Diagnostic Yield and Safety of Computed Tomography-guided Mediastinal Core Needle Biopsies

Diagnostic yield, complications, pathology and anatomical features in CT-guided percutaneous needle biopsy of mediastinal tumours

OBJECTIVES

This study presents the experiences of percutaneous CT-guided needle biopsy at a university hospital in Norway.

METHODS

A retrospective examination of all mediastinal biopsy procedures between April 2015 and August 2019 was performed at Akershus University Hospital in Norway. We registered patient and procedure characteristics, along with lesion pathology and characteristics including localization according to anatomical and Felson mediastinal compartments.

RESULTS

The study included 48 procedures, conducted in 45 patients (29 men and 16 women) with a mean age of 60,5 years. Pneumothorax occurred in 12 procedures (60% of the transpulmonary procedures) and pneumomediastinum in 18 procedures (38%). Pneumothorax was only seen in procedures with transpulmonal access. Four of the pneumothorax cases required pleural drainage. Diagnostic yield was 96%. We found significant (p = 0,006), moderate to high association between anatomical compartment localization and histopathological diagnosis (Cramér's V = 0,49) for tumours selected for CT-guided percutaneous biopsy. Felson's compartment division on the other hand, did not show any significant associations.

CONCLUSION

We found CT-guided percutaneous needle biopsy of mediastinal tumours to be an effective and safe procedure with a diagnostic yield of 96%. The main complications were pneumothorax and pnumomediastinum, with a relatively low chest drainage rate. Anatomical mediastinum compartment showed a significant, moderate to high association with the histopathological diagnosis for tumours selected for percutaneous CT-guided biopsies, where most malignancies were seen in the anterior compartment.

Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Efficacy of contrast-enhanced ultrasound-guided percutaneous core needle biopsy in anterior mediastinal masses

Objective

To evaluate the efficacy and safety of percutaneous core needle biopsy (PCNB) using ultrasound (US)-guided and contrast-enhanced ultrasound (CEUS)-guided procedures for anterior mediastinal masses (AMMs).

Methods

In total, 284 consecutive patients (166 men, 118 women; mean age, 43.0 ​± ​18.4 years) who underwent PCNB for AMMs were enrolled. Patients were divided into the US-guided group (n ​= ​133) and the CEUS-guided group (n ​= ​151). PCNB was performed using a core needle (16-gauge or 18-gauge). Internal necrosis, diagnostic yield, and diagnostic accuracy were compared between the two groups.

Results

The predominant final diagnosis of the cases in this study was thymoma (29.7%), lymphoma (20.5%), thymic carcinoma (13.3%), and germ cell tumour (13.3%), respectively. There was no significant difference in patient age, sex, number of percutaneous biopsies, or display rate of internal necrosis on conventional US between the two groups. The rate of internal necrosis of the lesions was significantly higher after contrast agent injection (72.2% vs. 41.7%; P ​< ​0.001). The CEUS-guided group had a higher diagnostic yield than the US-guided group (100% vs. 89.5%, P ​< ​0.001). There was no significant difference between the diagnostic accuracy of the CEUS-guided and US-guided groups (97.3% vs. 97.4%; P ​= ​1.000). None of the patients experienced adverse reactions or complications after US-guided or CEUS-guided PCNB.

Conclusions

CEUS-guided PCNB can improve the diagnostic yield by optimizing the biopsy procedure.

Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy

Objective

To retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy.

Patients and Methods

Retrospective review of an institutionally maintained biopsy registry identified 337 computed tomography- or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed.

Results

Mean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy.

Conclusion

Image-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.

ACR Appropriateness Criteria® Imaging of Mediastinal Masses

Mediastinal masses can present with symptoms, signs, and syndromes or incidentally. Selecting the appropriate diagnostic imaging study for mediastinal mass evaluation requires awareness of the strengths and weaknesses of the various imaging modalities with regard to tissue characterization, soft tissue contrast, and surveillance. This publication expounds on the differences between chest radiography, CT, PET/CT, ultrasound, and MRI in terms of their ability to decipher and surveil mediastinal masses. Making the optimal imaging choice can yield diagnostic specificity, avert unnecessary biopsy and surgery, guide the interventionist when necessary, and serve as a means of surveillance for probably benign, but indeterminate mediastinal masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Percutaneous CT Fluoroscopy-Guided Core Needle Biopsy of Mediastinal Masses: Technical Outcome and Complications of 155 Procedures during a 10-Year Period

PURPOSE

To evaluate technical outcome, diagnostic yield and safety of computed tomographic fluoroscopy-guided percutaneous core needle biopsies in patients with mediastinal masses.

METHODS

Overall, 155 CT fluoroscopy-guided mediastinal core needle biopsies, performed from March 2010 to June 2020 were included. Size of lesion, size of needle, access path, number of success, number of biopsies per session, diagnostic yield, patient's position, effective dose, rate of complications, tumor localization, size of tumor and histopathological diagnosis were considered. Post-interventional CT was performed, and patients observed for any complications. Complications were classified per the Society of Interventional Radiology (SIR).

RESULTS

148 patients (age, 54.7 ± 18.2) underwent 155 CT-fluoroscopy-guided percutaneous biopsies with tumors in the anterior (114; 73.5%), middle (17; 11%) and posterior (24; 15.5%) mediastinum, of which 152 (98%) were technically successful. For placement of the biopsy needle, in 82 (52.9%) procedures a parasternal trajectory was chosen, in 36 (23.3%) a paravertebral access, in 20 (12.9%) through the lateral intercostal space and in 17 (11%) the thoracic anterior midline, respectively. A total of 136 (89.5%) of the biopsies were considered adequate for a specific histopathologic analysis. Total DLP (dose-length product) was 575.7 ± 488.8 mGy*cm. Mean lesion size was 6.0 ± 3.3 cm. Neoplastic pathology was diagnosed in 115 (75.7%) biopsies and 35 (23%) biopsy samples showed no evidence of malignancy. Minor complications were observed in 18 (11.6%) procedures and major pneumothorax requiring drainage insertion in 3 interventions (1.9%).

CONCLUSION

CT fluoroscopy-guided percutaneous core needle biopsy of mediastinal masses is an effective and safe procedure for the initial assessment of patients with mediastinal tumors.

Diagnostic strategy for trigger identification in severe reactive hemophagocytic lymphohistiocytosis: A diagnostic accuracy study

Reactive hemophagocytic lymphohistiocytosis (rHLH) management requires early recognition, trigger identification, and adequate treatment in order to reduce mortality. We assessed the diagnostic yield of tissue biopsies to identify trigger in severe rHLH. We included all consecutive patients presenting an rHLH diagnosis (HLH-2004 criteria) admitted to the intensive care unit (ICU) of a tertiary hospital. This retrospective diagnostic accuracy study was conducted according to the Standards for Reporting Diagnostic Accuracy Statement. Among the 134 included patients (median age 47 years [IQR 47-56]), an underlying immunodeficiency was previously known in 61.2%. rHLH trigger was identified in 127 patients (94.8%) (hematological disorder 75%, infection 16%, systemic disease 4%). Diagnostic yield of tissue biopsies was as follows: lymph node 75% (95% confidence interval [CI], 61-85), skin 50% (95% CI, 27-73), bone marrow 44% (95% CI, 34-55), liver 30% (95% CI, 15-49). Splenectomy (yield 77%; 95% CI, 46-95) was reserved to cases of diagnostic deadlock. Procedural severe adverse events included two cases of reversible hemorrhagic shock. Seventy-eight percent of patients received etoposide regarding to the rHLH severity, and 68% could receive trigger-specific treatment in the ICU. A comprehensive diagnostic workup led to an rHLH trigger identification in 95% of patients, allowing prompt initiation of appropriate therapy. Prospective studies to validate a standardized diagnostic approach are warranted.

The role of needle core biopsies in the evaluation of thymic epithelial neoplasms

Thymic epithelial neoplasms are rare tumors derived from thymic epithelium that most often present as large anterior mediastinal masses. The vast majority of thymic epithelial neoplasms fall under the diagnostic category of thymoma, with a smaller percentage qualifying for a diagnosis of thymic carcinoma. The ability to render a definitive diagnosis on these tumors is generally hampered by their deep location and close proximity to vital structures, which makes biopsy sampling for histopathologic evaluation difficult. In recent years, the trend in medicine has been to opt for the least invasive procedure to obtain tissue samples that, by definition, implies also obtaining smaller and smaller biopsies, resulting in lesser amounts of tissue available for examination. In the mediastinum, the most common modalities for procuring biopsy samples from mass lesions include fine-needle aspiration, percutaneous core needle biopsy and video-assisted thoracoscopic biopsy. In this review, we will deal only with the role and limitations of percutaneous core biopsies in the interpretation of thymic epithelial neoplasms.

Lung cancer staging: a concise update

Diagnosis and clinical staging of lung cancer are fundamental to planning therapy. The techniques for clinical staging, i.e anatomic and metabolic imaging, endoscopies and minimally invasive surgical procedures, should be performed sequentially and with an increasing degree of invasiveness. Intraoperative staging, assessing the magnitude of the primary tumour, the involved structures, and the loco-regional lymphatic spread by means of systematic nodal dissection, is essential in order to achieve a complete resection. In resected tumours, pathological staging, with the systematic study of the resected specimens, is the strongest prognostic indicator and is essential to make further decisions on therapy. In the present decade, the guidelines on lung cancer staging of the American College of Chest Physicians and the European Society of Thoracic Surgeons are based on the best available evidence and are widely followed. Recent advances in the classification of the adenocarcinoma of the lung, with the definition of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma, and the publication of the eighth edition of the tumour, node and metastasis classification of lung cancer, have to be integrated into the staging process. The present review complements the latest guidelines on lung cancer staging by providing an update of all these issues.

Rapid, real time pathology review for ECOG/ACRIN 1412: a novel and successful paradigm for future lymphoma clinical trials in the precision medicine era

ECOG/ACRIN 1412 (E1412) is a randomized, phase II open-label study of lenalidomide/RCHOP vs. RCHOP alone in adults with newly diagnosed de novo diffuse large B-cell lymphoma (DLBCL) and requires NanoString gene expression profiling (GEP) for cell-of-origin testing. Because of high ineligibility rate on retrospective expert central pathology review (ECPR), real-time (RT) ECPR was instituted to confirm diagnosis and ensure adequate tissue for GEP prior to study enrollment. Goal was notification of eligibility within 2 working days (WD). Initially, 208 patients were enrolled, 74 (35.6%) of whom were deemed ineligible by retrospective ECPR. After initiation of RT-ECPR, 219 patients were registered. Of these, 73 (33.3%) were ineligible and were declined enrollment; 47 (21.5% of total) had an ineligible diagnosis on RT-ECPR, and 26 (11.9% of total) had inadequate tissue. Because the 73 ineligible patients were never enrolled, no study slots were “lost” during this phase. Notification of eligibility occurred in an average of 1 WD (Range 0–4) with 97.3% within 2 WD. This novel RT-ECPR serves as a model for future lymphoma trials. Real-time ECPR can help to reduce costs and ensure that study slots accurately reflect the targeted population. In the precision-medicine era, rapid collection of relevant pathology/biomarker data is essential to trial success.

Management of superior vena cava syndrome in critically ill cancer patients

PURPOSE

The purpose of this study is to describe the management and outcome of critically ill cancer patients with Superior Vena Cava Syndrome (SVCS).

METHODS

All cancer patients admitted to the medical intensive care unit (ICU) of the Saint-Louis University Hospital for a SVCS between January 2004 and December 2016 were included.

RESULTS

Of the 50 patients included in the study, obstruction of the superior vena cava was partial in two-thirds of the cases and complete in one-third. Pleural effusion was reported in two-thirds of the patients, pulmonary atelectasis in 16 (32%), and pulmonary embolism in five (10%). Computed tomography of the chest showed upper airway compression in 18 (36%) cases, while echocardiography revealed 22 (44%) pericardial effusions. The causes of SVCS were diagnosed one (0-3) day after ICU admission, using interventional radiology procedures in 70% of the cases. Thirty (60%) patients had hematological malignancies, and 20 (40%) had solid tumors. Fifteen (30%) patients required invasive mechanical ventilation, seven (14%) received vasopressors, and renal replacement therapy was implemented in three (6%). ICU, in-hospital, and 6-month mortality rates were 20, 26, and 48%, respectively. The cause of SVCS was the only factor independently associated with day 180 mortality by multivariate analysis. Patients with hematological malignancies had a lower mortality than those with solid tumors (27 versus 80%) (odds ratio 0.12, 95% confidence interval (0.02-0.60), p < 0.01).

CONCLUSION

Airway obstruction and pleural and pericardial effusions contributed to the unstable condition of cancer patients with SVCS. The vital prognosis of SVCS was mainly related to the underlying diagnosis.

The Intensive Care Medicine research agenda on critically ill oncology and hematology patients

Over the coming years, accelerating progress against cancer will be associated with an increased number of patients who require life-sustaining therapies for infectious or toxic chemotherapy-related events. Major changes include increased number of cancer patients admitted to the ICU with full-code status or for time-limited trials, increased survival and quality of life in ICU survivors, changing prognostic factors, early ICU admission for optimal monitoring, and use of noninvasive diagnostic and therapeutic strategies. In this review, experts in the management of critically ill cancer patients highlight recent changes in the use and the results of intensive care in patients with malignancies. They seek to put forward a standard of care for the management of these patients and highlight important updates that are required to care for them. The research agenda they suggest includes important studies to be conducted in the next few years to increase our understanding of organ dysfunction in this population and to improve our ability to appropriately use life-saving therapies or select new therapeutic approaches that are likely to improve outcomes. This review aims to provide more guidance for the daily management of patients with cancer, in whom outcomes are constantly improving, as is our global ability to fight against what is becoming the leading cause of mortality in industrialized and non-industrialized countries.

Computed tomography-guided percutaneous core needle biopsy for diagnosis of mediastinal mass lesions: Experience with 110 cases in two university hospitals in Isfahan, Iran

Background:

Computed tomography-guided percutaneous core needle biopsy (PCNB) is a diagnostic technique for initial assessment of mediastinal mass lesions. This study was conducted to evaluate its diagnostic yield and its complication rate.

Materials and Methods:

We reviewed the records of CT-guided PCNB in 110 patients with mediastinal mass lesions performed in Kashani and Alzahra Hospitals, Isfahan, from 2006 to 2012. Gender, age at biopsy, size, and anatomic location of the lesion, number of passes, site of approach, complications, and final diagnosis were extracted.

Results:

Our series encompasses 52 (47.2%) females and 58 (52/7%) males with mean age of 41 ± 8 years. The most common site of involvement was the anterior mediastinum (91.8% of cases). An average of 3/5 passes per patient has been taken for tissue sampling. Parasternal site was the most frequent approach taken for PCNB (in 78.1% of cases). Diagnostic tissue was obtained in 99 (90%) biopsies while, in 11 (10%) cases, specimen materials were inadequate. Lymphoma (49.5%) and bronchogenic carcinoma (33.3%) were the most frequent lesions in our series. The overall complication rate was 17.2% from which 10.9% was pneumothorax, 5.4% was hemoptysis, and 0.9% was vasovagal reflex.

Conclusion:

CT-guided PCNB is a safe and reliable procedure that can provide a precise diagnosis for patients with both benign and malignant mediastinal masses, and it is considered the preferred first diagnostic procedure use for this purpose.

Flat detector cone-beam CT-guided percutaneous needle biopsy of mediastinal lesions: preliminary experience

PURPOSE

The purpose of this study was to evaluate the usefulness of flat detector cone-beam CT-guided CBCT percutaneous needle biopsy (PNB) of mediastinal lesions.

METHODS

A total of 100 patients with 100 solid mediastinal lesions were retrospectively enrolled to undergo percutaneous needle biopsy (PNB) procedures. The mean diameter of lesions was 4.4 ± 1.8 cm (range 1.8-9.0 cm). The needle path was carefully planned and calculated on the CBCT virtual navigation guidance system, which acquired 3D CT-like cross-sectional images. Diagnostic performance, procedure details, complication rate, and patient radiation exposure were investigated.

RESULTS

The technical success rate of PNB under CBCT virtual navigation system was 100 % (100/100). The sensitivity, specificity, and accuracy of PNB of small nodules under iGuide CBCT virtual navigation guidance were 95.1 % (79/83), 100 % (12/12), and 95.7 % (91/95), respectively. The number of biopsies and CBCT acquisitions were 2.6 ± 1.2 (range 1-6) and 3.0 ± 1.1 (range 2-8), respectively. Complications occurred in five (5.0 %) cases. The mean total procedure time was 11.70 ± 3.44 min (range 6-27 min), resulting in a mean exposure dose of 9.7 ± 4.3 mSv.

CONCLUSION

Flat detector cone-beam CT-guided PNB is an accurate and safe diagnostic method for mediastinal lesions.

MRI-Guided Percutaneous Biopsy of Mediastinal Masses Using a Large Bore Magnet: Technical Feasibility

OBJECTIVE

To evaluate the diagnostic accuracy and safety of magnetic resonance imaging (MRI)-guided percutaneous biopsy of mediastinal masses performed using a wide-bore high-field scanner.

MATERIALS AND METHODS

This is a retrospective study of 16 consecutive patients (8 male, 8 female; mean age 74 years) who underwent MRI-guided core needle biopsy of a mediastinal mass between February 2010 and January 2014. Size and location of lesion, approach taken, time for needle placement, overall duration of procedure, and post-procedural complications were evaluated. Technical success rates and correlation with surgical pathology (where available) were assessed.

RESULTS

Target lesions were located in the anterior (n = 13), middle (n = 2), and posterior mediastinum (n = 1), respectively. Mean size was 7.2 cm (range 3.6-11 cm). Average time for needle placement was 9.4 min (range 3-18 min); average duration of entire procedure was 42 min (range 27-62 min). 2-5 core samples were obtained from each lesion (mean 2.6). Technical success rate was 100%, with specimens successfully obtained in all 16 patients. There were no immediate complications. Histopathology revealed malignancy in 12 cases (4 of which were surgically confirmed), benign lesions in 3 cases (1 of which was false negative following surgical resection), and one inconclusive specimen (treated as inaccurate since repeat CT-guided biopsy demonstrated thymic hyperplasia). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in our study were 92.3, 100, 100, 66.7, and 87.5%, respectively.

CONCLUSION

MRI-guided mediastinal biopsy is a safe procedure with high diagnostic accuracy, which may offer a non-ionizing alternative to CT guidance.