Japanese Journal of Clinical Oncology 30:259-262 (2000)
© 2000 Foundation for Promotion of Cancer Research
Computed Tomographic Fluoroscopy-guided Transthoracic Needle Biopsy for Diagnosis of Pulmonary Nodules
1Department of Thoracic Diseases, Tochigi Cancer Center, Togichi and 2First Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Background: The purpose of this study was to evaluate the usefulness of computed tomographic (CT) fluoroscopy-guided transthoracic needle biopsy (TTNB) with an 18-gauge automatic biopsy gun for the diagnosis of pulmonary nodules.
Methods: Between March 1996 and January 1998, 50 patients in whom pulmonary lesions could not be diagnosed cytopathologically with fiberoptic bronchoscopy or were not clearly visualized with fluoroscopy underwent CT fluoroscopy-guided TTNB.
Results: Final pathological diagnoses were 23 lung carcinomas, five pulmonary metastases and 22 benign lesions. Sufficient tissue for analysis was obtained from 48 of the 50 lesions (96%). The overall diagnostic yield of CT fluoroscopy-guided TTNB was 90%. The sensitivity, specificity and accuracy for malignancy were 89%, 100% and 94%, respectively. In 20 of the 22 cases (91%) of benign lesions, histological analysis yielded correct and specific diagnoses. Complications occurred in 22 of the 50 cases (44%). The most common complication was pneumothorax, which occurred in 21 of the 50 cases (42%). Chest tube insertion was required in 6 (12%).
Conclusions: Although CT fluoroscopy could not decrease the complication rate, CT fluoroscopy-guided TTNB with an automatic biopsy gun appears to be a promising technique for diagnosing pulmonary lesions, particularly benign lesions.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Computed tomography (CT) has improved the ability to detect and perform transthoracic needle biopsy (TTNB) of small pulmonary lesions, particularly lesions that were not previously visible or approachable with fluoroscopically guided biopsy (1). However, conventional CT systems do not allow real-time visualization during interventional procedures as do ultrasonography (US) and fluoroscopy. Recently, a CT fluoroscopy system was developed by Katada et al. (2). This system provides real-time reconstruction and display of CT images during interventional procedures.
The automatic biopsy gun has become popular for biopsy of various organs (3). Advantages of obtaining a core specimen include greater accuracy in diagnosing non-carcinomatous lesions, the ability to diagnose carcinomas without a trained cytopathologist and greater accuracy in defining cell types in patients with carcinoma (4). To our knowledge, no reports on CT fluoroscopy-guided needle biopsy with an automated biopsy gun have been published. The present study evaluated the diagnostic accuracy and complications of CT fluoroscopy-guided TTNB of pulmonary lesions performed with an automatic biopsy gun.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Between March 1996 and January 1998, 50 patients underwent CT fluoroscopy-guided TTNB to diagnose pulmonary nodules at our hospital. The study population included 30 men and 20 women with a mean age of 61 years (range, 17–82 years). This method was performed when lesions could not be diagnosed cytopathologically with fiber-optic bronchoscopy (38 cases) or were not clearly visualized with fluoroscopy (12 cases). The average lesion size was 23 mm (range, 8–60 mm) and the average depth of lesions from the skin surface was 51 mm (range, 18–106 mm).
Examinations were performed with the CT fluoroscopy unit (X vigor scanner; Toshiba, Tokyo, Japan). Preliminary scans were obtained without the use of a contrast medium to plan the biopsy approach with the following parameters: beam width, 5 mm; tube voltage, 120 kV; and tube current, 200 mA. At the time of biopsy, these parameters were 120 kV and 30 mA. Biopsies were performed with the patient in prone, supine or lateral decubitus positions, depending on the proximity of the lesion to the chest wall. After the lesion had been localized with CT, the depth of the lesion from the skin surface was measured. Under the local anesthesia, biopsy needles were inserted close to the pleura at inspiration, after which the patient exhaled slowly until the maximum diameter of the lesions was shown on the monitor and then the puncture was performed. Biopsies were mainly performed by four inexperienced pulmonologists under the supervision of two experienced pulmonologists. Biopsies were performed with an 18-gauge automatic biopsy gun with modified Tru-Cut needle (Monopty; Bard Radiology, Convington, GA). They were analyzed both histologically and cytologically. The quick-stain technique (on-site cytological evaluation for specimen adequacy) was not used.
Correct malignant results were confirmed by means of subsequent surgical pathological examination or a subsequent clinical course consistent with the given type of malignancy. Results were considered correct for benign disease if a specific benign pathological diagnosis was rendered and was confirmed with subsequent surgical pathological examination or if it was followed clinically by resolution of the lesion or showed no change in size for more than 24 months.
All patients were hospitalized. After patients had undergone biopsy, they rested in bed and underwent chest radiography 2 h later and the morning after biopsy. If pneumothorax was not present, the patient was discharged the morning after biopsy. Patients with a pneumothorax >30% or with respiratory symptoms were treated with placement of a 12-F chest tube (Argyle; Sherwood, Tokyo, Japan).
We used Fischer’s exact test to assess the significance of our findings, with p values <0.05 considered statistically significant.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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In 48 of the 50 cases (96%), adequate specimens of the lesion were obtained for histological evaluation, although specimens could not be obtained in two cases because of pneumothorax and pulmonary hemorrhage during examination. In 39 of the 50 cases (78%), a needle could be placed within the mass at the first try. The mean number of needle passes per biopsy was 1.3 (range, 1–3). No patients underwent repeat TTNB.
It was difficult to obtain tissue for cytopathological analysis of the lesions by a conventional CT approach when the lesions overlapped the scapula and the ribs and were contiguous to them. However, biopsy needles using CT fluoroscopy could be inserted into the lesions from any direction. This proved to be a good way to obtain tissue for cytopathological analysis of the above-mentioned lesions (Figure 1).
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Final pathological diagnoses and results of CT fluoroscopy-guided TTNB are shown in Table 1. Of 50 pulmonary nodules, 28 (56%) were malignant and 22 (44%) were benign. A definitive diagnosis was made for 45 of the 50 cases (90%). For malignancy, the sensitivity, specificity and accuracy of CT fluoroscopy-guided TTNB were 89%, 100% and 94% with cytological and histological analysis, respectively. No false-positive results were obtained. Twenty-one of the 23 cases of lung cancer were diagnosed by CT fluoroscopy-guided TTNB (Figure 2). Furthermore, in 16 cases diagnosed with this method and confirmed by surgery, there were no discrepancies in cell type identification. In 20 of the 22 cases (91%) of benign lesions, histological analysis yielded correct and specific diagnoses, while the cytological results indicated benign lesions but were non-specific. In five cases including two cases in which the needle missed the lesions, diagnoses by this method differed from the final diagnoses. The final diagnoses of the two cases in which the needle missed the lesion were lung cancer and pulmonary metastasis; the final diagnoses in the other three cases were lung cancer, hamartoma and atypical adenomatous hyperplasia. In one case of lung cancer for which the diagnosis by CT fluoroscopy-guided TTNB was incorrect, most of the lesion was occupied by mucous.
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The diagnostic accuracy did not differ with the lesion size and with the depth of lesions from the chest wall. An accurate diagnosis was made for 24 (89%) of the 27 pulmonary nodules <20 mm and for 21 (91%) of the 23 pulmonary nodules
20 mm, a not statistically significant difference (p = 0.56). An accurate diagnosis was made for 36 (92%) of the 39 nodules shallower than 60 mm and for nine (82%) of the 11 nodules deeper than or equal to 60 mm, a not statistically significant difference (p = 0.51). Complications occurred in 22 of the 50 cases (44%). The most common complication was pneumothorax, which occurred in 21 cases (42%). Chest tube insertion was required in six (12%) of these cases. Another 15 cases (30%) were asymptomatic and were only observed at bed rest. Intrapulmonary hemorrhage and hemoptysis occurred in two cases (4%) and one case (2%), respectively. No patient required treatment for intrapulmonary hemorrhage or hemoptysis. No air emboli were detected after biopsy. Chest wall implantation of tumor cells had not yet occurred.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Several authors have reported that accuracy rates of conventional CT systems-guided TTNB for malignancy range from 43 to 100% (1,5–10). The diagnostic accuracy of the present study was 94%, which was achieved by four inexperienced pulmonologists without a cytopathologist present during the procedures, and is comparable to those of previous conventional CT studies. Although reported needle passes with conventional CT systems-guided TTNB average 3–4 (1), in our series the mean number of needle passes per biopsy was only 1.3 (range, 1–3), which was possible because the CT fluoroscopy system provided real-time reconstruction and display of CT images.
Furthermore, even small lesions could be diagnosed histologically with the 18-gauge automatic biopsy gun owing to CT fluoroscopy. The advantages of obtaining a core specimen include greater accuracy in allowing a specific diagnosis for benign lesions, the ability to diagnose carcinomas without a trained cytopathologist and greater accuracy in defining cell types of carcinomas (3,4,7). The reported accuracy rates of conventional CT systems-guided TTNB for evaluating benign lesions and cell types of carcinomas range from 16 to 68% and 60 to 94%, respectively(1,5,6,10–12). In our study, the rate of specific diagnosis for benign tumors (91%) is considerably higher than that reported in series of conventional CT systems-guided TTNB, although surgical resection was not always performed. We believe the definitive diagnosis of benign lesions can obviate unnecessary thoracotomies. Furthermore, there were no discrepancies in cell type identification. Defining the cell type of carcinoma can aid in determining the type of surgery because primary lung cancer and pulmonary metastasis can be differentiated.
The reported accuracy rates of detection of cancer with conventional CT systems-guided TTNB for nodules <20 mm in diameter range from 68 to 95% (1,8,13). Although Westcott et al. (13) have shown that the diagnostic accuracy for small nodules is comparable to that for large nodules, Li et al. (8) have reported that diagnostic accuracy for small pulmonary nodules is significantly less than that for large nodules. In our study, a decrease in diagnostic accuracy according to the size of lesions was not observed. In addition, although a previous study (14) reported that the depth of lesions affects diagnostic accuracy for small nodules, in our study a decrease in the diagnostic accuracy with depth was not observed. We speculate that the diagnostic accuracy was not affected by the size and depth of lesions owing to the real-time monitoring by CT fluoroscopy.
Previously reported rates of pneumothorax with conventional CT systems-guided TTNB range from 8 to 61% (3,13,15). The pneumothorax rate in our study is equal to or slightly higher than that of previous studies. Factors affecting the occurrence of pneumothorax include obstructive pulmonary disease, lesion size, lesion depth from the chest wall, the number of needle passes and the needle size (1,5,16,17). The high rate of pneumothorax may relate to the use of an 18-gauge automatic biopsy gun. Despite the high rate of pneumothorax, we believe that the high yield for benign disease avoids further invasive diagnostic procedures and justifies the risk. Reported rates of bleeding range from 1 to 11% (1,3,13). In our study, intrapulmonary hemorrhage and hemoptysis occurred in 4 and 2% of patients, respectively.
Our study has a limitation. Radiation exposure to the patient and the operator, especially to the operator’s hands, remains a major concern with this method. We have not considered the effects of radiation exposure and did not use a needle holder in this study. However, Kato et al. (18) have recommended the use of a needle holder because the dose to the operator’s hands was thereby reduced. Radiation exposure should be investigated carefully in the future.
In conclusion, CT fluoroscopy-guided TTNB with an automatic biopsy gun appears to be a promising technique for diagnosing pulmonary lesions, particularly benign lesions that can not be diagnosed cytopathologically with fiber-optic bronchoscopy or pulmonary lesions that are not clearly visualized with fluoroscopy. To avoid radiation exposure to the operator, we recommend the use of this system for small lesions or lesions located near the diaphragm or large arteries where it is difficult to obtain tissue with conventional CT systems-guided TTNB.
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FOOTNOTES |
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+ For reprints and all correspondence: Takashi Hirose, First Department of Internal Medicine, Showa University School of Medicine, 1–5–8 Hatanodai, Shinagawa, Tokyo 142-8666, JapanAbbreviations: CT, computed tomography; TTNB, transthoracic needle biopsy; US, ultrasonography
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Received January 5, 2000; accepted March 22, 2000.
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