Complications of CT-guided percutaneous needle biopsy of the chest: prevention and management

Genetic traits for hematogeneous tumor cell dissemination in cancer patients

Metastatic relapse in patients with solid tumors is the consequence of cancer cells that disseminated to distant sites, adapted to the new microenvironment, and escaped systemic adjuvant therapy. There is increasing evidence that hematogeneous dissemination starts at an early stage of cancer progression with single tumor cells or cell clusters leaving the primary site and entering the blood circulation. These circulating tumor cells (CTCs) can extravasate into secondary tissues where they become disseminated tumor cells (DTCs). Patients might relapse years after initial resection of the primary tumor when DTCs become overt metastases. Current diagnostic strategies for stratification of therapies against metastatic cells focus on the primary tumor tissue. This approach is based on the availability of stored primary tumors obtained at primary surgery, but it ignores that the DTCs might have evolved over years, which can affect the antimetastatic drug response. However, taking biopsies from metastatic tissues is an invasive procedure, and multiple metastases located at different sites in an individual patient show marked genomic heterogeneity. Thus, capturing CTCs from the peripheral blood as a "liquid biopsy" has obvious advantages in particular when repeated sampling is required for monitoring therapies in cancer patients. However, the biology behind tumor cell dissemination and its contribution to metastatic progression in cancer patients is still subject to controversial discussions. This manuscript reviews current theories on the genetic traits behind the spread of CTCs and progression of DTCs into overt metastases.

CT-guided transthoracic biopsy: histopathologic results and complication rates

PURPOSE

We aimed to investigate the effectiveness and complications of transthoracic CT-guided biopsy techniques.

METHODS

A total of 94 CT-guided percutaneous transthoracic biopsy procedures performed in 85 patients were retrospectively evaluated. Core biopsy technique was used in 87 procedures and transthoracic fine-needle aspiration biopsy was used in seven procedures.

RESULTS

Diagnostic results were achieved in 79 of 94 biopsy procedures. Pathology results were malignant in 54 patients, suspicious for malignancy in three patients, benign in five patients, and benign nonspecific in 17 patients. Specific diagnoses were obtained in 59 patients (62.8%) using core biopsy, but no specific diagnosis could be reached with transthoracic fine-needle aspiration biopsy. Complications included pneumothorax in 27 patients (28.7%) and parenchymal hemorrhage during and after the procedure in eight patients (8.5%).

CONCLUSIONS

CT-guided percutaneous transthoracic needle biopsy is a highly accurate procedure for histopathological diagnosis of thoracic masses. In addition, percutaneous transthoracic biopsy has an acceptably low complication rate and it reduces the need for more invasive surgical procedures.

An Approach Toward Automatic Classification of Tumor Histopathology of Non-Small Cell Lung Cancer Based on Radiomic Features

Non–small cell lung cancer contributes toward 85% of all lung cancer burden. Tumor histology (squamous cell carcinoma, large cell carcinoma, and adenocarcinoma and “not otherwise specified”) has prognostic significance, and it is therefore imperative to identify tumor histology for personalized medicine; however, biopsies are not always possible and carry significant risk of complications. Here, we have used Radiomics, which provides an exhaustive number of informative features, to aid in diagnosis and therapeutic outcome of tumor characteristics in a noninvasive manner. This study evaluated radiomic features of non–small cell lung cancer to identify tumor histopathology. We included 317 subjects and classified the underlying tumor histopathology into its 4 main subtypes. The performance of the current approach was determined to be 20% more accurate than that of an approach considering only the volumetric- and shape-based features.

Computed tomography-guided percutaneous core needle biopsy for diagnosis of mediastinal mass lesions: Experience with 110 cases in two university hospitals in Isfahan, Iran

Background:

Computed tomography-guided percutaneous core needle biopsy (PCNB) is a diagnostic technique for initial assessment of mediastinal mass lesions. This study was conducted to evaluate its diagnostic yield and its complication rate.

Materials and Methods:

We reviewed the records of CT-guided PCNB in 110 patients with mediastinal mass lesions performed in Kashani and Alzahra Hospitals, Isfahan, from 2006 to 2012. Gender, age at biopsy, size, and anatomic location of the lesion, number of passes, site of approach, complications, and final diagnosis were extracted.

Results:

Our series encompasses 52 (47.2%) females and 58 (52/7%) males with mean age of 41 ± 8 years. The most common site of involvement was the anterior mediastinum (91.8% of cases). An average of 3/5 passes per patient has been taken for tissue sampling. Parasternal site was the most frequent approach taken for PCNB (in 78.1% of cases). Diagnostic tissue was obtained in 99 (90%) biopsies while, in 11 (10%) cases, specimen materials were inadequate. Lymphoma (49.5%) and bronchogenic carcinoma (33.3%) were the most frequent lesions in our series. The overall complication rate was 17.2% from which 10.9% was pneumothorax, 5.4% was hemoptysis, and 0.9% was vasovagal reflex.

Conclusion:

CT-guided PCNB is a safe and reliable procedure that can provide a precise diagnosis for patients with both benign and malignant mediastinal masses, and it is considered the preferred first diagnostic procedure use for this purpose.

Beware of positive pressure: coronary artery air embolism following percutaneous lung biopsy

Patients undergoing percutaneous lung biopsy are at risk of developing a systemic air embolism. Air embolism may manifest as a catastrophic iatrogenic event with ischemic insult to the end organs, with sites of least resistance such as coronary and cerebral circulation the most susceptible. We review the available literature and present a case of iatrogenic air embolism during computed tomography guided percutaenous lung biopsy under general anesthesia. Management, outcome, and periprocedural factors that may have contributed to the complication are discussed.

Instituting a Low-dose CT-guided Lung Biopsy Protocol

RATIONALE AND OBJECTIVES

We aimed to evaluate whether implementation of a low-dose computed tomography (CT)-guided lung biopsy protocol, with the support of individual radiologists in the section, would lead to immediate and sustained decreases in radiation dose associated with CT-guided lung biopsies.

MATERIALS AND METHODS

A low-dose CT-guided lung biopsy protocol was developed with modifications of kilovoltage peak, milliamperes, and scan coverage. Out of 413 CT-guided lung biopsies evaluated over a 3-year period beginning in 2009, 175 performed with a standard protocol before the development of a low-dose protocol, and 238 performed with a low-dose protocol. The dose-length product (DLP) was recorded for each lung biopsy and retrospectively compared between the two protocols. Individual radiologist level DLPs were also compared before and after the protocol change.

RESULTS

The mean biopsy dose decreased by 64.4% with the low-dose protocol (113.8 milligray centimeters versus 319.7 milligray centimeters; P < 0.001). This decrease in radiation dose persisted throughout the entire 18 months evaluated following the protocol change. After the protocol change, each attending radiologist demonstrated a decrease in administered radiation dose. The diagnostic outcome rate and complication rate were unchanged over the interval.

CONCLUSIONS

Implementation of a low-dose CT-guided lung biopsy protocol resulted in an immediate reduction in patient radiation dose that was seen with all attending radiologists and persisted for at least 18 months. Such an intervention may be considered at other institutions wishing to reduce patient doses.

MR-guided percutaneous biopsy of solitary pulmonary lesions using a 1.0-T open high-field MRI scanner with respiratory gating

OBJECTIVES

To prospectively evaluate the feasibility, safety and accuracy of MR-guided percutaneous biopsy of solitary pulmonary lesions using a 1.0-T open MR scanner with respiratory gating.

METHODS

Sixty-five patients with 65 solitary pulmonary lesions underwent MR-guided percutaneous coaxial cutting needle biopsy using a 1.0-T open MR scanner with respiratory gating. Lesions were divided into two groups according to maximum lesion diameters: ≤2.0 cm (n = 31) and >2.0 cm (n = 34). The final diagnosis was established in surgery and subsequent histology. Diagnostic accuracy, sensitivity and specificity were compared between the groups using Fisher's exact test.

RESULTS

Accuracy, sensitivity and specificity of MRI-guided percutaneous pulmonary biopsy in diagnosing malignancy were 96.9 %, 96.4 % and 100 %, respectively. Accuracy, sensitivity and specificity were 96.8 %, 96.3 % and 100 % for lesions 2.0 cm or smaller and 97.1 %, 96.4 % and 100 %, respectively, for lesions larger than 2.0 cm. There was no significant difference between the two groups (P > 0.05). Biopsy-induced complications encountered were pneumothorax in 12.3 % (8/65) and haemoptysis in 4.6 % (3/65). There were no serious complications.

CONCLUSIONS

MRI-guided percutaneous biopsy using a 1.0-T open MR scanner with respiratory gating is an accurate and safe diagnostic technique in evaluation of pulmonary lesions.

KEY POINTS

• MRI-guided percutaneous lung biopsy using a 1.0-T open MR scanner is feasibility. • 96.9 % differentiation accuracy of malignant and benign lung lesions is possible. • No serious complications occurred in MRI-guided lung biopsy.

Core Lung Biopsy for Biomarker Analysis: Is There Increased Risk Compared With Conventional Biopsy?

PURPOSE

The aim of the study was to compare the rate of pneumothorax and chest tube placement in patients undergoing conventional lung biopsy with those undergoing core lung biopsy for biomarker analysis.

MATERIALS AND METHODS

Twenty-three patients had biopsies performed for biomarker analysis (5 male, 18 female patients, mean age 67 y), and 173 patients underwent standard diagnostic lung biopsy (86 male, 87 female patients, mean age 68 y). All biopsies were performed under computed tomography guidance using the coaxial technique (19 G introducer needle and 20 G core biopsy needle). The number of core samples was noted for each case, and all complications were recorded in accordance with Society of Interventional Radiology guidelines.

RESULTS

In the biomarker analysis group, a mean of 5.1 core samples (range, 1 to 10) was obtained. In the conventional biopsy group, a mean of 2.9 core samples (range, 1 to 6) was obtained. The pneumothorax rate was 37.6% in the conventional biopsy group and 30.4% in the biomarker analysis group (P=0.505). The rate of chest tube placement was 16.8% in the conventional biopsy group and 8.7% in the biomarker analysis group (P=0.319). Lesion size was found to be an independent predictor of pneumothorax (P=0.031), whereas biopsy tract length was found to be an independent predictor of both pneumothorax (P<0.001) and chest tube placement (P=0.005) upon multivariate analysis.

CONCLUSIONS

There is no statistically significant difference in the incidence of pneumothorax or chest tube placement between patients undergoing standard diagnostic lung biopsy and those requiring increased core samples for biomarker analysis.

CT-guided fine-needle ago-biopsy of pulmonary nodules: predictive factors for diagnosis and pneumothorax occurrence

OBJECTIVE

To evaluate variables that could predict diagnosis during CT-guided fine-needle aspiration.

METHODS

Data from 249 patients who underwent FNAB from January 2010 to December 2012 were analyzed in a retrospective observational study.

RESULTS

Mean age was 66.7 ± 11.5 years, male/female ratio 158/91 (63 vs. 37 %). The nodules were in right lung in 123 patients (49 %), in left lung in 126 patients (51 %), the upper, lower and middle lobe localizations were, respectively in 122 (49 %), 100 (40 %) and 17 (6 %) patients. Mean nodule-chest wall distance was 63.89 ± 21.38 mm. The tumor location, the needle diameter, the presence of necrosis or cavitation, the node-chest wall distance and the number of passages were not related to the diagnostic outcome (p = NS). The nodule diameter was predictive of diagnosis. Odds ratio for a 10-30 mm tumor was 2.51 (95 % OR: 1.24-5.08, p value = 0.011), the odds ratio for a 30-50 mm tumor was 2.39 (95 % OR: 1.22-4.69, p value = 0.011), and the odds ratio for a tumor larger than 50 mm was 4.44 (95 % OR: 1.89-10.44, p value = 0.001). Post-procedure pneumothorax occurred in 62 cases (25 %). The determinant factors for pneumothorax occurrence were emphysema, odds ratio 6.87 (95 % CI 1.07-44.10, p value = 0.04), and the number of pleural passages, odds ratio of 5.47 (95 % OR: 1.92-15.58), 7.44 (95 % OR: 2.58-21.5), 6.13 (95 % OR: 2.07-18.11) p value = 0.001 for one, two, three or more of three passages, respectively.

CONCLUSIONS

In our experience, nodule size is the most important diagnostic factor during fine-needle aspiration, while the number of passages and the presence of emphysema constitute risk factors for pneumothorax occurrence.

Diagnostic Accuracy and Safety of CT-Guided Percutaneous Transthoracic Needle Biopsies: 14-Gauge versus 22-Gauge Needles

PURPOSE

To compare the diagnostic accuracy and safety of a 14-gauge core needle versus a 22-gauge fine needle in the evaluation of thoracic lesions by CT-guided percutaneous transthoracic needle biopsy (TTNB).

MATERIALS AND METHODS

Medical charts of all patients who underwent CT-guided percutaneous transthoracic core-needle biopsies (CNBs) with a 14-gauge Spirotome device (99 patients, 102 procedures) and fine-needle biopsies (FNBs) with a 22-gauge Rotex needle (92 patients, 102 procedures) between 2007 and 2013 at a single academic institution were retrospectively reviewed. Variables that could influence diagnostic accuracy and safety were collected.

RESULTS

The overall and cancer-specific diagnostic accuracy rates were 90% and 94%, respectively, with CNB, versus 82% and 89% with FNB. Precise cancer type/subtype was provided by 97% of CNBs versus 65% of FNBs (P < .001). In patients with lung cancer considered for targeted therapy, biomarker analyses were feasible in 80% of CNBs versus 0% of FNBs (P < .001). The rate of pneumothorax was significantly higher with CNB versus FNB (31% vs 19%; P = .004), but chest tube insertion rates were similar (10% vs 11%, respectively). Major bleeding complications occurred in 1% of CNBs versus 2% of FNBs and were associated with one death in the CNB group.

CONCLUSIONS

Percutaneous transthoracic CNB with a 14-gauge Spirotome needle provided better characterization of cancer lesions and allowed biomarker analyses without a significant increase in major procedural complications.

Transthoracic needle aspiration: the past, present and future

Transthoracic needle aspiration (TTNA) has been used to diagnose disease in the lung for many decades. Thanks to advances in technology and cytopathology, the diagnostic power, accuracy, safety, and efficacy of TTNA are constantly improving. The transition from fluoroscopy to computed tomography (CT) has yielded better visualization, and ability to enhance sophistication of tools used to biopsy. In addition, needles are being refined for obtaining better biopsy samples and increased capabilities. Because of the minimally invasive nature of TTNA, it is becoming a strong alternative to surgical intervention. In the future, these developments will continue and TTNA will become more efficient, and potentially open a door to personalized medicine. However, there are complications due to this procedure, which include pneumothorax, hemorrhage, air embolism, and others which are very rare. Probability of complication increases when patients are older, have significant past medical history, have larger lesions, and are uncooperative during procedure. Indications, contraindications, and other considerations should be contemplated before a patient is elected for TTNA.

Pneumothorax with prolonged chest tube requirement after CT-guided percutaneous lung biopsy: incidence and risk factors

PURPOSE

To evaluate the incidence and risk factors of pneumothoraces requiring prolonged maintenance of a chest tube following CT-guided percutaneous lung biopsy in a retrospective, single-centre case series.

MATERIALS AND METHODS

All patients undergoing CT-guided percutaneous lung biopsies between June 2012 and May 2014 who required chest tube insertion for symptomatic or enlarging pneumothoraces were identified. Based on chest tube dwell time, patients were divided into two groups: short term (0-2 days) or prolonged (3 or more days). The following risk factors were stratified between groups: patient demographics, target lesion characteristics, and procedural/periprocedural technique and outcomes.

RESULTS

A total of 2337 patients underwent lung biopsy; 543 developed pneumothorax (23.2 %), 187 required chest tube placement (8.0 %), and 55 required a chest tube for 3 days or more (2.9 % of all biopsies, 29.9 % of all chest tubes). The median chest tube dwell time for short-term and prolonged groups was 1.0 days and 4.7 days, respectively. The transfissural needle path predicted prolonged chest tube requirement (OR: 2.5; p = 0.023). Other factors were not significantly different between groups.

CONCLUSION

Of patients undergoing CT-guided lung biopsy, 2.9 % required a chest tube for 3 or more days. Transfissural needle path during biopsy was a risk factor for prolonged chest tube requirement.

KEY POINTS

• CT-guided percutaneous lung biopsy (CPLB) is an important method for diagnosing lung lesions • A total of 2.9 % of patients require a chest tube for ≥3 days following CPLB • Transfissural needle path is a risk factor for prolonged chest tube time.

Percutaneous computed tomography-guided aspiration and biopsy of intrathoracic lesions: Results of 265 procedures

Context:

Percutaneous computed tomography (CT)-guided needle aspiration and biopsy technique have developed over time as a method for obtaining tissue specimen. Although this is a minimally invasive procedure, complications do occasionally occur.

Aims:

The aim of the study was to evaluate the diagnostic yield and complications of 265 percutaneous CT-guided aspiration and biopsy procedures performed on various intrathoracic lesions.

Settings and Design:

Data of percutaneous CT-guided aspiration and biopsy procedures of intrathoracic lesions performed over a 4 year period were retrospectively analyzed.

Subjects and Methods:

Procedure details, radiological images, and pathological and microbiological reports were retrieved from radiology records and hospital information system. Technical success, diagnostic yield, and complication rates were calculated.

Results:

Total 265 procedures were performed for lung (n = 179), mediastinum (n = 73), and pleural lesions (n = 13). Diagnostic yield for lung, mediastinal, and pleural lesions was 80.7%, 74.2, and 75%, respectively, for core biopsy specimens. Major complication was noted in only one procedure (0.4%). Minor complications were noted in 13.6% procedures which could be managed conservatively.

Conclusions:

Percutaneous CT-guided aspiration and biopsy procedures for intrathoracic lesions are reasonably safe with good diagnostic yield. Complications are infrequent and conservatively managed in most of the cases.

The potential diagnostic power of circulating tumor cell analysis for non-small-cell lung cancer

In non-small-cell lung cancer (NSCLC), genotyping tumor biopsies for targetable somatic alterations has become routine practice. However, serial biopsies have limitations: they may be technically difficult or impossible and could incur serious risks to patients. Circulating tumor cells (CTCs) offer an alternative source for tumor analysis that is easily accessible and presents the potential to identify predictive biomarkers to tailor therapies on a personalized basis. Examined here is our current knowledge of CTC detection and characterization in NSCLC and their potential role in EGFR-mutant, ALK-rearranged and ROS1-rearranged patients. This is followed by discussion of the ongoing issues such as the question of CTC partnership as diagnostic tools in NSCLC.

Fluorodeoxyglucose-PET/Computed Tomography-Guided Biopsy

PET/computed tomography (CT) combines the anatomic information from CT with PET metabolic characterization. 18F-fluorodeoxyglucose (FDG) PET is helpful to differentiate malignant lesions from benign ones, that usually show lower or no uptake. However, active inflammation or infectious disease might also present FDG uptake. Studies confirm the great value of PET/CT as the imaging method of choice for guiding biopsy procedures. Novel PET radiopharmaceuticals are also being investigated for guiding biopsies.

Development of a prediction model and risk score for procedure-related complications in patients undergoing percutaneous computed tomography-guided lung biopsy

OBJECTIVES

To propose a risk score predicting the potential occurrence of procedure-related complications in patients undergoing computed tomography (CT)-guided lung biopsy.

METHODS

Institution review board approval was obtained. A total of 342 CT-guided lung biopsies were retrospectively evaluated taking into account procedure-related complications and associated risk factors, including patient gender and age, previous radiation therapy (RT) and/or chemotherapy (CHT), lesion size, depth and location, incomplete pulmonary fissures, associated diffuse lung diseases, previous pneumothorax (PNX), lung volumes, punctured fissures, thoracic access, needle size and operator experience. Complications were assessed on chest X-ray and/or CT scans. Stepwise logistic regression was used to identify risk factors, to evaluate their correlation with procedure-related complications and to calculate models of risk (MoRs).

RESULTS

PNX requiring chest tube placement occurred in 39 patients (11.4%), high-grade pulmonary parenchymal haemorrhage occurred in 62 patients (18.1%) and haemothorax occurred in 12 patients (3.5%). Risk factors increasing the incidence of complications were lesion size (P = 0.01), lesion depth (P = 0.01) and incomplete pulmonary fissures (P = 0.01); previous chemo-radiation therapy was correlated to a lower incidence of complications (P = 0.01). MoR for PNX was as follows: risk base line = 60%; age = +0.15%/year; punctured fissures = +20%; incomplete fissures = +9%; previous CHT/RT = -10%. MoR for parenchymal haemorrhage was as follows: risk base line = 20%, lesion depth = +0.8%/mm; age = +0.25%/year; incomplete fissures = +15%. MoR for haemothorax was as follows: risk base line = 1%; previous PNX = +20%; incomplete fissures = 7%; both previous PNX and incomplete fissures = +67%.

CONCLUSION

This study provides MoRs to predict the risk of complications in patients undergoing CT-guided percutaneous lung biopsies.

A novel technique for CT-guided transthoracic biopsy of lung lesions: improved biopsy accuracy and safety

OBJECTIVES

To present the diagnostic accuracy and safety of a novel technique for CT-guided transthoracic needle aspiration biopsy (TNAB) of lung lesions suspected of malignancy.

METHODS

A novel technique for coaxial CT-guided TNAB is reported in this single-centre, retrospective study. A 22-gauge guide wire is used to accurately locate the lesion prior to biopsy. The technique enables penetration of lung lesions in various locations with less risk of harm to adjacent organs. Malignant and benign diagnoses were confirmed by histology or radiologic resolution.

RESULTS

Clinical features of 181 patients included 59% men. Mean lesion size was 24 ± 14.9 mm with a mean depth of 13.6 ± 18.3 mm. Among 160 (88.4%) confirmed malignancies, 151 (94.4%) were diagnosed with TNAB. Among the 13 (7.2%) confirmed benign diagnoses, 11 (84.6%) received a specific, benign diagnosis with TNAB. The overall diagnostic accuracy of CT-TNAB was 93.6% among all confirmed diagnoses (173/181). Complications included 48 (26.5%) with pneumothorax, of which 77.8% resolved spontaneously, 20% by aspiration and 2.2% required chest drain insertion. Intrapulmonary haemorrhage was observed in 3.9% and hemoptysis in 6.0% without clinical significance.

CONCLUSION

The guide wire technique provides a novel method for needle biopsy of lung lesions with improved accuracy and safety.

KEY POINTS

Lung cancer screening has increased the detection of lung lesions. The guide wire technique is a novel method to biopsy lung lesions. The guide wire technique for lung biopsy demonstrates improved accuracy and safety. The chest tube insertion rate is reduced with aspiration during the procedure.

Predictors of technical success and rate of complications of image-guided percutaneous transthoracic lung needle biopsy of pulmonary tumors

PURPOSE

To investigate predictors of technical success and complications of computed tomography (CT)-guided percutaneous transthoracic needle biopsy of potentially malignant pulmonary tumors.

MATERIAL AND METHODS

From 2008 to 2009, technical success and rate of complications of CT-guided percutaneous transthoracic lung needle biopsies of patients with suspicious pulmonary tumors were retrospectively evaluated. The influence on technical success and rate of complications was assessed for intervention-related predictors (lesion diameter, length of biopsy pathway, number of pleural transgressions, and needle size) and patient-related predictors (age, gender, reduced lung function). In addition, technical success and rate of complications were compared between different interventional radiologists.

RESULTS

One hundred thirty-eight patients underwent biopsies by 15 interventional radiologists. The overall technical success rate was 84.1% and was significantly different between interventional radiologists (range 25%-100%; p<0.01). Intervention-related and patient-related predictors did not influence the technical success rate. The overall complication rate was 59.4% with 39.1% minor complications and 21.0% major complications. The rate of complications was influenced by lesion diameter and distance of biopsy pathway. Interventional radiologist-related rates of complications were not statistically different.

CONCLUSIONS

Technical success of percutaneous, transthoracic lung needle biopsies of pulmonary tumors is probably dependent on the interventional radiologist. In addition, lesion diameter and length of biopsy pathway are predictors of the rate of complications.

Transthoracic biopsy of lung masses: Non technical factors affecting complication occurrence

Background

To investigate the transthoracic computed tomography (CT)-guided lung nodule biopsy complications and risk factors associated with the development of these complications.

Methods

We retrospectively evaluated a total of 41 CT-guided transthoracic biopsy complications. Data was analyzed by chi-square and independent sample t-tests.

Results

Twenty-seven patients (28.7%) developed pneumothorax and eight patients (8.5%) developed parenchymal hemorrhage, and four patients (4.3%) hemothorax and two (2.1%) patients developed subcutaneous emphysema. A significant correlation was obtained between the development of pneumothorax and lesion size (P = 0.040), and the distance that traversed the parenchyma (P = 0.001). There was a statistically significant difference between the parenchymal hemorrhage and lesion size and the distance from passed parenchyma (P values were 0.021 and 0.008, respectively). An increased incidence of parenchymal hemorrhage and pneumothorax was observed at small size and deep-seated lesions.

Conclusion

Lesion size and the distance that traversed the parenchyma on the biopsy tract are the most important factors that influence the development of complications in CT-guided transthoracic biopsy.

Surgery for undiagnosed ground glass pulmonary nodules: decision making using serial computed tomography

BACKGROUND

Although long-term observation of ground glass nodules on computed tomography facilitates the ability to distinguish malignant lesions from benign lesions, the resulting treatment delay can increase the rate of cancer recurrence. We reviewed our surgical cases of pathologically undiagnosed lung nodules possessing ground glass to clarify the clinical impact of selecting surgical candidates based on serial computed tomography, not preoperative biopsy results.

METHODS

A consecutive series of 100 patients with clinically suspected lung cancer possessing ground glass among our prospective database of 262 surgical cases of suspected lung cancer were retrospectively reviewed.

RESULTS

Surgical indication was determined based on the interval change in the outer diameter or internal attenuation of the lesions in 53 patients (increasing lesions), while that was determined based on the specific marginal or internal features of the lesions in 47 patients (non-increasing lesions). The length of preoperative follow-up was significantly longer in the patients with increasing lesions than in the patients with non-increasing lesions (27 vs. 3 months, P < 0.001). The final pathological diagnoses consisted of 97 adenocarcinomas and three non-malignant lesions. All increasing lesions were adenocarcinomas. Surgical biopsy contributed in avoiding futile lobectomy in patients with non-malignant lesions, while that caused false-negative result in one patient with an increasing lesion. Postoperative recurrence occurred in two patients.

CONCLUSIONS

In a surgical series, serial computed tomography-diagnosed ground glass lesions are highly suggestive of adenocarcinoma, especially increasing lesions. Despite spending a long-term preoperative follow-up period without a pathological diagnosis, the surgical outcome is satisfactory. Surgical biopsy for increasing lesions is generally futile.

Interstitial Fluid Pressure Correlates Clinicopathological Factors of Lung Cancer

PURPOSE

Solid tumors show increased interstitial fluid pressure (IFP), which correlates to a number of pathophysiological features of tumors. There have been no reports on the usefulness of measuring IFP in lung cancer. The aim of this study was to examine the relationship between IFP and the clinicopathological characteristics of lung cancer.

METHODS

IFP was measured prospectively in 215 patients with 219 lesions showing solid or part-solid appearance. Four patients with double lung cancer were excluded from the analysis, resulting in 211 patients with lung cancer being analyzed for the correlation between IFP and computed tomography (CT) appearance, size, Tumor-node-metastasis (TNM) classification, maximal standardized uptake value (SUVmax), histological type, tumor grade, pleural and vessel invasion, Ki-67 index, and recurrence-free survival (RFS).

RESULTS

The mean IFP was 8.5 mmHg; IFP was significantly correlated with the tumor size, SUVmax, TNM, vessel and pleural invasion, and Ki-67 index. Low IFP was associated with a better RFS compared to high IFP. Multivariate analysis did not select IFP as independent prognostic factor. In subgroup analysis of patients with adenocarcinoma, IFP was selected as independent one.

CONCLUSIONS

IFP correlates clinicopathological factors of lung cancer. IFP might be used as a prognostic factor for lung cancer.

CT-guided core needle biopsy of pleural lesions: evaluating diagnostic yield and associated complications

Objective

The purpose of this study was to retrospectively evaluate the diagnostic accuracy and complications of CT-guided core needle biopsy (CT-guided CNB) of pleural lesion and the possible effects of influencing factors.

Materials and Methods

From September 2007 to June 2013, 88 consecutive patients (60 men and 28 women; mean [± standard deviation] age, 51.1 ± 14.4 years; range, 19-78 years) underwent CT-guided CNB, which was performed by two experienced chest radiologists in our medical center. Out of 88 cases, 56 (63%) were diagnosed as malignant, 28 (31%) as benign and 4 (5%) as indeterminate for CNB of pleural lesions. The final diagnosis was confirmed by either histopathological diagnosis or clinical follow-up. The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and complication rates were statistically evaluated. Influencing factors (patient age, sex, lesion size, pleural-puncture angle, patient position, pleural effusion, and number of pleural punctures) were assessed for their effect on accuracy of CT-guided CNB using univariate and subsequent multivariate analysis.

Results

Diagnostic accuracy, sensitivity, specificity, PPV, and NPV were 89.2%, 86.1%, 100%, 100%, and 67.8%, respectively. The influencing factors had no significant effect in altering diagnostic accuracy. As far as complications were concerned, occurrence of pneumothorax was observed in 14 (16%) out of 88 patients. Multivariate analysis revealed lesion size/pleural thickening as a significant risk factor (odds ratio [OR]: 8.744, p = 0.005) for occurrence of pneumothorax. Moreover, presence of pleural effusion was noted as a significant protective factor (OR: 0.171, p = 0.037) for pneumothorax.

Conclusion

CT-guided CNB of pleural lesion is a safe procedure with high diagnostic yield and low risk of significant complications.

[Invasive procedure for clarification of pulmonary nodules]

CLINICAL/METHODICAL ISSUE

The management of solitary lung nodules poses a common clinical problem and biopsy is oftten required. Several guidelines provide slightly different recommendations and there are no uniform recommendations regarding the ideal technique of puncture guidance (e.g. percutaneous versus bronchoscopic or thoracoscopic).

STANDARD RADIOLOGICAL METHODS

Fine needle aspiration biopsy (FNA) and core biopsy are well established techniques. Both can be performed under CT and to some extent ultrasound guidance.

PERFORMANCE

Diagnostic accuracies of FNA and core biopsy for malignant lesions are around 95 %. Core biopsy is superior to FNA for establishing a specific diagnosis with a diagnostic yield of 81-88 % versus 17-21 %.

ACHIEVEMENTS

In clinical routine practice core biopsy is the superior tool when compared to FNA.

PRACTICAL RECOMMENDATIONS

Central lesions in close proximity to bronchi may be biopsied with endobronchial ultrasound (EBUS)-guided bronchoscopy. In all other lesions percutaneous, ideally CT-guided biopsy should be the method of first choice.

Successful Diagnosis of a Thymoma by Endobronchial Ultrasound-guided Transbronchial Needle Aspiration: A Report of Two Cases

We herein report two cases of thymomas diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In both cases, the tumor was adjacent to the central airway. Therefore, we attempted to perform EBUS-TBNA in order to obtain specimens for a histopathological examination, which resulted in a diagnosis of thymoma. In one case, surgical resection was conducted and the histological evaluation of the resected specimen confirmed thymoma type AB, consistent with the histology from the EBUS-TBNA specimen. As a safe and minimally invasive procedure, EBUS-TBNA may be considered for the diagnosis of mediastinal tumors, including thymoma.

Influenceable and Avoidable Risk Factors for Systemic Air Embolism due to Percutaneous CT-Guided Lung Biopsy: Patient Positioning and Coaxial Biopsy Technique-Case Report, Systematic Literature Review, and a Technical Note

Following the first case of a systemic air embolism due to percutaneous CT-guided lung biopsy in our clinic we analysed the literature regarding this matter in view of influenceable or avoidable risk factors. A systematic review of literature reporting cases of systemic air embolism due to CT-guided lung biopsy was performed to find out whether prone positioning might be a risk factor regarding this issue. In addition, a technical note concerning coaxial biopsy practice is presented. Prone position seems to have relevance for the development and/or clinical manifestation of air embolism due to CT-guided lung biopsy and should be considered a risk factor, at least as far as lesions in the lower parts of the lung are concerned. Biopsies of small or cavitary lesions in coaxial technique should be performed using a hemostatic valve.

Patient reported experiences of CT guided lung biopsy: a prospective cohort study

Background

CT guided lung biopsy is a commonly performed procedure to obtain tissue for a histological diagnosis in cases of suspected lung cancer.

Methods

This is a prospective cohort study to obtain information directly from patients about their experiences of the biopsy procedure, thus obtaining a more accurate picture of complications compared with previously performed retrospective reviews. Patients participated in a post-procedure telephone interview and information was gathered about any procedural complications and personal experiences. We also compared the patient reported complications with those obtained from a retrospective review of hospital databases, analogous to previously performed retrospective studies.

Results

In our patient group, reported procedural complication rates were 10% pneumothorax rate (4% requiring a chest drain) and 10% haemoptysis. Post-procedural pain and shortness of breath showed positive correlation, with one patient experiencing prolonged pain. No statistical difference was found between the patient reported complication rates and those obtained from retrospective review of the hospital database.

Conclusions

Our study demonstrates CT guided lung biopsy is a safe procedure and is generally well tolerated. Some patients may experience significant and lasting pain and therefore should be counselled about this pre-procedure.

Invasive lung cancer staging: influence of CT-guided core needle biopsy on onset of pleural carcinomatosis

In lung cancer patients with single peripheral lesions, CT-guided needle biopsies (CTNBs) are common for histological sampling. Recently published studies showed conflicting results for the influence of CTNB on the onset of pleural carcinomatosis (PC). In order to estimate the influence of CTNB on pleural tumor spread, 146 histologically confirmed cases of lung cancer diagnosed by CTNB were retrospectively compared to 112 control lung cancer patients diagnosed by non-CTNB. CTNB was not associated with an earlier onset of PC, identifying CTNB as a safe procedure for minimally invasive lung cancer staging.

Risk factor analysis of pulmonary hemorrhage complicating CT-guided lung biopsy in coaxial and non-coaxial core biopsy techniques in 650 patients

PURPOSE

To evaluate the risk factors involved in the development of pulmonary hemorrhage complicating CT-guided biopsy of pulmonary lesions in coaxial and non-coaxial techniques.

MATERIALS AND METHODS

Retrospective study included CT-guided percutaneous lung biopsies in 650 consecutive patients (407 males, 243 females; mean age 54.6 years, SD: 5.2) from November 2008 to June 2013. Patients were classified according to lung biopsy technique in coaxial group (318 lesions) and non-coaxial group (332 lesions). Exclusion criteria for biopsy were: lesions <5mm in diameter, uncorrectable coagulopathy, positive-pressure ventilation, severe respiratory compromise, pulmonary arterial hypertension or refusal of the procedure. Risk factors for pulmonary hemorrhage complicating lung biopsy were classified into: (a) patient's related risk factors, (b) lesion's related risk factors and (d) technical risk factors. Radiological assessments were performed by two radiologists in consensus. Mann-Whitney U test and Fisher's exact tests for statistical analysis. p values <0.05 were considered statistically significant.

RESULTS

Incidence of pulmonary hemorrhage was 19.6% (65/332) in non-coaxial group and 22.3% (71/318) in coaxial group. The difference in incidence between both groups was statistically insignificant (p=0.27). Hemoptysis developed in 5.4% (18/332) and in 6.3% (20/318) in the non-coaxial and coaxial groups respectively. Traversing pulmonary vessels in the needle biopsy track was a significant risk factor of the development pulmonary hemorrhage (incidence: 55.4% (36/65, p=0.0003) in the non-coaxial group and 57.7% (41/71, p=0.0013) in coaxial group). Other significant risk factors included: lesions of less than 2 cm (p value of 0.01 and 0.02 in non-coaxial and coaxial groups respectively), basal and middle zonal lesions in comparison to upper zonal lung lesions (p=0.002 and 0.03 in non-coaxial and coaxial groups respectively), increased lesion's depth from the pleural surface (p=0.021 and 0.018 in non-coaxial and coaxial groups respectively), increased distance of traversed lung in the needle track of more than 2.5 cm (p=0.001 in both groups). Insignificant risk factors were patient's age, gender or emphysema in both groups (p value >0.1 in both groups). Concomitant incidence of pneumothorax was 32.3% (21/65) in non-coaxial group and 36.6% (26/71) in coaxial group. Pulmonary hemorrhage in the majority of cases was treated conservatively.

CONCLUSION

Pulmonary hemorrhage complicating CT-guided core biopsy of pulmonary lesions, showed insignificant difference between coaxial and non-coaxial techniques. Significant risk factors of pulmonary hemorrhage included small and basal lesions, increased lesion's depth from pleural surface, increased length of aerated lung parenchyma crossed by biopsy needle and passing through vessels within the lung during puncture.

Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance

Transthoracic needle biopsy (TTNB) is done with imaging guidance and most frequently by a radiologist, for the aim is to diagnose a defined mass. It is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. FNAC is a method of aspiration cytopathology, which with transthoracic biopsy ("core biopsy") is a group of percutaneous minimally invasive diagnostic procedures for exploration of lung lesions. Needle choice depends mostly upon lesion characteristics and location. A recent innovation in biopsy needles has been the introduction of automatic core biopsy needle devices that yield large specimens and improve the diagnostic accuracy of needle biopsy. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Common complications of TTNB include pneumothorax and hemoptysis. The incidence of pneumothorax in patients undergoing TTNB has been reported to be from 9-54%, according to reports published in the past ten years, with an average of around 20%. Which factors statistically correlate with the frequency of pneumothorax remain controversial, but most reports have suggested that lesion size, depth and the presence of emphysema are the main factors influencing the incidence of pneumothorax after CT-guided needle biopsy. On the contrary, gender, age, and the number of pleural passes have not been shown to correlate with the incidence of pneumothorax. The problem most responsible for complicating outpatient management, after needle biopsy was performed, is not the presence of the pneumothorax per se, but an increase in the size of the pneumothorax that requires chest tube placement and patient hospitalization. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications.

Percutaneous lung biopsy: technique, efficacy, and complications

Computed tomography-guided percutaneous needle biopsy of the lung is an indispensable tool in the evaluation of pulmonary abnormalities due to its high diagnostic accuracy in the detection of malignancy. Percutaneous biopsy in the lung plays a critical role in obtaining pathologic proof of malignancy, guiding staging and planning treatment. This article reviews biopsy techniques and their related efficacy and complications.

Tumor acquisition for biomarker research in lung cancer

The biopsy collection data from two lung cancer trials that required fresh tumor samples be obtained for microarray analysis were reviewed. In the trial for advanced disease, microarray data were obtained on 50 patient samples, giving an overall success rate of 60.2%. The majority of the specimens were obtained through CT-guided lung biopsies (N = 30). In the trial for early-stage patients, 28 tissue specimens were collected from excess tumor after surgical resection with a success rate of 85.7%. This tissue procurement program documents the feasibility in obtaining fresh tumor specimens prospectively that could be used for molecular testing.

Molecular analysis of circulating tumour cells-biology and biomarkers

Growing evidence for intratumour heterogeneity informs us that single-site biopsies fall short of revealing the complete genomic landscape of a tumour. With an expanding repertoire of targeted agents entering the clinic, screening tumours for genomic aberrations is increasingly important, as is interrogating the tumours for resistance mechanisms upon disease progression. Multiple biopsies separated spatially and temporally are impractical, uncomfortable for the patient and not without risk. Here, we describe how circulating tumour cells (CTCs), captured from a minimally invasive blood test-and readily amenable to serial sampling-have the potential to inform intratumour heterogeneity and tumour evolution, although it remains to be determined how useful this will be in the clinic. Technologies for detecting and isolating CTCs include the validated CellSearch(®) system, but other technologies are gaining prominence. We also discuss how recent CTC discoveries map to mechanisms of haematological spread, previously described in preclinical models, including evidence for epithelial-mesenchymal transition, collective cell migration and cells with tumour-initiating capacity within the circulation. Advances in single-cell molecular analysis are enhancing our ability to explore mechanisms of metastasis, and the combination of CTC and cell-free DNA assays are anticipated to provide invaluable blood-borne biomarkers for real-time patient monitoring and treatment stratification.

Evaluation of undiagnosed solitary lung nodules according to the probability of malignancy in the American College of Chest Physicians (ACCP) evidence-based clinical practice guidelines

Background

This study retrospectively investigated the clinical significance of undiagnosed solitary lung nodules removed by surgical resection.

Patients and methods

We retrospectively collected data on the age, smoking, cancer history, nodule size, location and spiculation of 241 patients who had nodules measuring 7 mm to 30 mm and a final diagnosis established by histopathology. We compared the final diagnosis of each patient with the probability of malignancy (POM) which was proposed by the American College of Chest Physicians (ACCP) guidelines.

Results

Of the 241 patients, 203 patients were diagnosed to have a malignant lung tumor, while 38 patients were diagnosed with benign disease. There were significant differences in the patients with malignant and benign disease in terms of their age, smoking history, nodule size and spiculation. The mean value and the standard deviation of the POM in patients with malignant tumors were 51.7 + 26.1%, and that of patients with benign lesions was 34.6 + 26.7%. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.67. The best cut-off value provided from the ROC curve was 22.6. When the cut-off value was set at 22.6, the sensitivity was 83%, specificity 52%, positive predictive value 90%, negative predictive value 36% and accuracy 77%, respectively.

Conclusions

The clinical prediction model proposed in the ACCP guidelines showed unsatisfactory results in terms of the differential diagnosis between malignant disease and benign disease of solitary lung nodules in our study, because the specificity, negative predictive value and AUC were relatively low.

Computed tomography-guided core needle biopsy of lung lesions: Diagnostic yield and correlation between factors and complications

The aim of the present study was to determine the diagnostic accuracy of computed tomography (CT)-guided core needle biopsy (CNB) and to retrospectively analyze the correlation between the factors and complications of the procedure. Between January 2009 and June 2010, CNB was performed on 345 lung lesions in 343 patients. These patients were then followed up for at least two years. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the CNB diagnoses were calculated. The correlation between factors, such as smoking, positoin and maximal diameter, and the complications of pneumothorax and hemorrhage was analyzed by χ² test. The sensitivity, specificity, accuracy, PPV and NPV of the CNB diagnoses were 97.3, 100, 97.7, 100 and 87.7%, respectively. A statistically significant correlation was found between pneumothorax and the factors of smoking (P=0.015) and position (P<0.01) and length of the needle in the normal parenchyma (P=0.011), as well as between hemorrhage and the maximal diameter (P=0.005) and length of the needle in the normal parenchyma (P<0.01) and the frequency of needle adjustments (P<0.01). A CT-guided core needle biopsy of the lung lesions provides a high diagnostic yield. Smoking, the decubitus position and a longer length of the needle in the normal parenchyma were found to represent risk factors for a pneumothorax. In addition, a small diameter and longer length of the needle in the normal parenchyma and a more frequent adjustment of the needle were poor predictive factors of hemorrhage.

Molecular characterization of scant lung tumor cells using iron-oxide nanoparticles and micro-nuclear magnetic resonance

Advances in nanotechnology and microfluidics are enabling the analysis of small amounts of human cells. We tested whether recently developed micro-nuclear magnetic resonance (μNMR) technology could be leveraged for diagnosing pulmonary malignancy using fine needle aspirate (FNA) of primary lesions and/or peripheral blood samples. We enrolled a cohort of 35 patients referred for CT biopsy of primary pulmonary nodules, liver or adrenal masses and concurrently obtained FNA and peripheral blood samples. FNA sampling yielded sufficient material for μNMR analysis in 91% of cases and had a sensitivity and specificity of 91.6% and 100% respectively. Interestingly, among blood samples with positive circulating tumor cells (CTC), μNMR analysis of each patient's peripheral blood led to similar diagnosis (malignant vs benign) and differential diagnosis (lung malignancy subtype) in 100% and 90% (18/20) of samples, respectively. μNMR appears to be a valuable, non-invasive adjunct in the diagnosis of lung cancer.

FROM THE CLINICAL EDITOR

The authors of this study established that recently developed micro-nuclear magnetic resonance (μNMR) technology can be leveraged for diagnosing pulmonary malignancy using fine needle aspirate (FNA) of primary lesions and/or peripheral blood samples derived from 35 patients, suggesting practical clinical applicability of this technique.