Tru-Cut biopsy of mediastinal masses guided by real-time sonography

Diagnostic value and complication rate of ultrasound-guided transthoracic core needle biopsy in mediastinal lesions

BACKGROUND

Ultrasound-guided transthoracic core needle biopsy (US-TCNB) is a promising method for establishing the correct diagnosis of mediastinal masses. However, the existing studies in this area are scant and with small samples.

PURPOSE

To evaluate the diagnostic value and the complication rate of US-TCNB, particularly large bore cutting biopsy in patients with mediastinal lesions.

MATERIAL AND METHODS

This retrospective study includes 566 patients with mediastinal lesions suspicious of malignancy evaluated between March 2004 and December 2018. Inclusion criteria: 1. Patients with mediastinal lesions detected on thoracic CT scan; 2. Lesions more than 15 mm; 3. Negative histological diagnosis after bronchoscopic biopsy; 4. Normal coagulation status; 5. Cooperative patient; 6. Written informed consent. US visualization of the mediastinal lesions was successful in 308 (54.4%). In all of them, US-TCNB was performed. All patients with mediastinal lesions unsuitable for US visualization were evaluated for a CT-guided transthoracic needle biopsy (CT-TTNB), which was done if the presence of a safe trajectory was available (n = 41, 7.2%). All patients inappropriate for image-guided TTNB were referred to primary surgical diagnostic procedures (n = 217, 38.3%).

RESULTS

The US-TCNB is a highly effective (accuracy 96%, sensitivity 95%) and safe tool (2.6% complications) in the diagnosis of all subgroups mediastinal lesions. It is non-inferior to CT-TTNB (90%) and comes close to the effectiveness of surgical biopsy techniques (98.4%), but is less invasive and with a lower complication rate.

CONCLUSION

US-TCNB of mediastinal lesions is highly effective and safe tool which is particularly helpful in critically ill patients.

Contrast-enhanced US-guided percutaneous biopsy of anterior mediastinal lesions

PURPOSE

We aimed to explore the value of contrast-enhanced ultrasonography (CEUS) in guidance of percutaneous biopsy of anterior mediastinal lesions.

METHODS

Ninety patients with solitary anterior mediastinal lesions (55 males, 35 females; mean age, 46±4 years) were included. Patients were randomly divided into CEUS group (n=45) and conventional ultrasonography (US) group (n=45). Real-time US-guided core needle (16 G) percutaneous biopsies were performed in all lesions. The display of internal mammary arteries, internal necrosis, and active areas were recorded and compared. Biopsy success rate and diagnostic accuracy were compared between the two groups.

RESULTS

Display rate of unenhanced internal necrosis was higher in the CEUS group than in the US group (88.9% vs. 46.7%, P = 0.041). With real-time CEUS guidance, internal mammary arteries were effectively displayed and avoided during biopsies in 68.9% of the lesions (31/45). Of the lesions, 88.9% (80/90) were histologically proven, including 13 benign lesions and 67 malignancies. There was a significant difference in the rate of successful puncture attempts between the two groups (P = 0.041). CEUS group had a higher biopsy success rate (100% vs. 95.5%, P = 0.045) and higher diagnostic accuracy (97.8% vs. 82.2%, P = 0.035) compared with the US group (P = 0.035).

CONCLUSION

CEUS guidance is a promising technique in depicting internal necrotic areas, viable areas, and internal mammary arteries during percutaneous biopsy of anterior mediastinal lesion, with satisfying safety, accuracy, and success rates.

Diagnostic Yield of CT-Guided Percutaneous Transthoracic Needle Biopsy for Diagnosis of Anterior Mediastinal Masses

OBJECTIVE

The purpose of this study was to evaluate the diagnostic yield and accuracy of CT-guided percutaneous biopsy of anterior mediastinal masses and assess prebiopsy characteristics that may help to select patients with the highest diagnostic yield.

MATERIALS AND METHODS

Retrospective review of all CT-guided percutaneous biopsies of the anterior mediastinum conducted at our institution from January 2003 through December 2012 was performed to collect data regarding patient demographics, imaging characteristics of biopsied masses, presence of complications, and subsequent surgical intervention or medical treatment (or both). Cytology, core biopsy pathology, and surgical pathology results were recorded. A per-patient analysis was performed using two-tailed t test, Fisher's exact test, and Pearson chi-square test.

RESULTS

The study cohort included 52 patients (32 men, 20 women; mean age, 49 years) with mean diameter of mediastinal mass of 6.9 cm. Diagnostic yield of CT-guided percutaneous biopsy was 77% (40/52), highest for thymic neoplasms (100% [11/11]). Non-diagnostic results were seen in 12 of 52 patients (23%), primarily in patients with lymphoma (75% [9/12]). Fine-needle aspiration yielded the correct diagnosis in 31 of 52 patients (60%), and core biopsy had a diagnostic rate of 77% (36/47). None of the core biopsies were discordant with surgical pathology. There was no statistically significant difference between the diagnostic and the nondiagnostic groups in patient age, lesion size, and presence of necrosis. The complication rate was 3.8% (2/52), all small self-resolving pneumothoraces.

CONCLUSION

CT-guided percutaneous biopsy is a safe diagnostic procedure with high diagnostic yield (77%) for anterior mediastinal lesions, highest for thymic neoplasms (100%), and can potentially obviate more invasive procedures.

Anterior mediastinal masses: A study of 50 cases by fine needle aspiration cytology and core needle biopsy as a diagnostic procedure

Background:

Mediastinal tumors are an uncommon abnormalities found in clinical practice. Anterior mediastinum is the common site and tissue diagnoses of anterior mediastinal masses (AMMs) are very important for correct therapeutic decision.

Objective:

We evaluate the different malignant AMMs in various age groups and the sensitivity of fine needle aspiration cytology (FNAC) and core needle biopsy (CNB). Cytology smears are reviewed with particular emphasis on pitfalls in the cytological diagnosis.

Materials and Methods:

This was a prospective study of 50 patients who were consulted for AMMs and underwent FNAC and CNB under guidance of ultrasound or computed tomography (CT) scan from 2006 to 2011. Cytology smears and histological sections were evaluated in all patients.

Results:

Among 50 cases, 36 were male and 14 were female. Most AMMs (52%) were identified in the fifth and sixth decades of life. Metastatic carcinoma and nonHodgkin's lymphoma are the common AMMs. Adequate tissue material was obtained in 49 of 50 cases by CNB. Of these 49 patients, 35 (71.42%) cases were diagnosed correctly by FNAC, whereas 14 (28.57%) cases were not diagnosed definitely by FNAC. The sensitivity of CNB for AMMs was 97.95%, significantly higher than FNAC (71.42%) (P < 0.05). CNB had statistically significant higher diagnostic rate than FNAC in the noncarcinoma group (100% versus 62.96%) (P < 0.05). There is no significant difference of CNB and FNAC in carcinoma group (P > 0.05). Diagnostic rate of FNAC was higher for carcinomatous lesions (81.81%) than for noncarcinomatous lesions (62.96%).

Conclusion:

Ultrasound or CT scan-guided CNB in combination with FNAC are safe, minimally invasive, and cost-effective procedure, which can provide a precise diagnosis in the AMMs, and may obviate the need for invasive surgical approach. FNAC usually suffice for carcinomatous lesions but CNB should be performed whenever the diagnosis of carcinoma is equivocal or noncarcinoma lesions are suspected.

Ultrasound-guided Chest Biopsies

Pulmonary nodules that are surrounded by aerated lung cannot be visualized with sonography. Therefore, percutaneous biopsy must be guided with computed tomography or fluoroscopy. Although this restriction only applies to central lung nodules, it has permeated referral patterns for other thoracic lesions and has retarded the growth of ultrasound-guided interventions. Nevertheless, sonography is an extremely flexible modality that can expeditiously guide many biopsy procedures in the thorax. Peripheral pulmonary nodules can be successfully biopsied with success rates exceeding 90% and complications rates of less than 5%. Orienting the probe parallel to the intercostal space facilitates biopsies of peripheral pulmonary nodules. Anterior mediastinal masses that extend to the parasternal region are often easily approachable provided the internal mammary vessels, costal cartilage, and deep great vessels are identified and avoided. Superior mediastinal masses can be sampled from a suprasternal or supraclavicular approach. Phased array probes or tightly curved arrays may provide improved access for biopsies in this location. Posterior mediastinal masses are more difficult to biopsy with ultrasound guidance because of the overlying paraspinal muscles. However, when posterior mediastinal masses extend into the posterior medial pleural region, they can be biopsied with ultrasound guidance. Because many lung cancers metastasize to the supraclavicular nodes, it is important to evaluate the supraclavicular region when determining the best approach to obtain a tissue diagnosis. When abnormal supraclavicular nodes are present, they often are the easiest and safest lesions to biopsy.

Imaging-guided Percutaneous Biopsy of Mediastinal Lesions: Different Approaches and Anatomic Considerations

Percutaneous needle biopsy with imaging guidance allows access to lesions in virtually all mediastinal locations. A direct mediastinal approach, which enables extrapleural needle placement, is the preferred method to avoid the risk of pneumothorax. Techniques that allow extrapleural access include the parasternal, paravertebral, transsternal, and suprasternal approaches, which are performed with computed tomographic or ultrasonographic guidance. The parasternal approach is used for biopsy of anterior or middle mediastinal lesions when the lesion or intervening mediastinal fat extends to the anterior chest wall, lateral to the sternum; injury to the internal mammary vessels is a potential complication. The paravertebral approach is used for biopsy of subcarinal and other posterior mediastinal lesions; saline solution is often injected to widen the mediastinum. The transsternal approach, which involves needle placement through the sternum, is used for biopsy of anterior or middle mediastinal lesions that are not accessible with the parasternal approach. Biopsy of superior mediastinal lesions can be performed with a suprasternal approach. An alternative to these direct mediastinal approaches involves advancing the needle through a pleural space created by an existing pleural effusion or iatrogenic pneumothorax. Another alternative is the transpulmonary approach, which involves transgression of the lung and visceral pleura by the needle and is associated with a substantial risk of pneumothorax.

Color Doppler sonographically guided transthoracic needle aspiration of lung and mediastinal masses

OBJECTIVE

This study investigated the diagnostic value of color Doppler sonographically guided transthoracic needle aspiration in lung and mediastinal masses.

METHODS

B-mode and colorDoppler sonographic images were obtained in 48 patients with mediastinal or peripheral pulmonary tumors. Color Doppler sonography was used to show the vascular structures before the transthoracic needle aspiration procedure. It was also used to locate the needle tip during the procedure by showing the twinkling sign. This maneuver was performed with motion of the inner stylet. Pathologic and microbiological examination of the aspirates was made.

RESULTS

Vascular structures were detected in 37 cases on color Doppler images and in 10 cases on B-mode images. Similarly, the needle tip was observed in 39 cases on color Doppler images but in only 9 cases on B-mode images. No complications were observed except partial pneumothorax in 2 cases. The method had sensitivity of 90.0%, specificity of 87.5%, a positive predictive value of 97.2%, a negative predictive value of 63.6%, and diagnostic accuracy of 89.6%.

CONCLUSIONS

Color Doppler sonographically guided transthoracic needle aspiration is a safe diagnostic method in malignant lung tumors, especially peripheral tumors, because of its ability to differentiate vascular structures within a tumor before the transthoracic needle aspiration procedure. It provides additional information about the location of the needle tip.

Deep-seated thoracic and abdominal masses: usefulness of ultrasound and computed tomography guidance in fine needle aspiration cytology diagnosis

Fine needle aspiration cytology (FNAC) was performed under ultrasound and CT guidance in 120 cases. These included abdominal masses (85 cases) and thoracic masses (35 cases) biopsied over a two and a half year period (March 1996 to September 1998). The aim of this study was to assess the contribution of clinico-imaging evaluation and image-guided FNAC to the management of patients with deep-seated mass lesions. Aspirations in the abdomen were performed from various anatomic sites such as liver (56 cases), lymph nodes (18 cases), gastrointestinal tract (three cases), pancreas (six cases), and kidney (two cases). In the thorax, biopsy was performed in the lung (19 cases) and mediastinum (13 cases). In 112 cases (93.4%) FNAC was diagnostic. Of the lesions that were successfully aspirated, 85% were < or = 5 cm in size. No major complication was encountered. All the successful aspirates could be defined as malignant or non-malignant, but tissue differentiation was possible in 63.7% of malignant lesions and 53.8% of benign lesions. Combined clinical and imaging evaluation for malignancy showed 80% sensitivity and 59% specificity. Although clinicoradiological parameters themselves have certain limitations in diagnosing benign versus malignant lesions, in conjunction with guided FNA they are very accurate and safe in diagnosing deep-seated mass lesions in the thorax and in the abdomen. However, the role of FNA in tissue differentiation of solid lesions such as lymphoma requires further study.

Transthoracic hilar and mediastinal biopsy

TNB of the mediastinum is an accurate, safe, and cost-effective diagnostic tool for the evaluation of mediastinal masses and lymphadenopathy. The technique is most useful in the staging of carcinoma, where it serves as a less expensive and minimally invasive alternative to mediastinoscopy for establishing unresectability. With recent advances in immunohistochemical and core biopsy techniques, TNB has become more accurate for establishing the initial diagnosis of lymphoma and for confirming recurrent disease. Core-needle biopsy has improved the accuracy of TNB and is particularly useful when fine-needle aspiration fails to yield a specific diagnosis, or when lymphoma or a noncarcinomatous lesion is suspected.

Diagnosis of mediastinal masses and principles of surgical tactics and technique for their treatment

The diagnosis of a mediastinal mass is first based on clinical features, supplemented by epidemiological data and laboratory results providing information on the nature and localization of the mass. The diagnosis is then defined further on the basis of imaging studies. The first examinations required are standard radiographs, ultrasound scan or computed tomography scan and occasionally magnetic resonance imaging (MRI), angiography, and scintigraphy. These studies are followed by a thoracoscopy, mediastinoscopy, and the necessary biopsy techniques. Finally, the author describes the general principles of surgical tactics and techniques that generally lead to a total regression of the disease.

A comparison of biopsy through a parasternal anterior mediastinotomy under local anesthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors

The various methods of treating the numerous types of anterior mediastinal neoplasms are undergoing refinements; however, prior to the commencement of any treatment, an accurate histologic diagnosis must be established. We conducted a retrospective analysis of biopsies performed through a parasternal anterior mediastinotomy (PAM) on 21 patients with an anterior mediastial mass suspected of being malignant by computed tomography (CT) and other clinical information. Patients with possible localized thymomas were excluded. Mediastinotomy, which enables relatively large tissue samples to be taken, was performed through the bed of the second or third costal cartilage under local anesthesia. In 19 of the 21 patients (90%), the histologic diagnosis made from the mediastinotomy biopsy was identical to the final diagnosis. Conversely, although the tissue obtained from needle biopsy was sufficient for a histologic diagnosis in 11 of 12 patients, the histologic diagnosis made from the needle biopsy was the same as the final diagnosis in only 5 of 10 patients (50%). Thus, diagnostic accuracy was significantly higher in the mediastinotomy biopsies than in the needle biopsies (P = 0.0318). Moreover, the mediastinotomy biopsy specimens revealed subtypes of lymphomas and germ cell tumors. All of the patients from whom a mediastinotomy biopsy had been taken began appropriate therapy without delay according to the histologic diagnosis. These results suggest that the PAM approach should be chosen as the preferred method of biopsy for suspected malignant anterior mediastinal tumors.

Ultrasonography of the thorax (excluding the heart)

Until recently, ultrasonography has had a subordinate role in the evaluation of the thorax in both small animals and humans, most likely due to the inability of sound to penetrate air-filled lung. When pathologic processes such as pleural effusion and lung consolidation provide an acoustic window to the thorax, however, thoracic ultrasonography becomes feasible. As this article illustrates, ultrasonography may be effectively employed in the diagnosis and management of various thoracic wall, pleural, mediastinal, pulmonary, and diaphragmatic diseases by providing valuable information not obtainable with routine radiography and enabling percutaneous aspiration or tissue core biopsy of lesions.

Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients

BACKGROUND

The authors attempted to determine the utility of percutaneous core needle biopsy (PCNB) compared with fine-needle aspiration (FNA) in the diagnosis of peripheral lung carcinoma.

METHODS

A retrospective review was undertaken of 156 computed tomography (CT)-guided PCNBs and FNAs of malignant lung lesions between 1988-1996. Both CT-guided FNA and PCNB biopsies were performed sequentially at the same visit for each subject.

RESULTS

The authors reviewed 156 malignant lesions whose specific diagnosis was obtained by FNA in 133 cases (85.3%) and by PCNB in 121 cases (77.6%) (P < 0.05). PCNB confirmed the FNA diagnosis in 90 patients (57.7%), provided additional information in 17 patients (10.9%), and was less informative than FNA in 35 patients (22.4%), mostly those with nonsmall cell carcinoma. The PCNB was marginally superior to FNA only in cases of metastatic carcinoma. The only significant complication encountered was a 24% rate of pneumothorax, which is comparable to the reported rate for FNA alone-induced complications.

CONCLUSIONS

PCNB offers no substantial advantage over FNA in the evaluation of peripheral malignant lung lesions. Therefore, the authors recommend the use of FNA biopsy as the initial diagnostic procedure in all cases of suspected malignancy. The use of the PCNB technique is recommended when the diagnosis of malignancy by FNA is uncertain, or when a more detailed characterization of the lesion is required.

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions

OBJECTIVE

To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions.

DESIGN

A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients.

RESULTS

A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization.

CONCLUSION

PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.

Thoracic sonography for diagnosis and intervention

Many physicians believe that ultrasound has limited usefulness in chest disease. Our clinical experiences and a review of the literature in preparation for this monograph have convinced us that sonography can be a very useful and versatile tool for thoracic diagnosis and intervention. Although there are some limitations caused by interposed ribs and air-containing lung, almost all of the compartments of the chest can be evaluated with ultrasound, which gives unique and clinically useful information. Ultrasound guidance for biopsy and drainage does take some time to learn, but we feel that the effort is very worthwhile. The same advantages ultrasound enjoys for other body regions make it a modality that will see increased use in the chest as well. We hope that this monograph will stimulate our colleagues to explore and expand upon the techniques described.

Thoraxsonography--Part II: Peripheral pulmonary consolidation

In many cases of pulmonary diseases extending up to the pleura, ultrasound (US) helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. Pneumonic infiltration shows a hypoechoic inhomogeneous echo texture, with multiple air inlets and bronchoaerograms. Fluid bronchogram indicates an obstructive pneumonitis. Pulmonary infarctions are visible in different stages as triangular pleural-based lesions in most cases of pulmonary embolism. The diagnostic accuracy of chest sonography in pulmonary embolism was 85%-90%. US-guided transthoracic biopsy shows a diagnostic yield of > 90% in malignancies and 50%-83% of benign lesions. The overall complication rate is very low: 1%-2% hemoptysis, 2%-4% pneumothoraces and 1%-2% requiring chest tube drainage. Color Doppler US can demonstrate the vascular patterns and may help in the understanding of underlying pathophysiology. Sonographic examinations of the upper and central mediastinum provide good results in 90-95% of cases. Some anatomical limitations of transcutaneous US can be circumvented by endoluminal US.

Fallibility of transthoracic needle biopsy of anterior mediastinal masses

Percutaneous transthoracic core needle biopsy has been advocated as a highly accurate technique for the diagnosis of anterior mediastinal masses. A patient is described with a large anterior mediastinal mass in whom the diagnosis of mediastinal carcinoid tumour was made by transthoracic core needle biopsy. At definitive surgical resection the tumour proved to be a B cell lymphoma. This case illustrates one of the important limitations of needle biopsy with its potential for sampling error.

Percutaneous needle biopsy of the mediastinum: review of 94 procedures

BACKGROUND

A number of reports of radiologically guided percutaneous biopsy of mediastinal masses have been described but techniques have varied, particularly the type of needle used. In this study mediastinal biopsies with fine aspiration needles and cutting needles have been compared, sometimes in the same patient. The results are reviewed with particular emphasis on the choice of biopsy needle and its influence on pathological diagnosis.

METHODS

A retrospective review was undertaken of radiologically guided mediastinal biopsies performed between 1981 and 1991.

RESULTS

Sixty fine needle aspiration biopsies (FNA) and 34 Tru-Cut biopsies of mediastinal masses were performed in 75 patients with fluoroscopic or computed tomographic guidance. Overall sensitivity and specificity in terms of diagnosis of malignant disease were 90% and 100% respectively for FNA biopsies, and 96% and 100% for Tru-Cut biopsies. Diagnostic accuracy in terms of precise diagnosis of the malignant or benign nature of a mass and its origin was 77% for FNA biopsies and 94% for Tru-Cut biopsies. For FNA biopsies sensitivity and accuracy were higher for carcinomatous lesions (96% and 88%) than for noncarcinomatous lesions (81% and 69%). The only significant complication encountered was a pneumothorax following a biopsy which required intercostal drainage.

CONCLUSIONS

Radiologically guided percutaneous needle biopsy is a safe procedure which provides useful diagnostic information in the majority of cases. Fine needle aspiration techniques usually suffice for carcinomatous lesions but a cutting needle biopsy should be performed whenever possible when lymphoma, thymoma, or neural masses are suspected to obtain larger specimens for more accurate histological diagnosis.

Interventional chest radiology

Radiologically guided percutaneous drainage procedures are commonly performed to manage a variety of intrathoracic collections. As a natural extension of similar procedures performed for abdominal and pelvic collections, these procedures use both the conventional and cross-sectional imaging modalities to detect intrathoracic collections and to guide safe percutaneous diagnostic aspiration and drainage. The high-resolution images obtainable on current computed tomographic and ultrasound units allow detection of lung abscesses, empyemas, malignant effusions, and infected mediastinal fluid collections that are amenable to percutaneous drainage. Advances in catheter design and introduction techniques have allowed drainage of collections previously managed by open procedures. The ease of fluoroscopically guided catheter placement for treatment of spontaneous or biopsy-induced pneumothorax has provided a safe, effective, and comfortable alternative to blind large-bore surgical tube placement. Transthoracic needle biopsy of lung, mediastinal, and pleural or chest-wall masses has resulted from the availability of image intensifiers and cross-sectional imaging modalities useful in guiding needle placement and tissue sampling. Equally important has been the development of cytopathology as a subspecialty that can provide diagnoses of malignant and benign thoracic conditions from needle aspirates. This technique has had a major impact on the preoperative evaluation of the patient with a solitary pulmonary nodule and has eliminated unnecessary surgery in a significant percentage of such patients. Transcatheter arterial embolization has made a significant contribution to the management of the patient with massive hemoptysis and is the procedure of choice for treatment of pulmonary arteriovenous malformations. A thorough knowledge of the vascular anatomy of the thorax and expertise in catheterization and embolization techniques are prerequisites for the safe performance of these procedures.