Repeat needle biopsies combined with clinical observation are safe and accurate in the management of a solitary pulmonary nodule

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Concordance Assessment of Pathology Results with Imaging Findings after Image-Guided Biopsy

PURPOSE

To assess the impact of radiology review for discordance between pathology results from computed tomography (CT)-guided biopsies versus imaging findings performed before a biopsy.

MATERIALS AND METHODS

In this retrospective review, which is compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board, 926 consecutive CT-guided biopsies performed between January 2015 and December 2017 were included. In total, 453 patients were presented in radiology review meetings (prospective group), and the results were classified as concordant or discordant. Results from the remaining 473 patients not presented at the radiology review meetings were retrospectively classified. Times to reintervention and to definitive diagnosis were obtained for discordant cases; of these, 49 (11%) of the 453 patients were in the prospective group and 55 (12%) of the 473 patients in the retrospective group.

RESULTS

Pathology results from CT-guided biopsies were discordant with imaging in 11% (104/926) of the cases, with 57% (59/104) of these cases proving to be malignant. In discordant cases, reintervention with biopsy and surgery yielded a shorter time to definitive diagnosis (28 and 14 days, respectively) than an imaging follow-up (78 days) (P < .001). The median time to diagnosis was 41 days in the prospective group and 56 days in the retrospective group (P = .46). When radiologists evaluated the concordance between pathology and imaging findings and recommended a repeat biopsy for the discordant cases, more biopsies were performed (50% [11/22] vs 13% [4/31]; P = .005).

CONCLUSIONS

Eleven percent of CT-guided biopsies yielded pathology results that were discordant with imaging findings, with 57% of these proving to be malignant on further workup.

Timeliness of lung cancer diagnosis and treatment: a single-center experience

Background

Lung cancer is the number one cause of cancer death in America. Timely and appropriate care is critical in the management of lung cancer. We retrospectively reviewed our experience at the University of Kentucky to determine whether there were delays from initial presentation to diagnosis and from diagnosis to treatment. Furthermore, if delays existed, whether they affected overall survival and what factors contributed to these holdups in patient care.

Methods

This was a retrospective review of all patients who were diagnosed with lung cancer at the University of Kentucky between 2014 and 2017, including only those newly diagnosed at our institution and excluding patients who were diagnosed at other hospitals as well as patients with cancer recurrence. Out of a cohort of 3588 patients, only 517 were included.

Results

The average time between presentation and diagnosis was 43 days, and 86.7% of patients were diagnosed within 60 days. The average time to treatment from diagnosis was 27.5 days with 77.7% of patients being treated with either surgery, chemotherapy, and/or radiation within 42 days.

Conclusion

The majority of our patients were diagnosed and treated within the recommended time. The 13.3% and 22.3% of patients who did not fall within this timeframe were delayed due to personal reasons, comorbidities, and/or “watchful waiting”. Mortality seemed to be unaffected by any delays in diagnosis or treatment. This analysis is the first step in understanding the challenges in patient care, and can be a tool to institute programs to help patients obtain necessary care.

Virtual bronchoscopic navigation as an aid to CT-guided transbronchial biopsy improves the diagnostic yield for small peripheral pulmonary lesions

BACKGROUND AND OBJECTIVE

Virtual bronchoscopic navigation (VBN) entails the provision of a virtual display of the bronchial routes that lead to small peripheral pulmonary lesions (PPL). It has been predicted that a combination of computed tomography (CT)-guided transbronchial biopsy (CT-TBB) with VBN might improve the diagnostic yield for small PPL. This study sought to investigate that prediction.

METHODS

A total of 100 patients with small PPL (<20 mm) were enrolled for CT-TBB and randomly allocated to either a VBN+ or VBN- group (50 subjects per group). Group results were then compared in terms of diagnostic yield, whole procedure time, times at which the first CT scan and biopsy were taken and the number of lung biopsy specimens retrieved.

RESULTS

The diagnostic yield for small PPL was significantly higher in the VBN+ group versus VBN- group (84% vs 58%, respectively (P = 0.013)), with no significant difference in (whole) examination time between groups (VBN+: 32:53 (32 min and 53 s) ± 12:01 vs VBN-: 33:06 ± 10:08 (P = NS)). However, the time periods between commencing the examination and either the first CT scan or first biopsy were significantly shorter for the VBN+ group, while the net biopsy time tended to be longer for this group with a significantly higher number of specimens collected (VBN+: 3.54 ± 1.07 specimens vs VBN-: 2.98 ± 1.06 specimens (P = 0.01)).

CONCLUSION

Combining VBN with CT-TBB significantly improved the diagnostic yield for small PPL.

Predictive value of dual-time 18F-FDG PET/CT to distinguish primary lung and metastatic adenocarcinoma in solitary pulmonary nodule

AIMS AND BACKGROUND

Distinction between primary lung adenocarcinoma and metastatic adenocarcinoma from extrapulmonary origin in solitary pulmonary nodule (SPN) is crucial for cancer treatment. We investigated the predictive role of dual-time-point ¹⁸F-FDG PET/CT to distinguish primary and metastatic lung adenocarcinoma in SPN.

METHODS

A total of 96 consecutive patients with newly diagnosed SPN and biopsy-proven adenocarcinoma were enrolled in this study, retrospectively (54 male; 42 female; age 59.68 ± 8.2 years). They all underwent dual-time-point ¹⁸F-FDG PET/CT at 60 minutes (early) for whole body and 120 minutes (delayed) for chest region after FDG injection. Maximum standardized uptake values (early SUVmax and delayed SUVmax) and retention index (RI) were acquired for analysis. Final pathology results were confirmed by surgical specimens.

RESULTS

Metastatic adenocarcinoma showed significantly higher early SUVmax, delayed SUVmax, and RI compared to primary lung adenocarcinoma. Delayed SUVmax and RI presented superior diagnostic performance for prediction of metastatic adenocarcinoma than early ¹⁸F-FDG PET/CT. Among metastatic adenocarcinoma, metastasis from colorectal origin showed significantly higher RI than from other origins. In addition, RI significantly predicted metastatic adenocarcinoma from colorectal cancer than early or delayed SUVmax.

CONCLUSIONS

Dual-timepoint ¹⁸F-FDG PET/CT can be useful to distinguish primary and metastatic lung adenocarcinoma in SPN. Furthermore, it may also be useful to predict metastatic adenocarcinoma from colorectal origin.

Lung Cancer Biopsies

Image-guided percutaneous transthoracic needle biopsy (PTNB) is a well-established and minimally invasive technique for evaluating pulmonary nodules. Implementation of a national lung screening program and increased use of chest computed tomography have contributed to the frequent identification of indeterminate pulmonary nodules that may require tissue sampling. The advent of biomarker-driven lung cancer therapy has led to increased use of repeat PTNB after diagnosis. Percutaneous insertion of markers for preoperative localization of small nodules can aid in minimally invasive surgery and radiation treatment planning. This article discusses PTNB, patient selection, and biopsy technique, including minimizing and managing complications.

Correlation Between Circulating Tumor DNA Levels and Response to Tyrosine Kinase Inhibitors (TKI) Treatment in Non-Small Cell Lung Cancer

BACKGROUND Clinical monitoring of EGFR-positive NSCLC patients is important to gauge treatment response. The current study addresses the usage of circulating tumor DNA (ctDNA) as a prognostic marker during treatment of first-generation TKIs. MATERIAL AND METHODS Serial samplings of peripheral blood from 200 EGFR-positive NSCLC patients were taken. Baseline ctDNA quantification was conducted by digital droplet PCR before TKI treatment was administered and compared to primary biopsies. Thereafter blood sampling at different treatment cycles were measured and assessed for its prognostic and predictive value. RESULTS ctDNA was successfully detected in a number of patients and overall concordance rate was 84%. Importantly, we observed a strong correlation to ctDNA increase with disease progression using radiographic scans. In addition to survival analysis, we noted patients with the largest ctDNA variations had worst outcome. A significant number of EGFR patients during treatment developed a secondary mutation T790M and this cohort had worst survival outcome as well. CONCLUSIONS Our study demonstrated a highly associative relation of ctDNA to NSCLC patients during treatment that can be utilized to gauge treatment response. CtDNA is an attractive means compared with conventional core needle biopsies and presents new methods for accurately profiling NSCLC disease progression.

Transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

Fluoroscopy-guided transbronchial needle aspiration (TBNA) has long been used in the diagnosis of peripheral pulmonary lesions (PPLs), although its diagnostic performance varies considerably.We conducted a systematic review and meta-analysis evaluating the accuracy of TBNA in the diagnosis of PPLs, comparing its diagnostic yield with transbronchial biopsy (TBB) and assessing the main predictors of a successful aspirate.In 18 studies, the overall TBNA yield was 0.53 (95% CI 0.44-0.61). TBNA showed a higher accuracy when directly compared to TBB (0.60 (95% CI 0.49-0.71) versus 0.45 (95% CI 0.37-0.54)). The subgroup analyses documented a higher TBNA yield when the computed tomography (CT) bronchus sign was present (0.70 (95% CI 0.63-0.77) versus 0.51 (95% CI 0.38-0.64)), when rapid on-site evaluation (ROSE) was performed (0.62 (95% CI 0.43-0.79) versus 0.51 (95% CI 0.42-0.60)), in the case of malignant lesions (0.55 (95% CI 0.44-0.66) versus 0.17 (95% CI 0.11-0.24)) and for lesions >3 cm (0.81 (95% CI 0.73-0.87) versus 0.55 (95% CI 0.47-0.63)).Conventional TBNA is a useful sampling technique for the diagnosis of PPL, with a higher diagnostic yield than TBB. The presence of CT bronchus sign, an underlying malignant process, lesion size >3 cm and ROSE employment are predictors of a higher yield.

Community hospital experience using electromagnetic navigation bronchoscopy system integrating tidal volume computed tomography mapping

Results of the first 50 consecutive patients referred for bronchoscopy or surgery by the tumor review board to confirm suspect lung lesions identified by computed tomography. Electromagnetic navigation was used to biopsy peripheral pulmonary nodules, (19.3 ± 10.7 mm). An electromagnetic tracking system was used to detect miniature position sensors integrated directly into tip-tracked instruments advanced through a 2 mm working channel in a bronchoscope. Learning curve, diagnostic yield, safety and use of the 4D positional information on the patient's tidal volume expiration computed tomography map demonstrate a potential to improve the diagnostic yield of transbronchial biopsies of peripheral pulmonary nodules less than 30 mm reporting a diagnostic yield of 83.3% (40/48). Early experience was safe and effective, with a limited learning curve.

Role of rebiopsy in relapsed non-small cell lung cancer for directing oncology treatments

Background. Currently, few rebiopsies are performed in relapses of advanced non-small cell lung cancer. They are not customary in clinical practice of lung cancer. However, it is not possible to properly target treatments in cases of relapse without knowing the nature of new lesions. Design. This paper comprehensively summarizes the available literature about rebiopsy and broadly discusses the importance of rebiopsy in advanced non-small cell lung cancer. Results. Altogether 560 abstracts were used as material for further analysis. 19 articles were about clinical rebiopsy in lung cancer and were reviewed in detailed manner. Conclusions. This review shows that rebiopsy is feasible in non-small cell lung cancer, and success rates can be high if rebiopsy is accompanied by adequate evaluation before biopsy. Its use may resolve the difficulties in sampling bias and detecting changes in cancer characteristics. In cases where treatment was selected based on tissue characteristics that then change, the treatment selection process must be repeated while considering new characteristics of the tumor. Rebiopsy may be used to predict therapeutic resistance and consequently redirect targeted therapies. Such knowledge may resolve the difficulties in sampling bias and also in selecting preexisting clones or formulating drug-resistant ones. Rebiopsy should be performed more often in non-small cell lung cancer.

TBNA with and without EBUS: a comparative efficacy study for the diagnosis and staging of lung cancer

INTRODUCTION

Conventional transbronchial needle aspiration (TBNA) has been around for over 30 years with sensitivities approaching 70-90%. Recent development of endobronchial ultrasound (EBUS) TBNA demonstrated even higher sensitivities among experts. However EBUS-TBNA is more costly and less available worldwide than conventional TBNA. A comparison study to determine the efficacy of TBNA with and without EBUS in the diagnosis and staging of lung cancer is described.

METHODS

A total of 287 patients with mediastinal and hilar lymphadenopathy presenting for diagnosis and/or staging of lung cancer at enrolling institutions were included. Equal numbers of punctures were performed at the target lymph node stations using conventional TBNA techniques followed by EBUS-TBNA at the same sites. Patients and puncture sites that were biopsied by both methods and were positive for lung cancer were compared to establish efficacy of each technique on the same patients.

RESULTS

In 253 patients at least one pair of specimens were obtained by conventional TBNA and EBUS-TBNA. In 83 of these patients malignancy was diagnosed. Among the 83 patients with a diagnosis of a malignancy there was no significant difference in the diagnostic yield of conventional TBNA versus EBUS-TBNA. When comparing diagnosis of malignancy for each lymph node sampled, there were a significantly greater number of positive (diagnostic for malignancy) lymph nodes sampled by EBUS-TBNA.

CONCLUSIONS

Recommendations for current practice depend on individual centers and bronchoscopist comfort level with TBNA (with or without EBUS). In our study, no significant difference was seen between the techniques for the diagnosis and staging of individual patients.

Granulomatous inflammation and organizing pneumonia: Role of computed tomography-guided lung fine needle aspirations, touch preparations and core biopsies in the evaluation of common non-neoplastic diagnoses

Background:

Fine-needle aspirations (FNAs) and core biopsies (CBs), with or without touch preparations (TPs), are performed to characterize pulmonary lesions. Although a positive (P) or suspicious report is sufficient for further management, the significance of unsatisfactory (U), negative (N) and atypical (A) cytological diagnoses remains uncertain. The aims of the study were to correlate U, N and A cytological diagnoses with histological and/or clinical/radiological follow-up and evaluate the utility of FNAs, TPs and CBs.

Materials and Methods:

We performed a retrospective search and examined 30 consecutive computed tomography-guided transthoracic U, N and A lung FNAs (n = 23) and TPs (n = 7) with surgical pathology (SP) (n = 17) and/or clinical/radiological follow-up (n = 13) and compared them to 10 SP-confirmed P FNAs, which served as controls.

Results:

The 30 FNAs and TPs were from 29 patients. All 6 U specimens were scantly cellular. Granulomas, the most common specific benign cytological diagnosis, were evident in 8 (of 13) and 7 (of 11) N and A cytology cases, respectively. Histology corroborated the presence of granulomas identified on cytology. Organizing pneumonia was the second leading benign specific diagnosis (5/17), but it was rendered on histology (n = 5) and not FNAs or TPs. Evaluation of the A cases revealed that type II pneumocytes were the source of “atypical”, diagnoses often associated with granulomas or organizing pneumonia and lacked 3-D clusters evident in all P cases.

Discussion:

U, N and A FNAs and TPs lacked 3-D clusters seen in carcinomas and were negative on follow-up. Granulomas and organizing pneumonia were the most common specific benign diagnoses, but the latter was recognized on histology only. In the absence of a definitive FNA result at the time of on-site assessment, a CB with a TP containing type II pneumocytes increases the likelihood of a specific benign diagnosis.

Radiographic and clinical characterization of false negative results from CT-guided needle biopsies of lung nodules

INTRODUCTION

Computed tomography-guided transthoracic fine-needle aspiration (FNA) is a highly sensitive technique for diagnosing malignancy in pulmonary nodules; however, there is great uncertainty regarding the reliability of a benign result. The goal of this study was to characterize the clinical, radiologic, and technical variables associated with a false negative result.

METHODS

We performed a consecutive series review of patients who had an initial benign result from an FNA between January 2002 and December 2004. Medical charts were reviewed to identify patients with false negative and true negative results and determine which variables were associated with a missed diagnosis.

RESULTS

One hundred and seventy patients underwent an FNA biopsy yielding an initial benign result and had adequate clinical follow-up. Eighteen of these proved to be false negatives and 152 were true negative. Compared with the patients with true negatives, those with false negative results had significantly larger nodules (mean, 27 mm versus 17 mm, p = 0.04), fewer imaging adjustments per needle pass (4.5 versus 6.4, p = 0.01), a higher proportion in whom the needle tip was not documented within the lesion (24% versus 5%, p =0.04), and a higher pneumothorax rate at any point during the procedure (50% versus 22%, p =0.04). When these variables were considered jointly, pneumothorax (p = 0.006), solitary nodule (p = 0.04), and the radiologist who performed the procedure (p = 0.04) were significant predictors of false negative results.

CONCLUSIONS

Factors that were associated with false negative results include increased size of lesion, fewer adjustments of the needle, lack of positive cultures, and the occurrence of a pneumothorax. A benign FNA biopsy result should have the procedure reviewed to ensure the results are reliable.

Does the availability of positron emission tomography modify diagnostic strategies for solitary pulmonary nodules? An observational study in France

Background

Previous studies showed that at the individual level, positron emission tomography (PET) has some benefits for patients and physicians in terms of cancer management and staging. We aimed to describe the benefits of (PET) in the management of solitary pulmonary nodules (SPNs) in a population level, in terms of the number of diagnostic and invasive tests performed, time to diagnosis and factors determining PET utilization.

Methods

In an observational study, we examined reports of computed tomography (CT) performed and mentioning "spherical lesion", "nodule" or synonymous terms. We found 11,515 reports in a before-PET period, 2002–2003, and 20,075 in an after-PET period, 2004–2005. Patients were followed through their physician, who was responsible for diagnostic management.

Results

We had complete data for 112 patients (73.7%) with new cases of SPN in the before-PET period and 250 (81.4%) in the after-PET period. Patients did not differ in mean age (64.9 vs. 64.8 years). The before-PET patients underwent a mean of 4 tests as compared with 3 tests for the after-PET patients (p = 0.08). Patients in the before-PET period had to wait 41.4 days, on average, before receiving a diagnosis as compared with 24.0 days, on average, for patients in the after-PET period who did not undergo PET (p < 0.001). In the after-PET period, 11% of patients underwent PET during the diagnostic process. A spiculated nodule was more likely to determine prescription for PET (p < 0.001). Multivariate analysis revealed that patients in both periods underwent fewer tests when PET was prescribed by general practitioners (p < 0.001) and if the nodule was not spiculated (p < 0.001). The proportion of unnecessary invasive approaches prescribed (47% vs. 49%) did not differ between the groups.

Conclusion

In our study, 1 year after the availability of PET, the technology was not the first choice for diagnostic management of SPN. Even though we observed a tendency for reduced number of tests and mean time to diagnosis with PET, these phenomena did not fully relate to PET availability in health communities. In addition, the availability of PET in the management of SPN diagnosis did not reduce the overall rate of unnecessary invasive approaches.

Percutaneous needle aspiration biopsy (PCNAB) of lung lesions: 5 years results with focusing on repeat PCNAB

PURPOSE

To evaluate 5 years results of percutaneous needle aspiration biopsy (PCNAB) for lung lesions and usefulness of the reaspiration or rebiopsy of lung lesions (repeat PCNAB).

MATERIALS AND METHODS

Six hundred and fifteen cases of PCNAB (591 initial PCNAB and 24 repeat PCNAB) performed under the CT or fluoroscopy guidance in 591 patients was enrolled. The procedure was done using an automated biopsy gun with a 20-G needle (519 cases) or a 20-G aspiration needle (96 cases). The pathologic results, type and rate of complications in the initial and repeat PCNAB were evaluated. The pathologic agreement rate between the initial and repeat PCNAB, and reasons of the repeat PCNAB were also evaluated.

RESULTS

Of the 615 PCNAB cases, 345 cases yielded tumors and 270 cases yielded non-tumorous lesions. Of the tumorous lesions, 307 cases were primary lung malignancies, 34 cases were metastases, and 4 were benign tumors. The repeat PCNAB rate was 4.1% (24/591). There was no statistically significant difference between automated gun biopsy and needle aspiration as a biopsy tool for calling repeat PCNAB (p=0.4034). The causes for a repeat PCNAB were inconclusive (n=14) and unexpected pathologic results (n=10). Of the 14 pathologically inconclusive cases on initial PCNAB, 9 cases revealed malignancy after the repeat PCNAB. Of the 10 cases with unexpected pathologic results on initial PCNAB, 3 cases yielded different pathologic results on repeat PCNAB from initial PCNAB. The cumulative complication rate of PCNAB was 11.4% (70/615).

CONCLUSION

PCNAB was useful for the diagnosis of pulmonary lesions. Repeat PCNAB might be helpful for the exact diagnosis of lung lesions where initial PCNAB yields inconclusive or unexpected pathologic results.

Evidence for the Treatment of Patients With Pulmonary Nodules: When Is It Lung Cancer?

BACKGROUND

The solitary pulmonary nodule (SPN) is a frequent incidental finding that may represent primary lung cancer or other malignant or benign lesions. The optimal management of the SPN remains unclear.

METHODS

We conducted a systematic literature review to address the following questions: (1) the prevalence of SPN; (2) the prevalence of malignancy in nodules with varying characteristics (size, morphology, and type of opacity); (3) the relationships between growth rates, histology, and other nodule characteristics; and (4) the performance characteristics and complication rates of tests for SPN diagnosis. We searched MEDLINE and other databases and used previous systematic reviews and recent primary studies.

RESULTS

Eight large trials of lung cancer screening showed that both the prevalence of at least one nodule (8 to 51%) and the prevalence of malignancy in patients with nodules (1.1 to 12%) varied considerably across studies. The prevalence of malignancy varied by size (0 to 1% for nodules < 5 mm, 6 to 28% for nodules 5 to 10 mm, and 64 to 82% for nodules > 20 mm). Data from six studies of patients with incidental or screening-detected nodules showed that the risk for malignancy was approximately 20 to 30% in nodules with smooth edges; in nodules with irregular, lobulated, or spiculated borders, the rate of malignancy was higher but varied across studies from 33 to 100%. Nodules that were pure ground-glass opacities were more likely to be malignant (59 to 73%) than solid nodules (7 to 9%). The sensitivity of positron emission tomography imaging for identifying a malignant SPN was consistently high (80 to 100%), whereas specificity was lower and more variable across studies (40 to 100%). Dynamic CT with nodule enhancement yielded the most promising sensitivity (sensitivity, 98 to 100%; specificity, 54 to 93%) among imaging tests. In studies of CT-guided needle biopsy, nondiagnostic results were seen approximately 20% of the time, but sensitivity and specificity were excellent when biopsy yielded a specific benign or malignant result.

CONCLUSIONS

The prevalence of an SPN and the prevalence of malignancy in patients with an SPN vary widely across studies. The interpretation of these variable prevalence rates should take into consideration not only the nodule characteristics but also the population at risk. Modern imaging tests and CT-guided needle biopsy are highly sensitive for identifying a malignant SPN, but the specificity of imaging tests is variable and often poor.