Percutaneous transthoracic needle aspiration biopsy: a comprehensive review of its current role in the diagnosis and treatment of lung tumors

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.

Diagnostic Performance of Electromagnetic Navigation versus Virtual Navigation Bronchoscopy-Guided Biopsy for Pulmonary Lesions in a Single Institution: Potential Role of Artificial Intelligence for Navigation Planning

Navigation bronchoscopy is an emerging technique used to evaluate pulmonary lesions. Using Veran’s SPiN electromagnetic navigation bronchoscopy (ENB) and Archimedes virtual bronchoscopy navigation (VBN), this study aimed to compare the accuracy and safety of these procedures for lung lesions and to identify potentially relevant knowledge for the application of artificial intelligence in interventional pulmonology in a single institute. This single-center, retrospective study compared the ENB and VBN results in patients with pulmonary lesions unsuitable for biopsy via percutaneous transthoracic needle biopsy methods. A total of 35 patients who underwent navigation bronchoscopy for pulmonary lesion diagnosis were enrolled. Nineteen patients were stratified in the ENB group, and sixteen were in the VBN group. The mean age of this cohort was 67.6 ± 9.9 years. The mean distance of the lesion from the pleural surface was 16.1 ± 11.7 mm (range: 1.0–41.0 mm), and most lesions were a solid pattern (n = 33, 94.4%). There were 32 cases (91.4%) of pulmonary lesions with an air-bronchus sign. A statistically significant difference was found between pulmonary size and transparenchymal nodule access (p = 0.049 and 0.037, respectively). The navigation success rate was significantly higher in the VBN group (93.8% vs. 78.9%). Moreover, no procedure-related complications or mortality were noted. The radiographic characteristics, such as size or solid component, can affect the selection of the biopsy procedure, either ENB or VBN. Navigation bronchoscopy-guided biopsy demonstrated acceptable accuracy and a good safety profile in evaluating pulmonary lesions when the percutaneous approach was challenging or life threatening.

Safety and effectiveness of simultaneous localization of multiple lung nodules using coils and risk factors for pneumothorax: a retrospective study

BACKGROUND

Localization of lung nodule before video-assisted thoracoscopic surgery (VATS) can help the surgeon to quickly and accurately find the lesion during surgery.

PURPOSE

To evaluate the safety and effectiveness of using coils to simultaneously locate multiple lung nodules under computed tomography guidance and to clarify the risk factors for pneumothorax.

MATERIAL AND METHODS

From January 2020 to December 2020, 61 patients underwent simultaneous localization of multiple lung nodules (Group A) and 120 patients underwent localization of a single lung nodule (Group B). The demographics, information related to localization procedure, and incidence of pulmonary hemorrhage and pneumothorax were compared between the patients in Groups A and B. Group A was further divided into a pneumothorax group and non-pneumothorax group. Univariate and multivariate regression analyses were used to determine the risk factors for pneumothorax in patients who underwent simultaneous localization of multiple lung nodules using coils.

RESULTS

The success rates in Groups A and B were 96.9% and 96.7%, respectively (P = 1.000). The number of pleural punctures (P<0.001), the positioning operation time (P<0.001), the rates of pneumothorax (P<0.001), and hemorrhage (P = 0.034) were higher in Group A than in Group B. The pneumothorax and bleeding in Group A did not require special treatment. Transfissural puncture (odds ratio [OR]=16.798; P = 0.033) and the numbers of pleural punctures (OR=2.437; P = 0.013) were independent risk factors for pneumothorax caused by simultaneous localization of multiple lung nodules, and hemorrhage was a protective factor against pneumothorax (OR=0.069; P = 0.002).

CONCLUSION

Simultaneous localization of multiple lung nodules using coils under computed tomography guidance is safe and effective. Transfissural puncture and higher numbers of pleural punctures will increase the risk of pneumothorax, whereas hemorrhage will reduce the risk of pneumothorax.

Ultrasound-Guided Transthoracic Mediastinal Biopsy: A Safe Technique for Tissue Diagnosis in Middle- and Low-Income Countries

Background and objectives

The high cost of video-assisted transthoracic procedures precludes their use in the diagnostics of mediastinal masses in low- and middle-income countries (LMICs). This study aims to assess the technical success rate and diagnostic yield of ultrasound-guided transthoracic mediastinal biopsies at a tertiary care hospital.

Methods

This descriptive cross-sectional study was conducted in patients presenting with mediastinal masses referred to radiology services at Dr. Ziauddin University Hospital. Karachi, Pakistan. Ultrasonography was performed using Toshiba Xario 200 & Aplio 500 using convex and linear probes accordingly. Biopsy was performed using a combination of 18G semiautomatic trucut and 17G co-axial needles. Complications and overall diagnostic yields were determined.

Results

In all 70 patients referred, the procedure was completed successfully with an overall procedural yield of 95.7%. Inconclusive biopsies due to inadequate specimen were seen in two (4.2%) patients. No post-procedure major complication or mortality was observed. Minor complications were seen in three (4.2%) out of 70, including hematoma (<3 cm) in one patient and small pneumomediastinum in two patients.

Conclusion

Ultrasound-guided transthoracic mediastinal biopsy may be the pragmatic technique of choice in LMICs for the diagnosis of mediastinal masses as they provide real-time visualization and is cost-effective and safe.

Pulmonary Langerhans Cell Histiocytosis Presenting as a Solitary Pulmonary Nodule on a Lung Cancer Screening CT

Pulmonary Langerhans cell histiocytosis (PLCH) is a rare inflammatory condition that mostly affects lungs in smokers. On imaging, it usually presents as multiple, upper lobe predominant, solid, and cavitary nodules, but presentation as solitary pulmonary nodule (SPN) is rare. We describe a case of SPN seen on low-dose lung cancer screening CT (LDCT) that was FDG avid on PET/CT. Given concern for malignancy, lobectomy was planned if intraoperative frozen section was consistent with malignancy. Lobectomy was performed based on frozen section; however, on formal pathology review, the nodule was ultimately found to be PLCH. This case illustrates an atypical presentation of PLCH as a solitary nodule. Furthermore, it helps demonstrate how rare etiologies (like PLCH) may be more frequently encountered and should be considered in the differential diagnosis for solitary lung nodules, especially in the era of lung cancer screening.

Patterns of percutaneous transthoracic needle biopsy (PTNB) of the lung and risk of PTNB-related severe pneumothorax: A nationwide population-based study

Background

As percutaneous transthoracic needle biopsy (PTNB) of the lung is a well-established diagnostic method for the evaluating pulmonary lesions, evidence of safety based on representative data is limited. This study investigated the practice patterns of PTNB of the lung and assessed the incidence and risk factors of PTNB-related severe pneumothorax in Korea.

Methods

We used a national-level health insurance database between January 1, 2007 and December 31, 2015. Patients who underwent PTNB of the lung were identified using procedure codes for organ biopsy, fluoroscopy, computed tomography, chest radiography, and lung-related diagnosis codes. The annual age-/sex-standardized rate of PTNB and the incidence of PTNB-related severe pneumothorax were calculated. We defined severe pneumothorax as the pneumothorax requiring intervention. The odds ratios of risk factors were assessed by a generalized estimating equation model with exchangeable working correlation matrix to address clustering effect within institution.

Results

A total of 66,754 patients were identified between 2007 and 2015. The annual age-/sex-standardized rate of PTNB per 100,000 population was 19.6 in 2007 and 22.4 in 2015, and it showed an increasing trend. The incidence of severe pneumothorax was 2.4% overall: 2.5% in men and 1.2% in women, and 2.6%, 2.7%, 2.1%, 2.1%, 1.9%, 2.4%, and 2.4% from 2009 to 2015. Older age (≥60), male sex, presence of chronic obstructive pulmonary disease, receiving treatment in an urban or rural area versus a metropolitan area, and receiving treatment at a general hospital were significantly associated with the risk of severe pneumothorax.

Conclusions

Considering the increasing trend of PTNB, more attention needs to be paid to patients with risk factors for severe pneumothorax.

Application of Modified Tailed Microcoil in Preoperative Localization of Small Pulmonary Nodules: A Retrospective Study

BACKGROUND

The localization of small pulmonary nodules (SPNs) during video-assisted thoracoscopic surgery (VATS) is challenging thoracic surgeon, especially in patients with severe pleural adhesion or visceral pleura pigmentation due to low success rate and future conversion to thoracotomy. This study aims to compare the efficacy and safety between modified microcoil and methylene blue in preoperative localization of small nodules, particularly patients with severe pleural adhesion or visceral pleura pigmentation.

MATERIALS AND METHODS

From January 2018 to February 2019 in our institute, 342 patients who underwent computed tomography-guided localization of SPN were recruited in this retrospective cohort study and divided into the modified microcoil group (n = 239) and the methylene blue group (n = 103) according to the localization method. Clinical characteristics and perioperative complications were collected to analyze.

RESULTS

All SPNs were successfully marked in both groups. Location-related complications, the duration of localization procedure, and the length of hospital stay were not different between the two groups. The operation time of modified microcoil and the duration of removal of nodule in operation were both shorter than the methylene blue (p = 0.014 and p = 0.047). The analysis stratified by gender showed that similar results were found in male patients (p = 0.01 and p = 0.00), while in female patients, no significant difference was found. Additionally, in senior patients (older than 60 years), the operation time in modified microcoil groups was less than methylene blue group (p = 0.024).

CONCLUSION

Compared with methylene blue, modified microcoil achieved a shorter operation time of removal of nodule in VATS, especially for patients with pleural adhesion and the pigmentation of the lung surface as well as the male patients and the patients older than 60 years.

Photoacoustic imaging to localize indeterminate pulmonary nodules: A preclinical study

PURPOSE

Diagnosis and resection of indeterminate pulmonary nodules (IPNs) is a growing challenge with increased utilization of chest computed tomography. Photoacoustic (PA) -guided surgical resection with local injection of indocyanine green (ICG) may have utility for IPNs that are suspicious for lung cancer. This preclinical study explores the potential of PA imaging (PAI) to detect ICG-labeled tumors.

MATERIALS AND METHODS

ICG uptake by H460 lung cancer cells was evaluated in vitro. A phantom study was performed to analyze PA signal intensity according to ICG concentration and tissue thickness/depth using chicken breast. PA signals were measured up to 48 hours after injection of ICG (mixed with 5% agar) into healthy subcutaneous tissue, subcutaneous H460 tumors and right healthy lung in nude mice.

RESULTS

Intracellular ICG fluorescence was detected in H460 cells co-incubated with ICG in vitro. The concentration dependence of the PA signal was logarithmic, and PA signal decline was exponential with increasing tissue depth. The PA signal of 2 mg/mL ICG was still detectable at a depth of 22 mm in chicken breast. The PA signal from ICG mixed with agar was detectable 48 hours post injection into subcutaneous tissue and subcutaneous H460 tumors in nude mice. Similar features of PA signals from ICG-agar in mice lung were obtained.

CONCLUSION

The results from this preclinical study suggests that PAI of injected ICG-agar may be beneficial for identifying deeply located tumors. These features may be valuable for IPNs.

First-in-Human Use of a Hybrid Real-Time Ultrasound-Guided Fine-Needle Acquisition System for Peripheral Pulmonary Lesions: A Multicenter Pilot Study

BACKGROUND

The ability to successfully perform a biopsy on pulmonary lesions by means of bronchoscopy varies widely due to anatomic and technological limitations. One major limitation is the lack of the ability to utilize real-time guidance during tissue sampling in the periphery. A novel system has been developed that enables real-time visualization and sampling of peripheral lesions by displaying an ultrasound image of the lesion and needle simultaneously.

METHODS

We performed a multicenter, prospective pilot in patients with peripheral pulmonary lesions undergoing a clinically indicated bronchoscopy. The purpose of this study was to demonstrate the feasibility of visualizing, accessing, and obtaining specimens adequate for the cytology of lung lesions when using a novel hybrid real-time ultrasound-guided fine-needle aspiration system for peripheral pulmonary lesions.

RESULTS

Twenty-three patients underwent bronchoscopic sampling of a peripheral pulmonary lesion with the study device. Mean lesion size was 3.6 (range 1.7-5.7) cm. Targeted lesions were located in all lobes of the lung. All lesions were successfully visualized and sampled under real-time visualization with specimens adequate for cytological evaluation. The needle was visualized in all lesions throughout targeting and sampling. There were no incidents of pneumothorax or moderate-to-severe bleeding.

CONCLUSION

In this feasibility study, we report the first-in-human use of a continuous real-time endobronchial ultrasound guidance system to sample peripheral pulmonary lesions. Future generations of this device may improve usability and further studies are needed to determine the true diagnostic capabilities of this novel technique.

Navigation bronchoscopy: A new tool for pulmonary infections

Infections remain a common cause of lung nodules, masses, and cavities. Safe tissue sampling is required to establish a diagnosis, differentiate between malignant and infectious causes, and provide microbiological material for characterization and sensitivity analysis. Tissue samples could be obtained bronchoscopically, percutaneously, or through surgical biopsy. Among these, bronchoscopy is the safest by avoiding the complications of pleural and chest wall puncture including pneumothorax, pain, pleural contamination and empyema, and hemothorax. However, the diagnostic yield with conventional bronchoscopy for small, peripheral lesions is poor. Electromagnetic navigation bronchoscopy (ENB) is a technique where the bronchoscope and working channel are guided through the bronchial tree to accurately reach a peripheral lesion. It dramatically improves on the diagnostic yield of peripheral lesions especially of small lesions, and its role has developed beyond diagnosis to treatment enablement and to direct therapy. Its role in infection is less defined, but it has value especially in the diagnosis of fungal and mycobacterial infections and in cavitating lesions. This review will explore what electromagnetic navigation bronchoscopy is, its use in diagnosis and therapy, and its role in the management of pulmonary infections. The potential for local therapy delivery for infection is also discussed.

Non-diagnostic Results of Percutaneous Transthoracic Needle Biopsy: A Meta-analysis

Non-diagnostic results can affect the diagnostic performance of percutaneous transthoracic needle biopsy (PTNB) but have not been critically meta-analyzed yet. To meta-analyze the incidence and malignancy rate of non-diagnostic results, 3-by-2 table approaches rather than the conventional 2-by-2 approaches are needed to know its impact on the diagnostic performance of PTNB. A systematic literature search identified studies evaluating the diagnostic performance of PTNB with extractable outcomes. A total of 143 studies with 35,059 biopsies were included. The pooled incidence of non-diagnostic results was 6.8% (95% CI, 6.0-7.6%; I² = 0.91). The pooled malignancy rate of non-diagnostic results was 59.3% (95% CI, 51.7-66.8%; I² = 0.80), and was correlated with the prevalence of malignancy (correlation coefficient, 0.66; 95% CI, 0.42-0.91). Pooled percentage decrease of sensitivity and specificity due to non-diagnostic results were 4.5% (95% CI, 3.2-5.7%; I² = 0.64) and 10.7% (95% CI, 7.7-13.7%; I² = 0.70), respectively, and the pooled incidence of non-diagnostic results was 4.4% (95% CI, 3.2-5.8%; I² = 0.83) in lesions ultimately diagnosed as malignancies and 10.4% (95% CI, 7.5-13.8%; I² = 0.74) in benign disease. In conclusion, non-diagnostic results averagely occurred in 6.8% of PTNB and more than half of the results were malignancies. The non-diagnostic results decreased specificity and sensitivity by 10.7% and 4.5%, respectively, demanding efforts to minimize the non-diagnostic results in PTNB.

Peripheral Lung Nodule Diagnosis and Fiducial Marker Placement Using a Novel Tip-Tracked Electromagnetic Navigation Bronchoscopy System

BACKGROUND

Electromagnetic navigation (EMN) has improved bronchoscopic access to peripheral pulmonary nodules. A novel EMN system utilizing novel tip-tracked instruments for endobronchial [electromagnetic navigation bronchoscopy (ENB)] as well as transthoracic lung biopsy [electromagnetic-guided transthoracic needle aspiration (EMTTNA)] has become available. The system provides real-time feedback as well as the ability to biopsy lesions outside of the airway. These advances have the potential to improve diagnostic yield over previous EMN systems.

METHODS

We performed a retrospective review of consecutive peripheral bronchoscopy cases utilizing a novel EMN platform for biopsy and/or fiducial marker (FM) placement at a tertiary care university hospital. We analyzed factors that may influence diagnostic yield including lesion size.

RESULTS

Our study included 108 patients who underwent EMN-guided bronchoscopy between June 2015 and April 2017 for the diagnosis of peripheral lung lesions and/or the placement of FMs for stereotactic body radiotherapy. Ninety-three patients underwent biopsy utilizing ENB +/- EMTTNA. The combined diagnostic yield was 78%. EMTTNA provided a diagnosis for 5 patients in whom the ENB biopsy results were negative. Diagnostic yield by nodules <20, 20 to 30, and >30 mm in size was 30/45 (67%), 27/30 (90%), and 16/18 (89%), respectively. Sixty-five patients underwent FM placement with a total of 133 FM placed.

CONCLUSION

This novel tip-tracked EMN system incorporating both ENB and EMTTNA can guide biopsy and FM placement with a high degree of success and with a low complication rate. Multicentered prospective trials are required to develop algorithmic approaches to combine ENB and EMTTNA into a single procedure.

CT-guided fine-needle aspiration biopsy of solitary pulmonary nodules under 15 mm in diameter: time for an afterthought?

Background

Many studies on fine-needle aspiration biopsy (FNAB) for undetermined pulmonary nodules reported that diagnostic accuracy tended to decline, whereas complication prevalence raised as the size of nodule decreased. Reconsideration on the effectiveness of FNAB would be appropriate considering the dramatic increase in the identification of small nodules with screening programs and new demands of target therapies. The aim of this study was to verify the efficacy of FNAB in pulmonary nodules smaller than 15 mm.

Methods

A retrospective, cohort study was conducted on patients with undetermined solitary pulmonary nodules (SPNs) who underwent computer tomography (CT) guided FNAB at our Institution from January 2012 to December 2014. Patients with SPNs with diameter up to 15 mm were considered; inclusion criteria comprised ASA 3, FEV1 <70% of predicted, cardiac comorbidity or previous chest surgery. FNAB diagnostic performance and clinical efficacy were calculated.

Results

Out of 225 patients referred for FNAB, 68 covered inclusion criteria. Forty-nine out of 68 smears (72%) were adequate for diagnosis. Specificity was 100% (95% CI: 77-100%), sensitivity was 100% (95% CI: 90-100%). Positive and negative predictive values were 1.0 (95% CI: 0.9-1.0) and 1.0 (95% CI: 0.77-1.0) respectively. A post-biopsy pneumothorax was detected in 27 cases (39%); the pneumothorax rate was significantly affected by the number of passages (P=0.01).

Conclusions

The satisfactory results of our study lead to reconsidering FNAB in patients with pulmonary nodules below 15 mm in diameter, especially in order to avoid unnecessary surgery.

Workup of Suspected Chest Metastases on 18F-FDG-PET/CT in Head and Neck Cancer: Worth the Wait?

The objective of our study is to assess the impact of equivocal or positive positron emission tomography combined with low-dose noncontrast computed tomography (PET/CT) findings in the chest on treatment for head and neck cancer (HNC). We reviewed charts of patients presented at Augusta University's Head and Neck Tumor Board (AUTB) between 2013 and 2016 with the following exclusion criteria: <18 years, Veterans Affairs patients, those with incomplete data, and those without a history of head and neck squamous cell carcinoma. The lung/thorax sections of the radiologists' PET/CT reports were graded as "Positive, Equivocal, or Negative" for chest metastases. Patients who underwent workup for suspected chest metastases were assessed for treatment delays, changes in treatment plans, and complications. In addition, we evaluated the time between AUTB presentation and peri-treatment PET/CT to primary treatment initiation were calculated between groups. There was a total of 363 patients with PET/CT prior to treatment, the read was "Negative" in 71.3% (n = 259), "Equivocal" in 20.9% (n = 76), and "Positive" in 5.8% (n = 21). Of 272 patients with complete treatment data, 22 underwent workup for suspected chest metastases. Mean time from PET/CT to treatment initiation was 27.5 days without workup and 64.9 days with workup ( P < .0001), and from AUTB presentation was 29.1 days without workup and 62.5 days with workup ( P < .0001). Five (19.2%) patients experienced a complication from workup. Twenty (76.9%) patients had no changes in their treatment plan after workup. In conclusion, our results for potential chest metastases on PET/CT in patients with HNC are often not clear-cut. Workup of suspected chest metastasis based on PET/CT findings significantly delays primary treatment initiation and may cause serious complications.

Evaluation of various patient-, lesion-, and procedure-related factors on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy

Purpose

To assess the influence of various patient-, lesion-, and procedure-related variables on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy.

Material and methods

In a total of 208 patients, 215 lung/mediastinal lesions (seven patients were biopsied twice) were sampled under CT guidance using coaxial biopsy set via percutaneous transthoracic approach. Incidence of post procedure pneumothorax was seen and the influence of various patient-, lesion-, and procedure-related variables on the frequency of pneumothorax with special emphasis on procedural factors like dwell time and needle-pleural angle was analysed.

Results

Pneumothorax occurred in 25.12% (54/215) of patients. Increased incidence of pneumothorax had a statistically significant correlation with age of the patient (p = 0.0020), size (p = 0.0044) and depth (p = 0.0001) of the lesion, and needle-pleural angle (p = 0.0200). Gender of the patient (p = 0.7761), emphysema (p = 0.2724), site of the lesion (p = 0.9320), needle gauge (p = 0.7250), patient position (p = 0.9839), and dwell time (p = 0.9330) had no significant impact on the pneumothorax rate.

Conclusions

This study demonstrated a significant effect of the age of the patient, size and depth of the lesion, and needle-pleural angle on the incidence of post-procedural pneumothorax. Emphysema as such had no effect on pneumothorax rate, but once pneumothorax occurred, emphysematous patients were more likely to be symptomatic, necessitating chest tube placement. Gender of the patient, site of the lesion, patient position during the procedure, and dwell time had no statistically significant relation with the frequency of post-procedural pneumothorax. Surprisingly, needle gauge had no significant effect on pneumothorax frequency, but due to the small sample size, non-randomisation, and bias in needle size selection as per lesion size, further studies are required to fully elucidate the causal relationship between needle size and post-procedural pneumothorax rate. The needle should be as perpendicular as possible to the pleura (needle-pleural angle close to 90°), to minimise the possibility of pneumothorax after percutaneous transthoracic needle biopsy.

Safety and diagnostic performance of pulmonologists performing electromagnetic guided percutaneous lung biopsy (SPiNperc)

BACKGROUND AND OBJECTIVE

Percutaneous lung biopsy for diagnostic sampling of peripheral lung nodules has been widely performed by interventional radiologists under computed tomography (CT) guidance. New technology allows pulmonologists to perform percutaneous lung biopsies using electromagnetic (EM) guided technology. With the adoption of this new technique, the safety, feasibility and diagnostic yield need to be explored. The goal of this study was to determine the safety, feasibility and diagnostic yield of EM-guided percutaneous lung biopsy performed by pulmonologists.

METHODS

We conducted a retrospective, multicentre study of 129 EM-guided percutaneous lung biopsies that occurred between November 2013 and March 2017. The study consisted of seven academic and three community medical centres.

RESULTS

The average age of participants was 65.6 years, BMI was 26.3 and 50.4% were females. The majority of lesions were in the right upper lobe (37.2%) and left upper lobe (31.8%). The mean size of the lesions was 27.31 mm and the average distance from the pleura was 13.2 mm. Practitioners averaged two fine-needle aspirates and five core biopsies per procedure. There were 23 (17.8%) pneumothoraces, of which 16 (12.4%) received small-bore chest tube placement. The diagnostic yield of percutaneous lung biopsy was 73.7%. When EM-guided bronchoscopic sampling was also performed during the same procedural encounter, the overall diagnostic yield increased to 81.1%.

CONCLUSION

In this large multicentred series, the use of EM guidance for percutaneous lung biopsies was safe and feasible, with acceptable diagnostic yield in the hands of pulmonologists. A prospective multicentre trial to validate these findings is currently underway (NCT03338049).

Controversies in MR targeted biopsy: alone or combined, cognitive versus software-based fusion, transrectal versus transperineal approach?

PURPOSE

To review the evidence addressing current controversies around prostate biopsy. Specific questions explored were (1) mpMRI targeted (TgBx) alone versus combined with systematic (SBx) biopsy; (2) cognitive versus software-based targeted biopsy; (3) transrectal or transperineal route (TP).

METHODS

We performed a literature search of peer-reviewed English language articles using PubMed and the words "prostate" AND "biopsy". Web search was implemented by manual search.

RESULTS

Prostate mpMRI is revolutionizing prostate cancer (PCa) diagnosis, and TgBx improves the detection of clinically significant (cs) PCa compared to SBx alone. The utility of combining SBx-TgBx is variable, but in non-expert centres the two should be combined to overcome learning curve-limitations. Whether SBx should be maintained in expert centres depends on what rate of missed cancer the urological community and patients are prone to accept; this has implications for insignificant cancer diagnosis as well. TgBx may be more precise using a software-based-approach despite cognitive TgBx proved non-inferior in some studies, and may be used for large accessible lesions. TP-biopsies are feasible in an in-office setting. Avoidance of the rectum and accessibility of virtually all prostate areas are attractive features. However, this has to be balanced with local setting and resources implications. Ongoing trials will shed light on unsolved issues.

CONCLUSION

The prostate biopsy strategy should be tailored to local expertise, needs and resources availability. Targeted biopsy enhance the ratio between cs and insignificant cancer diagnosis, although some csPCa might be missed. Software-based TgBx are likely to be more precise, especially for new users, although the additional cost might be not justified in all cases. TPBx have ideal attributes for performing TgBx and avoiding infection, although this has resources implications.

Nondiagnostic Percutaneous Transthoracic Needle Biopsy of Lung Lesions: A Multicenter Study of Malignancy Risk

Purpose To evaluate the malignancy risk of lung lesions that show nondiagnostic results at transthoracic needle biopsy (PTNB) of the lung and to identify any malignancy-associated risk factors in each nondiagnostic category. Materials and Methods In this retrospective study, 9384 initial PTNBs (9239 patients [mean age, 65 years; age range, 20-99 years] consisting of 5729 men [mean age, 66 years; age range, 20-99 years] and 3510 women [mean age, 63 years; age range, 20-94 years]) were performed in eight institutions between January 2010 and December 2014. PTNB results were categorized as diagnostic (malignant or specifically benign) or nondiagnostic (nonspecific benign pathologic findings, atypical cells, or insufficient specimen), and the proportion of final malignant diagnoses per nondiagnostic category was obtained. Malignancy-associated factors were determined by using multivariable analyses. Results Nondiagnostic results were present in 27.6% (2590 of 9384) of PTNBs. Proportions of final malignant diagnoses were 21.3% (339 of 1592) for nonspecific benignities, 90.1% (503 of 558) for atypical cells, and 46.6% (205 of 440) for insufficient specimens. In the nonspecific benign category, granulomatous inflammation (odds ratio [OR], 0.04; 95% confidence interval [CI]: 0.02, 0.12; P < .001), abscess (OR, 0.04; 95% CI: 0.01, 0.28; P = .001), and organizing pneumonia (OR, 0.05; 95% CI: 0.01, 0.23; P < .001) were demonstrated to be important factors negating malignancy. Atypical cells suspicious for malignancy were more associated with malignancy (OR, 6.3; 95% CI: 1.9, 21.0; P = .003) than were atypical cells of indeterminate malignancy. All 130 lesions with atypical cells suggestive of malignancy were finally malignant. Conclusion After nondiagnostic lung biopsies, lesions categorized as atypical cell lesions have a high likelihood of malignancy, with somewhat lower likelihood for lesions with insufficient specimens and nonspecific benign categories. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Elicker in this issue.

CT-guided Lung Fine Needle Aspiration Biopsy: Analysis of Efficacy, Yield and Intricacies

Aim: This study aims to evaluate various factors that affect the cytological yield while performing computed tomography (CT) guided lung fine needle aspiration biopsy and to determine the complication rate of this procedure. Materials and Methods: In this cross sectional study, we analyzed 70 patients undergoing CT-guided transthoracic lung fine-needle aspiration biopsy (FNAB). 22-gauge spinal needle was used in sixty patients and 20-gauge in ten patients. The presence and absence of an onsite cytopathologist affecting the adequacy of yield for a conclusive cytodiagnosis was compared in groups of 35 patients each. The incidence of complications such as pneumothorax, pulmonary hemorrhage was recorded. Results: Cytological yield was adequate for a conclusive cytodiagnosis in 59 cases (84.2%). Thirty-seven cases (52.8%) were malignant with adenocarcinoma (70.2%) being the most common, 22 cases (31.4%) had benign etiology. Cytological yield was adequate for a conclusive diagnosis in the group (n = 35) with an onsite cytopathologist (100%) compared with those cases without an onsite cytopathologist (68.6%) (P = 0.005). Pneumothorax was observed in 16 cases (22.8%), the incidence of pneumothorax was higher when there was an intervening parenchyma (P = 0.005). Conclusion: CT-guided transthoracic FNAB is an accurate method to rule out malignancy with a reasonable rate of complications. The presence of an onsite-cytopathologist significantly improves the adequacy of yield for a conclusive cytodiagnosis, and should be routinely employed. Pneumothorax and pulmonary hemorrhage are the most common complications as a result of FNAB. The incidence of pneumothorax is higher when there is intervening lung parenchyma.

Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer

Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.

Real-time intraprocedural 18F-FDG PET/CT-guided biopsy using automated robopsy arm (ARA) in the diagnostic evaluation of thoracic lesions with prior inconclusive biopsy results: initial experience from a tertiary health care centre

OBJECTIVE

The aim of this study was to assess the feasibility and appraise the diagnostic utility of real time ¹⁸F-FDG PET/CT-guided biopsy under automated robopsy arm (ARA) guidance for the evaluation of thoracic lesions with prior inconclusive biopsy results.

METHODS

PET/CT-guided biopsy of thoracic lesions was performed in patients who had at least one previous inconclusive biopsy. A total of 25 patients (male:female-18 males, 7 females; age: range, 13-75; mean, 53.7) were included in this study. All these patients underwent percutaneous needle biopsies under real-time PET/CT guidance using ARA (ROBIO-EX, Perfint healthcare Pvt Ltd, Chennai, India) needle navigation technique. Histopathology and clinical follow-up results were reviewed for assessing the accuracy of procedures.

RESULTS

Adequate representative tissue sample could be retrieved in all the patients. No major procedure-related complications were encountered in any patient. Of the 25 procedures, 21 lesions were positive for malignancy and benign findings were observed in the other 4 lesions on histopathology. None of the patients required further biopsy in arriving at a final diagnosis. Overall diagnostic yield of the procedure was 100%.

CONCLUSION

Real time ¹⁸F-FDG PET/CT guidance for percutaneous biopsies of lung and mediastinal lesions is a feasible technique with potential utility in patients with previous inconclusive biopsy results. Advances in knowledge: ¹⁸F-FDG PET/CT guidance reduces the sampling errors by specifically targeting areas of viability and avoiding necrosis/atelectasis. A navigational tool like ARA is thought to help in accurately targeting these areas.

Diagnostic Imaging and Newer Modalities for Thoracic Diseases: PET/Computed Tomographic Imaging and Endobronchial Ultrasound for Staging and Its Implication for Lung Cancer

Modalities to detect and characterize lung cancer are generally divided into those that are invasive [endobronchial ultrasound (EBUS), esophageal ultrasound (EUS), and electromagnetic navigational bronchoscopy (ENMB)] versus noninvasive [chest radiography (CXR), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI)]. This chapter describes these modalities, the literature supporting their use, and delineates what tests to use to best evaluate the patient with lung cancer.

Electromagnetic navigation transthoracic needle aspiration for the diagnosis of pulmonary nodules: a safety and feasibility pilot study

BACKGROUND

Pulmonary nodules remain a diagnostic challenge for physicians. Minimally invasive biopsy methods include bronchoscopy and CT guided transthoracic needle aspiration (TTNA). A novel electromagnetic guidance transthoracic needle aspiration (ETTNA) procedure which can be combined with navigational bronchoscopy (NB) and endobronchial ultrasound (EBUS) in a single setting has become available.

METHODS

A prospective pilot study examining the safety, feasibility and diagnostic yield of ETTNA in a single procedural setting. All patients enrolled underwent EBUS for lung cancer staging followed by NB and ETTNA. Feasibility of performing ETTNA and a safety assessment by recording procedural related complications including pneumothorax or bleeding was performed. Diagnostic yield of ETTNA defined by a definitive pathologic tissue diagnosis was recorded. An additional diagnostic yield analysis was performed using a cohort analysis of combined interventions (EBUS + NB + ETTNA). All non-diagnostic biopsies were either followed with radiographic imaging or a surgical biopsy was performed.

RESULTS

Twenty-four subjects were enrolled. ETTNA was feasible in 96% of cases. No bleeding events occurred. There were five pneumothoraces (21%) of which only two (8%) subjects required drainage. The diagnostic yield for ETTNA alone was 83% and increased to 87% (P=0.0016) when ETTNA was combined with NB. When ETTNA and NB were performed with EBUS for complete staging, the diagnostic yield increased further to 92% (P=0.0001).

CONCLUSIONS

This is the first human pilot study demonstrating an acceptable safety and feasibility profile with a novel ETTNA system. Further studies are needed to investigate the increased diagnostic yield from this pilot study.

Transthoracic needle biopsy of the lung

BACKGROUND

Image guided transthoracic needle aspiration (TTNA) is a valuable tool used for the diagnosis of countless thoracic diseases. Computed tomography (CT) is the most common imaging modality used for guidance followed by ultrasound (US) for lesions abutting the pleural surface. Novel approaches using virtual CT guidance have recently been introduced. The objective of this review is to examine the current literature for TTNA biopsy of the lung focusing on diagnostic accuracy and safety.

METHODS

MEDLINE was searched from inception to October 2015 for all case series examining image guided TTNA. Articles focusing on fluoroscopic guidance as well as influence of rapid on-site evaluation (ROSE) on yield were excluded. The diagnostic accuracy, defined as the number of true positives divided by the number of biopsies done, as well as the complication rate [pneumothorax (PTX), bleeding] was examined for CT guided TTNA, US guided TTNA as well as CT guided electromagnetic navigational-TTNA (E-TTNA). Of the 490 articles recovered 75 were included in our analysis.

RESULTS

The overall pooled diagnostic accuracy for CT guided TTNA using 48 articles that met the inclusion and exclusion criteria was 92.1% (9,567/10,383). A similar yield was obtained examining ten articles using US guided TTNA of 88.7% (446/503). E-TTNA, being a new modality, only had one pilot study citing a diagnostic accuracy of 83% (19/23). Pooled PTX and hemorrhage rates were 20.5% and 2.8% respectively for CT guided TTNA. The PTX rate was lower in US guided TTNA at a pooled rate of 4.4%. E-TTNA showed a similar rate of PTX at 20% with no incidence of bleeding in a single pilot study available.

CONCLUSIONS

Image guided TTNA is a safe and accurate modality for the biopsy of lung pathology. This study found similar yield and safety profiles with the three imaging modalities examined.

Comparative study of bronchoalveolar lavage, bronchial brushing, and FNAC in diagnosing malignant neoplasms of lungs

Background:

Lung cancer is the leading cause of death in developed countries and is increasing at alarming rates in developing countries. Cytological techniques such as bronchoalveolar lavage (BAL), bronchial brushing (BB), and fine needle aspiration cytology (FNAC) can aid in the early diagnosis of lung malignancies.

Materials and Methods:

A total of 67 cases, suspected of lung cancer between January 2010 and December 2012, were selected where samples of BAL, BB, FNAC, as well as biopsy were obtained and processed according to the standard procedures of cytology and histology. The aim of this study was to compare the diagnostic efficacy of the three modalities, i.e., BAL, BB, and FNAC in diagnosing malignant neoplasms of the lung. Biopsy was considered to be the gold standard diagnostic test.

Results:

Sensitivity of BAL, BB, and FNAC was found to be 47.61, 65.07, and 88.88%, respectively, whereas specificity of BAL, BB, and FNAC was 75, 75, and 100%, respectively.

Conclusions:

FNAC is the best technique among the three for the diagnosis of lung cancers.

CT-guided biopsy of pulmonary nodules: is pulmonary hemorrhage a complication or an advantage?

PURPOSE

We aimed to assess the correlation between pulmonary hemorrhage and pneumothorax in computed tomography (CT)-guided transthoracic fine needle aspiration (TTFNA), particularly its possible value as protection against the development of pneumotorax.

MATERIALS AND METHODS

We reviewed the CT images of 538 patients (364 males and 174 females, mean age 70 years, range 36-90 years) who underwent CT-guided TTFNA of pulmonary nodules between January 2008 and September 2013. The following CT findings were assessed: pulmonary hemorrhage (type 1, along the needle track; type 2, perilesional; low-grade, ≤6 mm; high-grade, >6 mm), pneumothorax, distance between the target nodule and the pleural surface, and emphysema.

RESULTS

Pneumothorax occurred in 154 cases (28.6%) and pulmonary hemorrhage occurred in 144 cases (26.8%). The incidence of pneumothorax was lower in patients showing type 1 and high-grade pulmonary hemorrhage pattern. The incidence of pneumothorax in biopsies ≥30 mm from pleural surface was 26% (12/46) in cases showing this pattern, while it was 71.4% (30/42) when this pattern was not seen. Similarly, the incidence of pneumothorax in biopsies <30 mm from the pleural surface was 0% (0/28) in cases showing this hemorrhage pattern, while it was 19% (76/394) when this pattern was not seen.

CONCLUSION

Pulmonary hemorrhage during TTFNA is a frequent event that protects against pneumothorax. A bleeding greater than 6 mm along the needle track is associated with lower incidence of pneumothorax, especially in biopsies deeper than 3 cm.

The role of ¹⁸F-FDG uptake features in the differential diagnosis of solitary pulmonary lesions with PET/CT

Background

The aim of this study is to evaluate the value of ¹⁸F-FDG uptake features in the diagnosis of solitary pulmonary lesions.

Methods

One hundred thirty-nine patients with solitary pulmonary lesions were divided into full uptake, circular uptake, multi-focus uptake, mild uptake, and no-uptake groups according to the uptake features of ¹⁸F-FDG in solitary pulmonary lesions. The incidence of benign and malignant lesions and the false-positive and false-negative rates in each group were analyzed. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of the method using ¹⁸F-FDG uptake features combined with maximum standard uptake value (SUVmax) (SUV method) in the differential diagnosis of solitary pulmonary lesions were evaluated.

Results

There were 89 malignant and 50 benign lesions. (1) The malignant incidence of the full uptake group was 84.0 % (63/75), and there were significant differences when compared with the other groups except the circular uptake group (16/23) (all P = 0.0001). The benign incidence of the multi-focus and no-uptake groups was 83.3 % (10/12) and 82.4 % (14/17), respectively, and there were significant differences when compared with the full uptake and the circular uptake groups, respectively (all P < 0.05). The benign incidence of the mild uptake group was 58.3 % (7/12), and there were no significant differences when compared with the others except the full uptake group (all P > 0.05). No statistical significance was found between either two of the no-uptake, mild uptake, and multi-focus uptake groups (all P > 0.05). (2) In cases with SUVmax ≥2.5, the false-positive rate in the multi-focus uptake group was 83.3 % (10/12), which was significantly higher than in the full uptake (12/75) or circular uptake group (7/23) (all P < 0.05). In cases with SUVmax <2.5, the false-negative rates in the mild and no-uptake groups were 41.7 and 17.6 % (P = 0.218). (3) The sensitivity, specificity, accuracy, PPV, and NPV of the method using ¹⁸F-FDG uptake features combined with SUVmax and the single SUV method were 88.7 %/91.0 %, 62.0 %/42.0 %, 79.1 %/73.4 %, 80.6 %/73.6 %, and 75.6 %/72.4 %, respectively.

Conclusions

The method using uptake features of ¹⁸F-FDG combined with SUVmax can improve the diagnostic specificity and accuracy of solitary pulmonary lesions. The multi-focus uptake feature maybe a benign sign, which still needs more researches to confirm.

Trends in use and safety of image-guided transthoracic needle biopsies in patients with cancer

PURPOSE

Image-guided transthoracic needle biopsy (IGTTNB) is an important tool in the diagnosis of patients with cancer. Common complications include pneumothorax and chest tube placement, with rates ranging from 6% to 57%. We performed a population-based study to determine patterns of use, complications, and costs associated with IGTTNB.

METHODS

The Premier Perspective database was used to identify patients with cancer with ≥ one claim for IGTTNB from 2006 to 2012. Patients were stratified on the basis of inpatient versus outpatient setting. Pneumothorax was defined by a new claim within 1 month of IGTTNB; hospitalization and chest tube placement rates were analyzed. Multivariable analysis was used to identify factors associated with pneumothorax.

RESULTS

We Identified 79,518 patients with cancer who underwent IGTTNB: 42,955 (54.0%) outpatients and 36,563 (46.0%) inpatients. Of patients who underwent outpatient IGTTNB, 5,261 (12.2%) developed a pneumothorax. Of those, 1,006 (19.1%, 2.3% of total) were hospitalized, and 180 (3.4%, 0.42% of total) required chest tubes. Pneumothorax after outpatient IGTTNB was associated with number of comorbidities, rural site, hospital bed size of more than 600, and biopsy of parenchymal as opposed to pleural lesions. Of patients who underwent inpatient IGTTNB, 7,830 (21.4%) developed a pneumothorax, and 2,894 (36.0%, 7.9% of total) required chest tube. Over time, total IGTTNB volume increased by 40.6%, and mean outpatient cost per procedure increased by 24.4%.

CONCLUSION

While pneumothorax was frequent in outpatients, rates of hospitalization and chest tube placement were low. As screening for lung cancer increases, we anticipate an increased need for IGTNBB. Patients can be reassured by the low rate of serious complications.

Virtually no thoracic lesion inaccessible: a pictorial case review

Access route considerations in percutaneous intrathoracic biopsy or ablation offers its own unique set of challenges, with special consideration toward reducing the rate of pneumothorax. This review highlights several novel and atypical methods to improve access to intrathoracic lesions through a series of representative cases. These methods include patient positioning, curved needles, hydrodissection, induced/artificial pneumothorax, and use of specialized equipment functions. No intrathoracic lesion should be considered "inaccessible" either for biopsy or treatment by percutaneous approaches without consideration of performing these adjunctive techniques.

Qualitative assessment of pain management in patients undergoing computed tomography-guided transthoracic lung biopsy

BACKGROUND

Unpublished questionnaire data collected by the authors' institution (Toronto General Hospital, Toronto, Ontario) indicates that patients often experience significant pain while undergoing lung biopsy, yet receive only a fraction of the maximum allowable dosage of analgesic.

OBJECTIVES

To qualitatively assess current pain management practices from the patient perspective. Patient education and patient satisfaction were also evaluated.

METHODS

From March through June 2012, participants were contacted via telephone within one week of their procedure until data saturation was reached. The semistructured interviews were based on a study-specific interview template. Thematic analysis of qualitative study data was used to identify recurring interview topics.

RESULTS

A consecutive sample of 16 outpatients who had undergone image-guided transthoracic lung biopsy at the authors' institution were interviewed. None of the study participants reported noteworthy pain associated with the insertion of lung biopsy needles. The most significant pain was caused by positioning within the computed tomography scanner, particularly among participants who were in the prone position. All participants reported high satisfaction with the amount of analgesic received. Potential complications and recovery period details were identified as areas for improved patient education.

CONCLUSIONS

At the authors' institution, pain associated with lung biopsy needle insertion was well controlled. Positional pain is common for patients required to be in the prone position. Potential solutions include increasing awareness of positional pain and instituting additional supportive equipment.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Predictive factors of diagnostic accuracy of CT-guided transthoracic fine-needle aspiration for solid noncalcified, subsolid and mixed pulmonary nodules

PURPOSE

The aim of this study was to analyse factors predicting the diagnostic accuracy of computed tomography (CT)-guided transthoracic fine-needle aspiration (TTFNA) for solid noncalcified, subsolid and mixed pulmonary nodules, with particular attention to those responsible for false negative results with a view to suggesting a method for their correction.

MATERIALS AND METHODS

From January 2007 to March 2010, we retrospectively reviewed the CT images of 198 patients of both sexes (124 males and 74 females; mean age, 70 years; range age, 44-90) used for the guidance of TTFNA of pulmonary nodules. Aspects considered were: lesion size and density, distance from the pleura, and lesion site. Multiplanar reformatted images (MPR) were retrospectively obtained in the sagittal and axial oblique planes relative to needle orientation.

RESULTS

The overall diagnostic accuracy of TTFNA CT-guided biopsy was 86% for nodules between 0.7 and 3 cm, 83.3% for those between 0.7 and 1.5 cm, and 92% for those between 2 and 3 cm. Accuracy was 95.1% for solid pulmonary nodules, 84.6% for mixed nodules, and 66.6% for subsolid nodules. The diagnostic accuracy of CT-guided TTFNA in relation to the distance between the nodule and the pleural plane was 95.6% for lesions adhering to the pleura and 83.5% for central ones. The diagnostic accuracy was 84.2% for the pulmonary upper lobe nodules, 85.3% for the lower lobe and 90.9% for those in the lingula and middle lobe. In 75% of false negative and inadequate/insufficient cases the needle was found to lie outside the lesion, after reconstruction of the needle path by MPR.

CONCLUSIONS

The positive predictive factors of CT-guided TTFNA are related to the nodule size, density and distance from the pleural plane. The most common negative predictive factor of CT-guided TTFNA is the wrong position of the needle tip, as observed in the sagittal and axial oblique sections of the MPR reconstructions. The diagnostic accuracy of CT-guided TTFNA can therefore be improved by using the MPR technique to plan the needle path during the FNA procedure.

Evaluation of precision of guidance techniques in image guided fine needle aspiration cytology of thoracic mass lesions

Background:

Transthoracic fine needle aspiration cytology (FNAC) is an established and safe technique for diagnosis of thoracic mass lesions. Computed tomography (CT) scan depicts clear anatomical details and provides access to any area of the body. It is, however, expensive and the needle is not passed in real time. Ultrasound is cheaper, radiation free, and allows real time monitoring. Its limitations are obscurement of lesions by aerated lung, smaller, deep seated, and cavitary lesions.

Aims:

This study aims to compare sensitivity and specificity of CT scan and ultrasonography (USG) in thoracic FNAC.

Materials and Methods:

The study was conducted on patients who presented with thoracic mass lesions in lungs, mediastinum, hilar lymph nodes, thoracic vertebrae, paraspinal soft tissue, and pleura. One hundred and twenty patients were studied. Only those cases in which sonographic guidance was not possible were taken up for CT guided FNAC. The lesions were assigned to benign and malignant categories and into specific diagnoses where possible. Biopsy correlation was available in 113 cases. Patients were lost to follow-up in five lung and two mediastinal masses.

Statistical Analysis:

Statistical tests applied included diagnostic tests for sensitivity and specificity.

Results:

An accuracy of 70.8% was found for image guided FNACs with a sensitivity and specificity of 92.2% and 100%, respectively. CT had a sensitivity of 93.2% and specificity of 100%. For USG guidance, the same was 91.3% and 100%, respectively.

Conclusions:

Precision of USG and CT scan is comparable for guidance in FNAC from thoracic mass lesions.

Quality-of-life improvement and cost-effectiveness of interventional pulmonary procedures

Most interventional pulmonology studies focus on the technical success of procedures without measuring validated quality-of-life (QoL) outcomes. Studies are now incorporating end points that include QoL measurements and there are examples of interventional procedures that likely improve QoL. It is vital for the interventional pulmonary literature to incorporate cost-effectiveness when introducing new technology. While not uniformly analyzed in a rigorous manner in all studies, there are examples of interventional pulmonary studies that analyze cost-effectiveness through avoidance of more expensive procedures, cost savings per day free of emergency room visit, or cost savings per day not requiring intensive care unit care.

Does Repeating CT-Guided Transthoracic Fine Needle Aspiration Increase Diagnostic Yield and Complication Rate? A Single Institution Experience

Background

Transthoracic fine needle aspiration biopsy is a well-established and safe technique for obtaining pulmonary tissue. However, there is very little data about repeating procedure.

Objectives

We aimed to investigate whether repeating CT-guided transthoracic fine needle aspiration (TFNA) increases diagnostic yield and complication rate.

Patients and Methods

Patients underwent TFNA and the final diagnoses achieved were included in the study. Consequently, 316 TFNA procedures performed in 240 patients were investigated retrospectively. A diagnosis was not reached in the first TFNA in 64 patients, then they underwent repeated TFNA. The factors that affected the diagnostic yield and complication rate were recorded.

Results

The final diagnoses of 199 (82.9%) patients were malignant and 41 patients were benign. One hundred seventy six patients underwent the TFNA procedure only once. Sixty-four patients underwent a second procedure, while 12 underwent a third one. The diagnosis rate in the first procedures (diagnosis obtained in 142 out of 240 patients) was 59%. With the repeated procedures, 30 other patients were diagnosed. The diagnosis rate increased to 72% (172 out of 240 patients) (P<0.001). Twenty-nine (9.2%) pneumothoraces in 26 patients were detected in 316 TFNA procedures. In the repeated TFNA group (64 patients) there were seven pneumothoraces (11%) in the first TFNA procedure and six pneumothoraces (9%) in the repeated TFNA procedures (P=0.41). In three patients, pneumothorax was detected in the first and repeated procedures. Pneumothorax was significantly associated with the maximum diameter of the lesion (P=0.003), distance to pleura (P=0.001), contact to the pleura (P=0.0001) and smoking history (pack/year) (P=0.04).

Conclusion

This study demonstrated that repeating the TFNA procedure in pulmonary lesions improves the diagnostic yield without an increase in the rate of pneumothorax.

CT-guided biopsies in lung infections in patients with haematological malignancies

CT-guided transparietal lung biopsy in imaging makes it possible to find the pathogenic agent in half of all fungal infections and most bacterial infections (sensitivity=55%, specificity=100%). Performance is decreased in consolidations (50% of infections) compared to masses. Complications, pneumothorax, alveolar bleeding and hemoptysis are generally benign and rarely (<5%) require specific treatment. On the other hand, the diagnostic performance increases significantly with the calibre of 18G co-axial systems compared to 20G. The risk is not related to the number of samples or platelet levels.

Analysis of tumor markers in cytological fluid obtained from computed tomography-guided needle aspiration biopsies for the diagnosis of ground-glass opacity pulmonary lesions

BACKGROUND

The purpose of this study was to assess whether analyses of tumor markers in cytological fluid can improve the performance of computed tomography (CT)-guided needle aspiration biopsy (NAB) for the diagnosis of ground-glass opacity (GGO) pulmonary lesions.

METHODS

Forty-two patients were prospectively enrolled for CT-guided NAB. Levels of cytokeratin 19 fragments (CYFRA 21-1) and carcinoembryonic antigen (CEA) from serum and cytological fluid were measured. The cutoff values of 3.3 ng/mL for CYFRA 21-1 and 5.0 ng/mL for CEA (threshold A) or thresholds by adding 2 standard deviations to the mean levels of markers found in patients without malignancy (threshold B) were used to identify malignancy. The sensitivity and area under the curve (AUC) of NAB alone were compared with those of NAB combined with serum or cytological tumor markers.

RESULTS

Among the 42 patients, 30 (71.4%) had malignant and 12 (28.6%) had benign lesions. For NAB alone, the sensitivity, specificity, and AUC for diagnosing GGO were 70.0%, 100%, and 0.850, respectively. The sensitivity and AUC increased significantly for NAB with cytological CYFRA 21-1 compared with NAB alone, using both thresholds (threshold A: 86.7%, P=.026 and .933, P=.016; threshold B: 93.3%, P=.008 and .925, P=.046).

CONCLUSIONS

Cytological fluid measurements of CYFRA 21-1 can improve the diagnostic performance of CT-guided NAB for GGO pulmonary lesions.

Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule

BACKGROUND

The detection of pulmonary nodules (PNs) is likely to increase, especially with the release of the National Lung Screen Trials. When tissue diagnosis is desired, transthoracic needle aspiration (TTNA) is recommended. Several guided-bronchoscopy technologies have been developed to improve the yield of transbronchial biopsy for PN diagnosis: electromagnetic navigation bronchoscopy (ENB), virtual bronchoscopy (VB), radial endobronchial ultrasound (R-EBUS), ultrathin bronchoscope, and guide sheath. We undertook this meta-analysis to determine the overall diagnostic yield of guided bronchoscopy using one or a combination of the modalities described here.

METHODS

We performed a MEDLINE search using “bronchoscopy” and “solitary pulmonary nodule.” Studies evaluating the diagnostic yield of ENB, VB, R-EBUS, ultrathin bronchoscope, and/or guide sheath for peripheral nodules were included. The overall diagnostic yield and yield based on size were extracted. Adverse events, if reported, were recorded. Meta-analysis techniques incorporating inverse variance weighting and a random-effects meta-analysis approach were used.

RESULTS

A total of 3,052 lesions from 39 studies were included. The pooled diagnostic yield was 70%, which is higher than the yield for traditional transbronchial biopsy. The yield increased as the lesion size increased. The pneumothorax rate was 1.5%, which is significantly smaller than that reported for TTNA.

CONCLUSION

This meta-analysis shows that the diagnostic yield of guided bronchoscopic techniques is better than that of traditional transbronchial biopsy. Although the yield remains lower than that of TTNA, the procedural risk is lower. Guided bronchoscopy may be an alternative or be complementary to TTNA for tissue sampling of PN, but further study is needed to determine its role in the evaluation of peripheral pulmonary lesions.

Percutaneous transthoracic needle biopsy of small (≤ 1 cm) lung nodules under C-arm cone-beam CT virtual navigation guidance

OBJECTIVES

To describe our initial experience with percutaneous transthoracic needle biopsy (PCNB) of small (≤1 cm) lung nodules using a cone-beam computed tomography (CBCT) virtual navigation guidance system in 105 consecutive patients.

METHODS

One hundred and five consecutive patients (55 male, 50 female; mean age, 62 years) with 107 small (≤1 cm) lung nodules (mean size, 0.85 cm ± 0.14) underwent PCNBs under CBCT virtual-navigation guidance system and constituted our study population. Procedural details-including radiation dose, sensitivity, specificity, diagnostic accuracy and complication rates of CBCT virtual navigation guided PCNBs-were described.

RESULTS

The mean number of pleural passages with the coaxial needle, biopsies, CT acquisitions, total procedure time, coaxial introducer dwelling time, and estimated radiation exposure during PCNBs were 1.03 ± 0.21, 3.1 ± 0.7, 3.4 ± 1.3, 10.5 min ± 3.2 and 7.2 min ± 2.5, and 5.72 mSv ± 4.19, respectively. Sixty nodules (56.1 %) were diagnosed as malignant, 38 (35.5 %) as benign and nine (8.4 %) as indeterminate. The sensitivity, specificity, and diagnostic accuracy of CBCT virtual-navigation-guided PCNB for small (≤1 cm) nodules were 96.7 % (58/60), 100 % (38/38) and 98.0 % (96/98), respectively. Complications occurred in 13 (12.1 %) cases; pneumothorax in seven (6.5 %) and haemoptysis in six (5.6 %).

CONCLUSION

CBCT virtual-navigation-guided PCNB is a highly accurate and safe diagnostic method for small (≤1 cm) nodules.

Is fine-needle aspiration diagnosis of malignancy adequate prior to major lung resections including pneumonectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether a fine-needle aspiration (FNA) diagnosis is of sufficient reliability for the diagnosis of lung cancer prior to a major lung resection. Altogether, 112 papers were found using the reported search, of which 13 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The tabulated studies include two meta-analyses, one systematic review, one randomized controlled trial (RCT) and nine cohort studies. The specificity reported for FNA in the diagnosis and staging of lung cancer ranged from 96.2 to 100%. One meta-analysis reported a specificity of 97%. Another meta-analysis reported a specificity of 98.8%. A systematic review reported a specificity of 97%. An RCT reported a specificity of 96.2-100%. We conclude that the FNA for lung cancer is reported to be highly specific prior to major lung resection with a very low false positive rate. However, although a false positive may occasionally be acceptable in lobectomies, where the lobes are often removed without histology, all steps should be taken to avoid a false positive result in pneumonectomy considering the serious consequences of embarking upon such an operation in the small number of patients with a false positive result, and we recommend that a positive FNA result should be confirmed by means of alternative sampling methods. We also acknowledge that obtaining an additional biopsy specimen would add to the risk of morbidity and costs; therefore, any benefits should be weighed against risks and additional costs.

Analysis of tumor markers in the cytological fluid obtained from computed tomography-guided needle aspiration biopsy for the diagnosis of non-small cell lung cancer

PURPOSE

The aim of this study was to prospectively assess whether analysis of the tumor markers cytokeratin 19 fragments (CYFRA 21-1), carcinoembryonic antigen (CEA), and squamous cell carcinoma (SCC) antigen in cytological fluid can improve the performance of computed tomography (CT)-guided needle aspiration biopsy (NAB) in the diagnosis of non-small cell lung cancer (NSCLC).

METHODS

A total of 100 patients (men:women = 41:59, mean age: 63 years) with suspected malignant pulmonary lesions were prospectively enrolled for CT-guided NAB procedures. Levels of CYFRA 21-1, CEA, and SCC in the cytological fluid were measured by immunoradiometric assays. The cutoff value for tumor markers was selected on the basis of best accuracy through receiver operating characteristic curves. The sensitivity and areas under the curve (AUC) of NAB alone were compared with those of NAB combined with cytological tumor markers (CYFRA 21-1, CEA, and SCC).

RESULTS

Among 100 patients, 71 (71%) had NSCLC and 29 (29%) had benign lesions. The sensitivity, specificity, and accuracy for diagnosing NSCLC were 85.7%, 100%, and 89%, respectively, for NAB alone. The sensitivity increased significantly for NAB combined with a tumor marker compared with NAB alone (100% for CYFRA 21-1, 92.9% for CEA, and 94.2% for SCC; p = 0.001, p = 0.025, and p = 0.014, respectively). The AUC of NAB with CYFRA 21-1 was significantly larger than the AUC of NAB alone (p = 0.001).

CONCLUSION

Evaluation of tumor markers CYFRA 21-1, CEA, and SCC in the cytological fluid can improve the diagnostic performance of CT-guided NAB for NSCLC. Of these markers, CYFRA 21-1 is the most useful cytological tumor marker.

Surgical resection of highly suspicious pulmonary nodules without a tissue diagnosis

OBJECTIVE

The safety and efficacy of surgical resection of lung nodule without tissue diagnosis is controversial. We evaluated direct surgical resection of highly suspicious pulmonary nodules and the clinical and radiological predictors of malignancy.

METHODS

Retrospective analyses were performed on 113 patients who underwent surgical resection without prior tissue diagnosis for highly suspicious pulmonary nodules. Clinical and radiological characteristics were compared between histologically proven benign and malignant nodules after resection. Total costs, length of hospitalization and waiting time to surgery were compared with those of patients who had tissue diagnosis prior to surgery.

RESULTS

Among 280 patients with pulmonary nodules suspicious for lung cancer, 113 (40.4%) underwent operation without prior tissue diagnosis. Lung nodules were diagnosed as malignant in 96 (85%) of the 113 patients. Except for forced expiratory volume in 1 s, clinical characteristics were not significantly different according to the pathologic results. Forty-five (90%) of 50 patients with ground-glass opacity nodules had a malignancy. Mixed ground-glass opacity, bubble lucency, irregular margin and larger size correlated with malignancy in ground-glass opacity nodules (P<0.05). Fifty-one (81%) of 67 patients with solid nodules had a malignancy. Spiculation, pre-contrast attenuation and contrast enhancement significantly correlated with malignancy in solid nodules (P<0.05). Surgical resection without tissue diagnosis significantly decreased total costs, hospital stay and waiting time (P<0.05).

CONCLUSIONS

Direct surgical resection of highly suspicious pulmonary nodules can be a valid procedure. However, careful patient selection and further investigations are required to justify direct surgical resection.