Fine-needle aspiration biopsy versus core-needle biopsy in diagnosing lung cancer: a systematic review

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 value of transthoracic needle biopsy in lung tumors

OBJECTIVE

Thoracic ultrasonography is widely used in imaging peripheral lesions and invasive interventional procedures. The aim of this study was to assess the diagnostic value of thoracic ultrasonography-guided transthoracic needle aspiration biopsy and the factors affecting the diagnosis of peripheral tumoral lung lesions.

METHODS

The lesion size, biopsy needle type, number of blocks, complications, and pathology results were compared in 83 patients between January 2015 and July 2018. The cases with pathological non-diagnosis and definite pathological diagnosis were determined. For the assessment of the factors affecting diagnosis, the size of the lesions and the biopsy needle type were evaluated. Biopsy preparations containing non-diagnostic atypical cells were referred to a cytopathologist. The effect of the cytopathological examination on the diagnosis was also evaluated.

RESULTS

Pathological diagnosis was made in 66.3% of the cases; cell type could not be determined in 22.9% of the cases, and they were referred to a cytopathologist. After the cytopathologist's examination, the diagnosis rate increased to 80.7%. Diagnosis rates were higher when using tru-cut than Chiba and higher in cases with tumor size >2 cm than smaller.

CONCLUSION

Thoracic ultrasonography-guided transthoracic needle aspiration biopsy is a preferred approach to the diagnosis of peripheral tumoral lung lesions, given its high diagnostic rate, in addition to being cheap, highly suitable for bedside use, and safe, and the lack of radiation exposure.

Efficacy of Computerized Tomography-Guided Core Biopsy in Identifying the Subtypes of Lung Adenocarcinoma: An Observational Perspective From Pakistan

Background Lung carcinoma is a leading cause of death worldwide. Histological subtype of lung adenocarcinoma is an important indicator of patient's outcome as it is helpful in surgical planning and guidance of prognosis. Objective To determine the diagnostic efficacy of computerized tomography-guided core needle biopsy (CNB) in identifying the histopathological subtype of lung adenocarcinoma. Methods and materials This is a retrospective, descriptive study including clinical data of 73 patients irrespective of their age and gender, who underwent computerized tomography-guided CNB for lung masses at the Department of Pathology, Aznostics - the Diagnostic Centre, Lahore, Pakistan from January 01, 2019 to June 30, 2023. Data collected was analyzed via Google Form (Google Inc., Mountainview, CA) and Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 24, released 2016; IBM Corp., Armonk, New York, United States) and was sent to statistician for descriptive analysis. Categorical data was used for calculating frequency and percentage, while continuous data was computed as mean and standard deviation. Results Seventy-three patients with adenocarcinoma underwent pulmonary biopsy. The mean age of included patients was 64.88 ± 11.39 year with a male predominance of 61.64%. Upper lobe was commonly affected by adenocarcinoma lung in 57.53% patients and 58.90% cases involved the right lung. The most common subtype was acinar with 51.65% followed by solid with 17.58% cases. Computerized tomography-guided CNB showed a diagnostic yield of 75.34% and identified histological subtypes of lung adenocarcinoma in 55 cases. Conclusion Computerized tomography-guided CNB is a useful, yet minimally invasive diagnostic tool to identify the histological subtype of lung adenocarcinoma. It not only helps in planning the surgical and adjuvant management of the patients, but also guides the patient-prognosis.

Special Considerations and Techniques of Interventions in Lung Transplant Recipients

Lung transplant remains an important treatment option for patients with end-stage lung diseases providing improvement in survival rates and quality of life. Specialized considerations should be applied with interventions of lung transplant recipients as they host specific anatomic variations and high risk towards certain complications. In this article, we highlight the role of interventional radiology for lung transplant recipients along with discussion of interventional techniques. Specific emphasis is placed on describing and explaining the techniques pertained to the points of anastomosis, diagnosis and treatment of malignancies, and management of complications in lung transplant recipients.

The MAGE A1-A10 Expression associated with Histopathological Findings of Malignant or Non-Malignant Cells in Peripheral Lung Tumors

OBJECTIVE

The objective was to evaluate the expression of melanoma antigen (MAGE) A from A1 to 10 (A1-10) and the individual MAGE A family in the peripheral lung tumors and to analyze its association with histopathological findings.

METHODS

A cross-sectional study was conducted on 67 samples of peripheral lung tumor obtained by core biopsies from patients with clinical diagnoses such as lung and mediastinal tumors. The specimens were divided into two, one to perform histopathological diagnosis and the last for mRNA MAGE A examination. A Nested polymerase chain reaction (PCR) was performed using universal primer, MF10/MR10 and MF10/MR12. The collected data were analyzed by appropriate statistical techniques.

RESULT

The histopathological finding showed 41 (61.2 %) of specimens as malignant cells and 26 (38.8 %) of specimens as non-malignant cells. MAGE A1-10 was expressed at 47 (70.1 %) and MAGE A1-6 was expressed at 25 (37.3 %) of specimens. In a malignant cell, MAGE A1-10 and MAGE A1-6 were expressed at 33 (80.5 %) and 19 (46.3 %), respectively. In non-malignant cells, MAGE A1-10 and MAGE A1-6 were expressed at 14 (53.9 %) and 6 (23.1 %,) respectively. The MAGE A1-10 and MAGE A8 expressions were significantly associated with histopathological findings of malignant or non-malignant cells. The sensitivity, specificity, and diagnostic accuracy of MAGE A1-10 were 80.5 %, 46.2 %, and 67.2 %, respectively; while for MAGE A8 were 41.5 %, 88.5 %, and 59.7 %, respectively.

CONCLUSION

The MAGE A1-10 expression was the most commonly detected and associated with the histopathological finding. Moreover, it was more sensitive and specific and had higher diagnostic accuracy than others. Therefore, the MAGE A1-10 assay may improve the accuracy of the diagnosis of malignancy in peripheral lung tumors.

Comparison of Performances of GeneXpert MTB/RIF, Bactec MGIT 960, and Bactec Myco/F Systems in Detecting Mycobacterium tuberculosis in Biopsy Tissues: a Retrospective Study

Tuberculosis remains a major global public concern as a leading cause of health care-associated infections. The detection of Mycobacterium tuberculosis (MTB) is challenging due to the paucibacillary nature of the pathogen. For suspected pulmonary and extrapulmonary tuberculosis patients, if sputum, bronchoalveolar lavage fluid (BALF), related samples are negative for MTB, or suspected tumors, biopsy tissues may provide a better diagnostic yield. This study was aimed at comparing the performances of three methods in identifying MTB in biopsy tissues, including the Bactec mycobacterial growth indicator tube 960 (MGIT 960) system, the GeneXpert MTB/RIF assay (GeneXpert), and the Bactec Myco/F lytic culture (Myco/F) system. Biopsy samples from 3,209 nonduplicated patients were retrospectively enrolled between January 2018 and September 2021, of which 180 (5.6%) were positive for MTB by at least one method. GeneXpert revealed the highest recovery rate (134/162, 82.7%), followed by MGIT 960 (99/135, 73.3%) and Myco/F (26/143, 18.1%), and the composite positive rate for GeneXpert and MGIT 960 was 96.6% (173/179). Pairwise comparisons were conducted after completion of both tests, and the results showed that Myco/F had significantly lower detection rates than GeneXpert and MGIT 960 (16.4% versus 82.8%, P < 0.001; 14.3% versus 71.4%, P < 0.001). In summary, GeneXpert was the most sensitive and recommended method for MTB detection in biopsy tissues, and the combination of GeneXpert and MGIT 960 could improve the overall diagnostic yield. IMPORTANCE Mycobacterium tuberculosis (MTB) poses a severe threat to public health worldwide. The diagnosis of tuberculosis is challenging due to the low load of the microorganism in samples. Biopsy tissues are sometimes collected via invasive procedures with limited size, and additional samples are often inaccessible. The GeneXpert MTB/RIF assay, Bactec MGIT 960 system, and Bactec Myco/F lytic system have been used in detecting MTB in our laboratory. Here, we evaluated the performances of these three methods in 3,209 biopsy tissues samples to establish a more effective protocol based on clinical requirements. Attempts for a locally optimized protocol should be always made.

Diagnostic performance and safety of percutaneous fine-needle aspiration immediately before microwave ablation for pulmonary ground-glass nodules

Background

This study sought to evaluate the safety and diagnostic performance of computed tomography (CT)-guided fine-needle aspiration (FNA) immediately before microwave ablation (MWA) for pulmonary ground-glass nodules (GGNs).

Methods

This retrospective study analyzed the synchronous CT-guided biopsy and MWA data of 92 GGNs (male to female ratio 37:55; age 60.4±12.5 years; size 1.4±0.6 cm). FNA was performed in all patients, and sequential core-needle biopsy (CNB) was performed in 62 patients. The positive diagnosis rate was determined. The diagnostic yield was compared on the basis of the biopsy methods (FNA, CNB, or both), the nodule diameter (<1.5 and ≥1.5 cm), and the lesion component (pure GGN or part-solid GGN). The procedure-related complications were recorded.

Results

The technical success rate was 100%. The positive rates of FNA and CNB were 70.7% and 72.6% respectively, but did not differ significantly (P=0.8). Sequential FNA and CNB showed better diagnostic performance (88.7%) than did either alone (P=0.008 and P=0.023, respectively). The diagnostic yield of CNB for pure GGNs was significantly lower than that for part-solid GGNs (P=0.016). The diagnostic yield was lower for smaller nodules (78.3% vs. 87.5%; P=0.28), but the differences were not significant. Grade 1 pulmonary hemorrhages were observed in 10 (10.9%) sessions after FNA, including 8 cases of hemorrhage along the needle track and 2 cases of perilesional hemorrhage, but these hemorrhages did not hamper the accuracy of the antenna placement.

Conclusions

FNA immediately before MWA is a reliable technique for the diagnosis of GGNs that does not alter the accuracy of the antenna placement. Sequential FNA and CNB improves the diagnostic ability of GGNs compared to either method used alone.

EB-OCT: a potential strategy on early diagnosis and treatment for lung cancer

Lung cancer is the leading cause of cancer-related death in China and the world, mainly attributed to delayed diagnosis, given that currently available early screening strategies exhibit limited value. Endobronchial optical coherence tomography (EB-OCT) has the characteristics of non-invasiveness, accuracy, and repeatability. Importantly, the combination of EB-OCT with existing technologies represents a potential approach for early screening and diagnosis. In this review, we introduce the structure and strengths of EB-OCT. Furthermore, we provide a comprehensive overview of the application of EB-OCT on early screening and diagnosis of lung cancer from in vivo experiments to clinical studies, including differential diagnosis of airway lesions, early screening for lung cancer, lung nodules, lymph node biopsy and localization and palliative treatment of lung cancer. Moreover, the bottlenecks and difficulties in developing and popularizing EB-OCT for diagnosis and treatment during clinical practice are analyzed. The characteristics of OCT images of normal and cancerous lung tissues were in good agreement with the results of pathology, which could be used to judge the nature of lung lesions in real time. In addition, EB-OCT can be used as an assistant to biopsy of pulmonary nodules and improve the success rate of biopsy. EB-OCT also plays an auxiliary role in the treatment of lung cancer. In conclusion, EB-OCT is non-invasive, safe and accurate in real-time. It is of great significance in the diagnosis of lung cancer and suitable for clinical application and is expected to become an important diagnostic method for lung cancer in the future.

Suspected Lung Cancer with Suspicious Liver Lesions: Diagnostic Yield and Safety of Same-Day Bronchoscopy and Liver Biopsy in the Hands of a Pulmonologist

BACKGROUND

Bronchoscopy and endobronchial ultrasound (EBUS) are standard procedures for the diagnosis and staging of patients suspected of lung cancer. If the patient simultaneously presents with suspicious liver lesions, it is tradition to refer the patient to a radiologist for ultrasound-guided percutaneous liver biopsy.

OBJECTIVE

The aim of this study was to investigate the results and complications when the pulmonologist performs all three procedures in the same setting.

METHODS

We retrospectively identified patients who during 2018-2020 underwent invasive workup of suspected lung cancer and liver metastases with percutaneous liver lesion biopsy with or without same-day endoscopy (bronchoscopy and EBUS). We compared diagnostic yield and safety of liver lesion biopsy stratified by same-day endoscopy or not.

RESULTS

In total, 89 patients were included, of whom 28 patients (31%) underwent same-day endoscopy. All liver lesion biopsies were fine-needle aspiration biopsies performed by experienced pulmonologists. No complications were reported, and overall diagnostic yield was 88%. The diagnostic yield was significantly lower in the same-day endoscopy group (71% vs. 95%), and undergoing endoscopy was significantly associated with having fewer liver lesions, higher prevalence of lung cancer, and lower overall prevalence of a malignant diagnosis.

CONCLUSION

Liver biopsy in the same session as endoscopy during lung cancer workup was feasible and safe. Confounding by indication was present in our study.

Comparative analysis of electromagnetic navigation bronchoscopy versus computed tomography-guided lung puncture for the sampling of indeterminate pulmonary nodules in the middle of an anatomic lung segment: A cohort study

BACKGROUND

To compare the diagnostic positive rate and complication rate between the electromagnetic navigation bronchoscopy (ENB) technique and computed tomography (CT)-guided lung puncture for the biopsy of lung nodules located in the middle of an anatomic lung segment.

METHODS

Electronic medical records of 114 patients who underwent lung nodule biopsy between June 2021 and June 2022 were retrospectively evaluated. In all patients, the nodules were located in the middle third lung segment. To compare the diagnostic positive and complication rates between the two biopsy modalities performed in this lung region, clinical data, complication rates, nodule pathology, and imaging results were reviewed based on nodule characteristics retrieved from the electronic medical records.

RESULTS

Ninety-three patients underwent CT-guided lung puncture, while the remaining 21 patients underwent the ENB technique. No significant difference was observed in the diagnostic positive rate between the two groups (73.6 and 76.1%, respectively). In the CT-guided lung puncture group, pneumothorax incidence, tube placement, postoperative hemorrhage, and symptomatic hemorrhage rates were 16.1, 6.5, 6.5, and 1.1%, respectively. In contrast, no complications occurred in the ENB group.

CONCLUSIONS

The ENB technique is a safe and effective method for performing biopsies of pulmonary nodules with a diagnostic positive rate comparable to that of CT-guided lung puncture and with a lower postoperative complication rate.

Accuracy of CT-Guided Core-Needle Biopsy in Diagnosis of Thoracic Lesions Suspicious for Primitive Malignancy of the Lung: A Five-Year Retrospective Analysis

BACKGROUND

Lung cancer represents a heterogeneous group of neoplasms, with the highest frequency and mortality in both sexes combined. In a clinical scenario characterized by the widespread of multidetector-row spiral CT, core-needle biopsy under tomographic guidance is one of the main and safest methods to obtain tissue specimens, even though there are relatively high rates of pneumothorax (0-60% incidence) and pulmonary hemorrhage (4-27% occurrence rates). The aim of this retrospective study is to assess the diagnostic accuracy of CT-guided core-needle biopsy in the diagnosis of primary lung malignancies and to compare our results with evidence from the literature.

MATERIALS AND METHODS

Our analysis included 350 thoracic biopsies, performed from 2017 to 2022 with a 64-row CT guidance and 16/18 G needles mounted on a biopsy gun. We included in the final cohort all samples with evidence of primary lung malignancies, precursor lesions, and atypia, as well as inconclusive and negative diagnoses.

RESULTS

There was sensitivity of 90.07% (95% CI 86.05-93.25%), accuracy of 98.87% (95% CI 98.12-99.69%), positive predictive value of 100%, and negative value of 98.74% (95% CI 98.23-99.10%). Specificity settled at 100% (93.84-100%). The AUC was 0.952 (95% CI 0.924-0.972). Only three patients experienced major complications after the procedure. Among minor complications, longer distances from the pleura, the presence of emphysema, and the lower dimensions of the lesions were correlated with the development of pneumothorax after the procedure, while longer distances from the pleura and the lower dimensions of the lesions were correlated with intra-alveolar hemorrhage. Immunohistochemistry analysis was performed in 51% of true positive cases, showing TTF-1, CK7, and p40 expression, respectively, in 26%, 24%, and 10% of analyzed samples.

CONCLUSIONS

The CT-guided thoracic core-needle biopsy is an extremely accurate and safe diagnostic procedure for the histological diagnosis of lung cancer, a first-level interventional radiology exam for peripheral and subpleural lesions of the lung, which is also able to provide adequate samples for advanced pathologic assays (e.g., FISH, PCR) to assess molecular activity and genetic sequencing.

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

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

Application of dual-energy computed tomography in preoperative evaluation of Ki-67 expression levels in solid non-small cell lung cancer

To investigate whether there were significant differences in dual-energy CT (DECT) in reflecting different quantitative parameters among different levels of Ki-67 expression in patients with solid non-small cell lung cancer (NSCLC). The diagnosis performance of DECT in patients with solid lung adenocarcinoma (LAC) among NSCLC was further discusses. Two hundred fifteen patients confirmed with solid NSCLC were enrolled and analyzed retrospectively in this study. 148 patients were confirmed with LAC among all patients. Three expression levels of Ki-67 were determined by the percentage of Ki-67 positive cancer cells with immunohistochemistry: high-level group (>30%), middle-level group (10%-30%), and low-level group (≤10%). And the latter two levels also known as non-high-level group. The quantitative parameters of enhanced chest DECT (venous phase, VP), including iodine concentration (IC), water concentration (WC), CT value at 40 keV (CT40keV), the slope of energy spectral attenuation curve (λHU) and normalized iodine concentration (NIC) were measured and calculated by gemstone spectral imaging Viewer software. One-way ANOVA was used for the comparison of normal distribution DECT parameters between three levels for patients with NSCLC and patients with LAC. Non-normal distribution data were tested by non-parametric test. In addition, the receiver operating characteristic curve of statistically significant DECT parameters was drawn to distinguish the non-high-level and the high-level of Ki-67. Area under the curve (AUC), sensitivity, specificity was calculated to measure the diagnostic performance of parameter. Both in solid NSCLC and LAC, the IC, NIC, WC, λHU and CT40keV at VP in the high-level group were significantly lower than those in the middle- and low-level group respectively, and the WC at VP in the high-level group was significantly higher than that in the middle- and low-level group respectively (all P < .05). Receiver operating characteristic analysis showed that IC and λHU at VP performed better in distinguishing the high-level and the non-high-level of Ki-67 (NSCLC: AUC = 0.713 and 0.714 respectively; LAC: AUC = 0.705 and 0.706 respectively). Quantitative parameters of DECT provide a new non-invasive method for evaluating the proliferation of cancer cells in solid NSCLC and LAC.

Impact of preoperative biopsy on tumor spread through air spaces in stage I non-small cell lung cancer: a propensity score-matched study

Background

Percutaneous needle biopsy (PNB) and bronchoscopic biopsy (BB) are widely used in the preoperative diagnosis of pulmonary nodules, but whether PNB or BB may cause tumor spread through air spaces (STAS) has not been reported.

Methods

433 postoperative patients with pathological stage I non-small cell lung cancer (NSCLC) from January 2015 to December 2018 at our hospital were enrolled and divided into PNB group (n = 40), BB group (n = 48) and non-biopsy group (n = 345). The PNB and BB groups were matched using propensity score matched (PSM) separately from the non-biopsy group, after which the effects of PNB and BB on STAS, recurrence-free survival (RFS) and overall survival (OS) were assessed.

Results

After PSM for 9 confounding factors (gender, age, smoking history, tumor site, scope of surgery, pathology type, stage, maximum tumor diameter and postoperative treatment), 38 cases in the PNB group were successfully matched with 38 cases in the non-biopsy group and 28 cases in the BB group were successfully matched with 28 cases in the non-biopsy group. After PSM, there was no significant difference in the incidence of STAS between the PNB and non-biopsy groups (42.1% vs. 34.2%, P > 0.05) and between the BB and non-biopsy groups (42.9% vs. 46.4%, P > 0.05). The results after PSM showed no significant effect of both PNB and BB on RFS and OS after radical surgery (P > 0.05).

Conclusion

Preoperative biopsy in patients with stage I NSCLC has not been shown to increase the occurrence of STAS, nor postoperative recurrence and death.

Risk Factors for Pneumothorax Development Following CT-Guided Core Lung Nodule Biopsy

BACKGROUND

This study aims to correlate nodule, patient, and technical risk factors less commonly investigated in the literature with pneumothorax development during computed tomography-guided core needle lung nodule biopsy.

PATIENTS AND METHODS

Retrospective data on 671 computed tomography-guided percutaneous core needle lung biopsies from 671 patients at a tertiary care center between March 2014 and August 2016. Univariate and multivariable logistic regression analyses were used to identify pneumothorax risk factors.

RESULTS

The overall incidence of pneumothorax was 26.7% (n=179). Risk factors identified on univariate analysis include anterior [odds ratio (OR)=1.98; P<0.001] and lateral (OR=2.17; P=0.002) pleural surface puncture relative to posterior puncture, traversing more than one pleural surface with the biopsy needle (OR=2.35; P=0.06), patient positioning in supine (OR=2.01; P<0.001) and decubitus nodule side up (OR=2.54; P=0.001) orientation relative to decubitus nodule side down positioning, and presence of emphysema in the path of the biopsy needle (OR=3.32; P<0.001). In the multivariable analysis, the presence of emphysematous parenchyma in the path of the biopsy needle was correlated most strongly with increased odds of pneumothorax development (OR=3.03; P=0.0004). Increased body mass index (OR=0.95; P=0.001) and larger nodule width (cm; OR=0.74; P=0.02) were protective factors most strongly correlated with decreased odds of pneumothorax development.

CONCLUSION

Emphysema in the needle biopsy path is most strongly associated with pneumothorax development. Increases in patient body mass index and width of the target lung nodule are most strongly associated with decreased odds of pneumothorax.

Conformity of Fine Needle Aspiration Biopsy (FNAB) and Core Needle Biopsy (CNB) in peripheral lung tumor patients: A cross-sectional study

Background

The problem of establishing lung tumor diagnostics is a challenge for clinicians, especially pulmonologists, in determining a definitive diagnosis of a lung tumor.

Objective

Analyzing the conformity of anatomical pathology results between fine-needle aspiration biopsy (FNAB) and core needle biopsy (CNB) materials in peripheral lung tumors.

Methods

A cross-sectional study was conducted from July 2019 to December 2020 with 66 participants. Participants were examined for CNB and FNAB, in which the results of these examinations were compared for conformity. Statistical analysis used the Kappa test with p < 0.05.

Result

Most participants' tumor size was >70 mm, with FNAB results showing malignant category (39.5%), non-malignant (40.0%), and undiagnosed (38.9%; p = 0.757). Meanwhile, CNB examination showed a tumor size of >70 mm that was categorized into malignant (40.4%) and non-malignant (33.3%; p = 0.510). Most tumors were located in the right superior lobe that had FNAB results in the malignant (39.5%), non-malignant (30.0%) and undiagnosed (27.8%; p = 0.306) categories. The CNB examination also showed that most tumors were located in the right superior lobe, which had resulted in the category of malignant (34.4%), non-malignant (26.7%), and undiagnosed (75.0%; p = 0.240). Conformity of anatomical pathology results from FNAB and CNB subject such as malignancy category of 35 participants (74.5%), non-malignancy of 7 participants (53.8%) and undiagnosed of 4 participants (16.7%) with an accuracy of 69.69% (Κ = 0.43; p = 0.001).

Conclusion

There is a conformity between the anatomical pathology results from FNAB and CNB materials for the diagnosis of lung tumors. CNB showed better results in the detection of anatomical malignancy and specimen adequacy.

•

There is a conformity between the results of FNAB and CNB assisted by ultrasound.

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FNAB and CNB results in lung cancer are similar >70%.

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The use of FNAB followed by CNB minimizes misdiagnosis.

Safety and Effectiveness of Transthoracic Core Needle Biopsy in a Newly Established Interventional Radiology Program in Tanzania

Background Transthoracic core needle biopsy (TTCNB) became a routinely offered procedure in Tanzania in October 2018. This study evaluates the safety and effectiveness of establishing a TTCNB program in a resource-limited setting.

Methodology A single center, prospective, observational cohort study was conducted at Muhimbili National Hospital on 90 patients who underwent computed tomography-guided TTCNB from October 2018 to May 2021. Patient and procedural data, including demographic information, complications, pathology results, and clinical outcomes, were stored in a Research Electronic Data Capture (REDCap) database. Follow-up was conducted at 4 weeks postprocedure by phone. Descriptive analysis was performed using Statistical Package for Social Sciences.

Results A total of 90 patients underwent TTCNB. Seven samples were lost or never processed. In total, 68/83 (81.9%) of processed samples were diagnostic, with 89.7% (n = 61) classified as malignant and 10.3% (n = 7) classified as benign. Overall, 82.4% (n = 56) were classified as primary malignancies, 7.4% (n = 5) as metastatic malignancies, 5.9% (n = 4) as benign tumors, and 4.4% (n = 3) as infectious. Reasons for nondiagnostic samples were crashed/insufficient samples in 53.3% (n = 8) and nonspecific chronic inflammation in 46.7% (n = 7). Minor (Society of Interventional Radiology [SIR] class A and B) complications occurred in 8 cases (8.9%), while there was 1 (1.1%) major complication (SIR class F). A total of 44/90 (48.9%) patients could be reached for follow-up at 4 weeks postprocedure. In addition, 31/44 (70.5%) of these patients had a diagnosis of malignancy. Of these, 20 received chemotherapy, 8 died prior to receiving any treatment, 2 declined any further medical or surgical intervention, and 1 was treated with surgical excision and adjuvant chemotherapy.

Conclusion Although recently introduced in Tanzania, TTCNB has been performed with 81.9% diagnostic accuracy and a complication rate comparable to existing literature.

Importance of Cytopathologic Diagnosis in Early Cancer Diagnosis in Resource-Constrained Countries

PURPOSE

The rising cancer burden in low- and middle-income countries (LMICs) stresses already weak health care systems and poses unique challenges. In resource-constrained LMICs and in circumstances where most patients must pay out of pocket for diagnostic tests, these may not be available or affordable for many. Cytopathology provides a simple, inexpensive, standardized, and low-technology diagnostic procedure that is increasingly used as an effective tool to address the hurdles faced in cancer control programs in LMICs. This review explores the potential role of cytopathology in LMICs in reducing the cancer burden.

METHODS

This review studied the existing literature across the globe regarding the utilization of cytopathology as a diagnostic or screening tool for various types of malignancies as well as its advantages and disadvantages, depending on the local situation.

RESULTS

Apart from the usefulness of cytopathology, this review also sheds light on the barriers to using cytopathology in LMICs. Most recently, SARS-CoV-2 has produced several unique challenges for cytopathology. These are being met with innovative measures to combat the effects of the pandemic and ensure the safe delivery of essential cytopathology services.

CONCLUSION

The usefulness of cytopathologic techniques has been demonstrated via various studies, even during the recent pandemic. If cytology is to be used appropriately, the focus needs to be on integrating it into the national cancer screening and diagnostic programs as well as providing well-trained human resources.

CT-Guided Transthoracic Biopsy of Pulmonary Lesions: Diagnostic versus Nondiagnostic Results

(1) Background: Despite the high accuracy of CT-guided transthoracic biopsy for diagnosis of pulmonary lesions, in a certain amount of cases biopsy results may indicate the presence of nonspecific findings or insufficient material. We aimed to investigate the effectiveness of CT-guided transthoracic biopsy of pulmonary lesions in providing a specific diagnosis and to analyze the variables affecting biopsy results. (2) Methods: In this retrospective study, a total of 170 patients undergoing 183 CT-guided transthoracic biopsies of pulmonary lesions were included. The clinical, radiological and pathological data were reviewed to classify biopsy results as diagnostic or nondiagnostic and to identify which variables were associated with the two groups. (3) Results: The biopsy results were diagnostic in 150 cases (82.0%), of which 131 (87.3%) positive for malignancy and 19 (12.7%) with specific benign lesions, and nondiagnostic in 33 cases (18.0%). Twenty-two of the thirty-three (66.7%) nondiagnostic cases were finally determined as malignancies and eleven (33.3%) as benign lesions. In the diagnostic group, all the 131 biopsies positive for malignancy were confirmed to be malignant at final diagnosis (87.3%); of 19 biopsies with specific benign lesions, 13 cases were confirmed to be benign (8.7%), whereas six cases had a final diagnosis of malignancy (4%). Multivariate analysis showed increased risk of nondiagnostic biopsy for lesions ≤ 20 mm (p = 0.006) and lesions with final diagnosis of benignity (p = 0.001). (4) Conclusions: CT-guided transthoracic lung biopsy is an effective technique for the specific diagnosis of pulmonary lesions, with a relatively acceptable proportion of nondiagnostic cases. Small lesion size and final benign diagnosis are risk factors for nondiagnostic biopsy results.

Successful Diagnosis of Epithelial Thymic Cancer Case Using EBUS-TBNA

Mediastinal masses are relatively uncommon. Surgical approach is often needed to diagnose mediastinal masses. Using endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) toward approaching a mediastinal mass has yet to be established. Here, we present a case of successful diagnosis of thymic cancer with the use of EBUS-TBNA.

Full core technology versus notch sampling technology: evaluation of the diagnostic accuracy and the risk of a pneumothorax after transthoracic needle biopsy of suspicious lung lesions

BACKGROUND

Percutaneous needle biopsy of the lung (PCBL) under image guidance has become a safe and effective minimal invasive method to obtain a specimen related histological diagnosis of pulmonary lesions.

PURPOSE

To evaluate the diagnostic yield and safety of two different coaxial biopsy technologies: full core and notch sampling technology. The former allowing the removal of full punch cylinders and the latter using a cutting-edge mechanism.

MATERIAL AND METHODS

A retrospective analysis of 48 consecutive PCBL procedures has been carried out for this prognostic study, involving patients with a documented pulmonary nodule or mass lesion on previous computed tomography (CT) scans. The study population included 38 men and 10 women (mean age = 67 years). Of these 48 patients who underwent a procedure with a co-axial cutting system, 24 have been performed with notch sampling technology and 24 with full core technology.

RESULTS

Out of the 48 biopsy procedures, 46 yielded specimens were adequate for histopathological evaluation, consistent with a technical success rate of 96%. The most common induced image-guided biopsy complication was a pneumothorax, occurring in 14 patients (35%). Seven patients with a pneumothorax were attributed to the full core technology and seven to the notch sampling technology (odds ratio = 1, 95% confidence interval = 0.28-3.51, P = 1).

CONCLUSION

In the setting of full core versus notch sampling percutaneous CT-guided coaxial needle biopsy of the lung, no significant difference in the diagnostic accuracy and the incidence of pneumothoraces could be shown, while both technologies have an excellent diagnostic performance.

Transthoracic lung biopsy for pulmonary nodules ≤20 mm in routine clinical care

Background

Computed tomography (CT) screening has improved lung cancer survival, yet increasingly detects small lung lesions. Thus, the number of transthoracic lung biopsies (TTLB) for small nodules is expected to rise significantly. The aim of the present study was to evaluate the diagnostic accuracy and safety of CT-guided TTLB for nodules ≤20 mm versus nodules >20 mm.

Study design and methods

Data for CT-guided TTLBs from 474 consecutive patients were prospectively collected over a 3-year period (198 lesions ≤20 mm and 276 lesions >20 mm) in a teaching hospital and analysed in terms of diagnostic performance and complications.

Results

There were more conclusive biopsies in the >20 mm lesion group (n=236, 85.5%) than in ≤20 mm lesion group (n=140, 70.7%; p<0.001). The overall accuracy, sensitivity, specificity and negative predictive value for diagnosing malignant lesions after first TTLB were 88.4%, 84%, 100% and 70.1%, respectively, for ≤20 mm lesions, and 94.2%, 93%, 100% and 74.6%, respectively, for >20 mm lesions. Pneumothorax requiring drainage was significantly more common for ≤20 mm lesions, compared to TTLB of larger lesions (9.6% versus 4.3%; p=0.02). Prolonged hospital stay due to pneumothorax occurred in 27 (17.4%) TTLBs of ≤20 mm lesions and 15 (7%) TTLBs of >20 mm lesions (p=0.002). There were no deaths. The only variable significantly associated with diagnostic failure in the ≤20 mm lesion group was the radiologist's experience.

Interpretation

TTLBs for lesions ≤20 mm were associated with slightly lower diagnostic performance, whereas the higher rate of major complications was still inferior to that extrapolated from United States insurance databases.

Lung cancer screening led to high rate of ≤20 mm nodule discovery. Small-nodule TTLB had 84% sensitivity with 70% NPV for cancer diagnosis. Pneumothorax needing chest tube insertion occurred in 9.6% of TTLBs for lesions ≤20 mm. No death was observed.https://bit.ly/3ohTd7f

Chondrosarcoma of the spine: a narrative review

Chondrosarcoma is an uncommon primary bone tumor with an estimated incidence of 0.5 per 100,000 patient-years. Primary chondrosarcoma of the mobile spine and sacrum cumulatively account for less than 20% of all cases, most .commonly causing patients to present with focal pain with or without radiculopathy, or myelopathy secondary to neural element compression. Because of the rarity, patients benefit from multidisciplinary care at academic tertiary-care centers. Current standard-of-care consists of en bloc surgical resection with negative margins; for high grade lesions adjuvant focused radiation with ≥60 gray equivalents is taking an increased role in improving local control. Prognosis is dictated by lesion grade at the time of resection. Several groups have put forth survival calculators and epidemiological evidence suggests prognosis is quite good for lesions receiving R0 resection. Future efforts will be focused on identifying potential chemotherapeutic adjuvants and refining radiation treatments as a means of improving local control.

Raman Imaging and Fluorescence Lifetime Imaging Microscopy for Diagnosis of Cancer State and Metabolic Monitoring

Hurdles for effective tumor therapy are delayed detection and limited effectiveness of systemic drug therapies by patient-specific multidrug resistance. Non-invasive bioimaging tools such as fluorescence lifetime imaging microscopy (FLIM) and Raman-microspectroscopy have evolved over the last decade, providing the potential to be translated into clinics for early-stage disease detection, in vitro drug screening, and drug efficacy studies in personalized medicine. Accessing tissue- and cell-specific spectral signatures, Raman microspectroscopy has emerged as a diagnostic tool to identify precancerous lesions, cancer stages, or cell malignancy. In vivo Raman measurements have been enabled by recent technological advances in Raman endoscopy and signal-enhancing setups such as coherent anti-stokes Raman spectroscopy or surface-enhanced Raman spectroscopy. FLIM enables in situ investigations of metabolic processes such as glycolysis, oxidative stress, or mitochondrial activity by using the autofluorescence of co-enzymes NADH and FAD, which are associated with intrinsic proteins as a direct measure of tumor metabolism, cell death stages and drug efficacy. The combination of non-invasive and molecular-sensitive in situ techniques and advanced 3D tumor models such as patient-derived organoids or microtumors allows the recapitulation of tumor physiology and metabolism in vitro and facilitates the screening for patient-individualized drug treatment options.

Percutaneous Transthoracic Lung Biopsy: Optimizing Yield and Mitigating Risk

ABSTRACT

Percutaneous computed tomography-guided transthoracic lung biopsy is an effective and minimally invasive procedure to achieve tissue diagnosis. Radiologists are key in appropriate referral for further workup, with percutaneous computed tomography-guided transthoracic lung biopsy performed by both thoracic and general interventionalists. Percutaneous computed tomography-guided transthoracic lung biopsy is increasingly performed for both diagnostic and research purposes, including molecular analysis. Multiple patient, lesion, and technique-related variables influence diagnostic accuracy and complication rates. A comprehensive understanding of these factors aids in procedure planning and may serve to maximize diagnostic yield while minimizing complications, even in the most challenging scenarios.

Methionyl-tRNA synthetase and aminoacyl-tRNA synthetases interacting multi-functional protein-lacking exon 2 as potential diagnostic biomarkers for lung cancer

Cytological specimens from computed tomography (CT)-guided needle aspiration biopsy (CT-NAB) have relatively low sensitivity for lung cancer diagnosis. This study evaluated the usefulness of the dual immunofluorescence (IF) staining method using methionyl-tRNA synthetase (MARS), aminoacyl-tRNA synthetases interacting multi-functional protein-lacking exon 2 (AIMP2-DX2), and pan-cytokeratin (pan-CK) obtained from clinical specimens. One-hundred forty-five cytology specimens were prospectively collected from patients who underwent CT-NAB under the suspicion of lung cancer. The results of two combinations of MARS, AIMP2-DX2, and pan-CK dual IF staining were compared with those of conventional cytology by calculating the area under the curve (AUC). The results of combining dual IF with conventional cytology showed higher AUC than conventional cytology alone: cytology/MARS/AIMP2-DX2 (0.891 vs. 0.829, P = 0.003), cytology/MARS/pan-CK (0.916 vs. 0.829, P < 0.001), and cytology/AIMP2-DX2/pan-CK (0.877 vs. 0.829, P = 0.005). In specimens with non-diagnostic results in conventional cytology, MARS/AIMP2-DX2 dual IF staining showed sensitivity, specificity, and AUC of 60.0%, 86.4%, and 0.79, respectively. The dual IF staining method using two combinations of MARS, AIMP2-DX2, and pan-CK is an effective diagnostic tool that can improve the lung cancer diagnostic yield by complementing conventional cytology.

Utility of liquid-based cytology on residual needle rinses collected from core needle biopsy for lung nodule diagnosis

BACKGROUND

Core needle biopsy (CNB) has become the most common tissue sampling modality for pathological diagnosis of peripheral lung nodules. However, approximately 10% of pulmonary CNB specimens cannot be unambiguously diagnosed, even with auxiliary techniques. This retrospective study investigated the diagnostic value of liquid-based cytology on residual pulmonary CNB material collected from needle rinses.

METHODS

Computed tomography-guided pulmonary CNB specimens and relevant cytology of CNB needle rinses (CNR) from July 2017 to June 2020 were reviewed. A total of 406 patients, each of whom underwent a CNB procedure, were included in the study.

RESULTS

Of the 406 cases, a more serious diagnosis was rendered by CNR in 6.4% (n = 26) of cases. Furthermore, among these 26 cases, 13 malignancies were confirmed only from CNR. Of the remaining 13 patients with uncertain lesions identified from CNR, six were diagnosed with definite benign lesions from tissue samples, five were found to harbor malignant neoplasms through repeated CNB or follow-up examination, and two had tuberculosis. The sensitivity (320/332, 96.4%) of combined CNR/CNB (both CNR and CNB) in distinguishing malignancies from benign lesions was higher than that of CNB alone (307/332, 92.5%). A total of 320 malignant neoplasms included 198 cases of primary lung adenocarcinoma and 71 cases of primary lung squamous cell carcinoma.

CONCLUSIONS

CNR with higher nuclear and cytoplasmic resolution than CNB exhibited a high diagnostic efficacy for differentiating malignant from benign lesions in the lung. Moreover, combined CNR/CNB achieved optimal results in reducing the false-negative rate and the subtyping of non-small cell lung cancer.

Nomogram model to predict pneumothorax after computed tomography-guided coaxial core needle lung biopsy

PURPOSE

To develop a predictive model to determine risk factors of pneumothorax in patients undergoing the computed tomography (CT)¹-guided coaxial core needle lung biopsy (CCNB).

METHODS

A total of 489 patients who underwent CCNBs with an 18-gauge coaxial core needle were retrospectively included. Patient characteristics, primary pulmonary disease, target lesion image characteristics and biopsy-related variables were evaluated as potential risk factors of pneumothorax which was determined on the chest X-ray and CT scans. Univariate and multivariate logistic regressions were used to identify the independent risk factors of pneumothorax and establish the predictive model, which was presented in the form of a nomogram. The discrimination and calibration of the model were evaluated as well.

RESULTS

The incidence of pneumothorax was 32.91 % and 31.42 % in the development and validation groups, respectively. Age, emphysema, pleural thickening, lesion location, lobulation sign, and size grade were identified independent risk factors of pneumothorax at the multivariate logistic regression model. The forming model produced an area under the curve of 0.718 (95 % CI = 0.660-0.776) and 0.722 (95 % CI = 0.638-0.805) in development and validation group, respectively. The calibration curve showed good agreement between predicted and actual probability.

CONCLUSIONS

The predictive model for pneumothorax after CCNBs had good discrimination and calibration, which could help in clinical practice.

Chordoma of the sacrum and mobile spine: a narrative review

Chordoma is a notochord-derived primary tumor of the skull base and vertebral column known to affect 0.08 to 0.5 per 100,000 persons worldwide. Patients commonly present with mechanical, midline pain with or without radicular features secondary to nerve root compression. Management of these lesions has classically revolved around oncologic resection, defined by en bloc resection of the lesion with negative margins as this was found to significantly improve both local control and overall survival. With advancement in radiation modalities, namely the increased availability of focused photon therapy and proton beam radiation, high-dose (>50 Gy) neoadjuvant or adjuvant radiotherapy is also becoming a standard of care. At present chemotherapy does not appear to have a role, but ongoing investigations into the ontogeny and molecular pathophysiology of chordoma promise to identify therapeutic targets that may further alter this paradigm. In this narrative review we describe the epidemiology, histopathology, diagnosis, and treatment of chordoma.

Ultra-low-dose CT-guided lung biopsy in clinic: radiation dose, accuracy, image quality, and complication rate

BACKGROUND

Computed tomography (CT)-guided percutaneous lung biopsy is usually performed by helical scanning. However, there are no studies on radiation dose, diagnostic accuracy, image quality, and complications based on axial scan mode.

PURPOSE

To determine radiation dose, accuracy, image quality, and complication rate following an ultra-low-dose (ULD) protocol for CT-guided lung biopsy in clinic.

MATERIAL AND METHODS

A total of 105 patients were enrolled to receive CT-guided lung biopsy. The use of an ULD protocol (axial scan) for CT-guided biopsy was initiated. Patients were randomly assigned to axial mode (Group A) and conventional helical mode (Group B) CT groups. 64-slice CT was performed for CT-guided pulmonary biopsy with an 18-G coaxial cutting biopsy needle. The radiation dose, accuracy, image quality, and complication rate were measured.

RESULTS

Ninety-seven patients were selected for the final phase of the study. There was no significant difference between the two groups for pulmonary nodule characteristics (P > 0.05). The mean effective dose in group A (0.077 ± 0.010 mSv) was significantly reduced relative to group B (0.653 ± 0.177 mSv, P < 0.001). There was no significant difference in accuracy, image quality, and complication rate (P > 0.050) between the two modes.

CONCLUSION

An ULD protocol for CT-guided lung nodule biopsy yields a reduction in the radiation dose without significant change in the accuracy, image quality, and complication rate relative to the conventional helical mode scan.

Practical Considerations Relating to Routine Clinical Biomarker Testing for Non-small Cell Lung Cancer: Focus on Testing for RET Fusions

For patients with advanced non–small cell lung cancer, genomic profiling of tumors to identify potentially targetable alterations and thereby inform treatment selection is now part of standard care. While molecular analyses are primarily focused on actionable biomarkers associated with regulatory agency-approved therapies, there are a number of emerging biomarkers linked to investigational agents in advanced stages of clinical development will become approved agents. A particularly timely example is the reported data and US Food and Drug Administration approval of highly specific small molecule inhibitors of the proto-oncogene tyrosine-protein kinase receptor RET indicate that testing for tumor RET gene fusions in patients with NSCLC has become clinically important. As the number of biomarkers to be tested in NSCLC grows, it becomes increasingly important to optimize and prioritize the use of biopsy tissue, in order to both continue to allow accurate histopathological diagnosis and also to support concurrent genomic profiling to identify perhaps relatively uncommon genetic events. In order to provide practical expert consensus guidance to optimize processes facilitating genomic testing in NSCLC and to overcome barriers to access and implementation, a multidisciplinary advisory board was held in New York, on January 30, 2019. The panel comprised physicians involved in sample procurement (interventional radiologists and a thoracic surgeon), surgical pathologists specializing in the lung, molecular pathologists, and thoracic oncologists. Particular consideration was given to the key barriers faced by these experts in establishing institutional genomic screening programs for NSCLC. Potential solutions have been devised in the form of consensus opinions that might be used to help resolve such issues.

The promises and challenges of early non-small cell lung cancer detection: patient perceptions, low-dose CT screening, bronchoscopy and biomarkers

Lung cancer survival statistics are sobering with survival ranking among the poorest of all cancers despite the addition of targeted therapies and immunotherapies. However, improvements in tools for early detection hold promise. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial recently corroborated the findings from the previous National Lung Screening Trial low‐dose Computerised Tomography (NLST) screening trial in reducing lung cancer mortality. Biomarker research and development is increasing at pace as the molecular life histories of lung cancers become further unravelled. Low‐dose CT screening (LDCT) is effective but targets only those at the highest risk and is burdensome on healthcare. An optimally designed CT screening programme at best will only detect a low proportion of overall lung cancers as only those at very high‐risk meet screening criteria. Biomarkers that help risk stratify suitable patients for LDCT screening, and those that assist in determining which LDCT detected nodules are likely to represent malignant disease are needed. Some biomarkers have been proposed as standalone lung cancer diagnosis tools. Bronchoscopy technology is improving, with better capacity to identify and obtain samples from early lung cancers. Clinicians need to be aware of each early lung cancer detection method’s inherent limitations. We anticipate that the future of early lung cancer diagnosis will involve a synergistic, multimodal approach, combining several early detection methods.

CT-guided transthoracic needle biopsy of pulmonary lesions: comparison between the cutting needle and aspiration needle

OBJECTIVES

To compare CT-guided transthoracic cutting needle biopsy (TCNB) with transthoracic aspiration needle biopsy (TANB) for pulmonary lesions with respect to the diagnostic accuracy and complication rate.

METHODS

Of the 859 cases that underwent consecutive CT-guided biopsy of pulmonary lesions, 713 cases confirmed by surgical pathology or clinical follow-up were enrolled. Of these, the first consecutive 275 cases underwent TANB, and the remaining 438 received TCNB. The final diagnosis determined the accuracy of biopsy. Based on the post-biopsy CT and clinical medical records, the presence or absence of biopsy-related complications was determined. The χ² test was used to compare the differences between TCNB and TANB in terms of diagnostic accuracy and complication rate.

RESULTS

Among the 713 biopsy lesions, the final diagnosis was malignant in 411 cases and benign in 302 cases. As compared to TANB, the diagnostic accuracy of TCNB (98.9% vs 93.8%, χ² = 14.35, p < 0.01), sensitivity to malignant lesions (97.8% vs 90.6%, χ² = 10.58, p < 0.01), negative predictive value (97.6% vs 84.8%, χ² = 19.03, p < 0.01), and specific diagnostic rate for benign lesions (73.4% vs 57.9%, χ² = 7.29, p < 0.01) were improved. On the other hand, a statistical difference was detected between TCNB and TANB with respect to the incidence of pneumothorax (20.6% vs 13.1%, χ² = 6.46, p = 0.01), hemorrhage (32.2% vs 13.1%, χ² = 33.03, p < 0.01), and hemoptysis (8.2% vs 3.3%, χ² = 6.87, p < 0.01). One patient died just several minutes after TCNB due to severe hemorrhage with hemoptysis.

CONCLUSIONS

Compared to TANB, CT-guided TCNB improves the diagnostic accuracy of pulmonary lesions, but complication rate increases significantly.

ADVANCES IN KNOWLEDGE

In general, TCNB should be recommended, especially for highly suspicious benign lesions. For patients with small lesions adjacent to vessels or vessels within the lesion, TANB should be considered.

Diagnostic utility of fine needle aspiration cytology and core biopsy histopathology with or without immunohistochemical staining in the subtyping of the non-small cell lung carcinomas: Experience from an academic centre in Turkey

INTRODUCTION

This retrospective morphological study compared the results of fine needle aspiration (FNA) cytology, haematoxylin-eosin (HE)-stained samples and immunohistochemical (IHC)-stained core needle biopsy (CNB) histology samples for primary non-small cell lung cancer (NSCLC) subtyping. We assessed the diagnostic utility of these methods to investigate the contribution of each method to NSCLC subtyping. We also identified the point at which NSCLC subtyping could be performed using histomorphology alone without IHC.

METHODOLOGY

Concurrent FNA and CNB specimens obtained via a single computed tomography-guided procedure and diagnosed as NSCLC in the Pathology Department of our university within 3 years were reviewed. The results of FNA samples, HE-stained biopsies and IHC-stained biopsies were compared according to subtype.

RESULTS

A total of 141 subjects were enrolled in the study. For subtyping, FNA provided an accurate diagnosis in 70 (55.1%) of 127 eligible subjects after the exclusion of 14 cases determined as not otherwise specified. CNB histology without IHC achieved a diagnosis in 53 (41.7%) of 127 subjects, which was a significant difference (P < .05). The compatibility rate between HE-stained biopsy samples and IHC-stained biopsy samples was 41.7% (53/127).

CONCLUSION

The diagnosis rates achieved using FNA, HE-stained CNB samples and IHC-stained CNB samples were 54.6% (77/141), 37.6% (53/141) and 90.1% (127/141), respectively. The subtype was identified in 55.1% of the subjects evaluated using FNA and 41.7% of subjects assessed using HE-stained biopsy samples without IHC. FNA provided a better result for squamous cell carcinoma than adenocarcinoma (55.1% vs 47.6%), but the diagnosing of adenocarcinoma and squamous cell carcinoma using HE-stained biopsy samples was similar (42% vs 41.7%).

Radial Basis Function Artificial Neural Network for the Investigation of Thyroid Cytological Lesions

Objective

This study investigates the potential of an artificial intelligence (AI) methodology, the radial basis function (RBF) artificial neural network (ANN), in the evaluation of thyroid lesions. Study Design. The study was performed on 447 patients who had both cytological and histological evaluation in agreement. Cytological specimens were prepared using liquid-based cytology, and the histological result was based on subsequent surgical samples. Each specimen was digitized; on these images, nuclear morphology features were measured by the use of an image analysis system. The extracted measurements (41,324 nuclei) were separated into two sets: the training set that was used to create the RBF ANN and the test set that was used to evaluate the RBF performance. The system aimed to predict the histological status as benign or malignant.

Results

The RBF ANN obtained in the training set has sensitivity 82.5%, specificity 94.6%, and overall accuracy 90.3%, while in the test set, these indices were 81.4%, 90.0%, and 86.9%, respectively. Algorithm was used to classify patients on the basis of the RBF ANN, the overall sensitivity was 95.0%, the specificity was 95.5%, and no statistically significant difference was observed.

Conclusion

AI techniques and especially ANNs, only in the recent years, have been studied extensively. The proposed approach is promising to avoid misdiagnoses and assists the everyday practice of the cytopathology. The major drawback in this approach is the automation of a procedure to accurately detect and measure cell nuclei from the digitized images.

Diagnosis of Lung Carcinoma on Small Biopsy

Given the growing desire in clinical practice to detect lung carcinoma early, small biopsies are becoming more common and vital to the diagnostic process. Accurately diagnosing lung carcinoma on small biopsies is challenging but can significantly affect patient management. The challenge is due in part to the overlapping features between benign, reactive, and malignant processes and the lack of discriminating biomarkers. Specimen preservation for ancillary tests is also increasingly important to provide targeted precision medicine. We focuses on the morphologic features and diagnostic pitfalls of the most common lung carcinoma seen in small biopsies and the appropriate specimen handling practice.

Usefulness of CT-Guided Percutaneous Transthoracic Needle Lung Biopsies in Patients with Suspected Pulmonary Infection

Objective

This study aimed to evaluate the clinical benefits and risks of CT-guided percutaneous transthoracic needle lung biopsies (PTNBs) in patients with a suspected pulmonary infection.

Materials and Methods

This study included 351 CT-guided PTNBs performed in 342 patients (mean age, 58.9 years [range, 17–91 years]) with suspected pulmonary infection from January 2010 to December 2016. The proportion of biopsies that revealed the causative organism for pulmonary infection and that influenced patient's treatment were measured. Multivariate analyses were performed to identify factors associated with PTNB that revealed the causative organism or affected the treatment. Finally, the complication rate was measured.

Results

CT-guided PTNB revealed the causative organism in 32.5% of biopsies (114/351). The presence of necrotic components in the lesion (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1–2.7; p = 0.028), suspected pulmonary tuberculosis (OR, 2.0; 95% CI, 1.2–3.5; p = 0.010), and fine needle aspiration (OR, 2.5; 95% CI, 1.1–5.8; p = 0.037) were factors associated with biopsies that revealed the causative organism. PTNB influenced patient's treatment in 40.7% (143/351) of biopsies. The absence of leukocytosis (OR, 1.9; 95% CI, 1.0–3.7; p = 0.049), presence of a necrotic component in the lesion (OR, 2.4; 95% CI, 1.5–3.8; p < 0.001), and suspected tuberculosis (OR, 1.7; 95% CI, 1.0–2.8; p = 0.040) were factors associated with biopsies that influenced the treatment. The overall complication rate of PTNB was 19% (65/351).

Conclusion

In patients with suspected pulmonary infection, approximately 30–40% of CT-guided PTNBs revealed the causative organism or affected the treatment. The complication rate of PTNB for suspected pulmonary infection was relatively low.

Combination of Percutaneous Lung Biopsy and Xpert MTB/RIF Ultra Enhances the Differential Diagnosis of Tuberculosis: A Prospective Cohort Study

Introduction

To evaluate the value of the combination of computed tomography (CT)-guided percutaneous lung biopsy and Xpert MTB/RIF Ultra (Xpert-Ultra) in enhancing the differential diagnosis of tuberculosis.

Methods

Patients with lesions in the lungs for whom the differential diagnosis was difficult were prospectively and consecutively enrolled. Specimens collected by percutaneous lung biopsy were subject to Xpert-Ultra and histopathologic examination, respectively.

Results

Biopsy was successfully performed for 147 patients who were eligible for analysis, including 65 TB, 55 lung cancer and 27 other chronic infection cases. The sensitivity, specificity, positive predictive value and negative predictive value of Xpert-Ultra for TB diagnosis were 75.38% (49/65) and 95.12% (78/82), 92.45% (49/53) and 82.98% (78/94), respectively. Among patients with strong evidence for TB diagnosis (categorized as confirmed or probable TB cases), the overall positive rate of the Xpert-Ultra assay was 83.63% (46/55), which was much higher than for any reported sample type with negative smear test outcomes to date. Five rifampicin (RIF)-resistant cases were identified using the biopsy tissues. However, “trace” positive did not seem reliable for TB diagnosis with lung biopsy specimens; a 25.61% (21/82) “trace”-positive rate was acquired in the non-TB group.

Conclusion

Percutaneous lung biopsy combined with Xpert-Ultra produced high sensitivity for culture-negative pulmonary TB patient diagnosis. “Trace” outcome might not be a reliable positive category for lung biopsy specimens.

Trial registration

ClinicalTrials.gov identifier, ChiCTR1900026412. Retrospectively registered on Oct 8th, 2019).

Diagnostic Accuracy of Percutaneous Transthoracic Needle Lung Biopsies: A Multicenter Study

Objective

To measure the diagnostic accuracy of percutaneous transthoracic needle lung biopsies (PTNBs) on the basis of the intention-to-diagnose principle and identify risk factors for diagnostic failure of PTNBs in a multi-institutional setting.

Materials and Methods

A total of 9384 initial PTNBs performed in 9239 patients (mean patient age, 65 years [range, 20–99 years]) from January 2010 to December 2014 were included. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PTNBs for diagnosis of malignancy were measured. The proportion of diagnostic failures was measured, and their risk factors were identified.

Results

The overall accuracy, sensitivity, specificity, PPV, and NPV were 91.1% (95% confidence interval [CI], 90.6–91.7%), 92.5% (95% CI, 91.9–93.1%), 86.5% (95% CI, 85.0–87.9%), 99.2% (95% CI, 99.0–99.4%), and 84.3% (95% CI, 82.7–85.8%), respectively. The proportion of diagnostic failures was 8.9% (831 of 9384; 95% CI, 8.3–9.4%). The independent risk factors for diagnostic failures were lesions ≤ 1 cm in size (adjusted odds ratio [AOR], 1.86; 95% CI, 1.23–2.81), lesion size 1.1–2 cm (1.75; 1.45–2.11), subsolid lesions (1.81; 1.32–2.49), use of fine needle aspiration only (2.43; 1.80–3.28), final diagnosis of benign lesions (2.18; 1.84–2.58), and final diagnosis of lymphomas (10.66; 6.21–18.30). Use of cone-beam CT (AOR, 0.31; 95% CI, 0.13–0.75) and conventional CT-guidance (0.55; 0.32–0.94) reduced diagnostic failures.

Conclusion

The accuracy of PTNB for diagnosis of malignancy was fairly high in our large-scale multi-institutional cohort. The identified risk factors for diagnostic failure may help reduce diagnostic failure and interpret the biopsy results.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Molecular and Genomic Profiling of Lung Cancer in the Era of Precision Medicine: A Position Paper from the Italian Association of Thoracic Oncology (AIOT)

The identification of the optimal cancer treatment has become progressively more intricate for non-small-cell lung cancer (NSCLC) patients due to the multitude of options available. The testing of biomarkers to predict clinical responses to therapies is pivotal to stratify the patients based on the molecular features of their tumors. The number of actionable genetic alterations to be tested is increasing together with the comprehension of the molecular mechanisms underlying tumor growth and development. The possibility of using next generation sequencing-based approaches enhanced the acquisition of genetic data with potential clinical usefulness, and favored the integration of precision medicine in clinical practice. The availability of targeted sequencing panels that cover genetic alterations in hundreds of genes allows the performance of a comprehensive genomic profiling (CGP) of lung tumors. However, different issues still need to be solved, from the tissue needed for next generation sequencing analysis, to the choice of the test and its interpretation in the clinical context. This position paper from the Italian Association of Thoracic Oncology (AIOT) summarizes the results of a discussion from a Precision Medicine Panel meeting on the challenges to bringing CGP and, therefore, precision medicine into the daily clinical practice.

Role of Computed Tomography-guided Biopsies in the Era of Electromagnetic Navigational Bronchoscopy: A Retrospective Study of Factors Predicting Diagnostic Yield in Electromagnetic Navigational Bronchoscopy and Computed Tomography Biopsies

Objectives:

Over 25% of the high-risk population screened for lung cancer have an abnormal computed tomography (CT) scan. Conventionally, these lesions have been biopsied with CT guidance with a high diagnostic yield. Electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy. It has been used to biopsy lung lesions, due to the low risk of pneumothorax. It is, however, a new technology that is expensive and its role in the diagnosis of the solitary pulmonary nodule (SPN) is yet to be determined. The purpose of this study was to evaluate the diagnostic yield of CT-guided biopsy (CTB) following non-diagnostic ENB biopsy and identify characteristics of the lesion that predicts a low diagnostic yield with ENB, to ensure appropriate use of ENB in the evaluation of SPN.

Materials and Methods:

One hundred and thirty-five lung lesions were biopsied with ENB from January 2017 to August 2019. Biopsies were considered diagnostic if pathology confirmed malignancy or inflammation in the appropriate clinical and imaging setting. We evaluated lesions for several characteristics including size, lobe, and central/peripheral distribution. The diagnostic yield of CTB in patients who failed ENB biopsies was also evaluated. Logistic regression was used to identify factors likely to predict a non-diagnostic ENB biopsy.

Result:

Overall, ENB biopsies were performed in 135 patients with solitary lung lesions. ENB biopsies were diagnostic in 52% (70/135) of the patients. In 23 patients with solitary lung lesions, CTBs were performed following a non-diagnostic ENB biopsy. The CTBs were diagnostic in 87% of the patients (20/23). ENB biopsies of lesions <21.5 mm were non-diagnostic in 71% of cases (42/59); 14 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% of them were diagnostic (12/14). ENB biopsies of lesions in the lower lobes were non- diagnostic in 59% of cases (35/59); 12 of these patients with non-diagnostic ENB biopsies had CTBs, and 83% were diagnostic (10/12). ENB biopsies of lesions in the outer 2/3 were non-diagnostic in 57% of cases (50/87); 21 of these patients with non-diagnostic ENB biopsies had CTBs, and 86% were diagnostic (18/21).

Conclusion:

CTBs have a high diagnostic yield even following non-diagnostic ENB biopsies. Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies. Although CTBs have a slightly higher pneumothorax rate, these lesions would be more successfully diagnosed with CTB as opposed to ENB biopsy, in the process expediting the diagnosis and saving valuable medical resources.

Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology

CONTEXT.—

The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples.

OBJECTIVE.—

To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies.

METHODS.—

The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered.

RESULTS.—

Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples.

CONCLUSIONS.—

Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

Fluid-filled Cystic Lesions of the Lungs

A pulmonary cyst usually refers to an air-filled space with a smooth, thin wall. Fluid-filled cystic lesions of the lungs include a range of etiologies such as true cysts, congenital malformations, infections, and benign and malignant neoplasms. With relatively little solid component, these lesions often have similar imaging appearances to one another. This article focuses on key imaging features and clinical characteristics that can be used to narrow the differential diagnosis.

Computed Tomography-guided Transthoracic Core Needle Biopsy of Lung Masses: Technique, Complications and Diagnostic Yield Rate

Objectives

Computed tomography-guided core needle biopsy has an important role in the accurate histopathological diagnosis of lung masses. The present study aims to share our results of computed tomography-guided percutaneous core needle biopsy of lung masses.

Methods

A total of 117 patients had computed tomography-guided percutaneous core needle biopsy for lung masses between January 2017-September 2019 in our institution. In this study, these patients' post-procedural complications, diagnostic-yield-rates and radiological-histopathological correlations were evaluated retrospectively.

Results

Complications occurred in 23 (20%) patients (20 (17%) of pneumothorax; 3 (3%) of hemorrhage). Chest-tube-drainage was needed in five (4%) of all patients. No significant difference was found between complication rates and patient gender/age, tumor volume/localization or needle-path-length (p>0.05). In 77 of the 85 (91%) primary-lung-cancer-cases radiological and pathological diagnostic results were correlated.

Conclusion

Computed tomography-guided core needle biopsy has a high diagnostic yield rate with acceptable complication rates in the diagnosis of lung masses.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Subtyping Lung Cancer Using DNA Methylation in Liquid Biopsies

BACKGROUND

Lung cancer (LCa) is the most frequently diagnosed and lethal cancer worldwide. Histopathological subtyping, which has important therapeutic and prognostic implications, requires material collection through invasive procedures, which might be insufficient to enable definitive diagnosis. Aberrant DNA methylation is an early event in carcinogenesis, detectable in circulating cell-free DNA (ccfDNA). Herein, we aimed to assess methylation of selected genes in ccfDNA from LCa patients and determine its accuracy for tumor subtyping.

METHODS

Methylation levels of APC, HOXA9, RARβ2, and RASSF1A were assessed in three independent study groups (study group #1: 152 tissue samples; study group #2: 129 plasma samples; study group #3: 28 benign lesions of lung) using quantitative methylation-specific PCR. Associations between gene promoter methylation levels and LCa subtypes were evaluated using non-parametric tests. Receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

In study group #2, HOXA9 and RASSF1A displayed higher methylation levels in small-cell lung cancer (SCLC) than in non-small-cell lung cancer (NSCLC). HOXA9 displayed high sensitivity (63.8%), whereas RASSF1A disclosed high specificity (96.2%) for SCLC detection in ccfDNA. Furthermore, HOXA9 methylation levels showed to be higher in squamous cell carcinoma in comparison with adenocarcinoma in study group #1.

CONCLUSIONS

Methylation level assessments in ccfDNA may provide a minimally invasive procedure for LCa subtyping, complementing standard diagnostic procedures.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.