Computed tomographic fluoroscopy-guided transthoracic needle biopsy for diagnosis of pulmonary nodules

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

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

Post-CT-guided lung biopsy optimisation of the observation period by identifying patients at risk of delayed pneumothorax

INTRODUCTION

Identify the risk factors for delayed pneumothorax after lung biopsy.

METHODS

A retrospective study of 355 CT-guided lung biopsies was performed at Fiona Stanley Hospital, Western Australia over 42 months. A comprehensive range of patient, lesion and procedural variables were recorded. All post-procedural complications including time, size of pneumothorax and post-biopsy radiographs were reviewed. Lasso logistic regression model was utilised to determine factors predicting patient complications.

RESULTS

A total of 167 patients (47%) developed a pneumothorax, in which 34% were significant, requiring longer observation or drain insertion. The majority of pneumothoraces occurred within the first hour (86%), with 90% detected at the time of the procedure. Then, 12% were detected more than 3 h post-procedure, of which 8 patients (5%) had a significant delayed pneumothorax. Factors increasing the likelihood of significant pneumothorax include the length of lung traversed, smaller nodule size, surrounding emphysema, increased age and lateral patient position with the lesion in the non-dependent aspect. Increasing patient age, longer length of lung traversed and smaller nodule diameter increase the risk of delayed onset of pneumothorax (more than 3 h).

CONCLUSION

The results of this study align with other studies indicating it is safe to discharge stable patients within an hour post-lung biopsy. However, specific risk factors, including age, small lesion size and deep lesions, may identify patients who could benefit from a longer observation period.

Safely Shortening the Observation Time After CT-Guided Lung Procedures

OBJECTIVE

To determine safety of shortened observation time without follow-up chest x-ray (CXR) after CT-guided transthoracic procedures (lung biopsy or fiducial placement) in patients without immediate postprocedural pneumothorax (PTX).

METHODS

Consecutive patients that underwent CT-guided procedures between January 5, 2015, and June 19, 2017, were included in this retrospective institutional review board-approved HIPAA-compliant study. Data regarding postprocedural course, complications, and clinical follow-up of the patients were obtained through a review of electronic medical records. Descriptive statistics were used.

RESULTS

There were 441 procedures for 409 patients performed; 82 procedures were excluded because of predefined criteria. In 312 of 336 asymptomatic procedures (92.9%), asymptomatic patients did not undergo CXR after procedure, with 7 of 312 of these patients (2.2%) diagnosed with delayed PTX 2 to 10 days after the procedure. In 24 of 336 procedures (7.1%), asymptomatic patients underwent CXR within 4 hours with no PTX detected, and despite that 1 of 24 of these patients (4.2%) presented with delayed PTX 7 days after procedure. When no immediate postprocedural PTX was present, rate of observation PTX and delayed PTX was 1 of 359 (0.3%) and 8 of 359 (2.2%), respectively. Average duration of monitoring for outpatients (n = 295) was 2.0 hours with median of 1.8 hours. In 23 of 359 (6.4%) procedures, the patient became symptomatic during postprocedural observation with 1 of 23 (4%) developing PTX.

CONCLUSIONS

Obtaining routine postprocedural CXRs in asymptomatic patients without immediate postprocedural PTX after CT-guided transthoracic procedures is likely not necessary given the low likelihood of PTX.

A Retrospective Multi-Site Academic Center Analysis of Pneumothorax and Associated Risk Factors after CT-Guided Percutaneous Lung Biopsy

PURPOSE

To assess the risk factors, incidence and significance of pneumothorax in patients undergoing CT-guided lung biopsy.

METHODS

Patients who underwent a CT-guided lung biopsy between August 10, 2010 and September 19, 2016 were retrospectively identified. Imaging was assessed for immediate and delayed pneumothorax. Records were reviewed for presence of risk factors and the frequency of complications requiring chest tube placement. 604 patients were identified. Patients who underwent chest wall biopsy (39) or had incomplete data (9) were excluded.

RESULTS

Of 556 patients (average age 66 years, 50.2% women) 26.3% (146/556) had an immediate pneumothorax and 2.7% (15/556) required chest tube placement. 297/410 patients without pneumothorax had a delayed chest X-ray. Pneumothorax developed in 1% (3/297); one patient required chest tube placement. Pneumothorax risk was associated with smaller lesion sizes (OR 0.998; 95% CI (0.997, 0.999); [p = 0.002]) and longer intrapulmonary needle traversal (OR 1.055; 95% CI (1.033, 1.077); [p < 0.001]). Previous ipsilateral lung surgery (OR 0.12; 95% CI (0.031, 0.468); [p = 0.002]) and longer needle traversal through subcutaneous tissue (OR 0.976; 95% CI (0.96, 0.992); [p = 0.0034]) were protective of pneumothorax. History of lung cancer, biopsy technique, and smoking history were not significantly associated with pneumothorax risk.

CONCLUSION

Delayed pneumothorax after CT-guided lung biopsy is rare, developing in 1% of our cohort. Pneumothorax is associated with smaller lesion size and longer intrapulmonary needle traversal. Previous ipsilateral lung surgery and longer needle traversal through subcutaneous tissues are protective of pneumothorax. Stratifying patients based on pneumothorax risk may safely obviate standard post-biopsy delayed chest radiographs.

Percutaneous core needle biopsy in the diagnosis of lung lesions: An experience on 280 consecutive cases from a university hospital in southern India

Context:

Percutaneous needle biopsy of lung (PCNBL) is advantageous over bronchoscopic biopsies to obtain adequate sample for peripheral lung lesions.

Objective:

The objective was to evaluate the diagnostic yield of image-guided PCNBL in the diagnosis of lung lesions and to classify lung carcinomas as per the recently proposed International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society/European Respiratory Society classification for small biopsies modified and adopted by the World Health Organization, 2015.

Materials and Methods:

A total of 280 image-guided PCNBL were analyzed. The radiological findings and routine hematoxylin and eosin (H&E)-stained sections along with immunohistochemistry (IHC) were analyzed in all the cases. Molecular testing was done depending on tissue diagnosis and availability.

Results:

Majority (81%) were diagnosed as malignant lesions, with adenocarcinoma (ADC) being the most common. More than 70% were diagnosed on H&E morphology alone, with thirty cases requiring IHC to categorize as ADC. Nearly 60% were categorized as squamous cell carcinoma on morphology alone and the rest required IHC. Though TTF1 showed higher sensitivity than napsin A, the latter is more specific. Both p63 and p40 were found to be highly sensitive for squamous cell carcinoma, but p40 was more specific than p63. Epidermal growth factor receptor could be evaluated on 94.4% of ADC samples, indicating good yield for molecular testing.

Conclusion:

PCNBL yields adequate sampling for tissue diagnosis and ancillary testing with minimal complications. The use of IHC markers reduces the number of non-small-cell not otherwise specified cases significantly.

The Diagnostic Value of CT-guided Percutaneous Co-axial Trans-thoracic Biopsy (PCTTB) and Evaluation of the Pathologic Examination

BACKGROUND

We investigated thoracic masses with Computed Tomography (CT)- guided Percutaneous Co-Axial Trans-Thoracic Biopsy (PCTTB).

METHODS

The retrospective data of 86 patients to whom CT-guided PCTTB had been applied were obtained. Eighty-four cases and their pathologic results were included in the study. Localization and appearance of the lesions, pathologic results, and complications were evaluated.

RESULTS

Diagnostic sensitivity of CT-guided PCTTB was 97.6%. In 60.7% of the cases, malign lesions and, in 39.3% of the cases, benign lesions were diagnosed. The mass size was on average greater than 2 cm, and one mass was detected as being more than ≥2 masses. Mainly, irregular contours were observed. Most of the malign tumors were primary malign tumors on both sides (91.7% on the right side and 88.9% on the left side). Squamous Cell Carcinoma (SCC) was the most often detected malign tumor on the right side, and adenocarcinoma was the most often detected malign tumor on the left side. In masses localized on the left inferior lobe, metastasis was often detected. When the number of the mass was ≥2 and the mass had the appearance of consolidation, metastasis was usually detected. Small and large masses were mainly localized on right and left upper lobes. In the small mass group, 75.0% of the cases were benign, and, in the large mass group, 64.5% of the cases were malign (p=0.031, χ2=4.666). Pneumothorax was the most commonly occurring complication (23.8%). In masses localized on the right lower lobe, the pneumothorax ratio increased in benign masses compared to malign masses. The hemorrhage detection rate was 13.0%, and hemoptysis occurred in 14.2% of the cases. Hemorrhage was detected during 11.8% of the large mass biopsies. In females, hemorrhage occurred more often than in males (p=0.026, r= 0.244).

CONCLUSION

CT-guided PCTTB is a safe method to utilize for lung biopsies. Co-axial method increased the diagnostic accuracy of CT-guided percutaneous trans-thoracic biopsies. A single cut also decreased the complication rates.

Distinction and Potential Prediction of Lung Metastasis in Patients with Malignant Primary Osseous Spinal Neoplasms

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

The aim of this study was to develop and validate a nomogram for the prediction of lung metastasis in patients with malignant primary spinal tumors.

SUMMARY OF BACKGROUND DATA

In patients with malignant primary spinal tumors, lung metastasis is usually found by computed tomography (CT) and is considered to be an essential factor affecting the prognosis and survival.

METHODS

We retrospectively collected 580 malignant primary osseous spinal neoplasms patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic analysis were used to identify independent factors. These prognostic factors were included in the nomograms. The nomograms were validated based on its calibration, discrimination, and clinical utility. The overall survival of the patients was analyzed using the Kaplan-Meier method and the survival differences were tested by the log-rank test.

RESULTS

We randomly divided all these patients (n = 580) into a training cohort (n = 408) and a validation cohort (n = 172). The results showed that the risk of lung metastasis was independently influenced by histologic type, use of surgery, clinical T stage, clinical N stage, and tumor extension (all P < 0.05). The nomogram consisted of five clinical features and provided good calibration and discrimination in the training and validation cohort, with an area under the curve of 0.858 and 0.811, respectively. Decision curve analysis showed that the nomogram was clinically useful. The Kaplan-Meier curves showed a significant difference between the higher and lower risk of lung metastasis groups (P < 0.001).

CONCLUSION

Nomograms were developed to predict the risk of lung metastasis in patients with malignant primary spinal tumors. The nomogram showed favorable discrimination and calibration values, which may help optimize treatment decision-making for patients.

LEVEL OF EVIDENCE

4.

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.

Initial Experience in CT-Guided Percutaneous Transthoracic Needle Biopsy of Lung Lesions Performed by a Pulmonologist

In the diagnosis of lung lesions, computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) has a high diagnostic yield and a low complication rate. The procedure is usually performed by interventional radiologists, but the diagnostic yield and safety of CT-guided PTNB when performed by pulmonologists have not been evaluated. A retrospective study of 239 patients who underwent CT-guided PTNB at Yeungnam University Hospital between March 2017 and April 2018 was conducted. A pulmonologist performed the procedure using a co-axial technique with a 20-gauge needle. Then diagnostic yield and safety were assessed. The overall sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of malignancy were 96.1% (171/178), 100% (46/46), 100% (171/171), and 86.8% (46/53), respectively. The diagnostic accuracy was 96.9% (217/224) and the overall complication rate was 33.1% (82/248). Pneumothorax, hemoptysis, and hemothorax occurred in 27.0% (67/248), 5.2% (13/248), and 0.8% (2/248) of the patients, respectively. Univariate analyses revealed that pneumothorax requiring chest tube insertion was a significant risk factor (odds ratio, 25.0; p < 0.001) for diagnostic failure. CT-guided PTNB is a safe procedure with a high diagnostic accuracy, even when performed by an inexperienced pulmonologist. The results were similar to those achieved by interventional radiologists as reported in previously published studies.

Complications and Accuracy of Computed Tomography-guided Transthoracic Needle Biopsy in Patients Over 80 Years of Age

OBJECTIVES

The purpose of this study was to evaluate the complications and diagnostic accuracy of computed tomography-guided percutaneous transthoracic needle biopsy (PTNB) in patients aged 80 years and older.

MATERIALS AND METHODS

Consecutive PTNB procedures performed in an academic institution between July 2009 and June 2013 were reviewed. Procedures were performed according to a standard protocol using conscious sedation and rapid on-site pathology evaluation. Patient demographics, lesion characteristics, complications, and final tissue diagnosis were reviewed. Patients below 80 years of age and over 80 years were compared using binary logistic regression.

RESULTS

Of 894 biopsies, 141 (16%) were performed on patients over 80 years of age. Comparison of patients over and below 80 years of age did not differ significantly with regard to lesion size and morphology (P=0.663 and 0.453, respectively), and diagnostic accuracy (P=0.268). Pneumothorax rates were 23% versus 24% (P=0.682), and chest tube insertion was required in 2% of both groups (P=0.924). Hemoptysis rates were 3% versus 2% (P=0.376).

CONCLUSIONS

PTNB is a safe and accurate procedure in patients aged 80 years and older. Complications and diagnostic accuracy are similar to those observed in younger patients.

Evaluation of various patient-, lesion-, and procedure-related factors on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy

Purpose

To assess the influence of various patient-, lesion-, and procedure-related variables on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy.

Material and methods

In a total of 208 patients, 215 lung/mediastinal lesions (seven patients were biopsied twice) were sampled under CT guidance using coaxial biopsy set via percutaneous transthoracic approach. Incidence of post procedure pneumothorax was seen and the influence of various patient-, lesion-, and procedure-related variables on the frequency of pneumothorax with special emphasis on procedural factors like dwell time and needle-pleural angle was analysed.

Results

Pneumothorax occurred in 25.12% (54/215) of patients. Increased incidence of pneumothorax had a statistically significant correlation with age of the patient (p = 0.0020), size (p = 0.0044) and depth (p = 0.0001) of the lesion, and needle-pleural angle (p = 0.0200). Gender of the patient (p = 0.7761), emphysema (p = 0.2724), site of the lesion (p = 0.9320), needle gauge (p = 0.7250), patient position (p = 0.9839), and dwell time (p = 0.9330) had no significant impact on the pneumothorax rate.

Conclusions

This study demonstrated a significant effect of the age of the patient, size and depth of the lesion, and needle-pleural angle on the incidence of post-procedural pneumothorax. Emphysema as such had no effect on pneumothorax rate, but once pneumothorax occurred, emphysematous patients were more likely to be symptomatic, necessitating chest tube placement. Gender of the patient, site of the lesion, patient position during the procedure, and dwell time had no statistically significant relation with the frequency of post-procedural pneumothorax. Surprisingly, needle gauge had no significant effect on pneumothorax frequency, but due to the small sample size, non-randomisation, and bias in needle size selection as per lesion size, further studies are required to fully elucidate the causal relationship between needle size and post-procedural pneumothorax rate. The needle should be as perpendicular as possible to the pleura (needle-pleural angle close to 90°), to minimise the possibility of pneumothorax after percutaneous transthoracic needle biopsy.

Computed tomography-guided localization with laser angle guide for thoracic procedures

Computed tomography (CT)-guided lung procedures such as preoperative localizations, biopsies, and ablations are associated with morbidity even mortality. Often, the puncture angle is determined by the 'experienced hand' without a precise guide. We describe here the Laser Angle Guide Assembly^® to direct and steer the puncture angles precisely. It decreases procedure-related complications, saves time, reduces costs, avoids repeated punctures, and minimizes radiation exposures.

Is a Routine Chest X-ray Necessary in Every Patient After Percutaneous CT-Guided Lung Biopsy? A Retrospective Review of 278 Cases

PURPOSE

To determine the rate, clinical significance, and predictors of delayed pneumothorax after CT-guided lung biopsy.

METHODS

Medical and imaging records of all patients who underwent CT-guided lung biopsy between January 1, 2012, and January 9, 2015, were reviewed. "Early pneumothorax" was defined as one visualized on CT scan at the time of biopsy, "delayed pneumothorax" as one discovered on the first follow-up chest X-ray (CXR), and "clinically significant pneumothorax" as one requiring chest tube placement.

RESULTS

Three hundred fifty-seven lung biopsies were performed; 79 patients did not have follow-up CXR and were excluded. Out of 278 cases included in the study, early pneumothorax occurred in 109 patients. Follow-up CXRs were available in the remaining 169 patients without early pneumothorax and were obtained 3.1 ± 2.9 h after biopsy. The rate of delayed pneumothorax was 8.6% (24/278). Clinically significant pneumothorax occurred in 10/24 (41.7%) patients with delayed pneumothorax, including one case of tension pneumothorax. Patients with delayed pneumothorax (n = 24) had smaller lesion long axial diameter (18.58 ± 9.84 vs 25.83 ± 17.69 mm, p = 0.005), longer intrapulmonary needle tract (23.45 ± 14.98 vs 14.17 ± 14.49, p = 0.004), and lower FEV1/FVC ratio (53.30 ± 22.47 vs 71.15 ± 13.77, p = 0.015), compared to those without delayed pneumothorax (n = 145). The length of intrapulmonary needle tract was the only independent predictor of delayed pneumothorax (p = 0.008) and symptomatic delayed pneumothorax (p = 0.019).

CONCLUSION

Obtaining a routine follow-up CXR in all patients after CT-guided lung biopsy appears warranted, given the high rate of delayed pneumothorax and large percentage of patients who will require a chest tube. The only independent predictor of (symptomatic) delayed pneumothorax was the length of intrapulmonary needle tract.

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.

Pneumothorax with prolonged chest tube requirement after CT-guided percutaneous lung biopsy: incidence and risk factors

PURPOSE

To evaluate the incidence and risk factors of pneumothoraces requiring prolonged maintenance of a chest tube following CT-guided percutaneous lung biopsy in a retrospective, single-centre case series.

MATERIALS AND METHODS

All patients undergoing CT-guided percutaneous lung biopsies between June 2012 and May 2014 who required chest tube insertion for symptomatic or enlarging pneumothoraces were identified. Based on chest tube dwell time, patients were divided into two groups: short term (0-2 days) or prolonged (3 or more days). The following risk factors were stratified between groups: patient demographics, target lesion characteristics, and procedural/periprocedural technique and outcomes.

RESULTS

A total of 2337 patients underwent lung biopsy; 543 developed pneumothorax (23.2 %), 187 required chest tube placement (8.0 %), and 55 required a chest tube for 3 days or more (2.9 % of all biopsies, 29.9 % of all chest tubes). The median chest tube dwell time for short-term and prolonged groups was 1.0 days and 4.7 days, respectively. The transfissural needle path predicted prolonged chest tube requirement (OR: 2.5; p = 0.023). Other factors were not significantly different between groups.

CONCLUSION

Of patients undergoing CT-guided lung biopsy, 2.9 % required a chest tube for 3 or more days. Transfissural needle path during biopsy was a risk factor for prolonged chest tube requirement.

KEY POINTS

• CT-guided percutaneous lung biopsy (CPLB) is an important method for diagnosing lung lesions • A total of 2.9 % of patients require a chest tube for ≥3 days following CPLB • Transfissural needle path is a risk factor for prolonged chest tube time.

The diagnostic accuracy of CT-guided percutaneous core needle biopsy and fine needle aspiration in pulmonary lesions: a meta-analysis

AIM

To determine and compare the diagnostic value of computed tomography (CT)-guided percutaneous core needle biopsy (PCNB) and percutaneous fine-needle aspiration biopsy (PNAB) in pulmonary lesions.

MATERIALS AND METHODS

PubMed, EMBASE, and the Web of Science were systematically searched for relevant studies that investigated the diagnostic accuracy of CT-guided PCNB and/or PNAB for pulmonary lesions up to December 2014. After study selection, data extraction, and quality assessment, the sensitivity (SEN), specificity (SPE), diagnostic odds rate (DOR), positive likelihood ratios (PLR), negative likelihood ratios (NLR), and summary receiver operating characteristic (SROC) curves were calculated using the Meta-Disc 1.4 software.

RESULTS

Nineteen publications, including 21 independent studies, met the inclusion criteria. Of them, 15 studies were included in the PCNB group and six studies in the PNAB group. The pooled SEN, SPE, DOR, PLR, NLR, and SROC were 0.95, 0.99, 54.72, 0.06, 821.90, and 0.98 in the PCNB group and 0.90, 0.99, 24.71, 0.14, 210.72, and 0.98 in the PNAB group, respectively.

CONCLUSION

Based on current evidence, both PCNB and PNAB can be used as diagnostic methods to distinguish benign and malignant pulmonary lesions; the difference between PCNB and PNAB regarding diagnostic accuracy of benign or malignant pulmonary lesions is not obvious.

Trends in use and safety of image-guided transthoracic needle biopsies in patients with cancer

PURPOSE

Image-guided transthoracic needle biopsy (IGTTNB) is an important tool in the diagnosis of patients with cancer. Common complications include pneumothorax and chest tube placement, with rates ranging from 6% to 57%. We performed a population-based study to determine patterns of use, complications, and costs associated with IGTTNB.

METHODS

The Premier Perspective database was used to identify patients with cancer with ≥ one claim for IGTTNB from 2006 to 2012. Patients were stratified on the basis of inpatient versus outpatient setting. Pneumothorax was defined by a new claim within 1 month of IGTTNB; hospitalization and chest tube placement rates were analyzed. Multivariable analysis was used to identify factors associated with pneumothorax.

RESULTS

We Identified 79,518 patients with cancer who underwent IGTTNB: 42,955 (54.0%) outpatients and 36,563 (46.0%) inpatients. Of patients who underwent outpatient IGTTNB, 5,261 (12.2%) developed a pneumothorax. Of those, 1,006 (19.1%, 2.3% of total) were hospitalized, and 180 (3.4%, 0.42% of total) required chest tubes. Pneumothorax after outpatient IGTTNB was associated with number of comorbidities, rural site, hospital bed size of more than 600, and biopsy of parenchymal as opposed to pleural lesions. Of patients who underwent inpatient IGTTNB, 7,830 (21.4%) developed a pneumothorax, and 2,894 (36.0%, 7.9% of total) required chest tube. Over time, total IGTTNB volume increased by 40.6%, and mean outpatient cost per procedure increased by 24.4%.

CONCLUSION

While pneumothorax was frequent in outpatients, rates of hospitalization and chest tube placement were low. As screening for lung cancer increases, we anticipate an increased need for IGTNBB. Patients can be reassured by the low rate of serious complications.

Age as a risk factor in the occurrence of pneumothorax after transthoracic fine needle biopsy: our experience

Transthoracic needle biopsy (TTNB) of the lung is a well-established technique for diagnosing many thoracic lesions, and is an important alternative to more invasive surgical procedures. Complications of TTNB include pneumothorax, hemoptysis, hemothorax, infection, and air embolism, with the most common complication as pneumothorax. From June 2011 to June 2014 we performed a prospective study of 188 patients who underwent TTNB with CT guidance at University Hospital of Salerno, Italy. Pneumothorax occurred in 14 of 188 biopsies (7.45%). With the respect of age of patients pneumothorax occurred more frequently in patients aged 60-70 years, while it was less frequent in younger (<60 years) and older patients (>70 years). In conclusion, data of our prospective study documented that CT-guided TTNB is a safe and reliable procedure in elderly patients with suspected chest malignancy and is well tolerated.

Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance

Transthoracic needle biopsy (TTNB) is done with imaging guidance and most frequently by a radiologist, for the aim is to diagnose a defined mass. It is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. FNAC is a method of aspiration cytopathology, which with transthoracic biopsy ("core biopsy") is a group of percutaneous minimally invasive diagnostic procedures for exploration of lung lesions. Needle choice depends mostly upon lesion characteristics and location. A recent innovation in biopsy needles has been the introduction of automatic core biopsy needle devices that yield large specimens and improve the diagnostic accuracy of needle biopsy. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Common complications of TTNB include pneumothorax and hemoptysis. The incidence of pneumothorax in patients undergoing TTNB has been reported to be from 9-54%, according to reports published in the past ten years, with an average of around 20%. Which factors statistically correlate with the frequency of pneumothorax remain controversial, but most reports have suggested that lesion size, depth and the presence of emphysema are the main factors influencing the incidence of pneumothorax after CT-guided needle biopsy. On the contrary, gender, age, and the number of pleural passes have not been shown to correlate with the incidence of pneumothorax. The problem most responsible for complicating outpatient management, after needle biopsy was performed, is not the presence of the pneumothorax per se, but an increase in the size of the pneumothorax that requires chest tube placement and patient hospitalization. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Comparison of Endobronchial Ultrasound and Computed Tomography With Fluoroscopy in the Guidance of Lung Cancer Biopsies

Open lung biopsy is the gold standard for diagnosing lung cancer, but it is an invasive approach. There have been several noninvasive methods developed to biopsy the lung. This literature review compares the use of endobronchial ultrasound (EBUS) and computed tomography with fluoroscopy (CTF) guidance in the biopsy of lung nodules. Computed tomography with fluoroscopy has a higher diagnostic yield than endobronchial ultrasound but has more postprocedural complications. Endobronchial ultrasound guided lung biopsy is effective when the lesions are located in the right middle lobe of the lung, and overall EBUS has a low rate of complications when compared to CTF.

[Accuracy of CT-guided chest biopsy for benign lesions]

PURPOSE

To demonstrate that CT-guided chest biopsy can effectively prevent surgery for patients with benign tumors.

PATIENTS AND METHODS

We present a cohort of patients who underwent CT-guided biopsy for a chest lesion where diagnosis could not be achieved through other means. The gold standard was defined, based on availability, by surgery or imaging and clinical follow-up over a 2-year period.

RESULTS

From a total of 114 biopsied lesions, 101 were malignant and 13 were benign. Sensitivity and specificity values for benign lesions were 92.1 and 92.3% respectively with PPV and NPV of 60 and 98.9%. Sensitivity and specificity values for malignant lesions were 86.1 and 100% respectively with PPV and NPV of 100 and 48%. No statistically significant correlation could be established between the groups with concordant and discordant results.

CONCLUSION

The diagnosis of specific benign lesion on CT-guided biopsy, all sizes and sites included, may effectively prevent unnecessary surgery.

Role of computed tomography fluoroscopy-guided cutting needle biopsy of lung lesions after transbronchial examination resulting in negative diagnosis

INTRODUCTION

Computed tomography (CT)-guided lung biopsy is occasionally used for the lesions that were diagnosed as nonmalignant by transbronchial examination despite the fact that other clinical data suggested those as malignant. The purpose of this study is to evaluate the outcomes of CT fluoroscopy-guided cutting needle biopsy of lung lesions after transbronchial examination resulting in negative diagnosis.

PATIENTS AND METHODS

We retrospectively evaluated the outcomes of CT fluoroscopy-guided lung biopsy for 351 lesions (mean size, 2.8 cm) that were found to be nonmalignant by transbronchial examination. Diagnostic yield, including sensitivity and specificity for the diagnosis of malignancy, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. Various variables were analyzed to determine the factors for diagnostic failure.

RESULTS

The biopsy result was nondiagnostic, true-positive, true-negative, false-positive, or false-negative for 2, 262, 70, 0, or 17 lesions, respectively. Thus, the sensitivity, specificity, PPV, NPV, and accuracy of CT fluoroscopy-guided cutting needle biopsy was found to be 93% (262/281), 100% (70/70), 100% (262/262), 80% (70/87), and 94% (332/351), respectively. There was no significant risk factor for diagnostic failure.

CONCLUSION

Computed tomography fluoroscopy-guided cutting needle lung biopsy is a useful technique to correct or confirm negative diagnosis by transbronchial examination.

CT fluoroscopy-guided lung biopsy versus conventional CT-guided lung biopsy: a prospective controlled study to assess radiation doses and diagnostic performance

OBJECTIVE

We evaluated radiation doses, complication rates, and diagnostic accuracy for CT-guided percutaneous needle aspiration biopsy (NAB) procedures of pulmonary lesions performed with or without fluoroscopic guidance.

METHODS

A total of 142 patients were prospectively enrolled to receive CT-guided NAB with (Group I, n = 72) or without (Group II, n = 70) fluoroscopic guidance. Outcome measurements were patient and doctor radiation dose, and complication rate. Sensitivity, specificity and accuracy were calculated based on 123 NAB results.

RESULTS

The mean estimated effective patient radiation dose was 6.53 mSv in Group I and 2.72 mSv in Group II (p < 0.001). The mean estimated effective doctor dose was 0.054 mSv in Group I and 0.029 mSv in Group II (p < 0.001). The complication rate was significantly different between the two groups (13.4% versus 31.4%, p = 0.012). Sensitivity, specificity and accuracy for diagnosing pulmonary lesions were 97.8%, 100% and 98.4% in group I and 95.3%, 100% and 89.5% in group II (p > 0.05).

CONCLUSIONS

CT fluoroscopy-guided NAB of pulmonary lesions provides high diagnostic accuracy and can be performed with significantly fewer complications. However, radiation exposure to both patient and doctor were significantly higher than conventional CT-guided NAB.

Diagnosis of peripheral pulmonary carcinoid tumor using endobronchial ultrasound

A 51-year-old woman with severe asthma underwent bronchoscopy and endobronchial ultrasound (EBUS) for investigation of a 15-mm peripheral lung nodule. Histology demonstrated a typical carcinoid tumor. Pulmonary location is the second commonest site for carcinoid tumors. Diagnosis of peripheral carcinoid tumor of the lung is difficult due to its small size, poor accuracy of cytologic diagnosis, and low sensitivity of positron emission tomography in detecting it. EBUS has a high diagnostic yield and a low complication rate in the evaluation of small solitary pulmonary nodules. The ultrasound appearance of carcinoid tumors is identical to that of lung carcinomas. Prompt diagnosis of carcinoid tumor is desirable as regional lymph node metastasis is seen in 10% of patients and is associated with a reduced 5-year survival. We feel that, where possible, all patients presenting with solitary pulmonary nodules should be investigated initially using EBUS due to its high diagnostic rate and the very low incidence of adverse events.

Endobronchial ultrasound in pediatric pulmonology

Endobronchial ultrasound (EBUS) is a recently introduced technique that has significantly advanced bronchoscopic techniques in adult medicine. Use of ultrasound allows far more accurate localization and sampling of both peripheral pulmonary, as well as mediastinal and hilar lesions. This has led to greater diagnostic success, with a reduced rate of complications. Its performance characteristics in adult populations are equivalent to surgical procedures previously considered gold standard, but it has dramatically reduced morbidity and mortality among patients requiring invasive diagnostic procedures, when compared to surgical approaches. We describe the types of EBUS in clinical use, the method of use, the clinical indications for each procedure, and the potential role for EBUS in pediatric pulmonology. Radial probe EBUS is used in the investigation of peripheral lung lesions and could be adopted in children to achieve accurate biopsy of such lesions. Linear probe EBUS allows minimally invasive biopsy of mediastinal and hilar lesions. It has potentially greater performance characteristics than current biopsy techniques, with no significant complications reported to date. It may be useful in the diagnosis of lymphoma, or neurogenic tumors, as well as many other diseases resulting in mediastinal or hilar lymphadenopathy. EBUS is a minimally invasive technique that allows tissue sampling of peripheral lung lesions, or mediastinal/hilar masses, with a high diagnostic accuracy, and a significantly lower morbidity and mortality than alternative approaches. The indications for and the use of EBUS in pediatric patients is certain to increase in the future.

Initial Diagnosis of Lung Cancer

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

CT-guided needle biopsy of lung lesions: A survey of severe complication based on 9783 biopsies in Japan

PURPOSE

The aim of our study was to update the rate of severe complications following CT-guided needle biopsy in Japan via a mailed survey.

MATERIALS AND METHODS

Postal questionnaires regarding CT-guided needle biopsy were sent out to multiple hospitals in Japan. The questions regarded: the total number and duration of CT-guided lung biopsies performed at each hospital, and the complication rates and numbers of pneumothorax, hemothorax, air embolism, tumor seeding, tension pneumothorax and other rare complications. Each severe complication was followed with additional questions.

RESULTS

Data from 9783 biopsies was collected from 124 centers. Pneumothorax was the most common complication, and occurred in 2412 (35%) of 6881 cases. A total of 39 (35%) hospitals reported 74 (0.75%) cases with severe complications. There were six cases (0.061%) with air embolism, six cases (0.061%) with tumor seeding at the site of the biopsy route, 10 cases (0.10%) with tension pneumothorax, six cases (0.061%) with severe pulmonary hemorrhage or hemoptysis, nine cases (0.092%) with hemothorax, and 27 cases (0.26%) with others, including heart arrest, shock, and respiratory arrest. From a total of 62 patients with severe complications, 54 patients (0.55%) recovered without sequela, however one patient (0.01%) recovered with hemiplegia due to cerebral infarction, and the remaining seven patients (0.07%) died.

CONCLUSIONS

This is the first national study documenting severe complications with respect to CT-guided needle biopsy in Japan. The complication rate in Japan is comparable to internationally published figures. We believe this data will improve both clinicians as well as patients understanding of the risk versus benefit of CT-guided needle biopsy, resulting better decisions.

Real-time electromagnetic navigation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study

STUDY OBJECTIVES

To characterize the feasibility, accuracy, and safety of the superDimension/Bronchus system (SDBS) [superDimension, Ltd; Hertzliya, Israel] in navigating to previously unreachable peripheral lung lesions and obtaining biopsy specimens.

DESIGN

Open-label, prospective, controlled clinical study.

SETTING

Pulmonary institute of a university-affiliated municipal hospital.

PATIENTS

Thirteen adult candidates for nonemergency bronchoscopy who gave informed consent to participate.

INTERVENTIONS

The patients underwent flexible bronchoscopy using the SDBS, which is based on real-time CT-guided electromagnetic navigation and is capable of reaching peripheral lung masses beyond the reach of the bronchoscope. A position sensor was used to navigate to and sample the various target lesions for biopsy.

MEASUREMENTS AND RESULTS

Three-dimensional chest CT was followed by SDBS methodology for marking anatomic landmarks and the target lesion on a virtual bronchoscopy screen and for sampling the lesion. The SDBS assisted in obtaining positive biopsy diagnoses in 9 of 13 cases (69%), with an average navigation accuracy of 5.7 mm. There were no SDBS-related adverse events.

CONCLUSIONS

The SDBS is safe and effective in navigating to peripheral lung lesions located beyond the optic limits of a standard flexible bronchoscope.

Accuracy and complications in computed tomography fluoroscopy-guided needle biopsies of lung masses

The aim of this study was to determine the diagnostic accuracy and frequency of complications of lung biopsy procedures with or without CTF guidance of needle insertion. Records and images of 99 consecutive percutaneous coaxial cutting needle lung biopsy procedures performed on 85 patients were reviewed retrospectively. Fifty-seven and 42 procedures had been done with and without CTF guidance, respectively. Histological results were compared to diagnosis after surgery or after a follow-up period of 12 months. Diagnostic accuracy and the occurrence of pneumothorax and/or bleeding related to the procedures were registered. The level of accuracy of the diagnosis was comparable. The diagnostic accuracy was 96% (50/52) and 95% (34/36) sensitivity 95% (35/37) and 93% (26/28), specificity 100% (15/15) and 100% (8/8) with CTF and conventional CT techniques, respectively. There were fewer post procedure pneumothoraces using the CTF than conventional technique [26% (15/57) vs. 38% (16/42)], but the difference was not statistically significant (P = 0.274). The insertion of a chest tube was required in only one (2%) procedure using the CTF technique, while this was needed in four (10%) using the conventional technique. Small or large hemorrhages occurred in 23% of the procedures, with no apparent difference between the two groups. In conclusion, CTF-guided biopsy of lung lesions provides high diagnostic accuracy, comparable to that of conventional CT-guided procedures, with a low rate of complications, even for small tumors.

Risk of Pleural Recurrence After Needle Biopsy in Patients With Resected Early Stage Lung Cancer

BACKGROUND

Concerning the complications resulting from percutaneous needle biopsy (PNB), although cases of tumor seeding into the needle track have occasionally been reported, there were only two cases of pleural recurrences to date. The aim of this study was to elucidate the real risk of pleural recurrence after needle biopsy in patients with resected early stage lung cancer.

METHODS

Between 1986 and 2000, 335 patients with stage I nonsmall cell lung cancer underwent complete resection of the lung tumor. We retrospectively reviewed their medical records and investigated the relationship between the diagnostic methods used and the cancer recurrence patterns.

RESULTS

Preoperative diagnoses were obtained for 290 patients; 220 were diagnosed by bronchoscopy and 66 by PNB. Among the patients without a preoperative diagnosis, 27 were diagnosed by intraoperative needle biopsy and 14 by wedge resection of the lung. Tumors diagnosed by needle biopsy including PNB and intraoperative needle biopsy were smaller and showed less vessel invasion than those diagnosed by other methods (p < 0.01). After surgical resection, 9 patients had pleural recurrence and 1 patient, needle track implantation. Seven of these 10 patients were diagnosed by needle biopsy using 18G cutting type needle. Pleural recurrence or needle track implantation was observed for 8.6% of the patients who underwent a needle biopsy, whereas it was 0.9% for patients who were examined using other diagnostic modalities (p = 0.0009).

CONCLUSIONS

Needle biopsy especially using a cutting-type biopsy needle can cause a pleural recurrence in addition to needle track implantation.

Evaluation of chronic infectious interstitial pulmonary disease in children by low-dose CT-guided transthoracic lung biopsy

BACKGROUND

Children with chronic infectious interstitial lung disease often have to undergo open lung biopsy to establish a final diagnosis. Open lung biopsy is an invasive procedure with major potential complications. Transthoracic lung biopsy (TLB) guided by computed tomography (CT) is a less-invasive well-established procedure in adults.

OBJECTIVE

Detailing the role of low-dose CT-guided TLB in the enhanced diagnosis of chronic lung diseases related to infection in children.

MATERIALS AND METHODS

A group of 11 children (age 8 months to 16 years) underwent CT-guided TLB with a 20-gauge biopsy device. All investigations were done under general anaesthesia on a multidetector CT scanner (SOMATOM Volume Zoom, Siemens, Erlangen, Germany) using a low-dose protocol (single slices, 120 kV, 20 mAs). Specimens were processed by histopathological, bacteriological, and virological techniques.

RESULTS

All biopsies were performed without major complications; one child developed a small pneumothorax that resolved spontaneously. A diagnosis could be obtained in 10 of the 11 patients. Biopsy specimens revealed chronic interstitial alveolitis in ten patients. In five patients Chlamydia pneumoniae PCR was positive, in three Mycoplasma pneumoniae PCR was positive, and in two Cytomegalovirus PCR was positive. The average effective dose was 0.83 mSv.

CONCLUSION

Low-dose CT-guided TLB can be a helpful tool in investigating chronic infectious inflammatory processes in children with minimal radiation exposure. It should be considered prior to any open surgical procedure performed for biopsy alone. In our patient group no significant complication occurred. A disadvantage of the method is that it does not allow smaller airways and vessels to be assessed.

CT arthrography of the glenohumeral joint: CT fluoroscopy versus conventional CT and fluoroscopy--comparison of image-guidance techniques

PURPOSE

To compare examination time with radiologist time and to measure radiation dose of computed tomographic (CT) fluoroscopy, conventional CT, and conventional fluoroscopy as guiding modalities for shoulder CT arthrography.

MATERIALS AND METHODS

Glenohumeral injection of contrast material for CT arthrography was performed in 64 consecutive patients (mean age, 32 years; age range, 16-74 years) and was guided with CT fluoroscopy (n = 28), conventional CT (n = 14), or conventional fluoroscopy (n = 22). Room times (arthrography, room change, CT, and total examination times) and radiologist times (time the radiologist spent in the fluoroscopy or CT room) were measured. One-way analysis of variance and Bonferroni-Dunn posthoc tests were performed for comparison of mean times. Mean effective radiation dose was calculated for each method with examination data, phantom measurements, and standard software.

RESULTS

Mean total examination time was 28.0 minutes for CT fluoroscopy, 28.6 minutes for conventional CT, and 29.4 minutes for conventional fluoroscopy; mean radiologist time was 9.9 minutes, 10.5 minutes, and 9.0 minutes, respectively. These differences were not statistically significant. Mean effective radiation dose was 0.0015 mSv for conventional fluoroscopy (mean, nine sections), 0.22 mSv for CT fluoroscopy (120 kV; 50 mA; mean, 15 sections), and 0.96 mSv for conventional CT (140 kV; 240 mA; mean, six sections). Effective radiation dose can be reduced to 0.18 mSv for conventional CT by changing imaging parameters to 120 kV and 100 mA. Mean effective radiation dose of the diagnostic CT arthrographic examination (140 kV; 240 mA; mean, 25 sections) was 2.4 mSv.

CONCLUSION

CT fluoroscopy and conventional CT are valuable alternative modalities for glenohumeral CT arthrography, as examination and radiologist times are not significantly different. CT guidance requires a greater radiation dose than does conventional fluoroscopy, but with adequate parameters CT guidance constitutes approximately 8% of the radiation dose.

Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence

STUDY OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

A systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer.

MEASUREMENT AND RESULTS

For sputum cytology, the pooled specificity was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central lesions than for peripheral lesions (0.71 vs 0.49, respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69. Peripheral lesions < 2 cm or > 2 cm in diameter showed sensitivities of 0.33 and 0.62, respectively. Updating a previous meta-analysis with 19 studies revealed a pooled sensitivity of 0.90 for TTNA. A trend toward lower sensitivity was noted for lesions that were < 2 cm in diameter. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive and false-negative rates were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions that are < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease. The distinction between small cell lung cancer and non-small cell lung cancer by cytology appears to be accurate.

The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy: the angle of the needle trajectory is a novel predictor

STUDY OBJECTIVE

Pneumothorax remains the most common complication of percutaneous CT-guided lung biopsy, despite improved techniques. The rate of pneumothorax reported in the literature ranges from 19 to 60%. The aims of this study were to estimate the risk of pneumothorax in patients undergoing CT-guided lung biopsy, and to determine which factors affect its occurrence.

DESIGN

Retrospective study.

PATIENTS AND METHODS

This study involved 289 consecutive patients who underwent biopsy in our hospital under consistent methods, using only one type of needle, the 19-gauge Tokyo Medical College (TMC) Needle (Takei; Tokyo, Japan), under CT guidance.

RESULT

Seventy-seven patients (26.6%) had pneumothorax after percutaneous CT-guided lung biopsy. Forty-one of the 77 patients (53.2%) who had pneumothorax (14.2% of the entire series) required placement of a chest tube. Our present study, using multivariate logistic regression analysis, confirmed that greater lesion depth, wider trajectory angle, and increasing FVC percent predicted are independent risk factors of pneumothorax, and that two former factors are independent risk factors of chest tube placement following percutaneous CT-guided lung biopsy.

CONCLUSIONS

The angle of needle route is a novel predictor of this complication. Our findings suggest that low pneumothorax rates are achieved by combining several techniques to reduce the risk of pneumothorax.

CT/fluoroscopy-guided transthoracic needle biopsy: sensitivity and complication rate in 98 procedures

PURPOSE

The purpose of this study was to evaluate CT/fluoroscopy (CTF)-guided core needle biopsies (CNBs) in the thorax.

METHOD

Ninety-eight biopsies were performed using a core biopsy needle (18G) with a reusable biopsy gun under CT/F. All results were compared to surgery plus histology or to clinical follow-up of >12 months. Sensitivity, specificity, and negative predictive value (NPV) were calculated.

RESULTS

For pulmonary biopsies, sensitivity was 94%, specificity 100%, and NPV 73%; no significant correlation between the pneumothorax rate and the intrathoracic penetration depth was found. For biopsies of the mediastinum and pleura, sensitivities were 87 and 80%, respectively; specificity was 100% in both locations. A pneumothorax occurred in 21%, a pneumothorax requiring drainage in 2.0%.

CONCLUSION

CT/F-guided CNB is a reliable method to obtain thoracic biopsies, with a complication rate of 2.0%.