients. The bronchi seen under VB imaging were highly consistent with the actual bronchi confirmed using an ultrathin bronchoscope. The ultrathin bronchoscope was inserted between the fifth and eighth generation bronchi. The average durations of the initial scan, the first biopsy, and the total examination were 5.46, 12.96, and 29.27 min, respectively. Seventeen lesions (65.4%) were diagnosed from pathology examinations (primary lung cancers, 13; atypical adenomatous hyperplasia, 1; metastatic cancer, 1; sarcoidosis, 1; and nontuberculous mycobacteriosis, 1). Diagnoses were not obtained for the remaining lesions due to an insufficient number of specimens (six specimens) or to the inability to reach the lesions even using the ultrathin bronchoscope (three specimens).

CONCLUSIONS

In summary, CT-guided TBB using an ultrathin bronchoscope with VB navigation was safely performed and was effective for diagnosing small peripheral pulmonary lesions.

CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate

PURPOSE

To evaluate the effect of coaxial needle size on pneumothorax rate and the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle aspiration biopsy (TNAB) of pulmonary nodules.

MATERIALS AND METHODS

Retrospective review of 846 consecutive CT-guided TNAB procedures was performed. A coaxial approach was implemented in all patients by using an 18- or 19-gauge outer stabilizing needle through which a smaller aspiration needle or automated biopsy gun was inserted for tissue sampling. Univariate and multivariate regression analyses were used to analyze coaxial needle size, age, sex, smoking history, lesion size, use of an automated core biopsy gun, number of needle passes, and frequency of chest tube placement. Sensitivity, specificity, and diagnostic accuracy were calculated for 676 patients with at least 18 months of clinical follow-up.

RESULTS

Pneumothorax occurred in 226 of 846 patients. Coaxial needle size and patient age had a significant effect on pneumothorax rate. Pneumothorax occurred in 124 (38%) of 324 patients who underwent procedures with 18-gauge needles and in 121 (23%) of 522 patients who underwent procedures with 19-gauge needles (P <.001). The overall diagnostic accuracy was 96% for procedures performed with 18-gauge needles and 92% for procedures performed with 19-gauge needles, with a sensitivity of 95% and 89% and a specificity of 100% and 99%, respectively. Pneumothorax occurred in 153 patients older than 60 years, in 99 patients 60 years and younger (P <.02), in 90 patients older than 70 years, and in 162 patients younger than 70 years (P <.01). The relationship between pneumothorax rate and age as a continuous distribution was not significant (P <.07), nor were the 50- or 75-year age cutoffs (P <.06 and P <.9, respectively).

CONCLUSION

Use of a smaller coaxial stabilizing needle produces a substantially decreased risk of pneumothorax with comparable diagnostic accuracy, sensitivity, and specificity for histopathologic diagnosis of pulmonary nodules.

Head and neck cancer patients with pulmonary nodules: Value and role of CT-guided transthoracic needle aspiration biopsies

BACKGROUND

To evaluate transthoracic needle aspiration biopsies of pulmonary lesions in patients with squamous cell cancer of head and neck.

METHODS

Retrospective series of 85 patients with squamous cell cancer of head and neck cancer and pulmonary nodules who underwent CT-guided needle aspiration biopsy.

RESULTS

Diagnostic samples were obtained in 85% of patients. There were 8 benign and 77 malignant lesions. Among the 73 proved cases, 4 were false-negative cases. CT-guided biopsy had an accuracy of 81%, a sensitivity of 94%, and a negative predictive value of 60%. Accuracies were 68% for lesions of 20 mm or smaller and 89% for lesions greater than 20 mm. In a subset of 45 solitary lesions, among 30 positive biopsies, 15 were categorized as primary malignancies, 3 as metastatic, and 12 as indeterminate malignancies.

CONCLUSIONS

In head and neck cancer patients, the prevalence of thoracic malignancies is high when a pulmonary lesion is detected. CT-guided biopsy of pulmonary lesion is an accurate procedure. However, a third of positive biopsies were categorized as indeterminate malignancies.

Transthoracic needle biopsy in the diagnosis of solitary pulmonary nodules: a survey of canadian physicians

OBJECTIVE

To describe Canadian physicians' opinions relative to the choice of diagnostic procedures in patients presenting with a solitary pulmonary nodule and to identify the attributes that may influence their decision.

METHODS

We conducted a mailed survey among Canadian physicians including pulmonologists, thoracic surgeons, radiologists, and internists. Five hypothetical clinical scenarios designed to illustrate a wide spectrum of clinical situations (including nodules associated to very low, indeterminate, and high probabilities of malignancy in patients medically fit or unfit to undergo surgical resection) were submitted to each physician who had to choose among options of diagnostic procedures and to estimate the pretest probability of malignancy.

RESULTS

The survey response rate was 47%. Overall, the physicians tended to overestimate the probability of malignancy. Twenty-eight percent of the respondents would have ordered a transthoracic needle biopsy in a medically fit patient presenting with a very low probability (< 2%) of malignancy, whereas 53% would have done so in a medically fit patient presenting with a very high probability (75%) of malignancy. In a regression analysis, the significant predictors of the use of transthoracic needle biopsy were (1) the pretest probability of cancer, (2) the patient's operability, (3) specialty (pulmonologists and thoracic surgeons being less likely to order a transthoracic needle biopsy than radiologists), and (4) the respondent's gender.

CONCLUSIONS

There are widespread variations in clinical opinions among Canadian physicians regarding the use of transthoracic needle biopsy in the investigation of solitary nodules. Hypothetical transthoracic needle biopsy was often preferred when the result was unlikely to affect patient management.

Cytologic approach to tumors of the tracheobronchial tree

Cytologic testing is an integral part of the workup of patients suspected of having lung cancer. These tests are less invasive than other tissue procurement methods, with minimal risk of complications. In experienced hands, the tests are highly accurate and reliable. To achieve good results and avoid diagnostic errors, clinicians must be educated in proper collection and fixation methods and the pathologist should be cognizant of clinical and radiologic data. Close communication between the clinician and pathologist should be encouraged.

Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence

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.

Value of FDG-PET in the management of non-small cell lung cancer

In the past 5 years, metabolic imaging with positron emission tomography (PET) using 18F-fluoro-2-deoxy-glucose (FDG) has become an important imaging modality in lung cancer patients. FDG-PET consistently proved to be superior to structure-based imaging modalities in both the diagnosis and staging of lung cancer. At this moment the use of FDG-PET in these indications needs further validation in multi-centre large-scale randomised studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. More recently, interesting findings have also been reported in the response assessment to cytotoxic treatments providing information of greater prognostic significance than can be obtained using conventional approaches. This review focuses on the potential role of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of non-small cell lung cancer. Emphasis is put on the potential clinical implementation of the numerous data of the last decade.

Positron emission tomography in lung cancer

Carcinoma of the lung is one of the most frequent malignancies and a major cause of mortality. The use of positron emission tomography (PET) has been extensively investigated in patients with carcinoma of the lung and has established clinical utility and cost-effectiveness in characterization of solitary pulmonary nodules and preoperative staging of carcinoma of the lung. Evolving applications in carcinoma of the lung include detection of recurrence, assessment of treatment response, radiotherapy planning, and prognosis. In addition, there is developing interest in combined anatomic/metabolic imaging and new tracer techniques, in particular gene expression imaging. This review aims to present existing data supporting the use of PET in carcinoma of the lung and to explore the evolving indications and future prospects of PET and lung cancer.

Preoperative cytodiagnosis of very small-sized peripheral-type primary lung cancer

To demonstrate the importance of preoperative diagnosis of pulmonary cancers presenting as peripheral small-sized solitary shadows we evaluated the results of morphologic definitive diagnosis together with various clinical factors in 91 tumors with less than 15-mm diameter resected surgically between 1983 and 1999. Histologically, these tumors consisted of 73 adenocarcinomas, nine squamous cell carcinomas, and nine other types. Regarding the pathologic stage, 57 tumors were classified in stage IA, three in IB, six in IIA, seven in IIIA, 14 in IIIB, and four in IV. Comparing various biopsy techniques, the sensitivity of preoperative cytodiagnosis was 43.7% for transbronchial brushing (n = 48), 52.9% for transbronchial forceps biopsy-stamp cytology (n = 51), 66.6% for transbronchial fine needle aspiration (n = 78), and 85.0% for percutaneous fine needle aspiration (n = 20). The overall sensitivity of preoperative cytodiagnosis was 79.0% for transbronchial biopsy (n = 81), and 87.3% for transbronchial and percutaneous biopsy (n = 87). Of 73 clinical N0 cases in which lobectomy was performed, 10 cases (13.6%) were diagnosed as between pathological degrees N1, N2 and N3. However, lung cancer cases with less than 10-mm diameter did not have lymph node metastasis. Our study of histologic differentiation showed that all cases of well-differentiated adenocarcinomas (n = 20) were pathological degree N0. The overall sensitivity of preoperative diagnosis increased to 89.1% in cases (n = 74) of tumors with 11-15-mm diameter. The sensitivity of cytodiagnosis for peripheral small-sized primary lung cancers is high, and we can estimate histological differentiation based on the cytological findings. Therefore, cytodiagnosis is an effective and indispensable diagnostic method for determination of the optimal treatment approach, including approaches such as intentionally limited resection.

Fine needle aspiration of the solitary pulmonary nodule

Percutaneous transthoracic needle biopsy is a well-established method of obtaining cytologic and histologic samples from a pulmonary nodule. Properly performed, needle biopsy is a simple and safe procedure. Pneumothorax is the most common complication, which, if symptomatic or large, is easily treated by chest tube insertion or aspiration. Minor hemorrhage and hemoptysis is the other common complication, which is rarely serious. Rare complications include air embolism and needle tract metastases. Needle biopsy has a high sensitivity and specificity for malignancy. For benign lesion, a specific diagnosis is less common, although with core needle biopsy, the yield of a specific benign diagnosis is increased.

The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy: the angle of the needle trajectory is a novel predictor

STUDY OBJECTIVE

Pneumothorax remains the most common complication of percutaneous CT-guided lung biopsy, despite improved techniques. The rate of pneumothorax reported in the literature ranges from 19 to 60%. The aims of this study were to estimate the risk of pneumothorax in patients undergoing CT-guided lung biopsy, and to determine which factors affect its occurrence.

DESIGN

Retrospective study.

PATIENTS AND METHODS

This study involved 289 consecutive patients who underwent biopsy in our hospital under consistent methods, using only one type of needle, the 19-gauge Tokyo Medical College (TMC) Needle (Takei; Tokyo, Japan), under CT guidance.

RESULT

Seventy-seven patients (26.6%) had pneumothorax after percutaneous CT-guided lung biopsy. Forty-one of the 77 patients (53.2%) who had pneumothorax (14.2% of the entire series) required placement of a chest tube. Our present study, using multivariate logistic regression analysis, confirmed that greater lesion depth, wider trajectory angle, and increasing FVC percent predicted are independent risk factors of pneumothorax, and that two former factors are independent risk factors of chest tube placement following percutaneous CT-guided lung biopsy.

CONCLUSIONS

The angle of needle route is a novel predictor of this complication. Our findings suggest that low pneumothorax rates are achieved by combining several techniques to reduce the risk of pneumothorax.

Management of pneumothorax and barotrauma: current concepts

Pneumothorax can be spontaneous, traumatic or iatrogenic. Pneumothorax ex vacuo, sports-related pneumothorax and barotrauma unrelated to mechanical ventilation are interesting and newer entities. Management consists of getting rid of the air and prevention of recurrence of pneumothorax.

Operable non-small cell lung cancer diagnosed by transpleural techniques : do they affect relapse and prognosis?

STUDY OBJECTIVE

We assessed whether transpleural methods for diagnosing peripheral lung cancer, such as needle aspiration or tumor excision, affect relapse and prognosis, because these techniques have potential to spread malignant cells from the tumor.

DESIGN

A retrospective study.

SETTING

National referral hospital.

PATIENTS

We reviewed 239 patients who underwent surgery between 1990 and 1998 and for whom non-small cell lung cancer (NSCLC) of < 3 cm in maximum diameter was completely resected. The duration of postoperative follow-up ranged from 12 to 105 months, with a median period of 45 months.

INTERVENTIONS

We defined the transbronchial method as using a bronchoscope, and the transpleural method as using needle aspiration cytology or tumor excision. Dichotomous variables included gender, histologic type of squamous cell carcinoma or other type of carcinoma, pathologic stage, and whether the diagnostic method was the transbronchial type only (first-line method) or the transpleural type (second-line method).

RESULTS

NSCLC was diagnosed in 45 patients by the transpleural technique and in 194 patients by the transbronchial technique. There were no significant statistical differences in age of patients, gender, histologic type, pathologic stage, and tumor size. There were 42 relapses, 7 in the transpleural technique group and 35 in the transbronchial technique group (p = 0.90). Of the 7 patients in the transpleural group, there were 4 distant metastasis and 3 local relapses; of the 35 patients in the transbronchial group, there were 20 distant metastasis and 15 local relapses (p = 0.99). Pleural carcinomatosis occurred in none of the 45 patients in the transpleural group and in 1 case (0.5%) in the 194 patients in the transbronchial group (p = 0.99). Patients in the transpleural group had a statistically better 5-year survival rate than patients in the transbronchial group (79.4% vs 60.3%, p = 0.04). This is also confirmed as an independent prognostic factor in a multivariate analysis.

CONCLUSIONS

Transpleural methods seem to be an advisable way to diagnose operable lung cancer that is difficult to diagnose using bronchoscopy, because these methods did not affect relapse and prognosis in the patients in our study.

Transthoracic fine-needle aspiration biopsy of pulmonary spindle cell and mesenchymal lesions: a study of 61 cases

BACKGROUND

Spindle cell and mesenchymal lesions of the lung encompass a wide variety of benign and malignant conditions. However, to the authors' knowledge, because of their rarity, few reports concerning their cytologic findings are available in the literature. The current review emphasizes the cytomorphologic features, differential diagnosis, and potential pitfalls associated with these lesions.

METHODS

Seven hundred seventy-nine percutaneous lung fine-needle aspiration (FNA) specimens were retrieved from the authors' cytopathology files over a period of 5 years. Sixty-one cases (7.8%) in which a spindle cell component was the dominant or key feature were identified. The authors reviewed the cytologic smears, immunocytochemical studies, and corresponding surgical material and clinical information.

RESULTS

Of these 61 aspirates, 33 (54%) were reactive processes (31 granulomas, 1 organizing pneumonia, and 1 inflammatory pseudotumor). Five cases (0.8%) were benign neoplasms (2 hamartomas, 2 solitary fibrous tumors, and 1 schwannoma). Twenty-three cases (38%) were malignant neoplasms (8 cases were primary tumors [including 5 carcinomas with spindle cell or sarcomatoid features, 1 spindle cell carcinoid tumor, 1 leiomyosarcoma, and 1 synovial sarcoma] and 15 cases were secondary tumors [including 9 melanomas, 2 leiomyosarcomas, 1 malignant fibrous histiocytoma, 1 meningioma, 1 sarcomatoid renal cell carcinoma, and 1 uterine malignant mixed müllerian tumor]). A specific diagnosis was rendered in 52 cases (85%). No false-positive cases were encountered but there was one false-negative case. One patient who was diagnosed with granulomatous inflammation on FNA was found to have nonsmall cell lung carcinoma on subsequent transbronchial biopsy. No malignant cells were identified in the smears on review. The FNA from the organizing pneumonia was interpreted as a solitary fibrous tumor whereas the inflammatory pseudotumor was diagnosed as granulomatous inflammation. The FNA from one pulmonary hamartoma initially was considered to be nondiagnostic. One solitary fibrous tumor and the schwannoma were diagnosed as smooth muscle tumor and spindle cell tumor, not otherwise specified, respectively. Among the malignant tumors, the primary synovial sarcoma and one of the metastatic malignant melanomas initially were interpreted as primitive neuroectodermal tumor/Ewing sarcoma and poorly differentiated carcinoma, respectively.

CONCLUSIONS

Spindle cell lesions of the lung rarely are encountered on transthoracic lung FNA and are comprised of a wide variety of benign and malignant entities. By correlating clinical and radiologic data, cytologic findings, and ancillary studies, a high diagnostic accuracy rate can be achieved with FNA.

The role of positron emission tomography with 18F-fluoro-2-deoxy-D-glucose in respiratory oncology

In the past 5 yrs, positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (FDG) has become an important imaging modality in lung cancer patients. At this time, the indication of FDG-PET as a complimentary tool to computed tomography in the diagnosis and staging of nonsmall cell lung cancer has gradually gained more widespread acceptance and also reimbursement in many European countries. This review focuses on the data of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of nonsmall cell lung cancer. Emphasis is put on the potential clinical implementation of the currently available FDG-PET data. The use of FDG-PET in these indications now needs further validation in large-scale multicentre randomized studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. Interesting findings with 18F-fluoro-2-deoxy-D-glucose-positron emission tomography have also been reported for the evaluation of response to radio- or chemotherapy, in radiotherapy planning, recurrence detection and assessment of prognosis. Finally, a whole new field of application of positron emission tomography in molecular biology, using new radiopharmaceuticals, is under extensive investigation.

CT-guided cutting needle biopsy of lung lesions--safety and efficacy of an out-patient service

AIM

To determine the safety and efficacy of CT-guided cutting needle biopsy of lung lesions as an out-patient procedure.

MATERIALS AND METHODS

A total of 185 consecutive biopsies were performed under CT guidance on 183 patients between January 1991 and December 1998 using 20-gauge (n= 33), 18-gauge (n= 151) or 14-gauge (n= 1) core biopsy needles. A chest radiograph was taken after observation in the Radiology department for 1 h and asymptomatic patients were discharged.

RESULTS

The histology was malignant in 150 biopsies (81. 1%) and benign in 23 (12.4%) with 12 false-negative results (6.5%); there were no false-positive results. The sensitivity was 92.6%; specificity 100%; negative predictive value 65.7%; and overall accuracy 93.5%. Pneumothoraces occurred in 48 patients (25.9%); one required aspiration only and four required insertion of an intercostal drain. One patient developed a pneumothorax after discharge. Small haemoptyses occurred in 13 patients without pneumothorax (7.0%), one of whom was admitted. In-patient treatment was required in 10 patients (5.4%).

CONCLUSION

Computed tomography-guided cutting needle biopsy of pulmonary lesions is a safe technique with a diagnostic accuracy and complication rate comparable to reported figures for fine needle aspiration biopsy. It can be safely performed on an out-patient basis.

Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract

BACKGROUND

Fine-needle aspiration cytologic technique (FNAC), a method to detect malignancy for undetermined pulmonary nodules, may have a high potential to spread malignant cells from the tumor to the pleural cavity.

OBJECTIVE

The authors assessed malignant cell spread through the needle tract following FNAC for peripheral lung carcinoma.

MATERIALS AND METHODS

Lung lobes resected from 20 patients during the treatment of lung carcinoma were examined. The visceral pleura over the lung carcinoma was irrigated by heparinized saline solution to clean the surface, and then irrigated before FNAC and irrigated following FNAC to collect cells on the visceral pleura. FNAC was performed once for each tumor. Papanicolau's method was employed for cytologic examination.

RESULTS

There were 15 specimens of adenocarcinoma, 4 specimens of squamous cell carcinoma, and 1 specimen of atypical carcinoid. The maximum diameter of the specimens ranged from 10 to 60 mm (median, 25 mm). Pleural indentation was observed in 15 samples. All results of FNAC were positive and matched the histologic diagnosis. Pre-FNAC specimens revealed a positive malignancy rate of 10% (2 of 20), but post-FNAC specimens had a rate of 60% (12 of 20; p = 0.002) CONCLUSION: FNAC has the potential to spread malignant cells to the pleural space. Further study is needed to determine the clinical significance of the spread of malignant cells in the pleural space.

CT-guided transthoracic needle biopsy using an ipsilateral dependent position

OBJECTIVE

We postulated that the pneumothorax rate of transthoracic needle biopsy might improve with an ipsilateral dependent position of the affected side. We tried to determine the feasibility, effectiveness, and safety of CT-guided biopsy with the patient in this position.

SUBJECTS AND METHODS

CT-guided needle biopsy with the patient in an ipsilateral dependent position was performed in 23 patients with 17 lung lesions (15 posterior and two anterior) and six mediastinal lesions. Fine-needle aspiration was used in all patients, and core biopsy was also used in six patients. The technical difficulty of the procedure was classified into three grades compared with a routine transthoracic needle biopsy as follows: grade I, no more difficult; grade II, somewhat more difficult; and grade III, much more difficult.

RESULTS

Adequate samples were obtained in 22 (96%) of 23 patients. A small asymptomatic pneumothorax occurred in two patients (8.7%). Difficulty was rated grades I, II, and III in 18 (78%), two (9%), and three (13%) procedures, respectively. Four of the five grades II and III procedures were biopsies of anterior lesions. Traversing the pleura was avoided in three of six mediastinal masses.

CONCLUSION

Transthoracic needle biopsy of selected lung and mediastinal lesions using an ipsilateral dependent position is feasible, effective, and safe. The role of this technique for reducing the rate of pneumothorax as a result of the biopsy requires further investigation.