Ultrasound-guided transthoracic co-axial biopsy of thoracic mass lesions

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.

Effectiveness and Safety of Transthoracic Ultrasound in Guiding Percutaneous Needle Biopsy in the Lung and Comparison vs. CT Scan in Assessing Morphology of Subpleural Consolidations

(1) Background: The aim of this study was to conduct a prospective analysis on the diagnostic accuracy of transthoracic ultrasound-guided percutaneous needle biopsy (TUS-PNB) for the histological assessment of peripheral lung lesions and to assess the performance of transthoracic ultrasound (TUS) examination vs. chest CT (gold standard) in the differentiation between malignant and benign peripheral lung lesions. (2) Methods: A total of 961 consecutive patients with subpleural pulmonary lesions were enrolled. All the patients received a CT scan with contrast; 762 patients underwent TUS-PTNB for suspicion of malignancy, and the remaining 199 enrolled patients underwent only TUS examination as a part of routine follow-up for known non-malignant subpleural consolidations. (3) Results: Among the 762 TUS-guided biopsies, there were 627 (82.28%) malignant lesions, 82 (10.76%) benign lesions, and 53 (6.96%) indeterminate lesions. The overall diagnostic accuracy was 93.04%. The rates of pneumothorax not requiring chest-tube insertion and self-limited hemoptysis were 0.79 and 0.26%, respectively. Patients were divided into two groups based on the benign or malignant nature of the subpleural consolidations. On TUS, both malignant and benign lesions showed mostly irregular margins and a hypoechoic pattern, but no differences were assessed in terms of sonographic margins and pattern between the two groups. There was poor agreement between TUS and chest CT in assessing air bronchograms and necrotic areas. The only finding in the detection of which TUS showed superiority compared to chest-CT was pleural effusion. (4) Conclusions: TUS-PNB was confirmed to be an effective and safe diagnostic method for peripheral pulmonary consolidation, but their sonographic pattern did not allow to rule out a malignant nature. A pre-operative evaluation on CT images, combined with the possibility of performing additional immunohistochemical and cytological investigations and the experience of the medical staff, may improve the diagnostic yield of TUS-guided biopsies.

Ultrasound-Guided Percutaneous Core Needle Biopsy of Peripheral Pulmonary Nodules ≤ 2 cm: Diagnostic Performance, Safety and Influence Factors

Purpose

To evaluate diagnostic performance and safety of ultrasound-guided needle biopsy in the diagnosis of peripheral pulmonary nodules (PPLs) ≤ 2 cm, and the influence factors of sample adequacy and safety.

Materials and Methods

194 patients (99 men, 95 women; mean age, 56.2 ± 13.7 years) who received biopsy for PPLs ≤ 2 cm between January 2014 to January 2019 were included. Variables including patient demographics, lesion location, lesion size, presence of lesion necrosis, presence of emphysema on CT, patient position, biopsy needle size and number of needle passes were recorded. Univariate analysis and multivariate logistic regression analysis were performed to explore the influence factor of sample adequacy and safety.

Results

Biopsy specimens were adequate for diagnosis in 161/194 (83%) cases; the diagnostic accuracy was 81.4% (158/194). The overall complication rate was 8.8% (17/194), including pneumothorax, hemoptysis and pleural effusion, which occurred in 2.1% (4/194), 5.2% (10/194), and 1.5% (3/194) of patients, respectively. The incidence of pneumothorax in the 16-gauge-needle group were significantly higher than that of the 18-gauge-needle group (5.6% vs 0%, P=0.018). Adequate sampling of 16-gauge and 18-gauge needles were achieved in 90.3%(65/72) and 78.7%(96/122) cases, respectively. Multivariate logistic regression analysis revealed needle size (16-gauge vs 18-gauge) was an independent influence factors of sample adequacy (P=0.015, odds ratio=3.419). A receiver operating characteristic curve was plotted and the area under the curve was 0.774.

Conclusion

US-guided percutaneous needle biopsy is a feasible and safe technique for small PPLs ≤ 2 cm. Needle size is an independent influence factor of sample adequacy and post-procedure pneumothorax. Sixteen-gauge needle has the advantage of achieving adequate sample for pathological analysis, though the risk of pneumothorax should be alerted.

Ultrasound-Guided Biopsy of Pleural-Based Pulmonary Lesions by Injection of Contrast-Enhancing Drugs

In this study, a total of 58 patients with single subpleural pulmonary lesions (males: 36, females: 22, mean age: 63 ± 16.2 years) who underwent contrast-enhanced ultrasonography (CEUS) and had a definite diagnosis (benign lesions:25, malignant lesions:33) were enrolled. The number of biopsies, diagnostic accuracy rate, and the incidence of complications were recorded. The nodules were divided into two size subgroups: ≥5 cm (group 1), and <5 cm (group 2). The display rate of internal necrosis and change of pre-scheduled puncture paths were compared between subgroups. Also, the arrival times, intensity and uniformity of enhancement after the contrast agent injection, as well as the display rate of internal necrosis were recorded and compared between malignant and benign lesions. Finally, the average number of punctures was 2.9 ± 0.7 times. The total diagnosis rate was 98.3%. Local pneumothorax occurred in 2 patients. Hemoptysis occurred in 1 patient. No serious complications occurred. Internal necrosis was demonstrated in 20 of 58 lesions (34.5%). Sixteen of them had changed the planned puncture path due to the large necrosis area (80%, 16/20). For lesions in group 1, necrosis was found in 15 lesions and there was a statistically significant difference in the necrosis rate between the two subgroups (15/26 vs 5/32, p = 0.001). The change in the pre-scheduled puncture path occurred in 12 patients in group 1 while 4 patients in group 2 exhibited a change in the planned puncture path (p = 0.004). There was a statistically significant difference in the arrival times and intensity of enhancement between benign and malignant lesions (p < 0.05). In conclusion, CEUS guided biopsy is an effective, sensitive, and safe method for the diagnosis of pleural-based pulmonary lesions by facilitating a distinction between necrosis and active tissue. The current findings indicated that CEUS before a biopsy may be especially vital in lesions ≥5 cm.

Ultrasound-guided Lung Biopsy in the Hands of Respiratory Physicians: Diagnostic Yield and Complications in 215 Consecutive Patients in 3 Centers

BACKGROUND

The aim of the study was to determine the diagnostic yield and prevalence of complications of ultrasound-guided transthoracic needle aspiration biopsies (US-TTNAB) performed by respiratory physicians after implementation of the procedure in an everyday clinical setting at 3 different centers.

METHODS

Patients were included if they during the period from January 2012 to August 2014 had a registered US-TTNAB procedure code or if a US biopsy registration form had been filled out at either of the participating centers. Histology or cytology results were used as a reference test for diagnoses that could be made based on these results. Reference test for the remaining diagnoses was clinical follow-up. The diagnostic yield of US-TTNAB was defined as the proportion of patients in which the result of the US-TTNAB was consistent with the reference test.

RESULTS

A total of 215 patients in which a primary US-TTNAB had been performed were identified. The most common biopsy sites were lungs and pleurae with a total of 164 (76.3%) patients and 31 patients (14.4%), respectively. US-TTNAB diagnostic yield was 76.9% (95% CI, 70.3%-83.4%) for malignant diagnoses and 47.6% (95% CI, 31.9%-63.4%) for nonmalignant diagnoses. The most common complications of US-TTNAB were pneumothorax (2.5%; 95% CI, 0.03%-4.6%) and pain at the biopsy site (2%; 95% CI, 0.04%-3.9%). No fatalities related to US-TTNAB were observed.

CONCLUSION

US-TTNAB performed by respiratory physicians is a safe procedure with a low risk of complications and the diagnostic yield to establish a malignant diagnosis is acceptable.

Value of Contrast-Enhanced Ultrasound in Guidance of Percutaneous Biopsy in Peripheral Pulmonary Lesions

Objectives. To investigate the value of contrast-enhanced ultrasound (CEUS) in guidance of percutaneous biopsy in peripheral pulmonary lesions. Methods. This study focused on 53 patients (male: 38, female: 15, and mean age: 55.7 years ± 10.7) with 53 single peripheral pulmonary lesions. Before core needle (16-gauge) percutaneous biopsy, CEUS were performed in all lesions, with injection of 2.4 mL SonoVue (Bracco, Italy). The contrast-enhancement pattern, display rate of internal necrosis (nonenhanced) and active (obviously enhanced) areas, biopsy success rate, and pathological diagnosis rate were recorded. Results. All the peripheral pulmonary lesions were proved pathologically as benign lesions (n = 7), primary malignancies (n = 41), or metastasis (n = 5). Forty (86.9%) malignant lesions and 4 (57.1%) benign lesions showed internal necrosis areas on CEUS. The detection rate and average size of internal necrosis areas had been significantly improved compared to conventional ultrasound (P < 0.05). After CEUS, core needle percutaneous biopsies were performed successfully in the active areas of all lesions. The sampling success rate and pathological diagnosis rate were 100% and 98.1%. Conclusions. CEUS before biopsy provided useful diagnostic information about peripheral pulmonary lesions. By depicting internal necrotic and active areas, it is a promising technique for guaranteeing the accuracy, success, and safety of core needle biopsy.

Lung transthoracic ultrasound elastography imaging and guided biopsies of subpleural cancer: a preliminary report

BACKGROUND

Despite the usefulness of elastography in assessing the stiffness/elasticity of tissues, and its proven diagnostic accuracy in thyroid, breast, and prostate cancers, among others, it is not yet applied in transthoracic ultrasound (TUS) scans to investigate lung nodules.

PURPOSE

To investigate the potential clinical utility of TUS elastography in diagnosing lung cancer proven by fine-needle aspiration biopsy (FNAB).

MATERIAL AND METHODS

TUS elastography was performed in 95 consecutive patients (71 men, 24 women; age, 62.84 ± 7.37 years) with lesions suspected of involving the chest wall or the pleura detected on chest X-ray or computed tomography (CT). Patients with pleural effusions were not enrolled, but were further evaluated by pleural fluid cytology. Patients were excluded from the study if a diagnosis had already been made based on sputum cytology and/or bronchoscopic histology (making TUS biopsy unnecessary) or if their lung lesions could not be visualized under standard US. Under FNAB, 34 consolidations were ascribed to pneumonia and 65 to cancer. Under TUS, tissue stiffness, detected using a convex multifrequency 2-8-mHz probe and a MyLab™Twice - ElaXto, was scored from 1 (greatest elasticity) to 5 (no elasticity). Subpleural solid masses (2-5 cm) were initially detected by TUS and subsequently assessed by FNAB.

RESULTS

Histological diagnoses were: small cell lung cancer (4/61), adenocarcinoma (29/61), squamous cell carcinoma (SCC) (12/61), large cell lung carcinoma (12/61), and lymphomas (4/61). Patients' age and mass sizes (3.06 ± 0.88 cm) were not significantly associated with any histological type. A significant lower elasticity of SCC (4.67 ± 0.492) was observed versus other types of lung cancer (P < 0.005), and versus pneumonia (2.35 ± 0.48).

CONCLUSION

Since only squamous cell lung carcinoma displays the feature of significantly reduced elasticity, and since no clear-cut diagnostic key is yet available, the clinical usefulness of TUS elastography is currently limited with a view to characterizing tumors. Nevertheless, it does enable good non-invasive imaging of lung nodules, providing information on their stiffness, and can improve the accuracy and yield of FNAB.

US-guided transthoracic biopsy of peripheral lung lesions: pleural contact length influences diagnostic yield

BACKGROUND

Transthoracic biopsy of peripheral lung lesions under ultrasonography (US) guidance is a useful diagnostic technique. However, factors affecting diagnostic yield of US-guided transthoracic biopsy of peripheral lung lesions are not well established.

PURPOSE

To determine the factors that influence diagnostic yield of US-guided transthoracic biopsy in peripheral lung lesions.

MATERIAL AND METHODS

A total of 100 consecutive patients underwent US-guided percutaneous cutting biopsy of peripheral lung lesions from October 2007 to March 2009. After seven unconfirmed cases were excluded, 97 procedures in 93 consecutive patients were included in this study. The accuracy of the lung biopsies was assessed by comparing the biopsy results with the final diagnoses. We divided the cases into a correct group (true-positive and true-negative) and an incorrect group (false-positive, false-negative, and non-diagnostic results) and analyzed the differences in the lesions, procedures, and patient variables between the two groups.

RESULTS

According to the final diagnoses, 56 cases (57.7%) were malignant and 41 cases (42.3%) were benign. An overall diagnostic accuracy of 91.8% was obtained. The median size of the lesions was 46.0 mm (interquartile range [IQR], 30.0-69.5 mm), and the median lesion-pleura contact arc length (LPCAL) was 31.0 mm (IQR, 18.0-51.0 mm). Multivariate logistic regression analysis showed that only LPCAL (odds ratio, 1.16; 95% CI, 1.04-1.30) was a significant predictor of a correct diagnosis. When we divided the lesions into those with LPCAL values >30 mm and LPCAL values ≤30 mm, the sensitivity (96.6% vs. 74.1%; P = 0.02) and the accuracy (98% vs. 85.4%; P = 0.03) were significantly higher in the group with larger LPCAL.

CONCLUSION

In US-guided transthoracic biopsy of peripheral lung lesions, the LPCAL of the lesions is an important factor for a correct diagnosis.

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

BACKGROUND

Lung cancer leads cancer-related mortality in the world. The objective of the present systematic review was to compare fine-needle aspiration biopsy (fnab) with core-needle biopsy (cnb) for diagnostic characteristics and yields for diagnosing lung cancer in patients with lung lesions.

METHODS

The medline and embase databases (from January 1, 1990, to September 14, 2009), the Cochrane Library (to Issue 4, 2009), and selected guideline Web sites were searched for relevant articles.

RESULTS

For overall diagnostic characteristics (benign vs. malignant) of fnab and cnb, the ranges of sensitivity were 81.3%-90.8% and 85.7-97.4% respectively; of specificity, 75.4%-100.0% and 88.6%-100.0%; and of accuracy, 79.7%-91.8% and 89.0%-96.9%. For specific diagnostic characteristics of fnab and cnb (identifying the histologic subtype of malignancies or the specific benign diagnoses), the ranges of sensitivity were 56.3%-86.5% and 56.5-88.7% respectively; of specificity, 6.7%-57.1% and 52.4%-100.0%; and of accuracy, 40.4%-81.2% and 66.7%-93.2%. Compared with fnab, cnb did not result in a higher complication rate (pneumothorax or hemoptysis). No study has yet compared the diagnostic yields of fnab and of cnb for molecular predictive-marker studies in patients with lung lesions.

DISCUSSION AND CONCLUSIONS

The evidence is currently insufficient to support a difference between fnab and cnb in identifying lung malignancies in patients with lung lesions. Compared with fnab, cnb might have a higher specificity to diagnose specific benign lesions. Well-designed, good-quality studies comparing fnab with cnb for diagnostic characteristics and yields in diagnosing lung cancer should be encouraged.

US-guided percutaneous needle biopsy of anterior mediastinal masses in children

BACKGROUND

Anterior mediastinal masses in children are clinically challenging, requiring prompt histological diagnosis.

OBJECTIVE

The purpose of this study was to review the experience with US-guided percutaneous core needle biopsy (PCNB) of anterior mediastinal masses in children, particularly with respect to safety and diagnostic accuracy.

MATERIALS AND METHODS

We retrospectively reviewed the clinical presentation, imaging, sedation approach, procedural details and pathology results of US-guided PCNB of mediastinal masses that occurred during an 8-year period (2001-2008). Complications were graded and pathology was categorized into four groups based on adequacy and diagnostic yield.

RESULTS

32 US-guided PCNBs were performed on 32 children, mean age 12 years (range 18 months to 17 years), mean weight 48 kg (range 11.5 to 109 kg, median 49 kg). A coaxial US-guided technique was used, with a mean of 8.2 passes and a mean 7.6 cores obtained (range 2-15). There were no major complications. The biopsies were adequate in volume and quality of specimens in 29/32, and 25/32 were diagnostic. PCNB was diagnostic in all cases of non-Hodgkin disease.

CONCLUSIONS

Experience with anterior mediastinal masses suggests that US-guided PCNB can be considered a viable, safe and accurate method of reaching a diagnosis in the pediatric population.

Ultrasound-guided Chest Biopsies

Pulmonary nodules that are surrounded by aerated lung cannot be visualized with sonography. Therefore, percutaneous biopsy must be guided with computed tomography or fluoroscopy. Although this restriction only applies to central lung nodules, it has permeated referral patterns for other thoracic lesions and has retarded the growth of ultrasound-guided interventions. Nevertheless, sonography is an extremely flexible modality that can expeditiously guide many biopsy procedures in the thorax. Peripheral pulmonary nodules can be successfully biopsied with success rates exceeding 90% and complications rates of less than 5%. Orienting the probe parallel to the intercostal space facilitates biopsies of peripheral pulmonary nodules. Anterior mediastinal masses that extend to the parasternal region are often easily approachable provided the internal mammary vessels, costal cartilage, and deep great vessels are identified and avoided. Superior mediastinal masses can be sampled from a suprasternal or supraclavicular approach. Phased array probes or tightly curved arrays may provide improved access for biopsies in this location. Posterior mediastinal masses are more difficult to biopsy with ultrasound guidance because of the overlying paraspinal muscles. However, when posterior mediastinal masses extend into the posterior medial pleural region, they can be biopsied with ultrasound guidance. Because many lung cancers metastasize to the supraclavicular nodes, it is important to evaluate the supraclavicular region when determining the best approach to obtain a tissue diagnosis. When abnormal supraclavicular nodes are present, they often are the easiest and safest lesions to biopsy.

Computed tomography-guided transthoracic fine-needle aspiration in diagnosis of lung cancer: A comparison of single-pass needle and multiple-pass coaxial needle systems and the value of immediate cytological assessment

OBJECTIVES

The aim of the present study was to compare single-pass needle and multiple-pass coaxial needle systems and to evaluate the value of immediate cytological assessment during the procedure in the diagnosis of lung cancer with CT-guided transthoracic fine-needle aspiration.

METHODOLOGY

One hundred and forty-three consecutive patients who underwent CT-guided transthoracic fine-needle aspiration were divided into three groups. In the first group (group A, 48 patients), a single-pass needle was used for aspiration, but immediate cytological examination was not performed. In the second group (group B, 48 patients), a single-pass needle was used for aspiration and a pathologist immediately assessed the adequacy of the sample obtained. In the third group (group C, 47 patients), a multiple-pass coaxial needle was used for aspiration and a pathologist immediately assessed the adequacy of the sample obtained.

RESULTS

The mean number of fine-needle aspirations was 1.25 in group A, 1.39 in group B and 1.34 in group C (group A vs group B, P = 0.08). The diagnostic accuracy was 83.3, 97.9 and 100.0%, respectively (group A vs group B, P = 0.03; group B vs group C, P > 0.05). Although immediate cytological assessment resulted in adequate samples being obtained from all patients in groups B and C, adequate samples were obtained in 41 of 48 patients (85.4%) in group A (P = 0.004). There was no statistically significant difference among the groups with respect to the rate of pneumothorax.

CONCLUSIONS

A single-pass needle technique in transthoracic fine-needle aspiration is preferred because there is no significant difference between single-pass needle and multiple-pass coaxial needle systems with respect to the diagnostic accuracy and the complication rate and, in addition, the single-pass needle has a lower cost. The results of the present study suggest that immediate cytological assessment during the procedure reduces an inadequate sampling rate, thus increasing the diagnostic accuracy of the procedure.