Percutaneous needle biopsy of the mediastinum: review of 94 procedures

Adenocarcinoma originating in the anterior mediastinum diagnosed by endobronchial ultrasound-guided transbronchial cryobiopsy: a case report

BACKGROUND

Endobronchial ultrasound-guided transbronchial cryobiopsy (EBUS-cryobiopsy) is advantageous for collecting larger specimens with minimal crushing; however, it has not been widely used for mediastinal tumors.

CASE PRESENTATION

A 73-year-old woman with a history of left breast cancer underwent surgery followed by radiotherapy. Computed tomography showed a mass in the anterior mediastinum that was in extensive contact with the sternum on the ventral side and partly with the trachea on the dorsal side. Two computed tomography-guided needle biopsies (CTNBs) were performed on the mass; however, a definitive diagnosis was not made because of severe crush artifacts. Subsequently, we performed EBUS-cryobiopsy and safely obtained sufficient specimen volume with minimal crushing. The histopathological diagnosis was adenocarcinoma, with immunobiological features distinct from those of previous breast cancers. Her overall diagnosis was a rare tumor originating in the anterior mediastinum.

CONCLUSIONS

EBUS-cryobiopsy can be safely performed in narrow areas surrounded by major blood vessels, and the obtained specimens may be superior to CTNBs for histopathological diagnosis.

Single-Setting Superior Vena Cava Biopsy and Stenting Utilizing Cone Beam Computed Tomography as an Additional Tool

BACKGROUND Malignant disease is a common etiology of superior vena cava syndrome (SVCS). Being a medical emergency, it often requires rapid diagnostic evaluation and therapy. Transcaval biopsy and endovascular stenting in a single-setting has been described, but only in a handful of cases. These cases utilized intra-operative venograms. In this study, we also used intra-operative cone beam computed tomography (CBCT) to increase the safety and efficacy of such single-setting procedures. CASE REPORT From January 2017 to July 2019, there were 5 patients with malignant SVCS who underwent single-setting superior vena cava biopsy and endovascular stenting utilizing intra-operative CBCT as an adjunct. Demographic data, clinical presentation, investigation results, procedural details, and patient outcomes were recorded. CBCT was utilized in all cases to optimize sampling of biopsies, visualize subsequent stent positioning, and for early detection of procedure-related complications. Transcaval biopsy was diagnostic in 4 of the 5 patients. Endovascular stents were deployed successfully in all cases, with post-stenting venogram demonstrating relief of prior obstructed segments. One patient had a complication of an apical pneumothorax, with no associated long-term pneumothorax-related morbidity or mortality. CONCLUSIONS This study demonstrates that single-setting transcaval biopsy and stenting in the context of malignant SVCS is a cost-efficient, safe, and feasible approach. In addition, the additional use of intra-operative CBCT is a useful tool to increase procedure efficacy and safety.

How to obtain adequate biopsy specımen in suspected thymic tumors

Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while the rest had gone to surgery for diagnosis and treatment. However, in the last two decades there was an increase in pretreatment procedures for optimal management of locally advanced or metastatic TTs. Pretreatment tissue diagnosis of a noninvasive TT is not a standard option but is required if there is suspect or atypical clinical presentation and imaging, an invasive tumor requiring a nonsurgical approach or preoperative chemotherapy or chemo-radiotherapy, strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor by imaging studies, or suspicion of a metastatic lesion. In surgical diagnosis anterior mediastinotomy, video-assisted thoracic surgery or mediastinoscopy can be chosen for invasive TTs whereas total resection is performed for small, noninvasive tumors. Nonsurgical diagnosis can be made by transthoracic fine or core needle biopsies (TTFNA, TTCNB), conventional bronchoscopy, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy depending on procedural amenability according to tumor extension. TTFNA and TTCNB have been the most frequently used nonsurgical methods. However, there is an upward trend in using conventional bronchoscopy, EBUS-TBNA, EUS-FNA and medical thoracoscopy recently. To increase the diagnostic performance of these procedures in TTs, recommendations are (I) obtaining histologic specimens, (II) combining smears or liquid based cytology preparations and cell blocks, (III) obtaining multiple sufficient samples, (IV) combining histologic and cytologic specimens, (V) performing morphologic, immunohistochemical and molecular analyses on all specimens, (VI) using rapid onsite evaluation for cytologic specimens, (VII) correlating pathologic, clinical and radiologic findings, (VIII) consulting experienced pathologists.

Contrast-Enhanced Ultrasound Improves the Pathological Outcomes of US-Guided Core Needle Biopsy That Targets the Viable Area of Anterior Mediastinal Masses

Based on the option that ultrasound-guided core needle biopsy (US-CNB) of the enhanced portion of anterior mediastinal masses (AMMs) identified by contrast-enhanced ultrasound (CEUS) would harvest viable tissue and benefit the histological diagnoses, a retrospective study was performed to elucidate the correlation between the prebiopsy CEUS and diagnostic yield of AMMs and found that CEUS potentially improved the diagnostic yield of AMMs compared with conventional US with a significant increase in the cellularity of samples. Furthermore, the marginal blood flow signals and absence of necrosis can predict the diagnostic yield of AMM. It was concluded that US-CNB of the viable part of AMMs, as verified by CEUS, was able to harvest sufficient tissue with more cellularity that could be used for ancillary studies and improve the diagnostic yield. And CEUS was recommended to those patients with AMMs undergoing repeated US-CNB, with the absence of marginal blood signals or presence of necrosis.

Sclerosing thymoma-like thymic amyloidoma with nephrotic syndrome: a case report

Background

Primary localized amyloidosis presenting as an isolated mediastinal mass is extremely rare, especially in the thymus. Sclerosing thymoma is also an extremely rare anterior mediastinal tumor, pathologically characterized by extensive sclerotic lesions with hyalinization and calcification. Only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date.

Case presentation

A 78-year-old Japanese woman was diagnosed as having sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma. She was diagnosed as having either lung cancer or mediastinal tumor with pericardial dissemination, and received palliative treatment. Three years later, she was readmitted with a complaint of general malaise. Since minimal change nephrotic syndrome was suspected based on the disease onset and selectivity index of urinary protein, steroid pulse therapy was started. Subsequently, because a marked reduction in tumor size was observed during maintenance treatment with prednisolone, a thoracoscopic needle biopsy was performed for a definitive diagnosis. According to the pathological findings and clinical investigations, a final diagnosis of sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma was made.

Conclusions

This is a case report of sclerosing thymoma-like thymic amyloidoma. Both sclerosing thymoma and thymic amyloidoma are extremely rare diseases: only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date. In either diagnosis, our case is the first case in which marked reduction in tumor size was observed with steroid therapy. All reported cases of sclerosing thymomas underwent surgical resection, but steroid therapy to sclerosing thymoma has not been reported. It is still unknown whether steroid therapy is effective or not. The hyalinized components of sclerosing thymoma possibly contain amyloid deposits. The marked reduction in tumor size with steroid therapy may result in amyloid deposits. The association between sclerosing thymoma and thymic amyloidoma remains uncertain. Sclerosing thymoma should be stained with Congo red.

Is a diagnostic video-assisted thoracoscopic thymectomy an acceptable first-line approach to the suspicious anterior mediastinal mass?

INTRODUCTION

The incidental early-stage thymic mass presents a diagnostic challenge. Video-assisted thoracoscopic (VAT) thymectomy is an attractive but potentially morbid solution. The aim was to show it can be safely applied as a first-line modality in those with undiagnosed thymic enlargement with acceptable long-term results.

METHODS

A total of 45 patients were identified (24 male, median age 52 interquartile range [IQR]: 41-66 years) in a 14-year experience who had CT evidence of an enlarged, possibly malignant thymic mass, but no tissue diagnosis before undertaking VAT thymectomy. The clinical outcomes of both benign and malignant diagnoses were compared.

RESULTS

Myasthenic symptoms were present in 20 patients (44%), whereas 15 (33%) were asymptomatic. Benign lesions were resected in 27 patients (60%): thymic hyperplasia (56%), thymic cyst (33%), lipoma (7%) and xanthogranulomatous inflammation (4%). Of the 18 malignant patients, 82% had thymoma (three had Masaoka Stage I, 11 Stage II and one Stage III), 6% thymic carcinoma, 6% teratoma and 6% seminoma. Seven patients required radiotherapy for R1 resection. There was no difference in median hospital stay in either group: Benign group: 4 versus 5 days (P = 0.07). One patient in both groups required conversion to open. Two patients in the malignant group had significant morbidity (one myocardial infarction and one pulmonary embolism). There were no cases of tumour recurrence or mortality at a median follow-up of 6.6 years (IQR: 4.4-9.5 years).

CONCLUSION

Right-sided diagnostic VAT thymectomy is a safe and effective first-line approach to suspected malignant thymic enlargement. At 5-year follow-up, there were no cases of recurrence in the malignant group.

Diagnostic evaluation of mediastinal lesions: Analysis of 144 cases

Background:

Mediastinum is a “Pandora's box” with many neoplastic and nonneoplastic lesions. The purpose of this study was to analyze our institutional experience of mediastinal lesions on fine-needle aspiration cytology (FNAC) and/or biopsy.

Materials and Methods:

This study was an analysis of 144 patients who had undergone ultrasound-guided FNAC and/or core biopsy for mediastinal lesions.

Results:

A total of 144 cases of suspected mediastinal masses were seen, and in 139 cases, tissue diagnosis was attempted. Out of 139 cases, 93 cases were neoplastic in nature (67%), 32 were nonneoplastic (23%), and 14 remained inconclusive (10%). Among neoplastic mediastinal lesions, metastatic carcinoma (37.4%) was the most common neoplastic lesion, followed by non-Hodgkin's lymphoma (12.2%), Hodgkin's lymphoma (7.1%), thymic lesions (3.5%), etc. Among nonneoplastic conditions, tuberculosis was the most common lesion (20.1%). An accurate tissue diagnosis was made in 89.9% cases by FNAC or core biopsy of mediastinal lesions in this study. Procedure-related mortality was nil. Complications were mostly minor and included chest pain in 24.5%, small pneumothorax in 13.6% requiring closed tube thoracostomy in 1.4%, and scanty hemoptysis in 9.3% cases.

Conclusion:

Neoplastic mediastinal lesions are more common than nonneoplastic lesions, with metastatic carcinoma being the most common cause followed by tuberculosis. A wide variety of lesions observed in this study stress on the importance of cytohistological diagnosis in all cases of mediastinal lesions for the final diagnosis and management planning. A guided FNAC or core biopsy is still accurate, well tolerated, and devoid of major complications.

Diagnostic Yield and Safety of Computed Tomography-guided Mediastinal Core Needle Biopsies

PURPOSE

Mediastinal masses of various origins can be encountered on imaging in symptomatic or asymptomatic patients. We aimed to evaluate the diagnostic yield and complication rate of computed tomography (CT)-guided mediastinal core needle biopsies in a large population of patients presenting with mediastinal masses and to identify the factors that could influence these results.

MATERIALS AND METHODS

In total, 293 consecutive CT-guided mediastinal biopsies, performed in 285 patients with equivocal masses at a single center from 2006 to 2011, were included. Lesion characteristics, technical biopsy parameters, final diagnoses, diagnostic yields (number of biopsies that yielded a complete diagnosis divided by the total number of biopsies), and complication rates were recorded.

RESULTS

Malignant diagnoses, including lymphoproliferative disorders (N=151, 53%) and lung cancers (N=54, 19%), were established in 233 cases (82%). Benign lesions were found in 52 procedures (18%), including sarcoidosis (N=19, 7%) and infections (N=17, 6%). The overall diagnostic yield was 87% and was lower for lymphoma residual masses (57%) than for initial diagnosis or relapses of known disease (90%). Complications occurred in 21 patients (7%), but only 2 patients (0.7%) required hospitalization for >12 hours. Neither the diagnostic yield nor the complication rate was influenced by the target characteristics or by technical parameters.

CONCLUSIONS

CT-guided core needle biopsy of equivocal mediastinal masses is a minimally invasive procedure that is effective and safe, even in cases of small targets or targets in challenging locations.

Thymoma and thymic carcinomas

Thymomas (Ts) and thymic carcinomas (TCs) are rare tumours of the mediastinum with an incidence rate of 1.7/million per year in Europe. Histological classification is based on rate of non-malignant-appearing thymic epithelial cells and proportions of lymphocytes (A, AB, B1, B2, B3, and C), while staging system concerns localisation of the involved areas. Surgery is the mainstay of treatment with a 10-year survival of 80%, 78%, 75%, and 42% for stages I, II, III and IV, respectively, with an R0 resection. Radiotherapy has a role in selected cases (stage III patients or R1-2 residual) and platinum-based chemotherapy remains the standard of care for patients with advanced disease. A multimodality approach would be advisable when surgery is not recommended. Since molecular aberrations are poorly understood and few responses are reported, targeted therapies are yet being studied. In this review, we describe key aspects of clinical management for Ts and TCs.

Diagnostic Yield of CT-Guided Percutaneous Transthoracic Needle Biopsy for Diagnosis of Anterior Mediastinal Masses

OBJECTIVE

The purpose of this study was to evaluate the diagnostic yield and accuracy of CT-guided percutaneous biopsy of anterior mediastinal masses and assess prebiopsy characteristics that may help to select patients with the highest diagnostic yield.

MATERIALS AND METHODS

Retrospective review of all CT-guided percutaneous biopsies of the anterior mediastinum conducted at our institution from January 2003 through December 2012 was performed to collect data regarding patient demographics, imaging characteristics of biopsied masses, presence of complications, and subsequent surgical intervention or medical treatment (or both). Cytology, core biopsy pathology, and surgical pathology results were recorded. A per-patient analysis was performed using two-tailed t test, Fisher's exact test, and Pearson chi-square test.

RESULTS

The study cohort included 52 patients (32 men, 20 women; mean age, 49 years) with mean diameter of mediastinal mass of 6.9 cm. Diagnostic yield of CT-guided percutaneous biopsy was 77% (40/52), highest for thymic neoplasms (100% [11/11]). Non-diagnostic results were seen in 12 of 52 patients (23%), primarily in patients with lymphoma (75% [9/12]). Fine-needle aspiration yielded the correct diagnosis in 31 of 52 patients (60%), and core biopsy had a diagnostic rate of 77% (36/47). None of the core biopsies were discordant with surgical pathology. There was no statistically significant difference between the diagnostic and the nondiagnostic groups in patient age, lesion size, and presence of necrosis. The complication rate was 3.8% (2/52), all small self-resolving pneumothoraces.

CONCLUSION

CT-guided percutaneous biopsy is a safe diagnostic procedure with high diagnostic yield (77%) for anterior mediastinal lesions, highest for thymic neoplasms (100%), and can potentially obviate more invasive procedures.

Diagnostic impact of color Doppler ultrasound-guided core biopsy on fine-needle aspiration of anterior mediastinal masses

Although lymphoma and thymoma are common etiologies of anterior mediastinal masses (AMMs), smaller percentages and numbers of patients with these diseases have been enrolled in previous ultrasound-guided biopsy studies. To date, there has been no study of color Doppler sonographic features to support the differentiation of AMMs. For this retrospective cohort study, a search of the database of the China Medical University Hospital using the clinical coding "ultrasound-guided biopsy" was conducted for the period December 2003 to February 2013. We selected patients diagnosed with AMMs (not cysts) using radiographic records. This search yielded a list of 80 cases. Real-time ultrasound-guided core needle biopsy (CNB) was performed in all but 5 patients without a sufficient safety range. In 89% (67/75) of these ultrasound-guided CNB cases, the diagnostic accuracy achieved subclassification. Fine-needle aspiration cytology achieved subclassification in only 10% of cases. On color Doppler sonography, 71% of lymphomas were characterized as "rich vascular with central/crisscross collocations" and 29% as "avascular or localized/scattered peripheral vessels." However, decreased proportions of "rich vascular with central/crisscross collocations" were found in lung cancer (4% [1/23], odds ratio = 0.018, 95% confidence interval: 0.002-0.154, p < 0.001) and thymoma/thymic carcinoma (25% [4/16]; odds ratio = 0.133, 95% confidence interval: 0.035-0.514, p = 0.003) compared with the lymphoma group. We conclude that the vessels in lymphoma AMMs have specific patterns on color Doppler sonography. Ultrasound-guided CNB of AMMs had an accuracy of ≤ 89% in diagnosis and subclassification. Fine-needle aspiration cytology itself cannot aid in the diagnosis. Color Doppler sonographic evaluation of AMMs followed by real-time CNB is a more efficient method.

Anterior mediastinal masses: A study of 50 cases by fine needle aspiration cytology and core needle biopsy as a diagnostic procedure

Background:

Mediastinal tumors are an uncommon abnormalities found in clinical practice. Anterior mediastinum is the common site and tissue diagnoses of anterior mediastinal masses (AMMs) are very important for correct therapeutic decision.

Objective:

We evaluate the different malignant AMMs in various age groups and the sensitivity of fine needle aspiration cytology (FNAC) and core needle biopsy (CNB). Cytology smears are reviewed with particular emphasis on pitfalls in the cytological diagnosis.

Materials and Methods:

This was a prospective study of 50 patients who were consulted for AMMs and underwent FNAC and CNB under guidance of ultrasound or computed tomography (CT) scan from 2006 to 2011. Cytology smears and histological sections were evaluated in all patients.

Results:

Among 50 cases, 36 were male and 14 were female. Most AMMs (52%) were identified in the fifth and sixth decades of life. Metastatic carcinoma and nonHodgkin's lymphoma are the common AMMs. Adequate tissue material was obtained in 49 of 50 cases by CNB. Of these 49 patients, 35 (71.42%) cases were diagnosed correctly by FNAC, whereas 14 (28.57%) cases were not diagnosed definitely by FNAC. The sensitivity of CNB for AMMs was 97.95%, significantly higher than FNAC (71.42%) (P < 0.05). CNB had statistically significant higher diagnostic rate than FNAC in the noncarcinoma group (100% versus 62.96%) (P < 0.05). There is no significant difference of CNB and FNAC in carcinoma group (P > 0.05). Diagnostic rate of FNAC was higher for carcinomatous lesions (81.81%) than for noncarcinomatous lesions (62.96%).

Conclusion:

Ultrasound or CT scan-guided CNB in combination with FNAC are safe, minimally invasive, and cost-effective procedure, which can provide a precise diagnosis in the AMMs, and may obviate the need for invasive surgical approach. FNAC usually suffice for carcinomatous lesions but CNB should be performed whenever the diagnosis of carcinoma is equivocal or noncarcinoma lesions are suspected.

Transthoracic needle biopsy

Transthoracic needle biopsy (TTNB) is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Needle choice depends mostly upon lesion characteristics and location. During the procedure, patients must be able to follow breathing instructions. Common complications of TTNB include pneumothorax and hemoptysis.

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.

Percutaneous computed tomography-guided core biopsy for the diagnosis of mediastinal masses

AIM

To describe various approaches of computed tomography (CT)-guided core biopsy and evaluate its ability to obtain adequate tissue for the assessment of mediastinal masses.

MATERIALS AND METHODS

Between February 2004 and October 2006, 83 percutaneous CT-guided biopsies of mediastinal lesions were performed on 82 patients under local anesthesia. Coaxial needles were used and minimum of 3-4 cores were obtained. Post-biopsy CT scan was performed and patients observed for any complications. Tissue samples were taken to Pathology Department in formalin solution.

RESULTS

From the 83 biopsies, adequate tissue for histological diagnosis was obtained in 80 (96%), and the biopsy was considered diagnostic. Of the 80 diagnostic biopsies, 74 biopsy samples were definitive for neoplastic pathology and 6 biopsy samples revealed no evidence of malignancy. There were no major complications. Minor complications were recorded in 5 patients.

CONCLUSION

Percutaneous image-guided core biopsy of mediastinal lesions is an accurate, safe and cost-effective tool for the initial assessment of patients with mediastinal masses.

Surgical treatment of thymic epithelial neoplasms

Resection continues to be the mainstay of treatment for epithelial lesions of the thymus. This has never been in doubt for encapsulated stage I and II lesions, but we recently have come to a greater appreciation of the role of preoperative therapy for locally advanced lesions, particularly stage III disease. For any lesion that presents in the anterior mediastinum and on CT scan does not appear to be eminently resectable, a biopsy should be performed to rule out lymphoma after serum germ cell markers have been obtained to rule out the rare primary mediastinal or metastatic germ cell tumor.

Surgical treatment of thymoma

PURPOSE

A case report is presented of a 66-year-old white woman with a 3-month history of atypical chest pain and shortness of breath.

METHODS

A lateral chest radiograph demonstrated an anterior mediastinal density. A subsequent computed tomography (CT) scan revealed a mass in the right anterolateral mediastinum. Fine-needle aspiration (FNA) revealed tumor cells positive for cytokeratin and negative for leukocyte common antigen.

RESULTS

The differential diagnosis at that time included thymoma versus thymic carcinoid. She underwent a median sternotomy with complete thymectomy. The pathology revealed a large thymoma with microinvasion into the surrounding adipose tissue. She had an uneventful postoperative course and later underwent adjuvant radiation therapy.

CONCLUSIONS

Surgical treatment of thymoma is discussed, with emphasis on diagnosis and treatment. Although some patients may present with symptoms caused by involvement of surrounding structures, most thymomas are discovered incidentally on chest radiograph. Various diagnostic procedures can aid the surgeon in ruling out other neoplasms, such as lymphoma or germ cell tumors. Prognosis is not based on histology, but on the tumor's gross characteristics at operation. Benign tumors are noninvasive and encapsulated. All patients with potentially resectable lesions should undergo en-bloc excision. Radiation or chemotherapy should be instituted in more advanced tumors.

Management of thymomas

Thymoma is a rare neoplasm usually with an indolent growth pattern, however, local invasion and/or metastases may occur. The association with several paraneoplastic syndromes, especially myasthenia gravis, is noteworthy. Surgery has been the standard of care for early stage disease with high cure rates anticipated. The most important prognostic factors after resection are Masaoka stage, World Health Organization (WHO) histology, complete resection status and size. Multimodality therapy can result in long-term disease-free survival for patients presenting with locally advanced disease. Thymomas are sensitive to both chemotherapy and radiation therapy and are utilized with good effects in unresectable patients.

Diagnostic accuracy of CT-guided percutaneous cutting needle biopsy for thymic tumours

AIM

To determine the diagnostic accuracy of computed tomography (CT)-guided percutaneous cutting needle biopsy (PCNB) for thymic tumours in accordance with the World Health Organization (WHO) classification.

MATERIAL AND METHODS

We retrospectively analysed a consecutive series of 138 cases in which CT-guided PCNB had been performed for an anterior mediastinal tumour. Its sensitivity and specificity for thymic epithelial tumours were evaluated, and the concordance between the histopathological diagnosis according to the WHO classification of thymic tumours based on PCNB and the diagnosis is based on the surgical specimens was assessed by Kappa statistic.

RESULTS

The diagnostic sensitivity and specificity of CT-guided PCNB for thymic tumours were 93.3 and 100%, respectively. The overall concordance between the diagnosis according to the WHO classification established by PCNB specimen and by the surgical specimen was 79.4% (weighted kappa=0.79).

CONCLUSION

CT-guided PCNB is a reliable method of diagnosing thymic tumours, and there was good concordance for the WHO classification between the diagnosis based on CT-guided PCNB specimen and that based on the surgical specimen.

Percutaneous CT-guided multisampling core needle biopsy of thoracic lesions

OBJECTIVE

The purpose of our study was to evaluate the diagnostic yield and the complication rate of percutaneous CT-guided coaxial 18-gauge (1.25-mm diameter) multisampling (five samples) core needle biopsy (CNB) of suspected thoracic lesions.

MATERIALS AND METHODS

The records of 75 consecutive patients (29 women, 46 men; age range, 33-92 years) who underwent percutaneous CT-guided adjustable coaxial 18-gauge multisampling (five samples) CNB of a suspected thoracic lesion (eight mediastinal lesions, two chest wall lesions, two pleural lesions, and 63 intrapulmonary lesions) were reviewed.

RESULTS

Ninety-seven percent (73/75) of CNB specimens were considered adequate for a specific diagnosis by the histopathology staff. Diagnostic yield was 97% (95% confidence interval, 91-99%) (72/74) (number of correct diagnoses obtained at CNB / number of definitive diagnoses). There were 61 malignant lesions and 11 benign lesions. There was no false-negative result when CNB was considered adequate for a specific diagnosis by the histopathology staff. Pneumothorax occurred in 19% (12/63 intrapulmonary lesions). One patient required placement of a chest tube. Minor postbiopsy hemoptysis occurred and resolved spontaneously in 11% (7/63) of patients.

CONCLUSION

Percutaneous CT-guided coaxial multisampling large CNB of suspected thoracic lesions, in a mainly cancer-based population, is an accurate procedure for a specific histologic diagnosis and has a low rate of complications.

Imaging-guided Percutaneous Biopsy of Mediastinal Lesions: Different Approaches and Anatomic Considerations

Percutaneous needle biopsy with imaging guidance allows access to lesions in virtually all mediastinal locations. A direct mediastinal approach, which enables extrapleural needle placement, is the preferred method to avoid the risk of pneumothorax. Techniques that allow extrapleural access include the parasternal, paravertebral, transsternal, and suprasternal approaches, which are performed with computed tomographic or ultrasonographic guidance. The parasternal approach is used for biopsy of anterior or middle mediastinal lesions when the lesion or intervening mediastinal fat extends to the anterior chest wall, lateral to the sternum; injury to the internal mammary vessels is a potential complication. The paravertebral approach is used for biopsy of subcarinal and other posterior mediastinal lesions; saline solution is often injected to widen the mediastinum. The transsternal approach, which involves needle placement through the sternum, is used for biopsy of anterior or middle mediastinal lesions that are not accessible with the parasternal approach. Biopsy of superior mediastinal lesions can be performed with a suprasternal approach. An alternative to these direct mediastinal approaches involves advancing the needle through a pleural space created by an existing pleural effusion or iatrogenic pneumothorax. Another alternative is the transpulmonary approach, which involves transgression of the lung and visceral pleura by the needle and is associated with a substantial risk of pneumothorax.

Surgical treatment of thymic tumors

Thymoma is a rare neoplasm usually with an indolent growth pattern; however, local invasion and/or metastases may occur. The association with several paraneoplastic syndromes, especially myasthenia gravis, makes thymoma an interesting biologic tumor model. Surgery has been the standard of care for early stage disease with high cure rates anticipated. Multimodality therapy can result in long-term disease-free survival for patients presenting with locally advanced disease.

Percutaneous biopsy of pediatric solid tumors

BACKGROUND

The objective of the current study was to determine the diagnostic accuracy of percutaneous biopsy of pediatric solid tumors, a procedure that is less invasive than open biopsy.

METHODS

The authors conducted a retrospective analysis of clinical data related to 202 percutaneous core-needle biopsies of solid tumors at St. Jude Children's Research Hospital over 5.5 years (from 1997 to 2003). In 103 patients, the procedure was performed to establish an initial diagnosis of a suspected malignancy; and, in 99 patients, disease recurrence was suspected. Biopsies were guided by ultrasound, computed tomography, or fluoroscopic imaging. From each tumor, 1-17 core biopsy samples (median, 6 samples) were obtained; the median needle size was 15 gauge (range, 13-20 gauge). The specimens were submitted for histopathologic analysis and other ancillary procedures (molecular pathology and/or cytogenetic analyses). The accuracy of the diagnoses from the biopsies was determined by subsequent surgery with or without pathologic assessment or by outcome.

RESULTS

When the biopsy samples were assessed for the presence of malignancy, there were 121 true-positive results (90% sensitivity), 67 true-negative results (100% specificity), and 14 false-negative results (93% accuracy). In 103 tumors, when the procedure was performed for initial diagnosis, percutaneous needle biopsy showed a sensitivity of 97%, a specificity of 100%, and an accuracy of 98%. The 99 procedures for suspected recurrence were less reliable (sensitivity, 83%; specificity, 100%; accuracy, 88%).

CONCLUSIONS

Image-guided percutaneous biopsy was highly accurate and safe in the diagnosis of pediatric malignant solid tumors. This technique may be able to supplant diagnostic open biopsy.

The value of a noninvasive diagnostic approach to mediastinal masses

BACKGROUND

Mediastinal tumors show a wide variability, and therefore, a standardized diagnostic and therapeutic workup is instrumental. We subdivided mediastinal tumors into nonlymphatic mediastinal tumors (NLMTs), most of which require surgical resection without need of preoperative histology, and mediastinal lymphadenopathy (MLA), requiring surgical biopsy for exact histologic classification. We investigated the accuracy of noninvasive diagnostic studies distinguishing between the two groups of MLA and NLMT.

METHODS

A retrospective analysis was performed on patients who had previously undergone surgery on mediastinal tumors. Their data were statistically analyzed (chi2 test, logistic regression analysis), and the values of medical history, physical examination, laboratory tests, and computerized tomography scan discriminating between MLA and NLMT were assessed.

RESULTS

Out of 299 patients included in the study, 242 (80.9%) had MLA and 57 (19.1%) had NLMT. Sensitivity and specificity of noninvasive investigations for differentiation of MLA and NLMT were 98.2% and 86.0%, respectively. Whereas the prevalence of thoracic symptoms such as shortness of breath, cough, or chest pain was similar in both groups (MLA, 165 [69.3%]; NLMT, 41 [69.5%]; p = 0.98), systemic symptoms, including fever, night sweats, or weight loss (MLA, 110 [49.8%]; NLMT, 17 [29.3%]; p < 0.01), and signs of inflammation, such as c-reactive protein, erythrocyte sedimentation rate, and leukocytosis (MLA, 202 [85.6%]; NLMT, 34 [57.6%]; p < 0.001), were significantly more common in MLA.

CONCLUSIONS

Noninvasive diagnostic procedures, including medical history, physical examination, laboratory tests, and computerized tomographic scan, are highly sensitive in detecting MLAs that should undergo surgical biopsy. Our data suggest confirming all suspected NLMTs by fine needle aspiration (FNA) biopsy before surgery.

Computed tomography-guided biopsy of mediastinal lesions: fine versus cutting needles

PURPOSE

To report the experience of a radiology department in the use of computed tomography guided biopsies of mediastinal lesions with fine and cutting needles, describing the differences between them. The results of adequacy of the sample and histologic diagnoses are presented according to the type of needle used.

METHODS

We present a retrospective study of mediastinal biopsies guided by computed tomography performed from January 1993 to December 1999. Eighty-six patients underwent mediastinal biopsy in this period, 37 with cutting needles, 38 with fine needles, and 11 with both types (total of 97 biopsies).

RESULTS

In most cases, it was possible to obtain an adequate sample (82.5%) and specific diagnosis (67.0%). Cutting-needle biopsy produced a higher percentage of adequate samples (89.6% versus 75.5%, P = 0.068) and of specific diagnosis (81.3% versus 53.1%, P = 0.003) than fine-needle biopsy. There were no complications that required intervention in either group.

CONCLUSION

Because they are practical, safe, and can provide accurate diagnoses, image-guided biopsies should be considered the procedure of choice in the initial exploration of patients with mediastinal masses. In our experience, cutting needles gave higher quality samples and diagnostic rates. We recommend the use of cutting needles as the preferred procedure.

Fine-needle aspiration biopsy of nonteratomatous germ cell tumors of the mediastinum

We assessed the usefulness of fine-needle aspiration biopsy (FNAB) in the diagnosis of mediastinal germ cell tumors (GCTs). In the archives of 3 pathology departments, we found records of 7 patients with mediastinal GCTs who underwent mediastinal FNAB as part of the diagnostic workup. The FNAB smears, results of the immunocytochemical analysis, the corresponding histologic findings, and the clinical charts were reviewed. All patients were men (age range, 24-44 years; mean, 32 years). One patient had a history of testicular mixed GCT 10 years earlier. The 6 primary mediastinal GCTs consisted of 3 seminomas and 3 yolk sac tumors. Based on the cytologic features and immunocytochemicalfindings, a cytologic diagnosis of GCT was made in 5 cases, including the case of metastatic GCT In 2 cases, the differential diagnosis was between poorly differentiated carcinoma and GCT Results of ancillary studies were noncontributory in 1 case, and the aspirate of the second case demonstrated extensive necrosis. Our findings demonstrate that a diagnosis of mediastinal GCT, primary or secondary, can be established with a high degree of accuracy on the basis of FNAB. Immunocytochemical analysis helps confirm the diagnosis.

Salinoma window technique for mediastinal lymph node biopsy

Computed tomographic-guided transthoracic needle biopsy can access virtually all mediastinal lymph node stations, but is limited by the potential for pneumothorax and bleeding. To avoid these possible complications, the extrapleural "salinoma" technique was used for computed tomographic-guided mediastinal biopsies in 15 patients. Sampling methods were coaxial (8), tandem (5), and single pass (2). Diagnostic yield was 93% with no significant bleeding or pneumothorax. The salinoma technique permits biopsy of deep mediastinal lesions to stage pulmonary malignancies, while providing a technique that limits complications.

Mediastinal transthoracic needle and core lymph node biopsy: should it replace mediastinoscopy?

STUDY OBJECTIVES

Primary assessment of mediastinal lymph nodes (N2 or N3) for staging lung cancer by transthoracic needle with or without core biopsy. Mediastinoscopy only performed after FNA failed to yield a diagnosis.

DESIGN AND SETTINGS

A retrospective study in a university setting.

PATIENTS

Eighty-nine patients with mediastinal lymphadenopathy (> 1.5 cm in short-axis diameter) by CT.

METHODS

Mediastinal transthoracic fine-needle aspiration (FNA) with or without core biopsy was performed prior to mediastinoscopy in 89 patients with mediastinal lymphadenopathy (lymph node > 1.5 cm in short-axis diameter) or masses by CT.

RESULTS

Mediastinal transthoracic FNA was used alone in 39 of 89 patients, or with core biopsy in 50 of 89 patients. Mediastinal transthoracic FNA with or without core biopsy was diagnostic in 69 of 89 patients (77.5%) for cancer cell type, sarcoidosis, or caseating granulomas with or without tuberculosis. Transthoracic FNA with or without core biopsy of nodal stations (total, 94 biopsies) judged readily accessible by mediastinoscopy (n = 59) included paratracheal (n = 56) and highest mediastinal (n = 3); those more difficult (n = 26) included subcarinal (n = 20) and aorticopulmonary window (n = 6); and those impossible (n = 9) included paraesophageal and pulmonary ligament (n = 6), parasternal (n = 2), and para-aortic (n = 1). Innovative lung protective techniques for CT-guided biopsy access windows included "iatrogenic-controlled pneumothorax" (n = 10) or saline solution injection creating a "salinoma" (n = 11). Pneumothorax was detected in only 10% with a "protective" technique but 60% when traversing lung parenchyma. Transthoracic FNA with or without core biopsy failed to yield a diagnosis in 20 of 89 patients (22.5%); all then underwent mediastinoscopy, with 11 of 20 procedures (55%) diagnostic for cancer, and 9 of 20 procedures diagnostic of benign diagnosis or no cancer.

CONCLUSION

Transthoracic FNA with or without core biopsy accesses virtually all mediastinal nodal stations is diagnostic in 78% of cases with mediastinal adenopathy or masses, and should precede mediastinoscopy in the staging of lung cancer or workup of mediastinal masses.

Thymic malignancies

Thymomas and thymic carcinomas are unique tumors of the anterior mediastinum. The association of a variety of different paraneoplastic syndromes with such lesions has fascinated physicians and researchers for years. Most recently, it has been demonstrated by numerous authors that thymomas are chemosensitive tumors. Their indolent nature and relative rarity have made evaluation through prospective randomized clinical trials extremely difficult. Further information regarding the molecular nature of these neoplasms and immunologic aspects is needed in future investigation.

Current status of the diagnosis and treatment of thymoma

Although thymomas are rare neoplasms, they are the most common tumor of the anterior mediastinum in adults. Preferred therapy for these neoplasms is complete surgical resection. If a thymoma cannot be completely resected, postoperative radiotherapy may produce satisfactory results in controlling the tumor. Significant 5- and 10-year survival rates have been recorded for patients with advanced thymomas who have been treated by radiation therapy alone. Chemotherapy may be used in patients with unresectable thymomas as well, but the results are less promising than with radiotherapy. Combinations of radiotherapy and chemotherapy used on patients with unresectable thymomas have produced encouraging results. Surveillance of patients with thymoma should be prolonged because late recurrence (more than 5 years after initial therapy) can be expected in a significant minority of patients. Aggressive therapy of late recurrence, including resection of new tumor masses and pleural metastases, has yielded successive disease-free intervals that validate persistent treatment.

Value of CT fluoroscopy for percutaneous biopsy procedures

PURPOSE

To assess the clinical impact of computed tomographic (CT) fluoroscopy (CTF) with regard to procedure time and success rate for CT image-guided biopsy procedures.

MATERIALS AND METHODS

One hundred ninety consecutive patients referred to the same radiologist underwent biopsy procedures performed with use of a CT scanner equipped with fluoroscopic capabilities during a 15-month period. CTF procedures were performed predominantly by means of a continuous fluoroscopic technique, with typical exposure factors of 50 mA at 120 kV and a slice thickness of 10 mm. The total procedure time, fluoroscopy time, and complication and procedure success rates were documented prospectively in this group. A control group consisted of retrospective analysis of 93 consecutive patients who had undergone a classic CT-guided procedure performed by the same radiologist.

RESULTS

Procedure success rate was increased in the CTF group (93.7 versus 88.2%), although the difference was not statistically significant (P > .05: Fisher exact test). A statistically significant difference was noted when comparing mean procedure times (CTF, 27.56 minutes; range, 20-60 minutes versus control, 43.17 minutes; range, 35-80 minutes; P < .0001; Welch unpaired t test).

CONCLUSION

CT fluoroscopy facilitates CT-guided biopsy procedures by allowing visualization of the needle trajectory from skin entry to the target point, allowing procedures to be performed more rapidly and efficiently.

Transthoracic hilar and mediastinal biopsy

TNB of the mediastinum is an accurate, safe, and cost-effective diagnostic tool for the evaluation of mediastinal masses and lymphadenopathy. The technique is most useful in the staging of carcinoma, where it serves as a less expensive and minimally invasive alternative to mediastinoscopy for establishing unresectability. With recent advances in immunohistochemical and core biopsy techniques, TNB has become more accurate for establishing the initial diagnosis of lymphoma and for confirming recurrent disease. Core-needle biopsy has improved the accuracy of TNB and is particularly useful when fine-needle aspiration fails to yield a specific diagnosis, or when lymphoma or a noncarcinomatous lesion is suspected.