Results and complications of CT-guided transthoracic fine-needle aspiration biopsy of pulmonary lesions

Diagnostic accuracy of imaging-guided biopsy of peripheral pulmonary lesions: a systematic review

The histologic definition of peripheral pulmonary lesion (PPL) is critical for a correct diagnosis and appropriate therapy. Non-invasive techniques for PPL biopsy are imaging-guided, using endobronchial ultrasound (EBUS), computed tomography (CT), and electromagnetic navigation bronchoscopy (ENB). To assess the diagnostic accuracy of PPL biopsy and provide a framework for reporting data for accuracy studies of PPL biopsy. A systematic review was conducted on PubMed, Scopus, and Web of Science to identify all the articles assessing the accuracy of EBUS, CT, and ENB between January 2000 and June 2023 basing search queries on keywords emerging from PICO question. Only studies investigating biopsy of PPL and reporting accuracy or necessary data to calculate it independently were included. Risk of bias was based on QUADAS-2 tool. In total, 81 studies were included. Median accuracy was 0.78 (range=0.51-0.94) in the EBUS group, 0.91 (range=0.73-0.97) in the CT group, 0.72 (range=0.59-0.97) in the ENB group, and 0.77 (range=0.61-0.92) in the combined group. Sensitivity and NPV ranges were 0.35-0.94 and 0.26-0.88 in the EBUS group, 0.71-0.97 and 0.46-1.00 in the CT group, 0.55-0.96 and 0.32-0.90 in the ENB group, and 0.70-0.90 and 0.28-0.79 in the combined group. Specificity and PPV were 1.00 in almost all studies. Overall complication rate was 3%, 30%, 8%, and 5% in the EBUS, CT, ENB, and combined groups. CT-guided biopsy was the most accurate technique, although with the highest complication rate. When calculating accuracy, indeterminate results must be considered false negatives according to the "intention-to-diagnose" principle.

Optimizing Precision: A Trajectory Tract Reference Approach to Minimize Complications in CT-Guided Transthoracic Core Biopsy

The advent of computed tomography (CT)-guided transthoracic needle biopsy has significantly advanced the diagnosis of lung lesions, offering a minimally invasive approach to obtaining tissue samples. However, the technique is not without risks, including pneumothorax and hemorrhage, and it demands high precision to ensure diagnostic accuracy while minimizing complications. This study introduces the Laser Angle Guide Assembly (LAGA), a novel device designed to enhance the accuracy and safety of CT-guided lung biopsies. We retrospectively analyzed 322 CT-guided lung biopsy cases performed with LAGA at a single center over seven years, aiming to evaluate its effectiveness in improving diagnostic yield and reducing procedural risks. The study achieved a diagnostic success rate of 94.3%, with a significant reduction in the need for multiple needle passes, demonstrating a majority of biopsies successfully completed with a single pass. The incidence of pneumothorax stood at 11.1%, which is markedly lower than the reported averages, and only 0.3% of cases necessitated chest tube placement, underscoring the safety benefits of the LAGA system. These findings underscore the potential of LAGA to revolutionize CT-guided lung biopsies by enhancing procedural precision and safety, making it a valuable addition to the diagnostic arsenal against pulmonary lesions.

The importance of endobag use with incision-protective devices in VATS lung resection: a preliminary study

OBJECTIVE

The advent of new techniques such as video-assisted thoracoscopic surgery (VATS) for the removal of lung segments leads to compression of the surgical specimen, with the possible dissemination of neoplastic cells. The sheer volume of surgeries performed using these techniques has caused many institutions to stop removing the surgical specimen using an endobag, even when retractors/protectors are used in the instrumentalization incision. This study aimed to collect data from patients undergoing lung resection by VATS and analyze the cytopathological results of the collected material.

RESULTS

A total of 47 endobag fluid samples were collected from patients who underwent VATS. The surgical specimen was subjected to histopathological analysis, and all patients underwent pathological TNM staging. In the cytopathological analyses, only 2 (4.3%) specimens of endobag fluid aspirate were positive for neoplastic cells. In these two cases, the tumors were peripheral, both with diagnoses of moderately differentiated adenocarcinoma and with classifications of T1bN0M0 and T3N0M0. These results indicate that although there is a low incidence of tumor cells in endobag fluid, it is always better to perform surgery using all available protective measures to avoid tumor implantation in the thoracic cavity to the greatest extent possible.

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.

Manual aspiration in the biopsy-side down position to deal with delayed pneumothorax after lung biopsy

Background

To assess the effect of aspiration in the biopsy-side down position to deal with delayed pneumothorax after computed tomography (CT)-guided lung biopsy.

Methods

A retrospective review was performed of the 236 delayed pneumothorax patients who underwent CT-guided transthoracic needle biopsies (TTNBs). Asymptomatic minimal pneumothorax patients were managed conservatively. Manual aspirations were applied for symptomatic cases with minimal pneumothorax and all cases with moderate to large pneumothorax. Patients were included into two groups: in group A (35 patients), aspiration was performed in the same position as the biopsy, while in group B (54 patients), patients were turned to the biopsy-side down position (from supine to prone or vice versa), and aspiration was conducted. The efficacy of two approaches was evaluated.

Results

One hundred forty-seven (62.3%) asymptomatic cases resolved without treatment. Distance between parietal and visceral pleura before and after aspiration were 4.24±1.87 and 1.93±2.33 cm for group A, 3.92±1.31 and 0.98±1.50 cm for group B, respectively. Volume of aspirated air in group A and group B were 735.4±231.8 and 434.8±320.3 mL, respectively. Complete lung expansion was detected in 28.6% (10/35) and 38.9% (21/54) for group A and group B, respectively. The overall effective rate and failure rate were 74.3% (26/35) and 25.7%(9/35) for group A, 92.6% (50/54) and 7.4%((4/54))for group B, respectively, which have significant statistic difference (P<0.05).

Conclusions

Manual aspiration in biopsy-side down position demonstrates the safety and efficacy in treating delayed pneumothorax after CT-guided TTNBs. Thus reduce the rate of pneumothorax requiring drainage catheter placement.

Lung cancer in Brazil

Lung cancer is one of the most incident types of cancer and a leading cause of cancer mortality in Brazil. We reviewed the current status of lung cancer by searching relevant data on prevention, diagnosis, and treatment in the country. This review highlights several issues that need to be addressed, including smoking control, patient lack of awareness, late diagnosis, and disparities in the access to cancer health care facilities in Brazil. We propose strategies to help overcome these limitations and challenge health care providers, as well as the society and governmental representatives, to work together and to take a step forward in fighting 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.

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.

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.

CT-guided biopsy of lung lesions: defining the best needle option for a specific diagnosis

OBJECTIVES

To evaluate the performance of fine and cutting needles in computed tomography guided-biopsy of lung lesions suspicious for malignancy and to determine which technique is the best option for a specific diagnosis.

METHODS

This retrospective study reviewed the data from 362 (71.6%) patients who underwent fine-needle aspiration biopsy and from 97 (19.7%) patients who underwent cutting-needle biopsy between January 2006 and December 2011. The data concerning demographic and lesion characteristics, procedures, biopsy sample adequacy, specific diagnoses, and complications were collected. The success and complication rates of both biopsy techniques were calculated.

RESULTS

Cutting-needle biopsy yielded significantly higher percentages of adequate biopsy samples and specific diagnoses than did fine-needle aspiration biopsy (p<0.05). The sensitivity, specificity, and accuracy of cutting-needle biopsy were 93.8%, 97.3%, and 95.2%, respectively; those of fine-needle aspiration biopsy were 82.6%, 81.3%, and 81.8%, respectively (all p<0.05). The incidence of pneumothorax was higher for fine-needle aspiration biopsy, and that of hematoma was higher for cutting-needle biopsy (both p<0.05).

CONCLUSIONS

Our experience using these two techniques for computed tomography-guided percutaneous biopsy showed that cutting-needle biopsy yielded better results than did fine-needle aspiration biopsy and that there was no significant increase in complication rates to indicate the best option for specific diagnoses.

Complications in CT-guided procedures: do we really need postinterventional CT control scans?

PURPOSE

The aim of this study is twofold: to determine the complication rate in computed tomography (CT)-guided biopsies and drainages, and to evaluate the value of postinterventional CT control scans.

METHODS

Retrospective analysis of 1,067 CT-guided diagnostic biopsies (n = 476) and therapeutic drainages (n = 591) in thoracic (n = 37), abdominal (n = 866), and musculoskeletal (ms) (n = 164) locations. Severity of any complication was categorized as minor or major. To assess the need for postinterventional CT control scans, it was determined whether complications were detected clinically, on peri-procedural scans or on postinterventional scans only.

RESULTS

The complication rate was 2.5 % in all procedures (n = 27), 4.4 % in diagnostic punctures, and 1.0 % in drainages; 13.5 % in thoracic, 2.0 % in abdominal, and 3.0 % in musculoskeletal procedures. There was only 1 major complication (0.1 %). Pneumothorax (n = 14) was most frequent, followed by bleeding (n = 9), paresthesia (n = 2), material damage (n = 1), and bone fissure (n = 1). Postinterventional control acquisitions were performed in 65.7 % (701 of 1,067). Six complications were solely detectable in postinterventional control acquisitions (3 retroperitoneal bleeds, 3 pneumothoraces); all other complications were clinically detectable (n = 4) and/or visible in peri-interventional controls (n = 21).

CONCLUSION

Complications in CT-guided interventions are rare. Of these, thoracic interventions had the highest rate, while pneumothoraces and bleeding were most frequent. Most complications can be detected clinically or peri-interventionally. To reduce the radiation dose, postinterventional CT controls should not be performed routinely and should be restricted to complicated or retroperitoneal interventions only.

Atrial fibrillation and pneumothorax after transthoracic needle lung biopsy

An obese 65-year-old male smoker with chronic obstructive pulmonary disease developed an iatrogenic pneumothorax with pulmonary haemorrhage during an elective transthoracic needle biopsy of a pulmonary lesion. Successful re-inflation was achieved with a chest drain which was then removed before transfer to the medical ward. He later developed persistent atrial fibrillation with breathlessness and haemoptysis. He was treated empirically for a pulmonary embolus, which was subsequently ruled out with CT pulmonary angiogram. Serial chest radiographs demonstrated recurrence of his pneumothorax and a chest drain was re-inserted. His atrial fibrillation was erroneously managed as supraventricular tachycardia, which was resistant to vagal manoeuvres and adenosine but later responded to intravenous amiodarone before a further relapse. Upon successful management of the pneumothorax, his atrial fibrillation terminated. This case highlighted the persistent and serious nature of complications posttransthoracic needle biopsy.