Ultrasound-guided aspiration biopsy of small peripheral pulmonary nodules

Augmented reality-assisted localization of solitary pulmonary nodules for precise sublobar lung resection: a preliminary study using an animal model

Background

Accurate localization of early lung cancer, manifested as solitary pulmonary nodules (SPNs) on computed tomography (CT), is critical in sublobar lung resection. The AR-assisted localization of SPNs was evaluated using a pig animal model.

Methods

A Microsoft HoloLens AR system was used. First, a plastic thoracic model was used for the pilot study. Three female 12 months 45 kg Danish Landrace Pigs were then used for the animal study. Thirty natural pulmonary structures, such as lymphonodus and bifurcated bronchioles or bronchial vessels, were chosen as simulated SPNs. The average angle between the actual puncturing needle and the expected path, the average distance between the puncture point and the plan point, and the difference between the actual puncturing depth and expected depth were recorded, and the accuracy rate was calculated.

Results

The point selected in the plastic thoracic model could be hit accurately with the assistance from the AR system in the pilot study. Moreover, the average angle between the actual puncturing needle and the expected path was 14.52°±6.04°. Meanwhile, the average distance between the puncture point and the expected point was 8.74±5.07 mm, and the difference between the actual and expected depths was 9.42±7.95 mm. Puncturing within a 1 cm³ area around the SPN using a hook-wire was considered a successful hit. The puncture accuracy was calculated. The average hit rate within a spherical area with a diameter of 1 cm range was 76.67%, and within a diameter of 2 cm range was 100%.

Conclusions

The HoloLens AR-assisted localization of SPNs may become a promising technique to improve the surgical treatment of early-stage lung cancer. Here, we evaluated its feasibility in an animal model. Nevertheless, its safety and effectiveness require further investigation in clinical trials.

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.

Hemoptysis complicating ultrasound-guided transthoracic needle lung biopsy: air bronchial sign is a risk predictor

Background

Hemoptysis is the most frequently reported complication of ultrasound-guided transthoracic needle lung biopsy (US-TTLB). However, factors influencing the occurrence of hemoptysis as a result of US-TTLB remain uncertain. Therefore, the aim of this study was to evaluate the incidence of hemoptysis as a complication of US-TTLB and to identify the related risk factors.

Methods

We retrospectively analyzed all data of patients who underwent US-TTLB from February 2013 through December 2016. The incidence, severity, and treatment of hemoptysis in each case were carefully recorded. Study variables were classified into patient-related factors (age, sex, smoking history, pulse oxygen saturation, laboratory tests and emphysema), biopsy-related factors (use of contrast agent, number of punctures and operators), and lesion-related factors (lesion location, size, pathology, length of puncture path and the grade of air bronchial sign). Univariate and multivariate logistic regression analyses were performed to analyze the risk factors of hemoptysis. We investigated whether incidence of hemoptysis increased according to increased grade of air bronchial sign by Mantel-Haenszel test.

Results

A total of 209 patients were evaluated. Hemoptysis occurred in 20 of the 209 patients (9.6%). In univariate analysis, the lesion pathology (P=0.037) and grade of air bronchial sign (P<0.001) were statistically significant factors between the hemoptysis group and the non-hemoptysis group. In multivariate analysis, the presence of multi-air bronchogram in sonographic image (odds ratio =8.946; 95% confidence interval: 2.873–27.863; P<0.001) was a statistically significant predictive risk factor for hemoptysis complicating US-TTLB. There was a significant tendency for incidence of hemoptysis with the grade of air bronchial sign (P<0.001).

Conclusions

We found that the rate of hemoptysis complicating US-TTLB was 9.6% and the severity of hemoptysis was not serious. Target lesion without air bronchogram is a safety sign, minor bronchogram means relatively low-risk, while multiple bronchogram is a highly dangerous ultrasound sign of hemoptysis.

Lung ultrasonography in pulmonary tuberculosis: A pilot study on diagnostic accuracy in a high-risk population

OBJECTIVES

The validity of lung ultrasound (LUS) in the diagnosis of interstitial or focal lung pathologies is well documented, we assessed its accuracy in the diagnosis of pulmonary tuberculosis (PTB).

METHODS

Sonographic signs suggestive of PTB and their diagnostic accuracy were evaluated in patients admitted with clinical suspicion of PTB. Consolidations, subpleural nodules, pleural thickenings or irregularities and pleural effusion were assessed. LUS signs significantly associated with PTB in the univariate analysis (p < .05) were entered in a multivariate logistic regression model.

RESULTS

PTB was confirmed in 51 out of 102 patients. Multiple consolidations (OR 3.54, 95%CI 1.43-8.78), apical consolidations (OR 9.65, 95%CI 3.02-30.78), superior quadrant consolidations (OR 4.01, 95%CI 1.76-9.14), and subpleural nodules (OR 5.29, 95%CI 2.27-12.33) were significantly associated with PTB diagnosis. Apical consolidation (OR 9.67, 95%CI 2.81-33.25, p 0.003) and subpleural nodules (OR 5.30, 95%CI 2.08-13.52, p 0.005) retained a significant association in a multivariate model, with an overall accuracy of 0.799.

CONCLUSIONS

Our data suggest a possible role of LUS in the diagnosis of PTB, a high burden pathological condition for which the delay in diagnosis still represents a critical point in the control of the disease.

[Advancement of Common Localization of Solitary Pulmonary Nodules for Video-assisted Thracoscopic Surgery]

最近，伴随着高分辨多层电子计算机断层扫描（computed tomography, CT）的大量普及，肺小结节的诊断也日益增多，尤其是在伴有肺癌高危因素的患者行CT筛查时尤为明显。电视辅助胸腔镜手术对于肺小结节的诊断和治疗提供了一种全新的微创治疗方式，胸腔镜手术后给患者带来的疼痛感减少、住院时间缩短、手术并发症减少等特点，使其推广更为广泛。如何精准定位及标记病灶，以助电视胸腔镜下切除病灶的方法层出不穷。本文综述近年来胸腔镜下肺小结节定位的各种技术手段，并对各种方法的利弊进行总结及分析。

The diagnostic yield using ultrasound-guided needle-aspiration for subpleural primary lung cancer is not affected by the radiological properties of the lesions resulting from computed tomography

BACKGROUND

It is well known that ultrasound-guided needle-aspiration (USGNA) for intrapulmonary subpleural lesion in contact with the pleura is useful and safe, and its diagnostic yield is high. However, reports concerned with the analyses of cases with intrapulmonary subpleural lesion which could not be diagnosed using USGNA are limited. The objective of this study is to clarify the radiological properties of subpleural primary lung cancer which obstruct diagnosis by USGNA.

METHODS

The consecutive cases with subpleural primary lung cancer whose radiological properties could be confirmed by thoracic computed tomography (CT) without contrast enhancement (CE), and examined by USGNA at our hospital between January 1999 and December 2014 have been analyzed. All cases were given pathological diagnoses of primary lung cancer. The diagnostic yield by USGNA was calculated, and the properties of the lesions of the subjects were analyzed by means of thoracic CT without CE images and pathological findings.

RESULTS

87 consecutive cases (41-86 year olds, 75 males, 12 females) were analyzed. The overall diagnostic yield by USGNA was 86.2%. There was no statistically significant difference regarding the diagnostic yield concerning radiological properties such as cavities, small airspaces and low density areas in the lesions and their sizes. However, the diagnostic yield for the cases with squamous cell carcinoma was statistically significantly low (p=0.02).

CONCLUSION

Although the diagnostic yield of USGNA is not distorted by the radiological properties of lesions, it is statistically significantly low in cases with squamous cell carcinoma.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Difficult biopsy and drainage: just say yes

Abdominal radiologists are often asked to perform difficult percutaneous chest, abdomen, and pelvis biopsies and drainages with imaging guidance. Many of these procedures involve small target lesions far from the skin surface, in close proximity to critical structures. Organ location is changeable due to respiration, peristalsis, and pulsation, further complicating the planning process. High-level three-dimensional spatial awareness is critical to mastery of complex image-guided procedures. A comprehensive grasp of anatomy and expected changes can be exploited in certain cases to target lesions within a solid organ or to avoid injury to sensitive structures during biopsy, drain placement, or thermal ablation. In this article, we will use illustrative cases to explore the use of anatomic knowledge and the ability to synthesize this three-dimensional data dynamically during planning and execution of difficult CT- and ultrasound-guided procedures. We will discuss unusual biopsy requests-such as bowel biopsies-and the benefits of using ultrasound guidance for certain procedures in the chest. Additionally, we will describe multiple special techniques, including out of standard plane angulation and endocavitary techniques, in order to maximize chances of success.

Transthoracic needle biopsy of the lung

BACKGROUND

Image guided transthoracic needle aspiration (TTNA) is a valuable tool used for the diagnosis of countless thoracic diseases. Computed tomography (CT) is the most common imaging modality used for guidance followed by ultrasound (US) for lesions abutting the pleural surface. Novel approaches using virtual CT guidance have recently been introduced. The objective of this review is to examine the current literature for TTNA biopsy of the lung focusing on diagnostic accuracy and safety.

METHODS

MEDLINE was searched from inception to October 2015 for all case series examining image guided TTNA. Articles focusing on fluoroscopic guidance as well as influence of rapid on-site evaluation (ROSE) on yield were excluded. The diagnostic accuracy, defined as the number of true positives divided by the number of biopsies done, as well as the complication rate [pneumothorax (PTX), bleeding] was examined for CT guided TTNA, US guided TTNA as well as CT guided electromagnetic navigational-TTNA (E-TTNA). Of the 490 articles recovered 75 were included in our analysis.

RESULTS

The overall pooled diagnostic accuracy for CT guided TTNA using 48 articles that met the inclusion and exclusion criteria was 92.1% (9,567/10,383). A similar yield was obtained examining ten articles using US guided TTNA of 88.7% (446/503). E-TTNA, being a new modality, only had one pilot study citing a diagnostic accuracy of 83% (19/23). Pooled PTX and hemorrhage rates were 20.5% and 2.8% respectively for CT guided TTNA. The PTX rate was lower in US guided TTNA at a pooled rate of 4.4%. E-TTNA showed a similar rate of PTX at 20% with no incidence of bleeding in a single pilot study available.

CONCLUSIONS

Image guided TTNA is a safe and accurate modality for the biopsy of lung pathology. This study found similar yield and safety profiles with the three imaging modalities examined.

Do respiratory comorbidities limit the diagnostic usefulness of ultrasound-guided needle aspiration for subpleural lesions?

BACKGROUND

The usefulness of ultrasound-guided needle aspiration for subpleural lesions has been reported. However, no reports have evaluated its usefulness and safety in patients with respiratory comorbidities such as chronic obstructive pulmonary disease (COPD) and interstitial pneumonia (IP), which can increase the risk of iatrogenic pneumothorax. In this study, we evaluated the influence of chronic respiratory diseases (CRDs) on the usefulness and safety of ultrasound-guided needle aspiration for subpleural lesions.

METHODS

Between January 2000 and September 2011, we examined 144 patients with intrapulmonary subpleural lesions. We retrospectively reviewed clinical data, including lesion size on thoracic computed tomography (CT), ultrasound findings, pathological findings obtained by ultrasound-guided needle aspiration, final diagnosis, and complications.

RESULTS

A positive definitive diagnosis was obtained in 74.3% of all 144 patients; 84.7% patients with malignant diseases, including lung cancer; and 26.9% patients with benign diseases. Of the 144 patients, 64 belonged to the CRD group and 80 to the non-CRD group. The former included 31 patients with COPD, six with emphysematous changes on thoracic CT, 17 with IP, and 10 with other diseases. The positive rate of diagnosis for malignant diseases was 84.7% in the CRD group, which was the same as that in the non-CRD group. With regard to complications related to ultrasound-guided aspiration, there were only two cases of pneumothorax in the CRD group and one in the non-CRD group.

CONCLUSION

Ultrasound-guided aspiration is safe and useful for subpleural lesions, particularly malignant lesions, even in patients with respiratory comorbidities such as COPD and IP.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae

OBJECTIVES

To create a state-of-the-art overview of the new and expanding role of ultrasonography in clinical decision-making, intervention and management of the upper and lower airways, that is clinically relevant, up-to-date and practically useful for clinicians.

METHODS

This is a narrative review combined with a structured Medline literature search.

RESULTS

Ultrasonography can be utilised to predict airway difficulty during induction of anaesthesia, evaluate if the stomach is empty or possesses gastric content that poses an aspiration risk, localise the essential cricothyroid membrane prior to difficult airway management, perform nerve blocks for awake intubation, confirm tracheal or oesophageal intubation and facilitate localisation of tracheal rings for tracheostomy. Ultrasonography is an excellent diagnostic tool in intraoperative and emergency diagnosis of pneumothorax. It also enables diagnosis and treatment of interstitial syndrome, lung consolidation, atelectasis, pleural effusion and differentiates causes of acute breathlessness during pregnancy. Patient safety can be enhanced by performing procedures under ultrasound guidance, e.g. thoracocentesis, vascular line access and help guide timing of removal of chest tubes by quantification of residual pneumothorax size.

CONCLUSIONS

Ultrasonography used in conjunction with hands-on management of the upper and lower airways has multiple advantages. There is a rapidly growing body of evidence showing its benefits.

TEACHING POINTS

• Ultrasonography is becoming essential in management of the upper and lower airways. • The tracheal structures can be identified by ultrasonography, even when unidentifiable by palpation. • Ultrasonography is the primary diagnostic approach in suspicion of intraoperative pneumothorax. • Point-of-care ultrasonography of the airways has a steep learning curve. • Lung ultrasonography allows treatment of interstitial syndrome, consolidation, atelectasis and effusion.

An update on the evaluation and management of small pulmonary nodules

The widespread utilization of chest CT scans has increased the importance of the proper evaluation of incidentally found lung nodules. The primary goal in the evaluation of these nodules is to determine whether they are malignant or benign. Clinical factors such as older age, tobacco smoking, and current or remote history of malignancy increase the pretest likelihood of malignancy. Radiological features of these nodules are important in differentiating benign from malignant lesions. However, the etiology of the lung nodules frequently remains indeterminate and requires further evaluation. The approach to the management of indeterminate lung nodules ranges between observation with repeat chest CT scan, further diagnostic studies such as PET scan or invasive procedures to obtain tissue diagnosis. This article reviews the importance of the different radiological features of lung nodules. This is followed by an update on the approach to the management of the different types of small lung nodules.

Evaluation of precision of guidance techniques in image guided fine needle aspiration cytology of thoracic mass lesions

Background:

Transthoracic fine needle aspiration cytology (FNAC) is an established and safe technique for diagnosis of thoracic mass lesions. Computed tomography (CT) scan depicts clear anatomical details and provides access to any area of the body. It is, however, expensive and the needle is not passed in real time. Ultrasound is cheaper, radiation free, and allows real time monitoring. Its limitations are obscurement of lesions by aerated lung, smaller, deep seated, and cavitary lesions.

Aims:

This study aims to compare sensitivity and specificity of CT scan and ultrasonography (USG) in thoracic FNAC.

Materials and Methods:

The study was conducted on patients who presented with thoracic mass lesions in lungs, mediastinum, hilar lymph nodes, thoracic vertebrae, paraspinal soft tissue, and pleura. One hundred and twenty patients were studied. Only those cases in which sonographic guidance was not possible were taken up for CT guided FNAC. The lesions were assigned to benign and malignant categories and into specific diagnoses where possible. Biopsy correlation was available in 113 cases. Patients were lost to follow-up in five lung and two mediastinal masses.

Statistical Analysis:

Statistical tests applied included diagnostic tests for sensitivity and specificity.

Results:

An accuracy of 70.8% was found for image guided FNACs with a sensitivity and specificity of 92.2% and 100%, respectively. CT had a sensitivity of 93.2% and specificity of 100%. For USG guidance, the same was 91.3% and 100%, respectively.

Conclusions:

Precision of USG and CT scan is comparable for guidance in FNAC from thoracic mass lesions.

Ultrasound-guided Fine Needle Aspiration Biopsy of Pleural-based Intrathoracic Lesions

BACKGROUND

Pleural-based intrathoracic lesions pose a diagnostic challenge. Image-guided percutaneous biopsy with fluoroscopy, computed tomography (CT) scan, and ultrasound (US) have been used to establish a diagnosis. We report the yield of US-guided fine needle aspiration biopsy (FNAB) of these lesions at our center.

METHODS

Twenty patients with pleural-based intrathoracic lesions underwent US-guided FNAB. All were considered to have an unresectable malignant process based on clinical evaluation. Nineteen patients had pleural-based parenchymal lesion and 1 had an anterior mediastinal mass touching the chest wall.

RESULTS

Twenty patients underwent 21 US-guided FNAB procedures. A final diagnosis was established in all the patients: 19 malignancies and 1 benign lesion. US-guided FNAB established a diagnosis of malignancy in 17 of 19 patients (89.5%) in the first attempt. In 1 patient, a diagnosis of malignancy was made on a repeat US-guided FNAB, increasing the overall yield to 18 of 19 (95%). In 1 patient with a nondiagnostic US-guided FNAB, a diagnosis of malignancy was established with CT scan-guided FNAB. US-guided FNAB was able to diagnose 15 of 16 cases of non-small cell carcinoma and 3 of 3 (100%) small cell carcinoma. In 1 patient with benign lesion, US-guided FNAB showed pulmonary macrophages. This patient was diagnosed as having pneumonia after antibiotic therapy and repeat CT scan showed complete resolution. For a diagnosis of malignancy, US-guided FNAB had 94.7% sensitivity, 100% specificity, 95% diagnostic accuracy, 100% positive predictive value, and 50% negative predictive value. There were no major complications.

CONCLUSIONS

US-guided FNAB of pleural-based intrathoracic lesions is a rapid, simple, and safe procedure with a high yield for malignancy.

Computed tomography-guided fine needle aspiration cytology of solitary pulmonary nodules suspected to be bronchogenic carcinoma: Experience of a general hospital

BACKGROUND

Fine needle aspiration cytology (FNAC) may be diagnostic in candidates with indeterminate solitary pulmonary nodules (SPNs) suspicious of bronchogenic carcinoma.

AIMS

The study was performed to evaluate the usefulness of computed tomography (CT)-guided FNAC in our centre.

MATERIALS AND METHODS

All the cases had a strong clinical suspicion of lung cancer, negative bronchoscopy, negative sputum cytology for malignant cells and acid fast bacilli. A thorough radiological evaluation was made to rule out primary malignancy elsewhere.

RESULTS

A total of 94 patients were studied in one year. May-Grünwald-Giemsa stain was used for the smears. The cytological diagnosis was correlated with clinical-radiological follow-up and biopsy to arrive at a final diagnosis. The procedure had a high sensitivity and specificity. Chi-square test was used to calculate statistical significance. Tumor of more than three centimeter and immediate cytological assessment significantly increased the yield. Review of slides added two cases of malignancy that were missed initially. There were very few complications.

CONCLUSIONS

CT-guided FNAC was an accurate and safe procedure for SPNs.

Echogenic swirling pattern as a predictor of malignant pleural effusions in patients with malignancies

OBJECTIVES

Chest ultrasonography is a useful diagnostic tool for the detection of pleural effusions of different etiologies. Our purpose was to determine whether the echogenic swirling pattern identifiable on real-time chest ultrasonographic images is a predictor of malignant pleural effusions in patients with malignancies.

DESIGN

Medical records of patients undergoing chest ultrasonography in the Tri-Service General Hospital (Taiwan) between January 2000 and December 2002 were reviewed retrospectively. Patients with an echogenic swirling pattern in the pleural effusion, or with malignant diseases associated with pleural effusions, whose pleural fluids had been examined cytologically or whose pleural tissues had been examined pathologically, were enrolled in this study (n = 140). Malignant pleural effusions were defined by the presence of malignant cells in the pleural fluid identified by thoracentesis or by pleural biopsy. The echogenic swirling pattern was defined as numerous echogenic floating particles within the pleural effusion, which swirled in response to respiratory movement or heartbeat. Correlation between malignant pleural effusions and the echogenic swirling pattern was compared in patients with an underlying malignant disease.

RESULTS

In patients with underlying malignancies, malignant pleural effusions were diagnosed in 81.8% of patients with a positive echogenic swirling pattern and in 48% of those with no echogenic swirling pattern. The presence of echogenic swirling was significantly more predictive of malignant pleural effusions than was the absence of echogenic swirling (p < 0.01).

CONCLUSIONS

The echogenic swirling pattern is a useful predictor of possible malignant pleural effusions, and may be a good marker for malignant pleural effusions in patients with underlying malignancies.

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

STUDY OBJECTIVES

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

DESIGN, SETTING, AND PARTICIPANTS

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

MEASUREMENT AND RESULTS

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

CONCLUSIONS

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

Real-time chest ultrasonography: a comprehensive review for the pulmonologist

This review discusses real-time pulmonary ultrasonography (US) for the practicing pulmonologist. US supplements chest radiography and chest CT scanning. Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast. US may help to diagnose conditions such as pneumothorax, hemothorax, pleural or pericardial effusion, pneumonia, and pulmonary embolism in the critically ill patient who is in need of bedside diagnostic testing. The technique of US, which is cost-effective compared to CT scanning and MRI, may be learned relatively easily by the pulmonologist.

Value of chest sonography in the diagnosis and management of acute chest disease

PURPOSE

The aim of this study was to investigate the value of chest sonography in the diagnosis and management of patients with chest radiograph opacities in an emergency department.

METHODS

Seventy-eight patients with acute chest complaints whose chest radiographs showed opacities underwent chest sonography. The initial diagnosis (based on clinical manifestations and the chest radiograph), the sonographic diagnosis (before any invasive procedures), and the final diagnosis were compared. The impact of chest sonography on the management of patients with chest opacities was also analyzed.

RESULTS

The initial diagnosis was in concordance with the final diagnosis in 60 (77%) of the 78 patients, while the sonographic diagnosis was in concordance with the final diagnosis in 75 (96%) of the patients. Chest sonography therefore significantly increased the rate of correct diagnoses from 77% (95% confidence interval, 67-87%) to 96% (95% confidence interval, 92-100%; p < 0.0001). Sonography provided new information in 52 patients (67%): a different diagnosis from the initial diagnosis in 18 patients and additional diagnostic information in 34 patients. New information gained from sonography affected the management of 35 patients. Sonography also provided help in guiding 42 (70%) of 60 invasive diagnostic procedures and 22 (73%) of 30 invasive therapeutic procedures for which chest radiography and physical examination had failed to or were unsuitable to provide guidance. Overall, sonography assisted in the management of 64 (82%) of 78 patients. Sonography was of no benefit in 14 patients (18%).

CONCLUSIONS

We conclude that chest sonography can complement chest radiography and is of value in the diagnosis and management of emergency department patients with acute chest diseases presenting as opacities on chest radiographs.

US-guided transthoracic cutting biopsy for peripheral thoracic lesions less than 3 cm in diameter

PURPOSE

To evaluate the safety and accuracy of ultrasonography (US)-guided transthoracic cutting biopsy for diagnosing peripheral thoracic lesions (<3 cm).

MATERIALS AND METHODS

Fifty consecutive patients with peripheral thoracic lesions less than 3 cm in diameter underwent US-guided percutaneous transthoracic cutting biopsy with a modified technique. Fifty lesions (43 parenchymal lung, two pleural, two chest wall, and three anterior mediastinal lesions) were sampled for biopsy. The final diagnosis was based on histopathologic analysis of surgical specimens (n = 18) or clinical follow-up (n = 32).

RESULTS

The histology recovery rate was 98% (49 lesions), and the correct diagnosis was obtained in 48 lesions (96%). Twenty-four (48%) lesions were malignant, and 26 (52%) were benign. The diagnostic accuracy for malignant lesions was 92% (22 of 24 lesions). A specific benign diagnosis was made in 17 (65%) of the 26 benign lesions, and the negative predictive value for malignancy was 93% (26 of 28 lesions). Only two patients (4%) developed postbiopsy pneumothorax, and three (6%) developed postbiopsy hemoptysis. Biopsy helped prevent surgery or thoracoscopy in 32 patients (64%): 18 patients with benign disease and 14 with multiple metastases or inoperable cancer.

CONCLUSION

US-guided transthoracic cutting biopsy appears to be a safe and effective method for diagnosing peripheral thoracic lesions less than 3 cm in diameter. The high diagnostic accuracy for benign lesions and metastatic lung cancer can help prevent surgery in many cases.

Semi-invasive and invasive procedures for the diagnosis and staging of lung cancer. I. Percutaneous transthoracic needle biopsy

PTNB is a well-established technique for the diagnosis of lung cancer. In recent years, CT guidance has become the primary imaging modality, replacing fluoroscopy guided biopsies in many institutions. CT fluoroscopy, which is currently not universally available, offers promising advantages and may permit accurate and rapid procedures. A recent innovation in biopsy needles has been the introduction of automatic core biopsy needle devices that yield large specimens and improve the diagnostic accuracy of needle biopsy, particularly in benign lesions. PTNB is one of several methods available for tissue diagnosis of suspected lung cancer. The decision as to which method to use should be tailored to each patient, and is preferably reached by a team consisting of pulmonary physicians, chest surgeons, oncologists, cytologists, and radiologists.

Ultrasound-guided transthoracic biopsy of the chest

Recent studies have confirmed that US is a very useful diagnostic tool for various diseases of the chest. The image information provided by US is helpful for etiologic diagnosis and clinical management. US-guided needle biopsy provides a precise and safe approach for transthoracic tissue sampling of lesions. The diagnostic yield is high, and the procedure is relatively easy and very safe. Color Doppler US and amplitude US angiography further extend the diagnostic potential and safety of this invasive procedure. Vascular information can be obtained and the needle shaft can be visualized clearly while conducting a biopsy. US examination and US-guided needle aspiration biopsy have now become indispensable diagnostic tools for various chest diseases.

Repeated ultrasonically guided needle biopsy of small subpleural nodules

STUDY OBJECTIVE

To detect the significance of repeated ultrasonically guided needle biopsy (UGNB) for the diagnosis of nodular lesions </= 2 cm in diameter.

DESIGN

Retrospective study to evaluate the diagnostic yield of UGNB.

SETTING

University hospital, outpatients, and inpatients of the respiratory department.

PATIENTS

One hundred seven cases with small nodular lesions </= 2 cm in diameter in contact with the pleura. Sixty-two of 107 cases were malignant, and the others were benign diseases.

RESULTS

Initial UGNB identified 56% (35/62) of the malignant lesions and 16% (7/45) of the benign lesions, ie, 39% (42/107) of the total. In 35 of 65 cases that were not diagnosed by the initial UGNB, it was repeated. Diagnostic yields of the second UGNB were 68% (13/19) of the malignant cases, 25% (4/16) of the benign cases, yielding a total of 49% (17/35) in those reexamined. Furthermore, 51 of 65 patients with negative findings on the initial UGNB underwent fiberoptic bronchoscopy. The resulting diagnostic yields were 22% (5/23) from the malignant lesions and 18% (5/28) from the benign lesions, 20% (10/51) in total. Thus, among the malignant cases, the repetition of UGNB increased the definitive diagnostic yield from 56% (the initial UGNB) to 77%. In these small tumors, no serious complications were caused by the procedure.

CONCLUSIONS

UGNB should be performed twice for a definitive diagnosis of small subpleural nodules before deciding on surgical biopsy or follow-up.

Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis

BACKGROUND

Persisting controversy surrounds the use of transthoracic needle aspiration biopsy (TNAB) stemming from its uncertain diagnostic accuracy. A systematic review and meta-analysis was therefore conducted to evaluate the accuracy of TNAB for the diagnosis of solitary or multiple localised pulmonary lesions.

METHODS

Searches for English literature papers in Index Medicus (1963-1965) and Medline (1966-1996) were performed and the bibliographies of the retrieved articles were systematically reviewed. Articles evaluating the accuracy of TNAB in series of consecutive patients presenting with solitary or multiple pulmonary lesions were considered. Only papers in which >/=90% of patients were given a final diagnosis according to an appropriate reference standard were included in the meta-analysis.

RESULTS

A total of 48 studies were included and five meta-analyses were conducted according to four diagnostic thresholds. From the pooled sensitivity and specificity corresponding to each diagnostic threshold, associated likelihood ratios (LRs) were derived for malignant disease as follows: (1) malignant versus all other categories, LR = 72; (2) malignant or suspicious versus all others, LR = 49; (3) suspicious versus all categories but malignant, LR = 15; (4) benign versus all others, LR = 0.07; and (5) specific benign diagnosis versus all others, LR = 0.005. Differences in methodological quality of the studies, needle types, or whether a cytopathologist participated in the procedure failed to explain the heterogeneity of the results found in almost every meta-analysis. Given a 50% probability of malignancy prior to the TNAB, post-test probabilities of malignancy upon receiving the results would be malignant, 99%; suspicious, 94%; non-specific benign, 7%; and benign with a specific diagnosis, 0.6%.

CONCLUSIONS

Given the intermediate pre-test probabilities that would probably lead to performing TNAB, findings of "malignant" or of a specific diagnosis of a benign condition provide definitive results. Findings of "suspicious" markedly increase the probability of malignancy, and "benign" markedly decreases it but may not be considered definitive.

Pulmonary scedosporiosis

A case of a solitary pulmonary nodule due to Scedosporium apiospermum (Pseudallescheria boydii) is related. A review of the pertinent literature was done and, in addition, similar lesions caused by other opportunistic fungi are commented.

Applications of colour Doppler ultrasound in the diagnosis of chest diseases

Colour Doppler ultrasound (US) or colour Doppler imaging is a new imaging modality that can simultaneously display blood flow information and Doppler spectral analysis. This new technique provides an opportunity to assess pulmonary blood flow and perfusion non-invasively. Colour Doppler US has many potential applications in diseases of the chest. Colour Doppler imaging is useful in assisting the diagnosis of pulmonary arteriovenous malformation and pulmonary sequestration. The 'fluid colour sign' can be used to detect minimal effusion amenable to thoracentesis. Colour Doppler US can be used to assess the angiogenesis of a lung tumour and may be helpful in differentiating a malignant tumour from a benign one. Colour Doppler US can be used to guide a transthoracic needle biopsy and improve the safety of this invasive procedure. Colour Doppler US can demonstrate the vascular patterns and assess the regional haemodynamic changes of a pulmonary consolidation. The information of spectral wave analysis is helpful for understanding the haemodynamic changes of a pulmonary consolidation. Colour Doppler US is useful in assessing perfusion and reperfusion status of a pulmonary infarction. The recent advent of amplitude US angiography further improved the sensitivity of colour Doppler US in detecting blood flow signal without angle restriction. The potential application of these new techniques in chest diseases may need further exploration.

Thoracic sonography for diagnosis and intervention

Many physicians believe that ultrasound has limited usefulness in chest disease. Our clinical experiences and a review of the literature in preparation for this monograph have convinced us that sonography can be a very useful and versatile tool for thoracic diagnosis and intervention. Although there are some limitations caused by interposed ribs and air-containing lung, almost all of the compartments of the chest can be evaluated with ultrasound, which gives unique and clinically useful information. Ultrasound guidance for biopsy and drainage does take some time to learn, but we feel that the effort is very worthwhile. The same advantages ultrasound enjoys for other body regions make it a modality that will see increased use in the chest as well. We hope that this monograph will stimulate our colleagues to explore and expand upon the techniques described.

Thoraxsonography--Part II: Peripheral pulmonary consolidation

In many cases of pulmonary diseases extending up to the pleura, ultrasound (US) helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. Pneumonic infiltration shows a hypoechoic inhomogeneous echo texture, with multiple air inlets and bronchoaerograms. Fluid bronchogram indicates an obstructive pneumonitis. Pulmonary infarctions are visible in different stages as triangular pleural-based lesions in most cases of pulmonary embolism. The diagnostic accuracy of chest sonography in pulmonary embolism was 85%-90%. US-guided transthoracic biopsy shows a diagnostic yield of > 90% in malignancies and 50%-83% of benign lesions. The overall complication rate is very low: 1%-2% hemoptysis, 2%-4% pneumothoraces and 1%-2% requiring chest tube drainage. Color Doppler US can demonstrate the vascular patterns and may help in the understanding of underlying pathophysiology. Sonographic examinations of the upper and central mediastinum provide good results in 90-95% of cases. Some anatomical limitations of transcutaneous US can be circumvented by endoluminal US.

Fine-needle aspiration as the initial diagnostic modality in malignant lung disease

Cytologic detection of lung cancer is accepted, accurate, and time-honored. Typically, cytologic workup of a radiologic abnormality proceeds sequentially from sputum to bronchoalveolar cytology, and, if necessary, to fine-needle aspiration biopsy (FNA). Initial use of FNA in lung cancer diagnosis is controversial, but increasingly popular. We therefore decided to objectively assess current practice in cytologic lung cancer diagnosis at our institution. All pulmonary cytologic diagnoses for 1993 and the first half of 1994 were retrieved. Positive diagnoses were then used to access all patient data. Patients were stratified according to the specimen from which the first positive diagnosis was obtained. Of 542 pulmonary cytology specimens, 15% were sputa, 65% were bronchoalveolar, and 20% were FNAs. One hundred sixty-one of 172 malignant diagnoses were first diagnoses. Three percent of first malignant diagnoses were made from sputa, 47% were from lavages, and 50% were from FNAs. Although FNAs comprised just 20% of all pulmonary cytologies, 50% of all new malignant cytologic diagnoses were made by FNA. Initial use of FNA is successful, has a high diagnostic yield and low complication rate, and offers the most direct approach to diagnosis.

Ultrasonographically guided fine-needle aspiration biopsy of intrathoracic tumors

PURPOSE

Evaluation of diagnostic accuracy and complication frequency at ultrasonographically guided fine-needle aspiration biopsy of intrathoracic tumors.

MATERIAL AND METHODS

A total of 134 ultrasonographically guided percutaneous fine-needle aspiration biopsies were performed on 128 patients with intrathoracic tumors abutting on the pleura. A cytologic diagnosis was obtained in 119 patients (93%).

RESULTS

In 83 patients, cytologic malignancy was found; in 34, benignity; and in 2, cellular atypia. A total of 117 diagnoses were correct and 2 diagnoses were false-positive. A malignancy subtyping based on the cytologic aspirates was made in 80 patients. In 40 (93%) of 43 histologically proven subtypes, the subtyping was correct. The complication frequency in terms of pneumothorax was 3.7%.

CONCLUSION

Ultrasonographically guided percutaneous fine-needle aspiration biopsy is a safe and reliable method of establishing the cytologic diagnosis of intrathoracic tumors.

Transthoracic needle biopsy of thoracic tumours by a colour Doppler ultrasound puncture guiding device

BACKGROUND

Ultrasound guided transthoracic needle aspiration biopsy has recently been used to obtain specimens for histological diagnosis of pulmonary and mediastinal tumours. Conventional real time, grey scale puncture guiding devices cannot differentiate vascular structures, and clear visualisation of the needle shaft or tip within a desired target is not always possible. This study describes a new built-in colour Doppler ultrasound puncture guiding device and assesses the relative safety of transthoracic needle aspiration biopsy of thoracic tumours by grey scale or colour Doppler ultrasound guidance.

METHODS

Thirty patients with radiographic evidence of pulmonary (22 patients) or mediastinal tumours (eight patients) underwent ultrasonographic evaluation and transthoracic needle aspiration biopsy by using the colour Doppler ultrasound puncture guiding device (Aloka UST 5045P-3.5). These tumours were initially examined by grey scale ultrasound, and colour Doppler imaging was then used to evaluate the number of blood vessels surrounding and within the target tumour and the possibility of visualisation of the needle shaft or needle tip during the aspiration biopsy procedure.

RESULTS

The colour Doppler ultrasound guiding device was far superior to the grey scale device for identification of the number of vessels surrounding or within the target tumour (83% v 20%) and for visualisation of the needle shaft or needle tip (80% v 17%).

CONCLUSIONS

By using the colour Doppler ultrasound puncture device, vascular structures surrounding or within the target tumour can be verified. Visualisation of the needle shaft or tip is also better. Biopsy routes can be selected to avoid puncturing vessels. This approach should be particularly helpful for guiding biopsies of mediastinal tumours, where puncturing the heart or great vessels is a potential complication.

Ultrasound-guided fine-needle aspiration biopsy of solitary pulmonary nodules

Ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB) was performed in 40 patients with solitary pulmonary nodules (SPNs) for evaluation of diagnostic results and complication rates. The final diagnoses of the 40 patients included 30 malignancies and 10 benign lesions. Using US-guided FNAB, the diagnostic yields were 97% (29/30) in malignancies and 60% (6/10) in benign lesions. Of the 29 patients with cytologically proven malignancies, 12 underwent surgical resection. The correlation between cytological results and histologic diagnoses in these 12 was excellent (100%). The size of the nodule did not affect the diagnostic rate or complication rate. Only two patients (5%) developed minimal pneumothorax after US-guided FNAB. We conclude that US-guided FNAB is a useful, safe, and convenient diagnostic tool for SPN, and that malignant pulmonary nodules are more easily diagnosed than benign nodules.