Ultrasound-assisted transthoracic biopsy: Cells or sections?

EGFR testing in paraffin-embedded cell block cytology material is reliable with increased detection for effusion fluid

INTRODUCTION

Cytology is integral to lung cancer diagnosis. Aspiration and exfoliative fluid specimens represent valuable tumor material for molecular testing. In this study, a large retrospective cohort of EGFR tests was reviewed to address the adequacy, detection and discrepancy rate in tests performed with cytology material.

METHODS

EGFR tests performed from 2013 to 2022 were reviewed and classified by the modality of obtaining tissue and by tissue type. EGFR tests for tissue specimens were performed on unstained sections of paraffin-embedded material on glass slides. Adequacy and types of mutation(s) detected were analysed. Cases where multiple EGFR testing was performed on the same patient were reviewed for discordance.

RESULTS

There were 5,504 tests retrieved, with 1,855, 3,607 and 42 performed on cytology, surgical and blood specimens. Lung and excision specimens were more often adequate (p < 0.001). Cytology material showed lower adequacy rates (p < 0.01). EGFR detection (positive) rate was higher in pleural fluid compared to biopsy (59.8 % vs 50.7 %, p = 0.022), but similar between lung and lymph node cytology and non-cytology specimens. Effusion fluid specimens had the highest adequacy (81.5 %) and detection rate (59.3 %) among cytology specimens (p < 0.001). Four (4.4 %) cases showed discordant results in cytology specimens. Two were false negatives in the non-cytology material. Only in one case was cytology material genuinely discrepant. The remaining discordance was attributed to the interval treatment effect.

CONCLUSION

The findings support that EGFR testing in cell block is reliable and complements tissue material. In addition, pleural fluid appears to be superior to pleural biopsies for molecular testing.

The role of ultrasound-guided transthoracic Tru-Cut core biopsy in the diagnosis peripheral thorax lesion

Background

The nature of opaque lesions such as effusions, atelectasis, masses, and consolidations can be clarified by sonography. This study investigated the sensitivity and accuracy of ultrasound-guided percutaneous core needle biopsy in different thoracic tumors (lung, pleural, chest wall, and mediastinal).

Results

Sixty patients underwent ultrasound-guided percutaneous transthoracic core biopsy of peripheral thoracic masses with a Tru-Cut needle with a big bore. Twenty masses were in the lung, seventeen lesions were in the pleura, ten masses were in the mediastinum, eleven were enlarged palpable lymph nodes, and two masses were in chest wall. The sensitivity, PPV, and accuracy for detection of chest tumors in the chest wall, mediastinum, lung, and pleura were 100% for all, and in LN 88.9, 100, and 90.9%, respectively. The overall diagnostic performance of sonar-guided Tru-Cut needle biopsy in diagnosis was 97.78% sensitivity, 98.18% accuracy, and 100% PPV.

Conclusion

Tru-Cut needle percutaneous transthoracic core biopsy is a convenient and sensitive process in obtaining samples under ultrasound guidance for exact histological diagnosis of thoracic tumors. The diagnostic efficiency is high, and the technique can also be used in outpatients, which is relatively simple.

Trial registration

NCT, NCT04741958 Registered 5 February 2021, retrospectively registered,

Diagnostic utility of fine-needle aspiration cytology of lesions involving bone

BACKGROUND

Fine-needle aspiration (FNA) is utilized in the diagnostic work-up of bone lesions in a number of institutions, either in isolation or in conjunction with core biopsy. We report our experience with FNA of bone-based lesions, including comparison of this approach with concurrent core biopsy specimens.

METHODS

Retrospective review over a 5-year period (2011-2015) revealed 233 cases of bone FNAs.

RESULTS

The most commonly encountered diagnosis was malignant neoplasm (160 cases, 68.7%); within this group of malignancies, 103 cases (64.4%) represented metastatic carcinoma. Benign lesions were encountered infrequently (9 cases, 3.9%). While 37 cases (15.9%) revealed "no evidence of malignancy," 12 cases (5.2%) showed atypical findings, 3 cases (1.3%) demonstrated inflammatory conditions, and 12 aspiration biopsies were deemed nondiagnostic (5.2%). In 202 cases, concurrent core biopsies were performed following FNA and rapid on-site evaluation (ROSE). Comparison of the FNA and core biopsy diagnoses among malignant neoplasms revealed 19 diagnostic discrepancies, including 16 cases with a false-negative FNA (7.9% of all FNAs with concurrent core biopsy) and 3 cases with a false-negative core biopsy (1.5% of all cases with corresponding FNA).

CONCLUSION

Our findings indicate that FNA of bone lesions is a useful diagnostic technique with high sensitivity, particularly when the cytologic findings are interpreted in conjunction with the core biopsy and pertinent clinical and radiologic findings. In addition, ROSE followed by open, dynamic communication with the performing radiologist leads to an extremely low rate of inadequate core biopsy specimens, resulting in optimal patient diagnosis and management. Diagn. Cytopathol. 2017;45:608-613. © 2017 Wiley Periodicals, Inc.

Ultrasound-guided Lung Biopsy in the Hands of Respiratory Physicians: Diagnostic Yield and Complications in 215 Consecutive Patients in 3 Centers

BACKGROUND

The aim of the study was to determine the diagnostic yield and prevalence of complications of ultrasound-guided transthoracic needle aspiration biopsies (US-TTNAB) performed by respiratory physicians after implementation of the procedure in an everyday clinical setting at 3 different centers.

METHODS

Patients were included if they during the period from January 2012 to August 2014 had a registered US-TTNAB procedure code or if a US biopsy registration form had been filled out at either of the participating centers. Histology or cytology results were used as a reference test for diagnoses that could be made based on these results. Reference test for the remaining diagnoses was clinical follow-up. The diagnostic yield of US-TTNAB was defined as the proportion of patients in which the result of the US-TTNAB was consistent with the reference test.

RESULTS

A total of 215 patients in which a primary US-TTNAB had been performed were identified. The most common biopsy sites were lungs and pleurae with a total of 164 (76.3%) patients and 31 patients (14.4%), respectively. US-TTNAB diagnostic yield was 76.9% (95% CI, 70.3%-83.4%) for malignant diagnoses and 47.6% (95% CI, 31.9%-63.4%) for nonmalignant diagnoses. The most common complications of US-TTNAB were pneumothorax (2.5%; 95% CI, 0.03%-4.6%) and pain at the biopsy site (2%; 95% CI, 0.04%-3.9%). No fatalities related to US-TTNAB were observed.

CONCLUSION

US-TTNAB performed by respiratory physicians is a safe procedure with a low risk of complications and the diagnostic yield to establish a malignant diagnosis is acceptable.

Direct comparison of liquid-based and smear-based cytology with and without rapid on-site evaluation for fine needle aspirates of thoracic tumors

BACKGROUND

Liquid-based cytology (LBC) and rapid on-site evaluation (ROSE) are proposed to improve the quality of fine needle aspirates (FNA) and their diagnostic yield compared with conventional smear cytology (CSC). This prospective study directly compared outcomes of sonar-guided FNA of thoracic tumors supported by LBC, CSC, or CSC with ROSE.

METHODS

Three aspirates each for both LBC and CSC with separate 22G spinal needles in a randomized, alternating sequence during 64 transthoracic FNA of thoracic tumors were collected. Smears were prepared by cytology staff on site but evaluated with ROSE only when all six samples had been collected. If no diagnostic material was found on the first three CSC additional needle passes guided by ROSE were performed.

RESULTS

Final diagnoses were non-small cell lung cancer in 50 (78.1%), small cell lung cancer in 11 (17.2%), mesothelioma in 1 (1.6%), and inflammation in 2 cases (3.1%), respectively. LBC and CSC were diagnostic in 42 (65.6%) and 49 (76.6%) cases, respectively (P = 0.039), with both methods diagnostic in 41 cases (64.1%). Fifteen cases (23.4%) remained undiagnosed following three passes for CSC but 9 (14.1%) of these were diagnosed using FNA and ROSE with a total yield of 58 cases (90.6%; P < 0.001).

CONCLUSION

The diagnostic yield of transthoracic FNA submitted for LBC is significantly lower than with CSC when slides are prepared professionally. ROSE significantly increases the yield of transthoracic FNA.

Fine-needle aspiration biopsy versus core-needle biopsy in diagnosing lung cancer: a systematic review

BACKGROUND

Lung cancer leads cancer-related mortality in the world. The objective of the present systematic review was to compare fine-needle aspiration biopsy (fnab) with core-needle biopsy (cnb) for diagnostic characteristics and yields for diagnosing lung cancer in patients with lung lesions.

METHODS

The medline and embase databases (from January 1, 1990, to September 14, 2009), the Cochrane Library (to Issue 4, 2009), and selected guideline Web sites were searched for relevant articles.

RESULTS

For overall diagnostic characteristics (benign vs. malignant) of fnab and cnb, the ranges of sensitivity were 81.3%-90.8% and 85.7-97.4% respectively; of specificity, 75.4%-100.0% and 88.6%-100.0%; and of accuracy, 79.7%-91.8% and 89.0%-96.9%. For specific diagnostic characteristics of fnab and cnb (identifying the histologic subtype of malignancies or the specific benign diagnoses), the ranges of sensitivity were 56.3%-86.5% and 56.5-88.7% respectively; of specificity, 6.7%-57.1% and 52.4%-100.0%; and of accuracy, 40.4%-81.2% and 66.7%-93.2%. Compared with fnab, cnb did not result in a higher complication rate (pneumothorax or hemoptysis). No study has yet compared the diagnostic yields of fnab and of cnb for molecular predictive-marker studies in patients with lung lesions.

DISCUSSION AND CONCLUSIONS

The evidence is currently insufficient to support a difference between fnab and cnb in identifying lung malignancies in patients with lung lesions. Compared with fnab, cnb might have a higher specificity to diagnose specific benign lesions. Well-designed, good-quality studies comparing fnab with cnb for diagnostic characteristics and yields in diagnosing lung cancer should be encouraged.

Pleural and peripheral lung lesions: comparison of US- and CT-guided biopsy

PURPOSE

To retrospectively compare the outcome of computed tomography (CT) and ultrasonography (US) guidance when sampling a consecutive series of peripheral lung or pleural lesions.

MATERIALS AND METHODS

Institutional review board approval was obtained, and the informed consent requirement was waived. From January 2000 to August 2011, 711 thoracic biopsies were performed at two institutions. Among these, 273 lesions in 273 patients (115 men, 158 women; mean age, 65 years ± 11 [standard deviation]; 86 pleural lesions; 187 pulmonary lesions) had pleural origin or were peripherally located in the lung with a small amount of pleural contact. These lesions were sampled with either CT (170 patients; mean age, 64 years ± 12; 55 pleural lesions, 115 peripheral pulmonary lesions) or US (103 patients; mean age, 67 years ± 10; 31 pleural lesions, 72 peripheral pulmonary lesions) guidance by using an 18-gauge modified Menghini needle. Procedure duration, postprocedural pneumothorax or hemorrhage, and sample adequacy were recorded. Fisher exact test, log-rank test, and Mann-Whitney U test were performed.

RESULTS

No significant difference was found for patient age (P = .741), sex (P = .900), lesion size (P = .206), or lesion origin (P = .788). Median time was 556 seconds for CT-guided biopsy (25th percentile, 408 seconds; 75th percentile, 704 seconds) and 321 seconds for US-guided biopsy (25th percentile, 157 seconds; 75th percentile, 485 seconds) (P < .001). Postprocedural pneumothorax was observed in 25 of 170 (14.7%) CT-guided procedures and in six of 103 (5.8%) US-guided procedures (P = .025); hemorrhage occurred in two of 170 (1.2%) CT-guided procedures and in one of 103 (1.0%) US-guided procedures (P = .875). Technical success was achieved in 100 of 103 US-guided procedures (97.1%) and in 164 of 170 CT-guided procedures (96.5%) (P = .999).

CONCLUSION

With pleural or peripheral lung lesions, US guidance is comparable to CT guidance in terms of sample accuracy, while allowing for a significant reduction in procedure time and postprocedural pneumothorax and being free from ionizing radiation.

Pleural controversy: close needle pleural biopsy or thoracoscopy-which first?

The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91-95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy.

Transbronchial fine needle aspiration biopsy and rapid on-site evaluation in the setting of superior vena cava syndrome

There is a paucity of prospective data on flexible bronchoscopy with rapid on-site evaluation (ROSE) in the setting of superior vena cava (SVC) syndrome. The aims of this prospective study were to assess the diagnostic yield and safety of these investigations and specifically to evaluate the role of ROSE in limiting the need for tissue biopsies. Over a 5-year period 48 patients (57.4 ± 9.7 years) with SVC syndrome secondary to intrathoracic tumors underwent flexible bronchoscopy with TBNA and ROSE. Endobronchial Forceps biopsy was reserved for visible endobronchial tumors with no on-site confirmation of diagnostic material. ROSE confirmed diagnostic material in 41 cases (85.4%), and in only one of the remaining cases did the addition of a forceps biopsy increase the diagnostic yield (overall diagnostic yield of 87.5%). No serious complications were noted. The final diagnoses made included nonsmall lung cancer (n = 27), small cell lung cancer (n = 16), and metastatic carcinoma (n = 3). Two undiagnosed cases died of suspected advanced neoplasms (unknown primary tumors). We conclude that TBNA has a high diagnostic yield and is safe in the setting of SVC syndrome. With the addition of ROSE, tissue biopsy is required in the minority of cases.

Interventional ultrasonography of the chest: Techniques and indications

Thoracic ultrasonography can be used for diagnostic purposes as well as a guide for diagnostic and therapeutic interventions.When the lesion or fluid collection has been located and the patient properly positioned, the angle of the needle is identified with respect to the transducer. The insertion tract should transgress the smallest possible area of aerated parenchyma. The needle can be introduced with a free-hand technique or with the aid of a needle guide. Correct planning of the procedure reduces intervention time and decreases the risk of complications.The main indications are superficial masses that require biopsy, pleural and parenchymal lesions formerly biopsied with CT or fluoroscopic guidance, and fluid collections that need to be drained.Ultrasound, thanks to its widespread use, simple execution, and low costs, represents a safe, manageable guide for thoracic interventions.

Control and Performance Characteristics of Eight Different Suction Biopsy Devices

PURPOSE

To determine the control and performance characteristics of eight different suction biopsy devices.

MATERIALS AND METHODS

Physician control of the syringe and needle was measured precisely with the validated linear displacement method during the aspiration phase and during five biopsy passes. The visual analog scale was used to measure operator difficulty in the following domains: (i) attachment to the needle, (ii) generation of vacuum, (iii) detection of loss of vacuum, (iv) release of the vacuum, and (v) clearing of the sample from the needle.

RESULTS

Performance in various phases of the biopsy procedure varied widely among the biopsy devices tested. Unintended forward penetration (ie, loss of control in the forward direction) was significant with the reverse aspiration syringe (31.5 +/- 1.7 mm), three-ringed control syringe (25.4 +/- 4.1 mm), BioSuc-C7 syringe (28.3 +/- 1.9 mm), conventional syringe with a plunger lock (6.1 +/- 1.5 mm), syringe pistol (9.2 +/- 2.4 mm), and conventional syringe (3.8 +/- 2.9 mm) but was significantly less for the reciprocating procedure device (RPD; 0.7 +/- 0.7 mm; P </= .001) and RPD syringe holder (0.6 +/- 0.6 mm; P </= .001). The mean performance rankings were the best for the RPD (3.42 +/- 2.57) and RPD syringe holder (4.29 +/- 2.50) and worst for the conventional syringe (6.14 +/- 2.67; P </= .001) and conventional syringe with a plunger lock (6.86 +/- 3.80; P </= .001).

CONCLUSIONS

Each of the suction biopsy devices has unique advantages and disadvantages. Suction biopsy devices with the least favorable overall performance were the conventional syringe and the conventional syringe with a plunger lock. The highest overall performance was seen with the RPD and RPD syringe holder.