Clinical applications of the C-arm cone-beam CT-based 3D needle guidance system in performing percutaneous transthoracic needle biopsy of pulmonary lesions

Percutaneous Nephroureteral Stent Placement and Antegrade Forceps Biopsy of Ureteral Obstruction

PURPOSE

To evaluate the feasibility of percutaneous transluminal ureteral biopsy (PTUB) combined with percutaneous nephroureteral stent placement for ureteral obstruction under fluoroscopy.

MATERIALS AND METHODS

From September 2011 to July 2021, 37 patients (27 men and 10 women; median age, 65.0 years) who experienced ureteroscopic biopsy failure or refused or were unable to undergo ureteroscopic biopsy underwent PTUB for ureteral obstruction during nephroureteral stent placement under fluoroscopic guidance. Data on technical success, early adverse events, and radiation dose were collected. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) of PTUB were analyzed.

RESULTS

The technical success of PTUB was 89.2%, with a mean irradiation dose of 76.9 mGy·cm2 ± 12.2. A total of 67.6% (25/37) of the cases were correctly diagnosed with malignancy, whereas 8 cases were confirmed to be true negatives. There were 4 false negatives and no false positives. PTUB had a sensitivity, specificity, PPV, NPV, and OA of 86.2% (25/29), 100% (8/8), 100% (25/25), 66.7% (8/12), and 89.2% (33/37), respectively. Eleven patients (29.7%) experienced Grade 1 adverse events (transient aggravated hematuria).

CONCLUSIONS

PTUB appears to be a safe and effective alternative to ureteroscopic biopsy for ureteral obstruction.

Chinese expert consensus on cone-beam CT-guided diagnosis, localization and treatment for pulmonary nodules

Cone-beam computed tomography (CBCT) system can provide real-time 3D images and fluoroscopy images of the region of interest during the operation. Some systems can even offer augmented fluoroscopy and puncture guidance. The use of CBCT for interventional pulmonary procedures has grown significantly in recent years, and numerous clinical studies have confirmed the technology's efficacy and safety in the diagnosis, localization, and treatment of pulmonary nodules. In order to optimize and standardize the technical specifications of CBCT and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Interventional Pulmonology of China Association for Promotion of Health Science and Technology.

PVP with or without microwave ablation for the treatment of painful spinal metastases from NSCLC: a retrospective case-control study

OBJECTIVE

To compare the clinical efficacy of percutaneous vertebroplasty (PVP) alone and microwave ablation (MWA) combined with PVP for the treatment of painful spinal metastases from non-small cell lung cancer (NSCLC).

METHODS

From October 2014 to October 2021, the data of 58 NSCLC patients with refractory painful spinal metastases (visual analog scale score ≥ 5) were retrospectively collected and analyzed. Patients in Group A (n = 30) and Group B (n = 28) received PVP alone and MWA combined with PVP, respectively. The primary endpoint was pain relief. The secondary endpoints were quality of life (QoL), local tumor progression (LTP), and complications.

RESULTS

The technical success rate was 100% in both groups. Patients in both groups showed similar pain relief at 1-12 weeks, but patients in Group B still showed sustained pain relief at 24 weeks compared to those in Group A (p = 0.03). The assessment of QoL showed similar changes. LTP (33.00% vs. 7.14%, p = 0.02) and cement leakage rates (40.00% vs. 7.14%, p = 0.03) were lower in Group B. The multivariate analysis demonstrated spinal metastases with a maximum diameter ≤ 3.0 cm (p = 0.027) and MWA combined with PVP (p = 0.028) were two independent protective factors for LTP. For cement leakage, spinal metastases with vertebral body compression (p = 0.019) was an independent risk factor, while MWA combined with PVP (p = 0.042) was an independent protective factor.

CONCLUSION

MWA combined with PVP for painful spinal metastases from NSCLC performed more sustained pain relief (>6 months) and ultimately improved QoL with lower LTP and cement leakage rates, compared to PVP alone.

Real-time three-dimensional fluoroscopy-navigated percutaneous pelvic screw placement for fragility fractures of the pelvis in the hybrid operating room

BACKGROUND

The prognosis of conservative treatment for fragility fracture of the pelvis (FFP) in the older patients remains poor. Percutaneous pelvic screw placement (PPSP), which aids in the treatment of FFP, can be challenging to perform using fluoroscopy alone because of the proximity of blood vessels and neuroforamina. Hence, this study aimed to investigate the accuracy and clinical outcomes of PPSP using real-time 3D fluoroscopic navigation for FFP in the hybrid operating room.

METHODS

This study included 41 patients with FFP who underwent PPSP in a hybrid operating room between April 2016 and December 2020. Intraoperative C-arm cone-beam CT was performed under general anesthesia. Guidewire trajectory was planned using a needle guidance system. The guidewire was inserted along the overlaid trajectory using 3D fluoroscopic navigation, and a 6.5 mm cannulated cancellous screw (CCS) was placed. The clinical outcomes and accuracy of the screw placement were then investigated.

RESULTS

A total of 121 screws were placed. The mean operative time was 84 ± 38.7 minutes, and the mean blood loss was 7.6 ± 3.8 g. The mean time to wheelchair transfer was 2 days postoperatively. Pain was relieved in 35 patients. Gait ability from preoperative and latest follow-up after surgery was maintained in 30 (73%) patients. All 41 patients achieved bone union. Of the 121 screws, 119 were grade 0 with no misplacement; only 2 patients had grade 1 perforations.

CONCLUSION

PPSP using real-time 3D fluoroscopic navigation in a hybrid operating room was accurate and useful for early mobilization and pain relief among older patients with FFP with an already-installed needle biopsy application.

Using 3D polylines to improve cone-beam CT-guided percutaneous transthoracic needle biopsy

OBJECTIVES

To investigate the diagnostic accuracy of using 3D polylines (3DPs) to improve cone-beam CT (CBCT) virtual navigation (VN)-guided percutaneous transthoracic needle biopsies (PTNB) of pulmonary lesions.

METHODS

From May 2021 to November 2021, patients (81 males and 41 females; age, 65 ± 12 years) who underwent CBCT VN with 3DPs for PTNB of pulmonary lesions were retrospectively reviewed. Fluoroscopic visibility of target lesions was evaluated using captured images from a Bull's eye view. Diagnostic accuracy was calculated, and complications were assessed.

RESULTS

The mean size of biopsied lesions was 23 ± 13 mm (range: 6-75 mm). Overall, 13.9% (17/122) were small pulmonary nodules (diameter ≤1 cm), and 68.0% (83/122) of biopsied lesions were fluoroscopic visible. The overall diagnostic accuracy was 94.3%. The diagnostic accuracy for visible and invisible lesions was 94.0 and 94.9%, respectively (p = 0.843), and 100% for small pulmonary nodules. Major complications occurred in 8.2% (10/122; eight pneumothorax with chest tube insertion, one hemoptysis with transfusion, and one air embolism) of patients.

CONCLUSION

CBCT VN with 3DP guidance provide a real-time outline of pulmonary lesions, thus enabling a reliable and accurate PTNB.

ADVANCES IN KNOWLEDGE

3DP guidance could be useful technique for CBCT-guided PTNB, especially in small pulmonary nodules.

C-Arm Cone-Beam CT Virtual Navigation versus Conventional CT Guidance in the Transthoracic Lung Biopsy: A Case-Control Study

C-arm cone-beam computed tomography (CBCT) virtual navigation-guided lung biopsy has been developed in the last decade as an alternative to conventional CT-guided lung biopsy. This study aims to compare the biopsy accuracy and safety between these two techniques and explores the risk factors of biopsy-related complications. A total of 217 consecutive patients undergoing conventional CT- or C-arm CBCT virtual navigation-guided lung biopsy from 1 June 2018 to 31 December 2019 in this single-center were retrospectively reviewed. Multiple factors (e.g., prior emphysema, lesion size, etc.) were compared between two biopsy techniques. The risk factors of complications were explored by using logistic regression. The patients’ median age and male-to-female ratio were 63 years and 2.1:1, respectively. Eighty-two (82) patients (37.8%) underwent conventional CT-guided biopsies, and the other 135 patients (62.2%) C-arm CBCT virtual navigation-guided biopsies. Compared with patients undergoing C-arm CBCT virtual navigation-guided lung biopsies, patients undergoing conventional CT-guided lung biopsies showed higher needle repositioning rate, longer operation time, and higher effective dose of X-ray (52.4% vs. 6.7%, 25 min vs. 15 min, and 13.4 mSv vs. 7.6 mSv, respectively; p < 0.001, each). In total, the accurate biopsy was achieved in 215 of 217 patients (99.1%), without a significant difference between the two biopsy techniques (p = 1.000). The overall complication rates, including pneumothorax and pulmonary hemorrhage/hemoptysis, are 26.3% (57/217), with most minor complications (56/57, 98.2%). The needle repositioning was the only independent risk factor of complications with an odds ratio of 6.169 (p < 0.001). In conclusion, the C-arm CBCT virtual navigation is better in percutaneous lung biopsy than conventional CT guidance, facilitating needle positioning and reducing radiation exposure. Needle repositioning should be avoided because it brings about more biopsy-related complications.

Computed Tomography-Navigation™ Electromagnetic System Compared to Conventional Computed Tomography Guidance for Percutaneous Lung Biopsy: A Single-Center Experience

The aim of our study was to assess the efficacy of a computed tomography (CT)-Navigation™ electromagnetic system compared to conventional CT methods for percutaneous lung biopsies (PLB). In this single-center retrospective study, data of a CT-Navigation™ system guided PLB (NAV-group) and conventional CT PLB (CT-group) performed between January 2017 and February 2020 were reviewed. The primary endpoint was the diagnostic success. Secondary endpoints were technical success, total procedure duration, number of CT acquisitions and the dose length product (DLP) during step ∆1 (from planning to initial needle placement), step ∆2 (progression to target), and the entire intervention (from planning to final control) and complications. Additional parameters were recorded, such as the lesion’s size and trajectory angles. Sixty patients were included in each group. The lesions median size and median values of the two trajectory angles were significantly lower (20 vs. 29.5 mm, p = 0.006) and higher in the NAV-group (15.5° and 10° vs. 6° and 1°; p < 0.01), respectively. Technical and diagnostic success rates were similar in both groups, respectively 95% and 93.3% in the NAV-group, and 93.3% and 91.6% in the CT-group. There was no significant difference in total procedure duration (p = 0.487) and total number of CT acquisitions (p = 0.066), but the DLP was significantly lower in the NAV-group (p < 0.01). There was no significant difference in complication rate. For PLB, CT-Navigation™ system is efficient and safe as compared to the conventional CT method.

Handheld Photoacoustic Imager for Theranostics in 3D

A handheld approach to 3D photoacoustic imaging is essential in clinical applications. To this end, we develop a 3D handheld photoacoustic imager for dynamic (temporally and spatially) volumetric visualization. In this 3D imager, the optically transmitting part and the acoustically receiving part are integrated into a single handheld probe with a compact size about 160 mm ×64 mm ×40 mm. Besides, a dedicated imaging reconstruction algorithm for the heterogeneous medium is developed based on the phase-shift migration method in the frequency domain, which deals well with the stratified condition in the designed system. Dynamic 3D imaging supporting flexible handheld operation is demonstrated with needle biopsy and in vitro temperature measurement for photothermal therapy. The development of such a 3D handheld photoacoustic system paves the way for compact and handheld-operating implementations, and its further clinical exploration is promising.

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.

Devices for image-guided lung interventions: State-of-the-art review

Lung cancer is the leading cause of cancer-related death. According to the American Cancer Society, there were an estimated 222,500 new cases of lung cancer and 155,870 deaths from lung cancer in the United States in 2017. Accurate localization in lung interventions is one of the keys to reducing the death rate from lung cancer. In this study, a total of 217 publications from 2006 to 2017 about designs of medical devices for localization in lung interventions were screened, shortlisted, and categorized by localization principle and reviewed for functionality. Each study was analyzed for engineering characteristics and clinical significance. Research regarding interventional imaging equipment, navigation systems, and surgical devices was reviewed, and both research prototypes and commercial products were discussed. Finally, the future directions and existing challenges were summarized, including real-time intra-procedure guidance, accuracy of localization, clinical application, clinical adoptability, and clinical regulatory issues.

Percutaneous nephrolithotripsy: C-arm CT with 3D virtual navigation in non-dilated renal collecting systems

PURPOSE

We aimed to evaluate the clinical superiority of using C-arm computed tomography (CT) to establish percutaneous nephrolithotripsy (PCNL) access for patients with non-dilated renal collecting systems.

METHODS

From May 2014 to May 2015, 33 patients underwent C-arm CT-guided puncture to establish PCNL access after failed attempts of ultrasonography-guided nephrostomy. Technical success, procedure details, radiation exposure, complications, and stone-free rate were recorded.

RESULTS

The technical success rate was 97% (32/33) with a mean puncture score of 4.5/5. Mean puncture, dilation, and fragmentation times were 17.9±6.0, 12.6±3.9, and 33.1±8.8 minutes, respectively. Mean radiation exposure was 4.8±2.1 mSv without serious complications. Stone-free rate was 93.8%.

CONCLUSION

C-arm CT is a useful tool to establish PCNL access, particularly in cases of upper pole access or complicated anatomy.

Percutaneous Computed Tomography-Guided Lung Biopsies using a Virtual Navigation Guidance: Our Experience

OBJECTIVE

To evaluate the effectiveness of a virtual CT-guided navigation system (Sirio-MASMEC Biomed) in performing lung biopsies, with greater attention to lesions smaller than 1 cm, compared to the traditional procedure.

METHODS

This study was approved by the Ethics Committee of our Institute. Two hundred patients were prospectively selected. Of these, 100 were subjected to percutaneous procedure with the use of Sirio and 100 to traditional CT-guided percutaneous procedure. The two methods were compared in terms of absorbed dose, procedure time, complications, and number of non-diagnostic specimens (diagnostic success).

RESULTS

Sirio has shown a significant reduction in the absorbed dose and procedure times (p < 0.05), with a lower incidence of complications compared to the traditional procedure. Sirio has also allowed to carry out biopsies of lesions' diameter ≤10 mm, obtaining fewer non diagnostic specimens thus resulting more effective in terms of diagnostic success.

CONCLUSIONS

The use of Sirio in sampling biopsy showed a statistically significant reduction in terms of performed scans and procedural time with lower incidence of post-procedural complications compared to the traditional percutaneous procedure, especially for lesions ≤10 mm. The best diagnostic result, the reduction of the dose absorbed and procedural complications makes the procedures more reliable, safety and less invasive. In addition, the reduction of execution time will increase the number of daily interventional procedures improving clinical management.

Open Bronchus Sign on CT: A Risk Factor for Hemoptysis after Percutaneous Transthoracic Biopsy

Objective

We hypothesized that open bronchi within target pulmonary lesions are associated with percutaneous transthoracic needle biopsy (PTNB)-related hemoptysis. We sought to analyze and compare patient characteristics and target features as well as biopsy-related factors between patients with and without PTNB-related hemoptysis.

Materials and Methods

We retrospectively analyzed 1484 patients (870 males and 614 females; median age, 66 years) who had undergone 1569 cone-beam CT (CBCT)-guided PTNBs. Patient characteristics (sex, age, and pathologic diagnosis), nodule features (nodule type, size, location, and presence of an open bronchus in target nodules), and biopsy-related factors (biopsy needle size, pleura-to-target distance, blood test results, open bronchus unavoidability [OBU] index, etc.) were investigated. OBU index, which was assessed using the pre-procedural CBCT, was a subjective scoring system for the probability of needle penetration into the open bronchus. Univariate analysis and subsequent multivariate logistic regression analysis were conducted to reveal the independent risk factors for PTNB-related hemoptysis. For a subgroup of nodules with open bronchi, a trend analysis between the occurrence of hemoptysis and the OBU index was performed.

Results

The independent risk factors for hemoptysis were sex (female; odds ratio [OR], 1.918; p < 0.001), nodule size (OR, 0.837; p < 0.001), open bronchus (OR, 2.101; p < 0.001), and pleura-to-target distance (OR, 1.135; p = 0.003). For the target nodules with open bronchi, a significant trend between hemoptysis and OBU index (p < 0.001) was observed.

Conclusion

An open bronchus in a biopsy target is an independent predictor of hemoptysis, and careful imaging review may potentially reduce PTNB-related hemoptysis.

Cone-Beam CT Virtual Navigation-Guided Percutaneous Needle Biopsy of Suspicious Pleural Metastasis: A Pilot Study

Objective

To evaluate the diagnostic performance of cone-beam computed tomography (CBCT) virtual navigation-guided percutaneous pleural biopsy for suspected malignant pleural disease.

Materials and Methods

This study enrolled 59 patients (31 males and 28 females; mean age, 63.4 years) with suspected malignant pleural disease diagnosed with CBCT from December 2010 to December 2016. Sixty-three CBCT-guided biopsies were performed using a coaxial system with 18- or 20-gauge cutting needles. Procedural details, diagnostic performance, radiation exposure, and complication rates were investigated.

Results

The mean diameter perpendicular to the pleura of 51 focal and 12 diffuse pleural lesions was 1.53 ± 0.76 cm. The mean distance from the skin to the target was 3.40 ± 1.51 cm. Mean numbers of CT acquisitions and biopsies were 3.21 ± 0.57 and 3.05 ± 1.54. Total procedure time and coaxial introducer indwelling time were 11.87 ± 5.59 min and 8.78 ± 4.95 min, respectively. The mean dose area product was 12013.61 ± 7969.59 mGym². There were 48 malignant, 10 benign, and 5 indeterminate lesions. Sensitivity, specificity, and diagnostic accuracy were 93.8% (45/48), 100% (10/10), and 94.8% (55/58), respectively. Positive and negative predictive values for malignancy were 100% (45/45) and 76.9% (10/13), respectively. Four patients (6.8%) with benign pathology during initial biopsy but still showing a high suspicion of malignancy underwent repeat biopsy and three of them were finally diagnosed with malignant pleural disease. There were three cases of minimal pneumothorax and no grave procedure-related complications.

Conclusion

Cone-beam computed tomography-guided biopsy is an accurate and safe diagnostic technique for suspected malignant pleural lesion with reasonable radiation exposure and procedure time.

Cone beam computed tomography virtual navigation-guided transthoracic biopsy of small (≤ 1 cm) pulmonary nodules: impact of nodule visibility during real-time fluoroscopy

OBJECTIVE

To evaluate the impact of nodule visibility during real-time fluoroscopy and other biopsy-related variables on the diagnostic accuracy and complication rates of cone beam CT (CBCT) virtual navigation (VN)-guided percutaneous transthoracic needle biopsies (PTNBs) of small (≤1 cm) pulmonary nodules.

METHODS

Patients (99 males and 114 females; age, 62.1 ± 11.1 years) who underwent CBCT VN-guided biopsies for lung nodules ≤ 1 cm were retrospectively reviewed. The visibility of target nodules was assessed on the captured fluoroscopy images. Diagnostic accuracies were calculated and logistic regression analyses were performed to determine independent influencing factors for the correct diagnosis and complications (pneumothoraxes and hemoptysis) in CBCT VN-guided PTNBs, respectively.

RESULTS

Among 213 nodules, 63 (29.6%) were invisible on real-time fluoroscopy during VN. The diagnostic accuracy of CBCT VN-guided PTNBs for the invisible nodules was 76.7%, while for the visible nodules was 89.1% (p = 0.042). In the logistic regression analysis, the visibility of a target nodule (odds ratio = 2.49, p = 0.047) was the only independent influencing factor for a correct diagnosis. As regards complication rates, nodule visibility was not a significant factor for the occurrence of a pneumothorax or hemoptysis.

CONCLUSION

Although nodule visibility on real-time fluoroscopy was an affecting factor for the correct diagnosis, CBCT VN-guided PTNB was feasible for the invisible nodules with diagnostic accuracy of 76.7%. Advance in knowledge: CBCT VN-guided PTNB can be tried safely for the subcentimeter-sized pulmonary nodules regardless of their fluoroscopic visibility.

Clinical role of guidance by C-arm CT for 125I brachytherapy on pulmonary tumors

PURPOSE

To evaluate the clinical value of C-arm CT (CACT)-guided interstitial iodine-125 (¹²⁵I) brachytherapy on pulmonary tumors.

MATERIALS AND METHODS

30 patients with 40 solid pulmonary tumors were enrolled to undergo CACT-guided interstitial ¹²⁵I brachytherapy between November 2011 and November 2014. The needle path was planned on a CACT virtual navigation and real-time fluoroscopy system. Technical success, puncture score, procedure time, local control rate (LCR), radiation exposure, complications and survival were investigated.

RESULTS

The technical success of interstitial ¹²⁵I brachytherapy under CACT guidance was 40/40 (100%). The performance score was 4.7 ± 0.5 with a mean total procedure time of 17.7 ± 5.6 min. LCR in small (≤2.0 cm), intermediate (2.1-4.9 cm) and large (≥5.0 cm) pulmonary tumors was 100, 89.5 and 72.7% at the 4-month follow-up, respectively. The mean effective dose was 10.1 ± 2.8 mSv. Major complications occurred in four patients (13.3%). The mean survival time was 28.4 ± 2.3 months.

CONCLUSION

CACT can provide virtual navigation and real-time fluoroscopy synchronously for interstitial ¹²⁵I seed implantation on pulmonary tumors.

C-arm cone-beam computed tomography with stereotactic needle guidance for percutaneous adrenal biopsy: initial experience

Background Metastasis to the adrenal glands is frequent in patients with various cancers and adrenal gland biopsy is routinely performed using ultrasound or computed tomographic (CT) guidance. However, this method is technically challenging, especially in the case of small masses. Purpose To determine whether the new real-time stereotactic needle guidance technique C-arm cone-beam CT (CBCT) allows safe and accurate biopsy of adrenal gland masses, especially those in hard-to-reach anatomical locations. Material and Methods CBCT guidance was used to perform 60 stereotactic biopsy procedures of lesions that were inaccessible with ultrasound or CT guidance. The needle path was carefully planned and calculated on the CBCT virtual navigation guidance system, which acquired 3D CT-like cross-sectional images. The adrenal biopsy procedures were performed with fluoroscopic feedback. Technical success rate, sensitivity, specificity, accuracy, and complications were investigated. Results The technical success rate of adrenal biopsy under CBCT virtual navigation was 100%, with a mean total procedure time of 14.6 ± 3.6 min. Of the 60 lesions, 46 were malignant, 11 were benign, and three were non-diagnostic. The three non-diagnostic lesions proved to be malignant. Thus, the sensitivity, specificity, and accuracy were 93.8%, 100%, and 95.0%, respectively. Minor bleeding occurred in two (3.3%) cases. Conclusion CBCT guidance allows safe and accurate biopsy of adrenal gland masses and may be especially useful for hard-to-reach anatomical locations.

A Systematic Review and Meta-Analysis of C-Arm Cone-Beam CT-Guided Percutaneous Transthoracic Needle Biopsy of Lung Nodules

Background

A systematic review and meta-analysis of all available publications was performed to evaluate the diagnostic accuracy of percutaneous transthoracic needle biopsy (PTNB) using a C-Arm Cone-Beam CT (CBCT) system in patients with lung nodules.

Material/Methods

Thedatabases of PUBMED, OVID, EBSCO, EMBASE, and China National Knowledge Infrastructure (CNKI) were systematically searched for relevant original articles on the diagnostic accuracy of CBCT-guided PTNB for the diagnosis of nodules in the lungs. Diagnostic indices including sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and diagnostic score (DS) were calculated. Moreover,summary receiver operating characteristic curves (SROC) were constructed with Stata (version 13.0), Rev Man (version 5.3), and Meta-disc (version 1.4) software. Other clinical indices such as incidence of complications were also recorded.

Results

Eight studies met the inclusion and exclusion criteria for the meta-analysis. The pooled sensitivity, specificity, PLR, NLR, DOR, DS, and SROC with 95% confidence intervals were 0.96 (0.93–0.98), 1.00 (0.91–1.00), 711.15 (9.48–53325.89), 0.04 (0.02–0.07), 16585.29 (284.88–9.7e+05), 9.72 (5.65–13.78), and 0.99 (0.97–0.99), respectively. The incidence of pneumothorax and hemorrhage was 10–29.27% and 1.22–47.25%, respectively.

Conclusions

CBCT-guided PTNB has an acceptable rate of complications and is associated with a reasonable radiation exposure. Moreover, it is a highly accurate and safe technique for the diagnosis of lung nodules and can be recommended to be used in routine clinical practice.

CT-guided transthoracic biopsy: histopathologic results and complication rates

PURPOSE

We aimed to investigate the effectiveness and complications of transthoracic CT-guided biopsy techniques.

METHODS

A total of 94 CT-guided percutaneous transthoracic biopsy procedures performed in 85 patients were retrospectively evaluated. Core biopsy technique was used in 87 procedures and transthoracic fine-needle aspiration biopsy was used in seven procedures.

RESULTS

Diagnostic results were achieved in 79 of 94 biopsy procedures. Pathology results were malignant in 54 patients, suspicious for malignancy in three patients, benign in five patients, and benign nonspecific in 17 patients. Specific diagnoses were obtained in 59 patients (62.8%) using core biopsy, but no specific diagnosis could be reached with transthoracic fine-needle aspiration biopsy. Complications included pneumothorax in 27 patients (28.7%) and parenchymal hemorrhage during and after the procedure in eight patients (8.5%).

CONCLUSIONS

CT-guided percutaneous transthoracic needle biopsy is a highly accurate procedure for histopathological diagnosis of thoracic masses. In addition, percutaneous transthoracic biopsy has an acceptably low complication rate and it reduces the need for more invasive surgical procedures.

The Impact of Iterative Reconstruction in Low-Dose Computed Tomography on the Evaluation of Diffuse Interstitial Lung Disease

OBJECTIVE

To evaluate the impact of iterative reconstruction (IR) on the assessment of diffuse interstitial lung disease (DILD) using CT.

MATERIALS AND METHODS

An American College of Radiology (ACR) phantom (module 4 to assess spatial resolution) was scanned with 10-100 effective mAs at 120 kVp. The images were reconstructed using filtered back projection (FBP), adaptive statistical iterative reconstruction (ASIR), with blending ratios of 0%, 30%, 70% and 100%, and model-based iterative reconstruction (MBIR), and their spatial resolution was objectively assessed by the line pair structure method. The patient study was based on retrospective interpretation of prospectively acquired data, and it was approved by the institutional review board. Chest CT scans of 23 patients (mean age 64 years) were performed at 120 kVp using 1) standard dose protocol applying 142-275 mA with dose modulation (high-resolution computed tomography [HRCT]) and 2) low-dose protocol applying 20 mA (low dose CT, LDCT). HRCT images were reconstructed with FBP, and LDCT images were reconstructed using FBP, ASIR, and MBIR. Matching images were randomized and independently reviewed by chest radiologists. Subjective assessment of disease presence and radiological diagnosis was made on a 10-point scale. In addition, semi-quantitative results were compared for the extent of abnormalities estimated to the nearest 5% of parenchymal involvement.

RESULTS

In the phantom study, ASIR was comparable to FBP in terms of spatial resolution. However, for MBIR, the spatial resolution was greatly decreased under 10 mA. In the patient study, the detection of the presence of disease was not significantly different. The values for area under the curve for detection of DILD by HRCT, FBP, ASIR, and MBIR were as follows: 0.978, 0.979, 0.972, and 0.963. LDCT images reconstructed with FBP, ASIR, and MBIR tended to underestimate reticular or honeycombing opacities (-2.8%, -4.1%, and -5.3%, respectively) and overestimate ground glass opacities (+4.6%, +8.9%, and +8.5%, respectively) compared to the HRCT images. However, the reconstruction methods did not differ with respect to radiologic diagnosis.

CONCLUSION

The diagnostic performance of LDCT with MBIR was similar to that of HRCT in typical DILD cases. However, caution should be exercised when comparing disease extent, especially in follow-up studies with IR.

3D CACT-assisted Radiofrequency Ablation Following Transarterial Chemoembolization for Hepatocellular Carcinoma: Early Experience

BACKGROUND

To explored the value of 3D C-arm CT (CACT) guidance system in performing radiofrequency ablation (RFA) following transarterial chemoembolizationon (TACE) for hepatocellular carcinomas.

MATERIALS AND METHODS

RFA of hepatocellular carcinomas (HCC) were performed on 15 patients (21 lesions) with the assistance of CACT guidance system. Technical success, procedure time, complications and patient radiation exposure were investigated. The puncture performance level was evaluated on a five-point scale (5-1: excellent- poor). Complete ablation rate was evaluated after two months follow-up using enhanced CT scans.

RESULTS

The technical success rate of RFA procedure under CACT navigation system was 100%. Mean total procedure time was 24.24 ± 6.53 min, resulting in a mean effective exposure dose of 15.4 ± 5.1 mSv. The mean puncture performance level rated for CACT guided RFA procedure was 4.87 ± 0.35. Complete ablation (CA) was achieved in 20 (95.2%) of the treated 21 tumors after the first RFA session. None of patients developed intra-procedural complications.

CONCLUSIONS

3D CACT guidance system enables reliable and efficient needle positioning by providing real-time intraoperative guidance for performing RFA on HCCs.

CT-guided percutaneous transthoracic needle biopsy for paramediastinal and nonparamediastinal lung lesions: Diagnostic yield and complications in 1484 patients

Computed tomography-guided percutaneous transthoracic needle biopsy (PTNB) is used for identifying paramediastinal lung lesions that cannot be diagnosed by bronchoscopy, but the diagnostic performance and complication rate are unreported.This retrospective study was approved by the institutional review board committee. A total of 1484 patients who underwent PTNB between April 2012 and April 2015 were enrolled. The cohort was divided into a paramediastinal (n = 195) and a nonparamediastinal group (n = 1289) based on lesion location. Diagnostic yield for malignancy and complication rates were analyzed in both groups. Univariate and multivariate logistic regression analysis was used to determine independent risk factors for hemoptysis complication in the paramediastinal group.Percutaneous transthoracic needle biopsy showed 95.6% (109/114) sensitivity and 100% (77/77) specificity for the diagnosis of lesions in the paramediastinal group, with similar accuracy (95.4%, 186/195) to that in the nonparamediastinal group (94.7%, 1221/1289; P = 0.699). Compared with PTNB for nonparamediastinal lesions, PTNB for paramediastinal lesions demonstrated a comparable pneumothorax rate (8.21% vs 8.69%; P = 0.823) and hemothorax rate (2.56% vs 1.47%; P = 0.261), and a higher hemoptysis rate (28.2% vs 19.4%; P = 0.005). Among 6 defined paramediastinal regions, the overall complication rate was the highest in the posterior region (42.4%) and the lowest in the paraventricular region (13.6%). Multivariate analysis revealed that lesion size of 2 to 3 cm (odds ratio [OR] 3.22), intrapulmonary length of needle path >2 cm (OR 8.85), and proximal to pulmonary artery (OR 10.33) were independent risk factors for hemoptysis in the paramediastinal group.Computed tomography-guided PTNB can diagnose paramediastinal lesions with high yield and acceptable complication rates. Given higher rate of hemoptysis in PTNB for paramediastinal lesions, more attention should be paid in cases with high risks.

Flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy of small (≤3 cm) pulmonary lesions

BACKGROUND

Nowadays, flat detector (FD) equipped angiographic C-arm computed tomography (CACT) systems can be used to acquire CT-like cross-sectional images directly within the interventional suite. The CACT systems offer real time visualization of transthoracic needle biopsy (TNB) procedure and more flexibility in the orientation of the detector system around the patient compared to traditional CT systems.

PURPOSE

To evaluate the value of a flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy (PTNB) for small (≤3 cm) pulmonary lesions in clinical practice.

MATERIAL AND METHODS

A total of 60 patients with solid lung lesions were retrospectively enrolled to undergo PTNB procedures. The mean diameter of lesions was 2.3 ± 0.6 cm (range, 0.6-3 cm). The needle path was carefully planned and calculated on the C-arm CT system, which acquired three-dimensional CT-like cross-sectional images. The PTNB procedures were performed under needle guidance with fluoroscopic feedbacks.

RESULTS

Histopathologic tissue was successfully obtained from 59 patients with a puncture success rate of 98.3% (59/60). The diagnostic accuracy rate was found to be 91.5% (54/59). There were only two cases of pneumothorax (3.3%) requiring therapy. The rates of pneumothorax and hemoptysis were low (15.0% [9/60] and 8.3% [5/60], respectively). The overall procedural time was in the range of 12-18 min, resulting in a mean exposure dose of 224.4 ± 4.8 mGy.

CONCLUSION

Our study shows that C-arm CT-based needle guidance enables reliable and efficient needle positioning and progression by providing real-time intraoperative guidance for small (≤3 cm) pulmonary lesions in clinical practice.

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.

C-arm CT-guided renal arterial embolisation followed by radiofrequency ablation for treatment of patients with unresectable renal cell carcinoma

AIM

To explore the value of using flat detector (FD) equipped angiographic C-arm CT (CACT) systems in treating unresectable renal cell carcinoma (RCC) by selective renal arterial embolisation (RAE) followed by radiofrequency ablation (RFA) (RAE-RFA).

MATERIALS AND METHODS

A total of 28 patients who were not candidates for surgery were enrolled. The average size of tumours was 6.7±2.2 cm (range 4.1-9.6 cm). Twenty-eight tumours were treated with CACT-guided RFA, 5-7 days after CACT-guided RAE.

RESULTS

CACT-guided RAE-RFA was technically successful in all patients. Tumour enhancement disappeared after a single RAE-RFA session in 20 patients, after two RAE-RFA sessions in four patients and after three RAE-RFA sessions in the other four patients. One patient died of lung metastasis and haematuria 13 months after RAE-RFA, and another patient died of pulmonary heart disease 23 months after repeat RAE-RFA. In the 26 living patients, tumours remained controlled during a mean follow-up period of 27 months and showed significant reduction in tumour size (6.7±2.2 cm to 3.9±1.7 cm, p<0.01). There were no significant changes in creatinine levels or urea nitrogen concentrations before and after the last RAE-RFA (p>0.05). There were no serious complications during and after the procedure.

CONCLUSION

CACT-guided RAE followed by RFA appears to be a safe and effective technique for treating patients with inoperable RCC.

C-Arm Cone-Beam CT Virtual Navigation-Guided Percutaneous Mediastinal Mass Biopsy: Diagnostic Accuracy and Complications

OBJECTIVES

To assess the usefulness of C-arm cone-beam computed tomography (CBCT) virtual navigation-guided percutaneous mediastinal mass biopsy in terms of diagnostic accuracy and complication rates.

METHODS

Seventy-eight CBCT virtual navigation-guided percutaneous mediastinal mass biopsies were performed in 75 patients (M:F, 38:37; mean age, 48.55 ± 18.76 years). The procedural details, diagnostic sensitivity, specificity, accuracy and complication rate were investigated.

RESULTS

Mean lesion size was 6.80 ± 3.08 cm, skin-to-target distance was 3.67 ± 1.80 cm, core needle biopsy rate was 96.2 % (75/78), needle indwelling time was 9.29 ± 4.34 min, total procedure time was 13.26 ± 5.29 min, number of biopsy specimens obtained was 3.13 ± 1.02, number of CBCTs performed was 3.03 ± 0.68, rate of lesion border discrimination from abutting mediastinal structures on CBCT was 26.9 % (21/78), technical success rate was 100 % (78/78), estimated effective dose was 5.33 ± 4.99 mSv, and the dose area product was 12,723.68 ± 10,665.74 mGy⋅cm(2). Among the 78 biopsies, 69 were malignant, 7 were benign and 2 were indeterminate. Diagnostic sensitivity, specificity and accuracy for the diagnosis of malignancies were 97.1 % (67/69), 100 % (7/7) and 97.4 % (74/76), respectively, with a complication rate of 3.85 % (3/78), all of which were small pneumothoraces.

CONCLUSIONS

CBCT virtual navigation-guided biopsy is a highly accurate and safe procedure for the evaluation of mediastinal lesions.

KEY POINTS

• CBCT virtual navigation-guided percutaneous mediastinal biopsy is highly accurate • CBCT virtual navigation-guided percutaneous mediastinal biopsy is a safe procedure • Mediastinal vascular injury can be avoided under CBCT virtual navigation guidance.