An investigation into false-negative transthoracic fine needle aspiration and core biopsy specimens

Computed-Tomography-Guided Lung Biopsy: A Practice-Oriented Document on Techniques and Principles and a Review of the Literature

Computed tomography (CT)-guided lung biopsy is one of the oldest and most widely known minimally invasive percutaneous procedures. Despite being conceptually simple, this procedure needs to be performed rapidly and can be subject to meaningful complications that need to be managed properly. Therefore, knowledge of principles and techniques is required by every general or interventional radiologist who performs the procedure. This review aims to contain all the information that the operator needs to know before performing the procedure. The paper starts with the description of indications, devices, and types of percutaneous CT-guided lung biopsies, along with their reported results in the literature. Then, pre-procedural evaluation and the practical aspects to be considered during procedure (i.e., patient positioning and breathing) are discussed. The subsequent section is dedicated to complications, with their incidence, risk factors, and the evidence-based measures necessary to both prevent or manage them; special attention is given to pneumothorax and hemorrhage. After conventional CT, this review describes other available CT modalities, including CT fluoroscopy and cone-beam CT. At the end, more advanced techniques, which are already used in clinical practice, like fusion imaging, are included.

The role of clinical characteristics and pulmonary function testing in predicting risk of pneumothorax by CT-guided percutaneous core needle biopsy of the lung

BACKGROUND

We aim to analyze the risk factors for pneumothorax associated with computed tomography (CT)-guided percutaneous core needle biopsy (PCNB) of the lung. Whether the lung function characteristics are related to pneumothorax is unclear.

METHODS

We retrospectively evaluated 343 patients who received CT-guided pulmonary PCNBs and underwent preoperative pulmonary function testing. Demographical, lesion-related, procedure-related features and histopathological diagnosis, as well as results of pulmonary function test were analyzed as risk factors of pneumothorax RESULTS: Variables associated with higher rate of pneumothorax were location of lesion, presence of emphysema, and dwell time. The proportion of middle lobe, lingular, or lower lobe lesions in pneumothorax group (30/50, 60.0%) is higher than non-pneumothorax group (113/293, 38.6%). The incidence of emphysema in pneumothorax group was significantly higher than that in non-pneumothorax group (34.0% vs. 7.5%). Obstructive pulmonary function abnormalities, not restrictive, mixed ventilation function abnormalities and small airway dysfunction, correlated with pneumothorax. Multivariate logistic regression analysis showed lower location of lesion sampled and presence of emphysema were independent predictors of pneumothorax. Although dwell time, FEV₁/FVC ratio, FEF_50%, FEF_75% and FEF_25-75% were significantly correlated with pneumothorax on univariate analysis, these were not confirmed to be independent predictors.

CONCLUSIONS

Patients with obstructive pulmonary dysfunction have a higher risk of pneumothorax. Presence of emphysema was the most important predictor of pneumothorax, followed by location of lesion.

Non-Diagnostic CT-Guided Percutaneous Needle Biopsy of the Lung: Predictive Factors and Final Diagnoses

OBJECTIVE

To investigate the predictive factors for a non-diagnostic result and the final diagnosis of pulmonary lesions with an initial non-diagnostic result on CT-guided percutaneous transthoracic needle biopsy.

MATERIALS AND METHODS

All percutaneous transthoracic needle biopsies performed over a 4-year period were retrospectively reviewed. The initial pathological results were classified into three categories-malignant, benign, and non-diagnostic. A non-diagnostic result was defined when no malignant cells were seen and a specific benign diagnosis could not be made. The demographic data of patients, lesions' characteristics, technique, complications, initial pathological results, and final diagnosis were reviewed. Statistical analysis was performed using binary logistic regression.

RESULTS

Of 894 biopsies in 861 patients (male:female, 398:463; mean age 67, range 18-92 years), 690 (77.2%) were positive for malignancy, 55 (6.2%) were specific benign, and 149 (16.7%) were non-diagnostic. Of the 149 non-diagnostic biopsies, excluding 27 cases in which the final diagnosis could not be confirmed, 36% revealed malignant lesions and 64% revealed benign lesions. Predictive factors for a non-diagnostic biopsy included the size ≤ 15 mm, needle tract traversing emphysematous lung parenchyma, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Non-diagnostic biopsies with a history of malignancy or atypical cells on pathology were more likely to be malignant (p = 0.043 and p = 0.001).

CONCLUSION

The predictive factors for a non-diagnostic biopsy were lesion size ≤ 15 mm, needle tract traversing emphysema, introducer needle outside the lesion, procedure time > 60 minutes, and presence of alveolar hemorrhage. Thirty-six percent of the non-diagnostic biopsies yielded a malignant diagnosis. In cases with a history of malignancy or the presence of atypical cells in the biopsy sample, a repeat biopsy or surgical intervention should be considered.

Diagnostic efficacy and molecular testing by combined fine-needle aspiration and core needle biopsy in patients with a lung nodule

BACKGROUND

Combined image-guided fine-needle aspiration biopsy (FNA) and core needle biopsy (CNB) has become the standard of care for diagnosis and/or molecular testing for patients with a solitary lung nodule at our institution. Our purpose was to evaluate the efficacy of this practice.

METHODS

We identified patients who underwent combined lung FNA/CNB during 2012 at our institution. A total of 667 patients who underwent 682 combined lung FNA/CNB procedures were included in the study, including 355 men and 312 women. Combined lung FNA/CNB procedures were performed by a radiologist. The adequacy of FNA specimens was assessed immediately by a cytopathologist. The FNA and CNB specimens were interpreted separately by a cytopathologist and a surgical pathologist, respectively. The diagnostic accuracy of the combined technique was determined.

RESULTS

The rate of diagnostic consistency between FNA and CNB was 83.4%, and the rate of diagnostic accuracy for malignancy was 98.5% for combined FNA/CNB. Combined FNA/CNB showed a high diagnostic efficacy for malignancy (sensitivity, 97.6%; specificity, 100%). Combined FNA/CNB had a lower false-negative rate for malignancy (2.2%) than either FNA (7.2%) or CNB (6.2%) alone. FNA contributed to 10.3% of molecular analyses as a complementary tissue source.

CONCLUSIONS

Combined lung FNA/CNB has high diagnostic efficacy for malignancy and a lower false-negative rate than either procedure alone. FNA was a valuable complement to CNB for molecular testing, potentially reducing patient inconvenience and morbidity associated with repeated lung needle biopsy.

Diagnostic Performance of Core Needle Biopsy and Fine Needle Aspiration Separately or Together in the Diagnosis of Intrathoracic Lesions Under C-arm Guidance

Purpose:

To evaluate and compare the diagnostic accuracy of fine needle aspiration (FNA) and core needle biopsy (CNB) of intrathoracic lesions using the same coaxial guide-needle under a C-arm Cone-Beam computed tomography system.

Materials and Methods:

Two hundred and eighty-eight patients (181 male, 107 female; 65.8 ± 13.3 years) with 293 lesions underwent 300 procedures, in which both FNA and CNB were performed. After inserting the coaxial guide-needle into the target lesion, we performed 18-gauge CNB, followed by 20-gauge FNA through the same coaxial guide-needle. The comparison of the procedures in which both showed adequate sample was performed with McNemar’s test (n = 229).

Results:

Of 300 procedures, 293 were technically successful. Adequate samples were obtained in 248/300 FNA and 288/300 CNB cases. The sensitivity and specificity for diagnosis of malignancy were respectively 84.7% (133/157), 100% (72/72) for FNA, when atypical cells included benign entity; 97.5% (153/157), 100% (72/72) for FNA, when atypical cells included malignancy; 97.6% (162/166), 100% (102/102) for CNB; and 100% (166/166), 100% (102/102) for combined FNA and CNB. Diagnosis of malignancy was significantly higher for CNB than for FNA (p < 0.001); however, it was not significantly higher when atypical cells included malignancy for FNA. Pneumothorax occurred in 50 (16.7%) and hemoptysis in 18 (6.0%) procedures.

Conclusions:

Combined use of CNB and FNA using the same coaxial guide-needle showed better diagnostic performance than using one alone. When comparing CNB and FNA, CNB showed significantly better performance, when atypical cells included a benign entity in FNA.

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.

Lung Cancer Diagnosis by Fine Needle Aspiration Is Associated With Reduction in Resection of Nonmalignant Lung Nodules

BACKGROUND

The rates of resection of nonmalignant lung nodules suspected preoperatively to be lung cancer vary widely and are reported to be as high as 40%. We determined the impact of the frequent use of computed tomography (CT)-guided fine needle aspiration (FNA) on the resection rate of nonmalignant nodules and frequency of resections of benign disease among patients undergoing evaluation for lung cancer resection operation in an academic medical center.

METHODS

Eligible patients underwent CT-guided FNA, surgical resection, or both during the 12-month period between July 2013 and July 2014 for known or suspected first primary resectable stage I-III lung cancer. Patient data were extracted from the electronic medical records.

RESULTS

One hundred ninety-seven patients underwent surgical resection; among them the overall resection rate of nonmalignant lesions was 13.1% (26/197). For those with preoperative FNA, the rate was 7.9% (11/139), and for those with no biopsy, the rate was 25.9% (15/58) (p = 0.001). The sensitivity and specificity of FNA biopsy were 96% and 98%, respectively. The false-negative rate was 3.9% (5/128).

CONCLUSIONS

The resection rate of nonmalignant nodules was significantly lower for patients with preoperative CT-guided FNA biopsy than in those without. The diagnostic accuracy of FNA in these patients at moderate to high risk for lung cancer is higher than that of positron emission tomography, with a low rate of adverse events. These findings suggest that the frequent use of preoperative diagnostic confirmation by FNA results in a low rate of nonmalignant resection.

Non-specific benign pathological results on transthoracic core-needle biopsy: how to differentiate false-negatives?

OBJECTIVES

To determine the negative predictive value (NPV) of non-specific benign results from cone-beam CT (CBCT)-guided transthoracic core-needle biopsy (TTNB) and identify predicting factors for false-negative for malignancies.

METHODS

From January 2009-December 2011, 1,108 consecutive patients with 1,116 lung lesions underwent CBCT-guided TTNB using an 18-gauge coaxial cutting needle. Among them, 226 patients with 226 TTNBs, initially diagnosed as non-specific benign, were included in this study. The medical charts, radiological or pathological follow-ups were reviewed to classify false-negative and true-negative results and to identify which variables were associated with false-negatives.

RESULTS

Of 226 lesions, 24 (10.6%) were finally confirmed as malignancies and 202 (89.4%) as benign, of which the NPV was 89.4% (202/226). Multivariate analysis revealed that part-solid nodule (PSN) (odds ratio (OR), 3.95; P = 0.022), a biopsy result of 'granulomatous inflammation' (OR, 0.04; P = 0.022), and exact location of needle tip within targets (OR, 0.37; P = 0.045) were significantly associated with false-negatives among initial non-specific benign biopsy results.

CONCLUSION

The NPV of the non-specific benign biopsy was 89.4%. PSN was a significant positive indicator, but a biopsy result of 'granulomatous inflammation' and exact location of needle tip within targets were significant negative indicators for false-negatives.

KEY POINTS

• The negative predictive value of the non-specific benign biopsy was 89.4%. • A part-solid nodule is a significant predictor for false-negative biopsy (OR = 3.95). • Pathological diagnosis of granulomatous inflammation is a robust indicator for 'true-negatives'. • Identifying needle tip within target lesions is a significant predictor for 'true-negatives'.

Predictors of False-Negative Results from Percutaneous Transthoracic Fine-Needle Aspiration Biopsy: An Observational Study from a Retrospective Cohort

PURPOSE

We investigated factors predictive of false-negative pulmonary lesions with nonspecific benign cytology results on percutaneous transthoracic fine-needle aspiration biopsy (FNAB).

MATERIALS AND METHODS

We included 222 pulmonary lesions that had a nonspecific benign result from percutaneous transthoracic FNAB between March 2005 and December 2012, and were confirmed by subsequent pathologic results or adequate clinical follow up over at least 2 years. Clinical, imaging, and biopsy procedure-related findings were compared between lesions with a final diagnosis of malignancy (false-negative) and lesions with a benign diagnosis (true-negative). Multivariate logistic regression analysis was performed to identify significant predictors of false-negatives.

RESULTS

Of 222 lesions, 115 lesions were proved to be false-negatives, and 107 were true-negatives. Compared with the true-negatives, false-negative lesions showed significantly older age (p=0.037), higher maximum standardized uptake value (SUVmax) on positron emission tomography (p=0.001), larger lesion size (p=0.007), and lesion characteristics of a subsolid nodule (p=0.007). On multivariate logistic regression analysis, SUVmax, lesion size, and lesion characteristics were significant predictors of false-negative results.

CONCLUSION

Among the clinical, radiologic, and procedure-related factors analyzed, high SUVmax, large lesion size, and subsolid lesions were useful for predicting malignancy in pulmonary lesions with nonspecific benign cytology results on FNAB.