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

[Discrepancies between primary tumor and metastasis: impact on personalized medicine]

Molecular characterization of tumors is critical for the development and appropriate use of many anti-cancer agents. Potential discrepancies between primary tumor and secondary lesions lead to question on the optimal modalities for evaluation of biomarkers. In light of recent data, the need of iterative biopsies in metastatic setting has been suggested but technical and methodological limits in such analyses should not be ignored and this strategy can not be definitively validated. The evaluation of spatial and temporal variability of biomarkers in solid tumors should take into account tumoral context and therapeutic history of each patient for the development of personalized medicine in oncology.

Newer modalities in the work-up of peripheral pulmonary nodules

Technological advances in recent years have translated into the availability of newer modalities to establish the cause of peripheral pulmonary nodules (PPN). Even though the verdict is still out on the ideal diagnostic modality, there is no doubt that the bronchoscope is becoming a popular tool in the armamentarium of physicians who deal with PPN. This article focuses on newer bronchoscopic modalities being studied for the work-up of PPN. The authors also summarize the value of established diagnostic modalities to provide a balanced perspective.

CT-Guided Thoracic Biopsy: Evaluating Diagnostic Yield and Complications

Introduction: This study retrospectively evaluated CT-guided thoracic biopsies for diagnostic yield, accuracy and complications. Materials and Methods: A retrospective analysis of 384 patients (mean age 62.7 years; male/female = 251/133) who underwent 399 CT-guided thoracic biopsies were performed for evaluating diagnostic yield, accuracy and complications. Correlations between patients age, procedure factors (biopsy-needle size, number of passes, lesion-size, lesion-depth and traversed lung-length) and complications such as pneumothorax, haemothorax and haemoptysis were evaluated. A comparison between fine needle aspiration (FNA) group and core ± FNA group for diagnostic yield and complications was also performed. Results: FNA was performed in 349 patients and core ± FNA in 50 patients. The biopsy samples were adequate in 91.9% and the diagnostic accuracy for malignant lesions was 96.8% with 95.7% sensitivity and 100% specificity. Pneumothorax (detected on CT) occurred in 139 cases (34.8%) and only 12 (3.0%) required insertion of an intercostal drain. Mild haemoptysis occurred in 13 patients (3.2%) and small haemothoraces in 2 patients. Pneumothorax occurrence was significantly associated with the traversed lung-length (>3mm), lesion-size (≤33 mm) and lesion-depth (≥60mm) (P <0.05). Haemoptysis occurrence was also significantly associated with traversed lung-length (>3mm) and lesion-size (≤33 mm) (P <0.05). There was no significant difference between diagnostic yield and complication rate between FNA and core ± FNA groups. Conclusion: CT-guided thoracic biopsy is a safe procedure with high diagnostic yield and low risk of significant complications. Traversed lung-length and smaller lesion size are associated with occurrence of pneumothorax and haemoptysis. Key words: Accuracy, Complications, Diagnostic yield, Haemoptysis, Pneumothorax

Next-Generation Sequencing Reveals High Concordance of Recurrent Somatic Alterations Between Primary Tumor and Metastases From Patients With Non–Small-Cell Lung Cancer

Purpose

Characterization of the genomic changes that drive an individual patient's disease is critical in management of many cancers. In patients with non–small-cell lung cancer (NSCLC), obtaining tumor samples of sufficient size for genomic profiling on recurrence is often challenging. We undertook this study to compare genomic alterations identified in archived primary tumors from patients with NSCLC with those identified in metachronous or synchronous metastases.

Patients and Methods

Primary and matched metastatic tumor pairs from 15 patients were analyzed by using a targeted next-generation sequencing assay in a Clinical Laboratory Improvement Amendments laboratory. Genomic libraries were captured for 3,230 exons in 182 cancer-related genes plus 37 introns from 14 genes often rearranged in cancer and sequenced to high coverage.

Results

Among 30 tumors, 311 genomic alterations were identified of which 63 were known recurrent (32 in primary tumor, 31 in metastasis) and 248 were nonrecurrent (likely passenger). TP53 mutations were the most frequently observed recurrent alterations (12 patients). Tumors harbored two or more (maximum four) recurrent alterations in 10 patients. Comparative analysis of recurrent alterations between primary tumor and matched metastasis revealed a concordance rate of 94% compared with 63% for likely passenger alterations.

Conclusion

This high concordance suggests that for the purposes of genomic profiling, use of archived primary tumor can identify the key recurrent somatic alterations present in matched NSCLC metastases and may provide much of the relevant genomic information required to guide treatment on recurrence.

CT-guided percutaneous core needle biopsy for small (≤20 mm) pulmonary lesions

AIM

To assess the accuracy and risk factors for complications of computed tomography (CT)-guided percutaneous core needle biopsy (CNB) for small (≤20 mm) pulmonary lesions.

MATERIALS AND METHODS

A retrospective study was undertaken comprising 169 patients who underwent CT-guided CNB for small (≤20 mm) pulmonary lesions. To assess the accuracy of the procedure, the diagnosis at biopsy was compared with the diagnosis after definitive surgery or clinical follow-up. The risk factors for pneumothorax and bleeding were determined by multivariate analysis of variables.

RESULTS

The overall diagnostic accuracy was 93.5%. The sensitivity for malignancy and specificity for benign lesions were 90.4% and 100%, respectively. Positive and negative predictive values were 100% and 83.3%, respectively. Twenty-five patients (14.8%) had pneumothorax after CT percutaneous CNB of the lung. The significant risk factors affecting the incidence of pneumothorax were lesion-pleural distance (p = 0.008) and needle-pleural angle (p = 0.012). The highest rate of pneumothorax correlated with a lesion-pleural distance ≥21 mm (OR = 18.46; 95%CI: 2.27-149.95) and a needle-pleural angle ≥51° (OR = 8.22; 95%CI: 2.14-31.49). Bleeding occurred in 30 patients (17.8%). The only significant risk factor affecting the incidence of bleeding was lesion-pleural distance (p = 0.011). The highest bleeding rate correlated with a lesion-pleural distance ≥21 mm (OR = 7.93; 95%CI: 1.73-36.43).

CONCLUSION

CT-guided percutaneous CNB of small (≤20 mm) pulmonary lesions provides high diagnostic accuracy with acceptable complications. A lesion-pleural distance of ≥21 mm and needle-pleural angle of ≥51° are identified as the risk factors for highest pneumothorax rate. In addition, the needle-pleural angle is a novel predictor of pneumothorax. A lesion-pleural distance of ≥21 mm is also identified as a risk factor for the highest bleeding rate.

The impact of coaxial core biopsy guided by FDG PET/CT in oncological patients

OBJECTIVE

When deciding on therapy, FDG PET/CT-positive results should be confirmed by histology if possible. We evaluated the impact of percutaneous PET/CT-guided biopsies on histological confirmation of PET/CT-positive lesions.

METHODS

We prospectively evaluated 126 patients who had undergone a PET/CT scan with positive results with an indication for histological evaluation of lesions. Imaging was performed in a PET/CT scanner with a fluoroscopic imaging system. A total of 130 lesions were accessed by PET/CT-guided biopsy. The technical feasibility, clinical success and complication rates of PET/CT-guided biopsies were evaluated.

RESULTS

Of 130 PET/CT-positive lesions, 128 (98.5 %) were successfully accessed and representative tissue samples obtained. Two lesions were reaccessed due to inconclusive histological results. Histology showed that 99 of the 130 lesions (76.2 %) were malignant, and 31 lesions (23.8 %) were benign (inflammatory cells or necrotic tissue); these patients had no recurrence of disease after a minimum follow-up of 6 months. Also, in 23 of the 130 lesions (17.7 %), the patient was referred for the PET/CT-guided biopsy due to a previous nontumoral biopsy result, and of these 23 lesions, 21 were found to be malignant. The complication rates were: pneumothorax in 15/130 (11.5 %; resolved spontaneously), haemoptysis in 2/130 (1.5 %) and severe haemothorax in 1/130 (0.8 %); there was no procedure-related mortality.

CONCLUSION

PET/CT-guided biopsy is feasible and may optimize the diagnostic yield of image-guided interventions. Also, PET/CT-positive lesions with no morphological correlation may now be accessible to percutaneous interventions.

CT-guided percutaneous biopsy of intrathoracic lesions

Percutaneous CT-guided needle biopsy of mediastinal and pulmonary lesions is a minimally invasive approach for obtaining tissue for histopathological examination. 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. In this pictorial review, we reviewed important anatomical approaches, technical aspects of the procedure, and its associated complications.

Atrial fibrillation and pneumothorax after transthoracic needle lung biopsy

An obese 65-year-old male smoker with chronic obstructive pulmonary disease developed an iatrogenic pneumothorax with pulmonary haemorrhage during an elective transthoracic needle biopsy of a pulmonary lesion. Successful re-inflation was achieved with a chest drain which was then removed before transfer to the medical ward. He later developed persistent atrial fibrillation with breathlessness and haemoptysis. He was treated empirically for a pulmonary embolus, which was subsequently ruled out with CT pulmonary angiogram. Serial chest radiographs demonstrated recurrence of his pneumothorax and a chest drain was re-inserted. His atrial fibrillation was erroneously managed as supraventricular tachycardia, which was resistant to vagal manoeuvres and adenosine but later responded to intravenous amiodarone before a further relapse. Upon successful management of the pneumothorax, his atrial fibrillation terminated. This case highlighted the persistent and serious nature of complications posttransthoracic needle biopsy.