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

Ultrasound versus computed tomography-guided transthoracic biopsy for pleural and peripheral lung lesions: a systematic review and meta-analysis

BACKGROUND

An accurate diagnosis of peripheral lung and pleural lesions using image-guided transthoracic biopsy procedure becomes a good diagnostic performance protocol.

PURPOSE

To examine the difference between ultrasonography (USG)-guided versus computed tomography (CT)-guided transthoracic biopsy for pleural and peripheral lung lesions by pooling data from published studies.

MATERIAL AND METHODS

PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched for comparative studies up to 20 February 2023 irrespective of the language of publication. The outcomes were adequacy of the sample and complications (pneumothorax and hemothorax).

RESULTS

Two randomized controlled trials (RCTs) and eight non-RCTs were eligible. The total sample size was 1618. Meta-analysis showed that there was no difference in the adequacy of the sample obtained by USG- or CT-guided biopsies; however, an analysis of only non-RCTs indicated better adequacy with USG. On pooled analysis of any pneumothorax, there was a lower risk associated with USG-guided biopsies, but the risk of pneumothorax requiring interventional treatment was not different in the two groups. Similarly, the pooled analysis also demonstrated a reduced risk of hemothorax with USG-guided biopsies.

CONCLUSION

While there seems to be no difference in the adequacy of the sample obtained with either imaging modality, retrospective data show that USG guidance offers better diagnostic yield compared to CT guidance for peripheral lung and pleural biopsies. The risk of pneumothorax and hemothorax is also significantly lower with USG-guided biopsies. Results should be interpreted with caution owing to selection bias among studies. There is a need for large-scale RCTs to enhance current evidence.

Ultrasound-guided core-needle biopsy for peripheral pulmonary lesions: a systematic review and meta-analysis

AIM

To evaluate the diagnostic value and safety of ultrasound-guided core-needle biopsy for peripheral pulmonary lesions (PPLs).

MATERIALS AND METHODS

PubMed, EMBASE, and the Cochrane Library for relevant were searched for studies published up to June 2022. The diagnostic accuracy of US-guided percutaneous transthoracic needle biopsy (PTNB) for the diagnosis of PPLs was evaluated using pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR), and the area under the summary receiver operating characteristic curves value (SROC).

RESULTS

The search included 12 original studies (3,830 procedures). For US-guided PTNB, the pooled sensitivity and specificity for the diagnosis of PPLs were 0.93 (95% confidence interval [CI]: 0.91-0.94) and 0.99 (95% CI: 0.96-1.00), respectively. The pooled estimates of the PLR, NLR, and DOR were 134.88 (95% CI: 24.88-731.74), 0.07 (95% CI: 0.06-0.09), and 1,814.95 (95% CI: 333.62-9,873.76), respectively. The area under the SROC curve was 0.95 (95% CI: 0.93-0.97). The overall complication rate was 3.6% (136 of 3,830), including self-limited haemoptysis and asymptomatic pneumothorax, and only six cases of pneumothorax requiring chest tube drainage and one case of severe bleeding were reported.

CONCLUSIONS

US-guided core-needle biopsy is an excellent diagnostic tool for PPLs, with high accuracy and excellent technical performance and safety.

Enhanced ultrasound-guided versus non-enhanced ultrasound-guided percutaneous needle biopsy in tissue cellularity of lung malignancies: a propensity score matched study

BACKGROUND

Though ultrasound-guided percutaneous lung needle biopsy (US-PLNB) is a first-line small biopsy method for peripheral lung lesions, quality of cellularity in specimens obtained via US-PLNB is uncertain. This study investigated the accuracy, sensitivity, and cellularity of US-PLNB. It examined the ability of contrast-enhanced ultrasound (CEUS) to improve the effectiveness of US-PLNB.

METHODS

We retrospectively analyzed all data of patients with subpleural lung lesions who underwent US-PLNB. The cellularity of US-PLNB from malignant lesions included the tumor cell number and proportion. The definition of high-quality cellularity (HQC) was concurrently achieving a tumor cell number ≥400 and a proportion ≥20%. The sensitivity, the actual numbers of tumor cell number/proportion, and the rate of HQC were calculated and compared between the CEUS and non-enhanced US groups after propensity score matching (PSM) with subgroup analyses by lesion size (small lesion ≤30 mm and large lesion >30 mm).

RESULTS

A total of 345 patients undergoing 345 US-PLNBs were evaluated, with 3.7±1.1 of punctures on average. There were 201 malignant and 144 benign lesions with a mean size of 43.8±24.1 mm. Among the 201 malignant lesions, 124 cases underwent CEUS and 77 underwent non-enhanced US. The quantity of tumor cells, the proportion of tumor cells, and the rate of HQC in 201 cases of US-PLNB from malignant lesions were 2,862.1±2,288.0, 44.6%±24.5%, and 82.1% [95% confidence interval (CI): 76.6% to 87.1%], respectively. The quantity of tumor cells, the proportion of tumor cells, and rate of HQC were significantly higher in the CEUS group than that in the non-enhanced US group, both in the analysis of overall malignant lesions and in large malignant lesions (all P<0.05).

CONCLUSIONS

The US-PLNB has high sensitivity and thereby obtains HQC samples for subpleural lung malignant lesions. The CEUS helps improve the rate of HQC and tissue cellularity of lung malignancies.

Ultrasound-guided interventional radiology procedures in the chest

Ultrasonography is a very good tool for guiding different interventional procedures in the chest. It is the ideal technique for managing conditions involving the pleural space, and it makes it possible to carry out procedures such as thoracocentesis, biopsies, or drainage. In the lungs, only lesions in contact with the costal pleura are accessible to ultrasound-guided interventions. In this type of lung lesions, ultrasound is as effective as computed tomography to guide interventional procedures, but the rate of complications and time required for the intervention are lower for ultrasound-guided procedures.

Ultrasound-guided lung biopsy with coaxial technique: pleural contact length affects the occurrence of pneumothorax after first puncture

PURPOSE

To assess prebiopsy characteristics influencing the occurrence of pneumothorax after first puncture of ultrasound (US)-guided lung biopsy with coaxial technique.

MATERIALS AND METHODS

From January 2007 to September 2018, 180 peripheral lung lesions in 174 patients who underwent B-mode US-guided lung biopsy with coaxial technique at single institution were included in this study. Technical success was defined as the ability to make a diagnosis using the acquired sample with/without an adverse event of pneumothorax. Statistical analyses of prebiopsy characteristics were performed to identify the most important cutpoint and to evaluate the effect on diagnostic accuracy.

RESULTS

Of the 180 lesions (mean size, 37 mm ± 26.2; mean pleural contact length, 38.2 mm ± 34.4), technical success rate was 97.2% (175/180 lesions) and diagnostic accuracy rate was 91.6% (165/180 lesions). Pneumothorax occurred immediately after first puncture for seven of 180 lesions. Classification and regression tree analysis and Fisher's exact test showed the proportion of the pneumothorax immediately after first puncture was higher in lesions with pleural contact length less than 9.78 mm (p = 0.002). No significant difference was shown between the pneumothorax and non-pneumothorax after first puncture in technical success and final diagnosis success rate.

CONCLUSION

Pleural contact length affects the occurrence of pneumothorax after first puncture of US-guided lung biopsy with coaxial technique.

Intraoperative Lung Ultrasound (ILU) for the Assessment of Pulmonary Nodules

Background: The primary aim of this study was to confirm the validity of intraoperative lung ultrasound (ILU) as a safe and effective method of localization for difficult to visualize pulmonary nodules during Video-Assisted Thoracoscopic Surgery (VATS) and open thoracotomy. The secondary aim was to enhance knowledge on the morphological patterns of presentation of pulmonary nodules on direct ultrasound examination. Materials and methods: 131 patients with lung nodule and indication for surgery were enrolled. All patients underwent pre-operative imaging of the chest, including Chest Computed Tomography (CT) and Transthoracic Ultrasound (TUS), and surgical procedures for histological assessment of pulmonary nodules (VATS or open thoracotomy). Results: The identification of 100.00% of lung nodules was allowed by ILU, while the detection rate of digital palpation was 94.66%. It was not possible to associate any specific ILU echostructural pattern to both benign or malignant lesions. However, the actual histological margins of the lesions in the operating samples were corresponding to those visualized at ILU in 125/131 (95.42%) cases. No complications have been reported with ILU employment. Conclusions: In our experience, ILU performed during both open surgery and VATS demonstrated to be a reliable and safe method for visualization and localization of pulmonary nodules non previously assessed on digital palpation. In addition, ILU showed to allow a clear nodule’s margins’ definition matching, in most cases, with the actual histological margins.

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

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

Transthoracic Ultrasound in Infectious Organizing Pneumonia: A Useful Guide for Percutaneous Needle Biopsy

In patients presenting with classical features of CAP (i.e., new peripheral pulmonary consolidations and symptoms including fever, cough, and dyspnea), a clinical response to the appropriate therapy occurs in few days. When clinical improvement has not occurred and chest imaging findings are unchanged or worse, a more aggressive approach is needed in order to exclude other non-infective lesions (including neoplasms). International guidelines do not currently recommend the use of transthoracic ultrasound (TUS) as an alternative to chest X-ray (CXR) or chest computed tomography (CT) scan for the diagnosis of CAP. However, a fundamental role for TUS has been established as a guide for percutaneous needle biopsy (US-PNB) in pleural and subpleural lesions. In this retrospective study, we included 36 consecutive patients whose final diagnosis, made by a US-guided percutaneous needle biopsy (US-PTNB), was infectious organizing pneumonia (OP). Infective etiology was confirmed by additional information from microbiological and cultural studies or with a clinical follow-up of 6–12 months after a second-line antibiotic therapy plus corticosteroids. All patients have been subjected to a chest CT and a systematic TUS examination before biopsy. This gave us the opportunity to explore TUS performance in assessing CT findings of infective OP. TUS sensitivity and specificity in detecting air bronchogram and necrotic areas were far lower than those of CT scan. Conversely, TUS showed superiority in the detection of pleural effusion. Although ultrasound findings did not allow the characterization of chronic subpleural lesions, TUS confirmed to be a valid diagnostic aid for guiding percutaneous needle biopsy of subpleural consolidations.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

The Application of Contrast Enhanced Ultrasound for Core Needle Biopsy of Subpleural Pulmonary Lesions: Retrospective Analysis in 92 Patients

The purpose of this study was to investigate the role of contrast-enhanced ultrasound (CEUS) in determining the viable target area in patients with subpleural pulmonary lesions before ultrasound-guided transthoracic core biopsy. In this retrospective study, we analyzed 92 patients with subpleural pulmonary lesions (63 males and 29 females; mean age: 65.17 ± 11.72 y). All patients underwent B-mode ultrasound, color Doppler and CEUS. Color Doppler was performed to identify the major vessels. The time to enhancement of the contrast agents, homogeneity of enhancement and the presence of areas without enhancement were recorded after administration of the contrast agents. The viable target areas were defined as regions showing enhancement relative to those without enhancement and regions showing delayed enhancement in reference to peripheral lung tissues showing early enhancement. Afterward, real-time ultrasound-guided transthoracic core needle (18 gauge) biopsies were performed and the complication rate, success rate and diagnostic accuracy were calculated. With CEUS, the needle pathways of these lesions were readjusted the biopsy strategy in 40/92 patients (43.5%). It was determined that the satisfactory rate of the subsequent biopsy specimen was 100%. The histologic diagnostic accuracy of the biopsy was 97.83%. No serious complications occurred during the biopsy. In conclusion, the application of CEUS before biopsy was able to depict the viable target areas of the lesion to readjust the biopsy routes. With the help of CEUS, ultrasound-guided core biopsy could obtain adequate samples, improve the diagnostic accuracy and reduce the complication rates of biopsies.

Ultrasound-guided transthoracic needle biopsy of the lung: sensitivity and safety variables

OBJECTIVES

Variables affecting the performance of ultrasound-guided transthoracic needle biopsy (US-TTNB) are not well established. We examined clinical and imaging variables affecting the sensitivity and the complication rates of US-TTNB.

METHODS

We retrospectively reviewed a consecutive series of 528 US-TTNBs performed from 2008 to 2017. Univariate analyses were used to assess the influence of clinical and imaging variables on sensitivity and complication rates. Multivariate logistic regression was used to account for possible confounding variables.

RESULTS

In 397 malignant lesions, the sensitivity of US-TTNB was 72% (95% CI 68-77%; 285/397). The overall pneumothorax rate was 15% (95% CI 12-18%; 77/528), leading to a chest tube in 2% (95% CI 1-3%; 9/528). Multivariate analysis showed that increasing pleural contact length (up to 30 mm) was associated with increased sensitivity (OR 1.08 per mm; 95% CI 1.04-1.12; p < 0.001), and pleural contact length (OR 0.98 per mm; 95% CI 0.97-0.99; p = 0.013), lesion size (OR 0.98 per mm; 95% CI 0.96-0.99; p = 0.006), and core needle diameter of 18G (OR 0.47 as compared with 20G; 95% CI 0.26-0.83; p = 0.010) were associated with a decreased pneumothorax rate. Graphical inspection of cubic splines showed that the probability of a positive biopsy rose sharply with increasing pleural contact length up to 30 mm and was stable thereafter. A similar, but inverse, relationship was observed for the probability of a pneumothorax.

CONCLUSION

Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. Lesion size also predicts pneumothorax rates.

KEY POINTS

• US-TTNB has a high sensitivity and a low complication rate for pleural and pulmonary lesions with pleural contact. • Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. • This study suggests that relying on US-TTNB may not be optimal for lesions < 10 mm for which the risk of pneumothorax is as high as the chance of obtaining diagnosis.

Propensity-score-matching analysis to compare efficacy and safety between 16-gauge and 18-gauge needle in ultrasound-guided biopsy for peripheral pulmonary lesions

Background

Definitive diagnosis of peripheral pulmonary lesions (PPLs) depends on the histological analysis of the pleural biopsy sample. Ultrasound (US)-guided sampling is now standard practice in the clinical setting. However, determining a suitable needle size and sampling times to improve the efficacy and safety of the biopsy remains challenging. Here, we compared the efficacy between 16- and 18-gauge core biopsy needles in US-guided percutaneous transthoracic biopsy for PPLs on histological diagnosis and procedure-related complications.

Materials and methods

In total, 1169 patients (767 men, 402 women; mean age, 59.4 ± 13.2 years) who received biopsy for PPLs between September 2011 and February 2019 were included. The propensity score matching (PSM) analysis was performed to adjust the baseline differences, and the rate of successful specimen assessment and complications were compared between the 16-gauge (249 patients) and 18-gauge (920 patients) groups. The number of pleural surfaces crossed (NOPSC) was defined as the number of times the visceral pleural surface was transgressed. Stratified analysis was performed based on NOPSC.

Results

The overall success rate was 92.0% (1076/1169). The overall complication rate was 9.6%, including pneumothorax, hemorrhage, and vasovagal reaction, which occurred in 2.5% (29/1169), 6.6% (77/1169), and 0.5% (6/1169) of the patients, respectively. When NOPSC was 1 or > 2, the success and complication rates in the 16-gauge group were comparable to those of the 18-gauge group (all P > 0.05). When the NOPSC was 2, the success rate in the 16-gauge group was significantly higher than that in the 18-gauge group (P = 0.017), whereas the complication rate was comparable (P > 0.05).

Conclusion

Higher success rate could be achieved using a 16-gauge than an 18-gauge core biopsy needle in the US-guided percutaneous transthoracic biopsy for PPLs when the NOPSC was 2. We recommend using 16-gauge needles with 2 times of needle passes in biopsy for PPLs in clinical practice.

Ultrasound-guided percutaneous biopsy of thoracic lesions: high diagnostic yield and low complication rate

AIM

To investigate the use of ultrasound (US)-guided biopsy of thoracic lesions aiming to determine diagnostic success and complication rates and to identify factors that may affect sample adequacy and safety.

MATERIAL AND METHODS

This was a retrospective study of consecutive percutaneous US-guided biopsy over 10-year period, including 147 procedures in 146 patients (66 ± 7 years, 83 men, 63 women) with lesions located in the lung (67/147), chest wall (54/147), mediastinum (14/147) and pleura (12/147). Overall diagnostic success, yield for benign and malignant diagnoses and diagnostic success according to lesion location, biopsy type (fine-need aspiration [FNA] or core-needle biopsy [CNB]) and number of specimens were calculated. Presence of complications and effect of age, lesion location, biopsy type, and number of specimens were measured.

RESULTS

The overall diagnostic success rate was 90.5% and was similar for malignant (90.6%) and benign (87.5%) diagnoses. Specimen adequacy was similar for FNA and CNB (91.2% and 88.9%, p=0.66); number of specimens did not affect yield. Diagnostic success was highest for mediastinal and chest wall lesions (92.9% and 94.4%) and lowest for pleural lesions (75%), albeit not statistically significant (p=0.45). Complications occurred in 4/147(2.7%) cases, exclusively in lung lesions, and were not associated with any covariates analysed.

CONCLUSIONS

US-guided biopsy is an effective and safe technique for diagnosis of thoracic lesions, with high diagnostic yield and low complication rate. In the presence of an adequate acoustic window, US guidance can be valuable for diagnosis of peripheral lung and mediastinal lesions. Radiologists performing thoracic biopsy should be encouraged to implement or expand the use of US guidance in their practice.

Should We Perform Transthoracic Trucut Lung Biopsies of Pleural-Based Lung Masses Under Ultrasound Guidance or Computed Tomography Guidance?

We aimed to emphasize which method should be prioritized by comparing the ultrasound and computed tomography (CT) guidance for percutaneous transthoracic biopsy of pleural-based lung lesions in terms of comorbidity, diagnostic success, time, and costs.Approximately 700 biopsy procedures performed between 2014 and 2018 were retrospectively reviewed. The files of these patients and picture archiving and communication system were scanned.Size and localization of the lesion, pathological diagnosis, comorbidity status, pneumothorax complications at the end of the procedure, and whether or not a thoracic tube was placed due to pneumothorax were recorded. Fisher exact test and Pearson χ test were used for statistical analysis.A total of 181 patients who underwent the pleural-based biopsy procedure, the subject of study, were included in the study. One hundred (55.2%) of the biopsy procedures of these patients were performed under the guidance of tomography, and 81 (44.8%) were performed under the guidance of ultrasound (US). Median size of the lesions is 38 mm (25%-75%, 33-55 mm). Pneumothorax complications were observed in 6 patients (6%) who had CT-guided procedures and 4 patients (4.9%) who had US-guided procedures. Of the patients who developed pneumothorax, 2.8% were inserted thoracic tubes owing to the complication. Diagnostic efficacy of our procedures is 99.8% in US-guided procedures and 97% in CT-guided transthoracic biopsy. The average duration of US-guided transthoracic biopsy procedures is 17 minutes, and the average duration of CT-guided biopsy procedures is 35 minutes.

2020 Clinical Practice Guideline for Percutaneous Transthoracic Needle Biopsy of Pulmonary Lesions: A Consensus Statement and Recommendations of the Korean Society of Thoracic Radiology

Percutaneous transthoracic needle biopsy (PTNB) is one of the essential diagnostic procedures for pulmonary lesions. Its role is increasing in the era of CT screening for lung cancer and precision medicine. The Korean Society of Thoracic Radiology developed the first evidence-based clinical guideline for PTNB in Korea by adapting pre-existing guidelines. The guideline provides 39 recommendations for the following four main domains of 12 key questions: the indications for PTNB, pre-procedural evaluation, procedural technique of PTNB and its accuracy, and management of post-biopsy complications. We hope that these recommendations can improve the diagnostic accuracy and safety of PTNB in clinical practice and promote standardization of the procedure nationwide.

Pneumothorax after CT-guided transthoracic lung biopsy: A comparison between immediate and delayed occurrence

Background

In CT-guided transthoracic lung biopsy (CTLB), pneumothorax can occur as a late complication (delayed pneumothorax). The incidence, risk factors, and clinical significance of delayed pneumothorax are not well known.

Objectives

To compare the risk factors for immediate and delayed pneumothorax after CTLB and to know their clinical significance.

Methods

Images and medical records of 536 consecutive patients who underwent CTLB were reviewed. All biopsies were performed as inpatient procedures. Follow-up chest radiographs were obtained at least twice at 4 h after procedure and before discharge. Risk factors for immediate and delayed pneumothorax were assessed based on patient-, lesion-, and procedure-related variables. Rates of chest tube insertion were also compared.

Results

Pneumothorax developed in 161 patients (30.0%) including 135 (25.2%) immediate and 26 (4.9%) delayed cases. Lesion size was an independent risk factor for both immediate and delayed pneumothorax (OR = 0.813; CI = 0.717–0.922 and OR = 0.610; CI = 0.441–0.844, respectively). While emphysema, lower lobe location, and long intrapulmonary biopsy track were risk factors (OR = 1.981; CI = 1.172–3.344, OR = 3.505; CI = 2.718–5.650, and OR = 1.330; CI = 1.132–1.563, respectively) for immediate pneumothorax, upper lobe location and increased number of pleural punctures were independent risk factors (OR = 5.756; CI = 1.634–20.274 and OR = 3.738; CI = 1.860–7.511, respectively) for delayed pneumothorax. The rate of chest tube insertion was significantly (p < 0.001) higher in delayed pneumothorax.

Conclusion

Pneumothorax tends to occur immediately after CTLB in patients with emphysema, lower lobe lesion, and long intrapulmonary biopsy track. Further attention and warnings are needed for those with multiple punctures of small lesions involving upper lobes due to the possibility of delayed development of pneumothorax and higher requirement for chest tube drainage.

Contrast-enhanced ultrasound for needle biopsy of thoracic lesions

Two-dimensional ultrasound (US) and color doppler flow imaging are associated with certain limitations in the preprocedural evaluation and design of the puncture path for biopsies of thoracic lesions, such as a poorly defined boundary between the tumor and the atelectatic lesions in central lung cancer with atelectasis. Contrast-enhanced ultrasound (CEUS) can be valuable in the preoperative evaluation of the biopsy site and in increasing the accuracy of the biopsy. The present study investigated the value of clinical application of CEUS in US-guided core needle biopsy (US-CNB) in improving the diagnostic accuracy in thoracic lesions. A total of 120 patients with first-stage thoracic lesions from the Affiliated Tumor Hospital of Guangxi Medical University who underwent US-CNB were recruited and randomnly assigned to a conventional US group (n=66) and a CEUS group (n=54). All patients underwent preoperative evaluation and US-guided puncture of thoracic lesions. The intergroup differences in sonographic features, biopsy duration, biopsy success rate and complications were assessed. The CEUS group had a higher rate of detection of necrotic tissue (40.7% vs. 16.7%; χ²=8.633; P=0.003) and change of initial puncture path (48.1%) compared with the US group. In central lung cancer with atelectasis, the ability to distinguish between tumor and atelectasis was higher in the CEUS group compared with the conventional US group (31.5 vs. 7.6%; χ²=11.336; P=0.001). In addition, the CEUS group had a higher puncture success (96.3 vs. 80.3%; χ²=6.946; P=0.008) and a lower complication rate (3.7% vs. 18.2%; χ²=6.041; P=0.014) compared with the US group. CEUS can identify necrotic areas and occult tumors within atelectatic lung tissue and can be used for guiding puncture biopsy of thoracic lesions to improve the diagnostic accuracy with greater comparative clinical utility than conventional US. Pre-biopsy CEUS is especially useful for patients undergoing repeated US-CNB and those with hypovascular lesions, atelectasis or necrosis.

Ultrasound-guided percutaneous needle biopsy skill for peripheral lung lesions and complications prevention

Background

To investigate puncture skills and complications prevention in ultrasound-guided percutaneous needle biopsy for peripheral lung lesions.

Methods

Ninety-two peripheral lung lesions in 92 patients, detected via computed tomography (CT) and also visible on ultrasound, were retrospectively analyzed. All patients underwent percutaneous peripheral lung lesion needle biopsy under traditional ultrasound or contrast enhanced ultrasound (CEUS) guidance paying attention to avoiding necrotic areas and large blood vessels. All the specimens were examined histopathologically. Preprocedure all 92 lesions were performed by traditional ultrasonography to evaluate the size, the echogenecity, liquefaction areas and blood flow on color Doppler imaging, some of which were performed by CEUS for evaluating non-enhanced necrosis areas, contrast agent arrival time (AT) and characteristics of blood perfusion.

Results

The histopathologic results of all 92 lesions were as follows: 67 malignant tumors (including 28 adenocarcinomas, 19 squamous cell carcinomas, 6 bronchoalveolar carcinomas, 5 small cell carcinomas, 5 metastatic cancers, 3 poorly differentiated cancers and 1 malignant mesothelioma), 20 benign lesions (including 9 pneumonia, 6 inflammatory pseudotumors and 5 tuberculomas), 5 undetermined lesions. Of 52 lesions by CEUS guidance, 7 lesions showed enhancement in the pulmonary arterial-phase (including 6 pneumonia and 1 malignant tumors), 45 lesions showed enhancement in the bronchial artery phase (including 37 malignant tumors, 3 inflammatory pseudotumors, 4 tuberculomas and 1 undetermined lesion). According to needle insertion angle along linear path, a total of 92 lesions were divided into two groups, 49 lesions at an angle of 70°-80° needle insertion and 43 lesions at an angle of 80°-90° needle insertion. In the study, linear and non-linear two puncture paths were used, we first tried to puncture along linear path in all lesions, if an attempt to insert into the lesions failed due to be blocked by the ribs and then changed to puncture along non-linear path instead. The success rate of biopsy procedure along linear puncture was significantly higher at an angle of 80°-90°group (93.0% vs. 20.4%, P<0.01), and the adoption rate of non-linear path biopsy for solving the puncture needle blocked by the ribs was significantly higher at angle of 70°-80°group (79.6% vs. 7.0%, P<0.01). Of 52 lesions by CEUS guidance, 27 (51.9%) showed non enhanced necrosis areas on CEUS, only 5 showed liquefaction necrosis areas on gray-scale ultrasound. Of 40 lesions by traditional ultrasound guidance, 4 showed necrosis areas on gray-scale ultrasound. There were no significant differences in lesion size, the average number of biopsy attempts and complication rates between CEUS guidance group and traditional ultrasound guidance group (P>0.05), the pathological confirmation rate in CEUS guidance group was higher than that in traditional ultrasound guidance group, but without significant difference (98.1% vs. 90.0%, P>0.05). Of all 92 cases, 3 cases (3.3%) had mild pneumothorax and 4 cases (4.3%) had hemoptysis.

Conclusions

In ultrasound-guided needle biopsy for peripheral lung lesions, using a combination of linear and non-linear puncture techniques and keeping away from necrotic areas and large blood vessels, may help to increase the success rate and reduce the incidence of complications further.

Diagnostic value and safety of color doppler ultrasound-guided transthoracic core needle biopsy of thoracic disease

Objective: The aim of the present study was to explore the diagnostic value and safety of color Doppler ultrasound (US)-guided transthoracic core needle biopsy (CNB) of peripheral lung, chest wall and mediastinal lesions using automated biopsy guns.Materials and methods: We analyzed clinical and image data, histopathologic and microbiologic details and complications from 121 patients with peripheral lung, chest wall and mediastinal lesions who underwent color Doppler US-guided transthoracic CNB in Ningbo First Hospital between January 2015 and June 2018.Results: Color Doppler US-guided transthoracic CNB performed with a freehand technique using automated biopsy guns had a sensitivity of 93.94%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 78.57%, and a diagnostic accuracy of 95.04%. Lesion size did not affect the diagnostic rate (P=0.40). No serious complications of the procedure were noted.Conclusion: Color Doppler US-guided transthoracic CNB of peripheral lung, chest wall and mediastinal lesions is a safe and inexpensive procedure. The diagnostic accuracy of color Doppler US-guided transthoracic CNB was higher than that of color Doppler US-guided transthoracic fine needle aspiration biopsy (FNAB).

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

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

Efficacy and safety of ultrasound (US) guided percutaneous needle biopsy for peripheral lung or pleural lesion: comparison with computed tomography (CT) guided needle biopsy

Background

Ultrasound (US)-guided percutaneous needle biopsy is a useful diagnostic technique with short examination time and real-time monitoring at the bedside. However, there are only a few studies that report on thoracic lesions, whereas the computed tomography (CT)-guided biopsy is well established. There is also limited data comparing US- and CT-guided biopsy. We aimed to clarify the efficacy and safety of US-guided biopsy for thoracic lesions adjacent to the chest wall.

Methods

We retrospectively enrolled consecutive patients who underwent US- or CT-guided percutaneous biopsies for thoracic lesions adjacent to the chest wall between April 2012 and December 2017. Clinical characteristics, lesion size, lesion-pleura contact arc length (LPCAL), diagnostic rate, and complications were compared between the 2 groups.

Results

This study enrolled 61 US-guided and 70 CT-guided biopsies. No significant difference was found in age or sex. The lesion size and LPCAL in the US-guided group were significantly larger than those in the CT-guided group (P<0.0001). The diagnostic rate was marginally higher in the US-guided group (93.4%) than in the CT-guided group (84.3%) (P=0.101). When the median cut-off of the LPCAL was defined as 40 mm in all cases, the diagnostic rate for lesion size >40 mm was significantly higher in the US-guided group than in the CT-guided group (P=0.009). Complication rates were significantly lower in the US-guided group (3.3%) than in the CT-guided group (24.3%) (P<0.001).

Conclusions

US-guided percutaneous needle biopsy for thoracic lesions adjacent to the chest wall is a feasible technique compared with CT-guided biopsy because of its higher diagnostic rate with a longer LPCAL and reduced complications.

The application of conventional us and transthoracic ultrasound elastography in evaluating peripheral pulmonary lesions

The aim of the present study was to evaluate the diagnostic value of ultrasound (US) elastography in differentiating between benign and malignant peripheral lung lesions (PLLs). This retrospective study included 91 consecutive patients with 91 PLLs. Conventional US, strain elastography (SE), acoustic radiation force impulse imaging (ARFIimaging) and point share wave elastography (p-SWE) were performed. All of the pathological results were confirmed by US-guided biopsies or surgeries. There were 36 benign PLLs and 55 malignant PLLs on pathology. For conventional US, a lesion diameter ≥5 cm, irregular contour, presence of air bronchogram and non-abundant vascularity were predictive factors of malignancy (P<0.05). SE scores were observed to be invalid in differentiating between malignant and benign PLLs (P=0.542). For ARFIimaging scores, an elasticity score of 3 or greater was predictive of malignancy, with a sensitivity of 83.6% (46/55) and a specificity of 52.8% (19/36). For p-SWE, the share wave velocity of malignant PLLs was higher than benign ones (2.47±0.92 vs. 1.85±0.92 m/sec; P=0.0022). When 1.951 m/sec was selected as the cut-off value, a sensitivity of 70.9% (39/55) and a specificity of 69.4% (25/36) were obtained. Thus, US, particularly US elastography, is helpful in distinguishing malignant PLLs from benign PLLs.

Ultrasound Guidance Versus CT Guidance for Peripheral Lung Biopsy: Performance According to Lesion Size and Pleural Contact

OBJECTIVE

The purpose of this study was to compare efficacy and safety of biopsy guided by ultrasound (US) versus CT for lung lesions with pleural contact.

MATERIALS AND METHODS

Among 1269 image-guided thoracic biopsies obtained at our institution between 2004 and 2016, 150 were US-guided for lung lesions with pleural contact (78 men, 72 women; mean age, 67 years). Of those, 94 were performed using US only; 56 had initial CT localization. A comparison cohort of 100 consecutive CT-guided biopsies for lung lesions with pleural contact was identified (60 men, 40 women; mean age, 65 years). Biopsy type, number of passes, sample adequacy, final pathologic results, complications, procedural time, lesion diameter, and pleural contact were recorded. Fisher exact and t tests were used for statistical analysis.

RESULTS

US-guided biopsy was associated with fewer complications (7%) than CT-guided procedures (24%; p < 0.001). Mean procedure times (± SD) were shorter with US only (31 ± 16 min) than with CT only (45 ± 26 min; p < 0.001) or US with CT localization (45 ± 18 min; p < 0.001). Procedural times were longer for patients with small lesions and those with lesser pleural contact. Sample adequacy was best when core biopsy was performed with US and CT. Fewer passes were performed with US guidance than with CT guidance (mean, 3.1 ± 1.8 vs 4.4 ± 1.9, respectively, p < 0.001), with a trend toward improved pathologic adequacy (98% vs 93%, respectively, p = 0.122). Subgroup analysis showed fewer complications for lesions 31-50 mm (p = 0.029), improved sample adequacy for lesions 10-30 mm (p = 0.0032), and shorter procedural times for lesions 10-30 mm (p = 0.0001) with US than with CT.

CONCLUSION

US guidance should be considered for biopsy of peripheral lung and pleural lesions larger than 10 mm, because it is safer, faster, and possibly more accurate than CT guidance.

Assessment of thoracic ultrasound in complementary diagnosis and in follow up of community-acquired pneumonia (cap)

Background

Chest X-ray (CXR) is the primary diagnostic tool for community-acquired pneumonia (CAP). Some authors recently proposed that thoracic ultrasound (TUS) could valuably flank or even reliably substitute CXR in the diagnosis and follow-up of CAP. We investigated the clinical utility of TUS in a large sample of patients with CAP, to challenge the hypothesis that it may be a substitute for CXR.

Methods

Out of 645 consecutive patients with a CXR-confirmed CAP diagnosed in the emergency room of our hospital over a three-years period, 510 were subsequently admitted to our department of Internal Medicine. These patients were evaluated by TUS by a well-trained operator who was blinded of the initial diagnosis. TUS scans were performed both at admission and repeated at day 4-6th and 9-14th during stay.

Results

TUS identified 375/510 (73.5%) of CXR-confirmed lesions, mostly located in posterior-basal or mid-thoracic areas of the lungs. Pleural effusion was detected in 26.9% of patients by CXR and in 30.4% by TUS. TUS documented the change in size of the consolidated areas as follows: 6.3 ± 3.4 cm at time 0, 2.5 ± 1.8 at 4-6 d, 0.9 ± 1.4 at 9-14 d. Out of the 12 patients with delayed CAP healing, 7 of them turned out to have lung cancer.

Conclusions

TUS allowed to detect lung consolidations in over 70% of patients with CXR-confirmed CAP, but it gave false negative results in 26.5% of cases. Our longitudinal results confirm the role of TUS in the follow-up of detectable lesions. Thus, TUS should be regarded as a complementary and monitoring tool in pneumonia, instead of a primary imaging modality.

State of the art thoracic ultrasound: intervention and therapeutics

The use of thoracic ultrasound outside the radiology department and in everyday clinical practice is becoming increasingly common, having been incorporated into standards of care for many specialties. For the majority of practitioners, their experience of, and exposure to, thoracic ultrasound will be in its use as an adjunct to pleural and thoracic interventions, owing to the widely recognised benefits for patient safety and risk reduction. However, as clinicians become increasingly familiar with the capabilities of thoracic ultrasound, new directions for its use are being sought which might enhance practice and patient care. This article reviews the ways in which the advent of thoracic ultrasound is changing the approach to the investigation and treatment of respiratory disease from an interventional perspective. This will include the impact of thoracic ultrasound on areas including patient safety, diagnostic and therapeutic procedures, and outcome prediction; and will also consider potential future research and clinical directions.

Ultrasound-guided versus computed tomography-scan guided biopsy of pleural-based lung lesions

Background:

Computed tomography (CT) guided biopsies have long been the standard technique to obtain tissue from the thoracic cavity and is traditionally performed by interventional radiologists. Ultrasound (US) guided biopsy of pleural-based lesions, performed by pulmonologists is gaining popularity and has the advantage of multi-planar imaging, real-time technique, and the absence of radiation exposure to patients. In this study, we aim to determine the diagnostic accuracy, the time to diagnosis after the initial consult placement, and the complications rates between the two different modalities.

Methods:

A retrospective study of electronic medical records was done of patients who underwent CT-guided biopsies and US-guided biopsies for pleural-based lesions between 2005 and 2014 and the data collected were analyzed for comparing the two groups.

Results:

A total of 158 patients underwent 162 procedures during the study period. 86 patients underwent 89 procedures in the US group, and 72 patients underwent 73 procedures in the CT group. The overall yield in the US group was 82/89 (92.1%) versus 67/73 (91.8%) in the CT group (P = 1.0). Average days to the procedure was 7.2 versus 17.5 (P = 0.00001) in the US and CT group, respectively. Complication rate was higher in CT group 17/73 (23.3%) versus 1/89 (1.1%) in the US group (P < 0.0001).

Conclusions:

For pleural-based lesions the diagnostic accuracy of US guided biopsy is similar to that of CT-guided biopsy, with a lower complication rate and a significantly reduced time to the procedure.

Clinical value of contrast-enhanced ultrasound in improving diagnostic accuracy rate of transthoracic biopsy of anterior-medial mediastinal lesions

Objective

To evaluate the clinical value of contrast-enhanced ultrasound (CEUS) in transthoracic biopsy of anterior-medial mediastinal lesions.

Methods

A total of 123 patients with anterior or middle mediastinum lesions required ultrasound guided transthoracic biopsy for pathological diagnosis. Among them, 72 patients received CEUS examinations before biopsy. After CEUS, 8 patients were excluded from biopsy and the rest 64 patients underwent biopsy (CEUS group). During the same period, 51 patients received biopsy without CEUS examination (US group). The ultrasonography characteristics, the number of biopsy puncture attempts, diagnostic accuracy rate and the incidence of complications were recorded and compared between the two groups.

Results

A large portion of necrosis area or superficial large vessels was found in 8 patients, so the biopsy was cancelled. The internal necrosis was demonstrated in 43.8% of the lesions in CEUS group and in 11.8% of US group (P>0.001). For thymic carcinoma, CEUS increased the detection rate of internal necrosis and pericardial effusion than conventional ultrasound (62.5% vs. 18.8%, P=0.012; 56.3% vs. 12.5%, P=0.023). The average number of punctures in CEUS group and US group was 2.36±0.70 and 2.21±0.51 times, respectively (P>0.05). The diagnostic accuracy rate of biopsy in CEUS group (96.9%, 62/64) was significantly higher than that in US group (84.3%, 43/51) (P=0.022). In US group, 2 patients suffered from mediastinal bleeding (3.9%), while no major complications occurred in CEUS group.

Conclusions

CEUS examination provided important information before transthoracic mediastinum biopsy and improved diagnostic accuracy rate in biopsy of anterior and middle mediastinum lesions than conventional ultrasound.

Benefit of Chest Ultrasonography in the Diagnosis of Peripheral Thoracic Lesions in an Interventional Pulmonology Unit

INTRODUCTION AND OBJECTIVES

The use of ultrasound in peripheral thoracic lesions offers advantages over other radiological guiding methods. This diagnostic procedure has been applied in most studies published by radiologists. Our aim was to determine the diagnostic efficacy of percutaneous ultrasound-guided punctures and biopsies of peripheral thoracic lesions performed by pulmonologists.

METHODOLOGY

A retrospective analysis of 58 patients who underwent real-time ultrasound-guided transthoracic punctures and biopsy of peripheral thoracic lesions between March 2011 and September 2014 in the pulmonology department of our hospital. Cases were classified into the following diagnostic categories: malignant, benign and non-diagnostic (non-specific benign without evidence of malignancy and insufficient specimen).

RESULTS

A conclusive diagnosis was obtained in 47 procedures (81%), of which 13 (22.4%) were specific benign lesions and 34 (58.6%) cancers. In the remaining 11 (19%) patients, a non-diagnostic result was obtained [non-specific benign in 5 cases (8.6%) and insufficient specimen in 6 (10.3%)]. Sensitivity was 75.6%, negative predictive value was 54.2%, specificity and positive predictive value were 100%, and diagnostic accuracy was 81%. Excluding procedures with insufficient specimens, the results were 87.2%, 72.3%, 100%, 100% and 90.4% respectively. There were no serious complications.

CONCLUSIONS

Percutaneous ultrasound-guided puncture and biopsy in the diagnosis of peripheral thoracic lesions performed by pulmonologists is a safe procedure with high diagnostic accuracy. We achieved similar results to those previously obtained by radiologists.

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

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Contrast-Enhanced Ultrasound in Selection Indication and Improveing Diagnosis for Transthoracic Biopsy in Peripheral Pulmonary and Mediastinal Lesions

Objective. To investigate the value of contrast-enhanced ultrasound (CEUS) in transthoracic biopsy of peripheral lung and mediastinal lesions. Methods. Of 142 patients, 82 patients received CEUS before biopsy and were defined as CEUS group. The remaining 60 patients only underwent conventional ultrasound (US) before biopsy and were served as US group. The information of CEUS was used for selecting indication and instructing biopsy. The imaging features, number of punctures, diagnostic successful rate, and complication rate between the two groups were compared. Results. Necrosis was demonstrated in 43.9% of the lesions in CEUS group and in 6.7% of US group (P < 0.001). Detection rate of lesion hidden in pulmonary atelectasis in CEUS group was 13.4%, which was statistically higher than 1.7% of US group (P = 0.013). The diagnostic success rate was 96.3% for CEUS group and 80% for US group, respectively (P = 0.002). The average number of punctures was 2.5 ± 0.7 and 2.6 ± 0.6, respectively. There was no significant difference in complications between CEUS group and US group. Conclusions. CEUS could play an important role in selecting proper indication and improving diagnostic accuracy rate of lung biopsy.