New horizons in surgical treatment of ground-glass nodules of the lung: experience and controversies

Impact of annual trend volume of low-dose computed tomography for lung cancer screening on overdiagnosis, overmanagement, and gender disparities

BACKGROUND

With the increasing prevalence of nonsmoking-related lung cancer in Asia, Asian countries have increasingly adopted low-dose computed tomography (LDCT) for lung cancer screening, particularly in private screening programs. This study examined how annual LDCT volume affects lung cancer stage distribution, overdiagnosis, and gender disparities using a hospital-based lung cancer database.

METHODS

This study analyzed the annual utilized LDCT volume, clinical characteristics of lung cancer, stage shift distribution, and potential overdiagnosis. At the individual level, this study also investigated the relationship between stage 0 lung cancer (potential strict definition regarding overdiagnosis) and the clinical characteristics of lung cancer.

RESULTS

This study reviewed the annual trend of 4971 confirmed lung cancer cases from 2008 to 2021 and conducted a link analysis with an LDCT imaging examination database over these years. As the volume of lung cancer screenings has increased over the years, the number and proportion of stage 0 lung cancers have increased proportionally. Our study revealed that the incidence of stage 0 lung cancer increased with increasing LDCT scan volume, particularly during the peak growth period from 2017 to 2020. Conversely, stage 4 lung cancer cases remained consistent across different time intervals. Furthermore, the increase in the lung cancer screening volume had a more pronounced effect on the increase in stage 0 lung cancer cases among females than it had among males. The estimated potential for overdiagnosis brought about by the screening process, compared to non-participating individuals, ranged from an odds ratio of 7.617 to one of 17.114. Both strict and lenient definitions of overdiagnosis (evaluating cases of stage 0 lung cancer and stages 0 to 1 lung cancer) were employed.

CONCLUSIONS

These results provide population-level evidence of potential lung cancer overdiagnosis in the Taiwanese population due to the growing use of LDCT screening, particularly concerning the strict definition of stage 0 lung cancer. The impact was greater in the female population than in the male population, especially among females younger than 40 years. To improve lung cancer screening in Asian populations, creating risk-based prediction models for smokers and nonsmokers, along with gender-specific strategies, is vital for ensuring survival benefits and minimizing overdiagnosis.

Morphological Predictors of Primary Lung Cancer among Part-Solid Ground-Grass Nodules on High-Resolution CT

Recent advancements in computed tomography (CT) scanning have improved the detection rates of peripheral pulmonary nodules, including those with ground-glass opacities (GGOs). This study focuses on part-solid pure ground-glass nodules (GGNs) and aims to identify imaging predictors that can reliably differentiate primary lung cancer from nodules with other diagnoses among part-solid GGNs on high-resolution CT (HRCT). A retrospective study was conducted on 609 patients who underwent surgical treatment or observation for lung nodules. Radiological findings from pre-operative HRCT scans were reviewed and several CT imaging features of part-solid GGNs were examined for their positive predictive value to identify primary lung cancer. The proportions of the nodules with a final diagnosis of primary lung cancer were significantly higher in part-solid GGNs (91.9%) compared with solid nodules (70.3%) or pure GGNs (66.7%). Among CT imaging features of part-solid GGNs that were evaluated, consolidation-to-tumor ratio (CTR) < 0.5 (98.1%), pleural indentation (96.4%), and clear tumor border (96.7%) had high positive predictive value to identify primary lung cancer. When two imaging features were combined, the combination of CTR < 0.5 and a clear tumor border was identified to have 100% positive predictive values with a sensitivity of 40.8%. Thus we conclude that part-solid GGNs with a CTR < 0.5 accompanied by a clear tumor border evaluated by HRCT are very likely to be primary lung cancers with an acceptable sensitivity. Preoperative diagnostic procedures to obtain a pathological diagnosis may potentially be omitted in patients harboring such part-solid GGNs.

Artificial intelligence in lung cancer diagnostic imaging: a review of the reporting and conduct of research published 2018-2019

Objective

This study aimed to describe the methodologies used to develop and evaluate models that use artificial intelligence (AI) to analyse lung images in order to detect, segment (outline borders of), or classify pulmonary nodules as benign or malignant.

Methods

In October 2019, we systematically searched the literature for original studies published between 2018 and 2019 that described prediction models using AI to evaluate human pulmonary nodules on diagnostic chest images. Two evaluators independently extracted information from studies, such as study aims, sample size, AI type, patient characteristics, and performance. We summarised data descriptively.

Results

The review included 153 studies: 136 (89%) development-only studies, 12 (8%) development and validation, and 5 (3%) validation-only. CT scans were the most common type of image type used (83%), often acquired from public databases (58%). Eight studies (5%) compared model outputs with biopsy results. 41 studies (26.8%) reported patient characteristics. The models were based on different units of analysis, such as patients, images, nodules, or image slices or patches.

Conclusion

The methods used to develop and evaluate prediction models using AI to detect, segment, or classify pulmonary nodules in medical imaging vary, are poorly reported, and therefore difficult to evaluate. Transparent and complete reporting of methods, results and code would fill the gaps in information we observed in the study publications.

Advances in knowledge

We reviewed the methodology of AI models detecting nodules on lung images and found that the models were poorly reported and had no description of patient characteristics, with just a few comparing models' outputs with biopsies results. When lung biopsy is not available, lung-RADS could help standardise the comparisons between the human radiologist and the machine. The field of radiology should not give up principles from the diagnostic accuracy studies, such as the choice for the correct ground truth, just because AI is used. Clear and complete reporting of the reference standard used would help radiologists trust in the performance that AI models claim to have. This review presents clear recommendations about the essential methodological aspects of diagnostic models that should be incorporated in studies using AI to help detect or segmentate lung nodules. The manuscript also reinforces the need for more complete and transparent reporting, which can be helped using the recommended reporting guidelines.

Hemorrhagic shock caused by preoperative computed tomography-guided microcoil localization of lung nodules: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is an emerging technology in minimally invasive surgery, which has become recognized as standard treatments for early-stage lung cancer. Microcoil localization is considered to be a safe and effective way of preoperative localization, and is essential to facilitate VATS wedge-resection for lung nodules.

Case presentation

Here we report a rare case of a 28-year-old female who developed hemorrhagic shock caused by delayed pneumothorax after preoperative computed tomography (CT)-guided microcoil localization. The thoracic CT revealed hydropneumothorax in the right thoracic cavity at 10 h after microcoil localization, and the patient later had significant decreased hemoglobin level (87 g/L). Emergency thoracoscopic exploration demonstrated that the hemorrhagic shock was induced by delayed pneumothorax, which led to the fracture of an adhesive pleura cord and an aberrant vessel. Electrocoagulation hemostasis was then performed for the fractured vessel and the patient gradually recovered from the hypovolemic shock.

Conclusions

Microcoil localization is a relatively safe and effective way of preoperative localization of lung nodules, however, hemorrhagic shock could be induced by rupture of pleural aberrant vessels subsequent to puncture related pneumothorax. Shorten the time interval between localization and thoracoscopic surgery, extend the monitoring time after localization might help to reduce the risk of these complications.

Ground glass opacity: can we correlate radiological and histological features to plan clinical decision making?

BACKGROUND

The spectrum of ground glass opacity (GGO) is a diagnostic and clinical management quandary. The role of computed tomographic scans in detecting malignant GGO has inter-observer variability. Pure GGO have been traditionally thought to be predominantly benign in nature and has long volume doubling times. This study was undertaken to correlate the findings of radiology and histology of ground glass opacities at our institute.

METHODS

This study is a retrospective observational study of patients who underwent lung resection surgery for radiology proven ground glass opacities between January 2010 and December 2018. A total of 115 patients were included in the study based on inclusion and exclusion criteria and were analysed.

RESULTS

The patients were divided into two groups; pure GGO (n = 50), mixed GGO (n = 65). The pathological tumour size was ≤ 2 cm in 51% of the patients and 27 patients had the size between 2.1 and 3.0 cm. The predominant histopathologic feature was lepidic predominance in 54 patients followed by 24 patients with acinar predominance. Among patients with radiological tumour size of ≤ 2 cm, pure GGO was present in 48% of the patients. Among patients with pure GGO, 96% of the patients had no solid component. 44 patients had only single CT scan before proceeding to surgery. All these patients had mixed GGO.

CONCLUSION

Our study concludes pure GGOs, though lacking solid component have a high propensity to be malignant. The role of repeated CT surveillance in this context without offering curative surgery may be questionable.

Características clinicopatológicas de nódulos pulmonares: Experiencia en Clínica Reina Sofía, Bogotá, Colombia

Introducción. El cáncer de pulmón es la primera causa de mortalidad por cáncer a nivel mundial, lo que hace que sea considerado un problema de salud pública. Existen diferentes hallazgos imagenológicos que hacen sospechar la presencia de cáncer de pulmón, uno de los cuales son los nódulos pulmonares; sin embargo, estos también pueden verse en entidades benignas. Métodos. Se incluyeron 66 pacientes con biopsia de nódulo pulmonar en la Clínica Reina Sofía, en la ciudad de Bogotá, D.C., Colombia, entre el 1° de marzo del 2017 y el 28 de febrero del 2020. Se analizaron las características demográficas de los pacientes, las características morfológicas e histopatológicas de los nódulos pulmonares y la correlación entre sus características imagenológicas e histopatológicas. Resultados. El 69,2 % de los nódulos estudiados tenían etiología maligna, de estos el 55,5 % era de origen metástasico y el 44,5 % eran neoplasias primarias de pulmón, con patrón sólido en el 70,6 % de los casos. El patrón histológico más frecuente fue adenocarcinoma. Respecto a las características radiológicas, en su mayoría los nódulos malignos medían de 1 a 2 cm, de morfología lisa y distribución múltiple, localizados en lóbulos superiores. Conclusiones. La caracterización de los nódulos pulmonares brinda información relevante que orienta sobre los diagnósticos más frecuentes en nuestro medio, cuando se estudian nódulos sospechosos encontrados incidentalmente o en el seguimiento de otro tumor. Como el nódulo es la manifestación del cáncer temprano del pulmón, establecer programas de tamización que permitan el diagnóstico oportuno, es hoy día una imperiosa necesidad, para reducir la mortalidad.

Mathematical prediction model of computed tomography signs is superior to intraoperative frozen section in the diagnosis of ground-glass nodular invasive adenocarcinoma of the lung

Background

At present, lobectomy is still the standard treatment for lung cancer. Judging whether a lesion is invasive adenocarcinoma (IA) has important guiding significance for determining the scope of surgical resection. The commonly used methods are intraoperative frozen sections and computed tomography (CT) signs. There is still controversy about the accuracy of both in judging the invasiveness of ground‐glass nodules (GGNs).

Methods

The clinical data of patients with GGNs who underwent surgery were collected. According to the results of univariate analysis, the variables with statistical differences were selected and included in logistic regression multivariate analysis. The predictive variables were determined and the receiver operating characteristic (ROC) curve was drawn in order to achieve the area under the curve (AUC) value.

Results

According to the results of logistic regression analysis, the longest diameter and maximum CT value of nodules were independent risk factors for IA. The mathematical prediction model of CT signs was determined, and the ROC curves of CT signs and intraoperative frozen sections (FS) were drawn, respectively. The AUC values under the curves were calculated to be 0.873 and 0.807, respectively. The mathematical prediction model of intraoperative frozen section combined with CT signs was established. A ROC curve was drawn and the AUC was calculated to be 0.925.

Conclusions

The diagnostic accuracy of CT signs in judging whether nonbenign GGNs were IA was higher than that of intraoperative FS. Combined with CT signs and intraoperative FS to establish a mathematical prediction model, the diagnostic accuracy of judging whether nonbenign GGNs are IA is significantly improved.

Evolution of DNA methylome from precancerous lesions to invasive lung adenocarcinomas

The evolution of DNA methylome and methylation intra-tumor heterogeneity (ITH) during early carcinogenesis of lung adenocarcinoma has not been systematically studied. We perform reduced representation bisulfite sequencing of invasive lung adenocarcinoma and its precursors, atypical adenomatous hyperplasia, adenocarcinoma in situ and minimally invasive adenocarcinoma. We observe gradual increase of methylation aberrations and significantly higher level of methylation ITH in later-stage lesions. The phylogenetic patterns inferred from methylation aberrations resemble those based on somatic mutations suggesting parallel methylation and genetic evolution. De-convolution reveal higher ratio of T regulatory cells (Tregs) versus CD8 + T cells in later-stage diseases, implying progressive immunosuppression with neoplastic progression. Furthermore, increased global hypomethylation is associated with higher mutation burden, copy number variation burden and AI burden as well as higher Treg/CD8 ratio, highlighting the potential impact of methylation on chromosomal instability, mutagenesis and tumor immune microenvironment during early carcinogenesis of lung adenocarcinomas.

Glutathione Peroxidase 3 as a Biomarker of Recurrence after Lung Cancer Surgery

We aimed to examine the usefulness of serum glutathione peroxidase 3 (GPx3) as a biomarker of lung cancer recurrence after complete resection. We prospectively collected serial serum samples at the baseline, as well as 3, 6 and 12 months after surgery from complete resection cases in 2013. GPx3 levels were measured by enzyme-linked immunosorbent assay. Statistical tests including t-tests and Cox proportional hazard regression analyses were performed. Totally, 135 patients were enrolled, and 39 (28.9%) showed relapse during the median follow-up period (63.60 months; range, 0.167–81.867). The mean GPx3 change was significantly higher in the recurrence group at 6 months (0.32 ± 0.38 vs. 0.15 ± 0.29, p = 0.016) and 12 months (0.40 ± 0.37 vs. 0.13 ± 0.28, p = 0.001). The high GPx3 change group showed significantly higher 60-months recurrence rates than the low group (48.1% vs. 25.2% at 3 months, p = 0.005; 54.5% vs. 28.9% at 6 months, p = 0.018; 38.3% vs. 18.3% at 12 months, p = 0.035). High GPx3 change at 3 months were independent risk factors of recurrence (hazard ratio (HR) 3.318, 95% confidence interval (CI), 1.582–6.960, p = 0.002) and survival (HR 3.150, 95% CI, 1.301–7.628, p = 0.011). Therefore, serum GPx3 changes after surgery may be useful predictive biomarkers for recurrence in lung cancer. Larger-scale validation studies are warranted to confirm these findings.

Shades of Gray: Subsolid Nodule Considerations and Management

Subsolid nodules are common on chest CT imaging and may be either benign or malignant. Their varied features and broad differential diagnoses present management challenges. Although subsolid nodules often represent lung adenocarcinomas, other possibilities are common and influence management. Practice guidelines exist for subsolid nodule management for both incidentally and screening-detected nodules, incorporating patient and nodule characteristics. This review highlights the similarities and differences among these algorithms, with the intent of providing a resource for comparison and aid in choosing management options.

Clinical characteristics of resected solitary ground-glass opacities: Comparison between benign and malignant nodules

BACKGROUND

The management of ground-glass opacities (GGOs) depends mainly on personal experience. In clinical practice, benign GGOs are not rare in resected specimens, for which operations may be avoided. We retrospectively compared the clinical features of resected GGOs to identify differential diagnostic characteristics.

METHODS

Among 1456 patients with suspected malignant GGOs who underwent surgical resection, 105 patients (35 with benign GGOs and 70 matched controls with malignant GGOs) were included. Clinical characteristics, including demographics and radiologic, surgical and pathologic characteristics, were collected.

RESULTS

The smoking index (P = 0.044), frequency of coughing (P = 0.026), GGO size (P = 0.003), size change during follow-up (P = 0.011), location (P = 0.022), presence of air bronchogram sign (P = 0.004), distance to the pleura (P = 0.021) and positron emission tomography/computed tomography (PET/CT) appearance (P = 0.003) showed significant differences between the benign and malignant groups. Pathologically, the resected benign GGOs included focal fibrosis (17), inflammation or infection (seven), lymphoproliferative disorder (one), hamartoma (three), inflammatory myofibroblastic tumor (two), hemangioma or vascular malformation (two), endometriosis (two) and pulmonary cyst (one).

CONCLUSIONS

A higher smoking index, coughing, larger size, similar or increased size during follow-up, location in the upper and middle lobes, air bronchogram sign on CT, lesion margin to pleura distance over 1 cm, and malignant tendency on PET/CT reports were associated with malignant GGOs. Relatively active surgical interventions could be considered for GGOs highly suspected of malignancy.

Predictive Factors for Lymph Node Metastasis in Clinical Stage I Part-Solid Lung Adenocarcinoma

BACKGROUND

Accurate clinical staging of tumors with a small solid portion is essential for developing an appropriate treatment plan. This study evaluated predictive factors for lymph node (LN) metastasis in patients with clinical stage I part-solid lung adenocarcinoma.

METHODS

Medical records of patients with clinical stage I part-solid adenocarcinoma who underwent anatomic pulmonary resection with systematic node evaluation between January 2009 and June 2018 were retrospectively reviewed. To identify predictive factors for LN metastasis, univariate and multivariable logistic regression analyses were performed.

RESULTS

Among the 593 patients in this study, the overall prevalence of LN metastasis was 3.7% (n = 22), which included 3.0% (n = 18) of patients with N1 LN metastasis and 1.5% (n = 9) of patients with N2 LN metastasis. Combined N1 and N2 nodal involvement was observed in 5 patients. Nodal metastasis was not observed in tumors with a solid portion sized 1.1 cm or smaller. The nodal metastasis rates in cT1b, cT1c, and cT2a tumors were 5.5% (13 of 237), 7.1% (6 of 84), and 13.6% (3 of 22), respectively. According to the multivariable analysis, predictive factors included the size of the solid portion (P = .015) and the high maximum standardized uptake value (SUVmax) of the primary tumor (P = .044).

CONCLUSIONS

Large solid portion and high SUVmax of the primary tumor were predictive factors of LN metastasis in patients with clinical stage I part-solid lung adenocarcinoma. Systematic LN evaluation should be performed, especially in those who have a large solid portion and high SUVmax of the primary tumor.

Preoperative CT-based radiomics combined with intraoperative frozen section is predictive of invasive adenocarcinoma in pulmonary nodules: a multicenter study

Objectives

Develop a CT-based radiomics model and combine it with frozen section (FS) and clinical data to distinguish invasive adenocarcinomas (IA) from preinvasive lesions/minimally invasive adenocarcinomas (PM).

Methods

This multicenter study cohort of 623 lung adenocarcinomas was split into training (n = 331), testing (n = 143), and external validation dataset (n = 149). Random forest models were built using selected radiomics features, results from FS, lesion volume, clinical and semantic features, and combinations thereof. The area under the receiver operator characteristic curves (AUC) was used to evaluate model performances. The diagnosis accuracy, calibration, and decision curves of models were tested.

Results

The radiomics-based model shows good predictive performance and diagnostic accuracy for distinguishing IA from PM, with AUCs of 0.89, 0.89, and 0.88, in the training, testing, and validation datasets, respectively, and with corresponding accuracies of 0.82, 0.79, and 0.85. Adding lesion volume and FS significantly increases the performance of the model with AUCs of 0.96, 0.97, and 0.96, and with accuracies of 0.91, 0.94, and 0.93 in the three datasets. There is no significant difference in AUC between the FS model enriched with radiomics and volume against an FS model enriched with volume alone, while the former has higher accuracy. The model combining all available information shows minor non-significant improvements in AUC and accuracy compared with an FS model enriched with radiomics and volume.

Conclusions

Radiomics signatures are potential biomarkers for the risk of IA, especially in combination with FS, and could help guide surgical strategy for pulmonary nodules patients.

Key Points

• A CT-based radiomics model may be a valuable tool for preoperative prediction of invasive adenocarcinoma for patients with pulmonary nodules.

• Radiomics combined with frozen sections could help in guiding surgery strategy for patients with pulmonary nodules.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06597-8) contains supplementary material, which is available to authorized users.

A feasibility and safety study of computed tomography-guided percutaneous microwave ablation: a novel therapy for multiple synchronous ground-glass opacities of the lung

Purpose: The present study retrospectively evaluated the feasibility, safety, and short-term efficacy of computed tomography (CT)-guided percutaneous microwave ablation (MWA) to treat multiple synchronous ground-glass opacities (GGOs) of the lung.Materials and Methods: From October 2016 to May 2019, 33 patients (9 males and 24 females, mean age: 59.6 ± 10.0 years) with multiple GGOs (103 GGOs with mean size 12.3 ± 6.3 mm) were enrolled in this study. Patients underwent 66 procedures of CT-guided percutaneous MWA. The feasibility, safety, local progression-free survival, and overall survival were evaluated.Results: The technical success and technique efficacy rate were 100% and no MWA procedure-related deaths were reported. The median follow-up period was 18.1 (range: 6.8-37.7) months. Major complications included pneumothorax (11/66, 16.7%), pleural effusion (2/66, 3.0%), pneumonia (3/66, 4.5%), and nerve injury (1/66, 1.5%), which were well controlled by appropriate treatment. Minor complications included pneumothorax (38/66, 57.6%), pleural effusion (43/66, 65.2%), hemoptysis (13/66, 19.7%), subcutaneous emphysema (4/66, 6.1%), and hemothorax (2/66, 3.0%). Currently, all patients are alive without local progression or tumor recurrence, despite the relatively insufficient follow-up time.Conclusion: CT-guided percutaneous MWA for the treatment of multiple synchronous lung GGOs is feasible, safe, and efficacious over short-term follow-up. It may also be employed as an alternative approach for nonsurgical candidates. A longer follow-up is warranted to evaluate the oncologic outcomes.

Metabolic profiles of serum samples from ground glass opacity represent potential diagnostic biomarkers for lung cancer

Background

Lung cancer is a leading cause of cancer deaths worldwide. Low-dose computed tomography (LDCT) screening trials indicated that LDCT is effective for the early detection of lung cancer, but the findings were accompanied by high false positive rates. Therefore, the detection of lung cancer needs complementary blood biomarker tests to reduce false positive rates.

Methods

In order to evaluate the potential of metabolite biomarkers for diagnosing lung cancer and increasing the effectiveness of clinical interventions, serum samples from subjects participating in a low-dose CT-scan screening were analyzed by using untargeted liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-Q-TOF-MS). Samples were acquired from 34 lung patients with ground glass opacity diagnosed lung cancer and 39 healthy controls.

Results

In total, we identified 9 metabolites in electron spray ionization (ESI)(+) mode and 7 metabolites in ESI(-) mode. L-(+)-gulose, phosphatidylethanolamine (PE)(22:2(13Z,16Z)/15:0), cysteinyl-glutamine, S-japonin, threoninyl-glutamine, chlorate, 3-oxoadipic acid, dukunolide A, and malonic semialdehyde levels were observed to be elevated in serum samples of lung cancer cases when compared to those of healthy controls. By contrast, 1-(2-furanylmethyl)-1H-pyrrole, 2,4-dihydroxybenzoic acid, monoethyl carbonate, guanidinosuccinic acid, pseudouridine, DIMBOA-Glc, and 4-feruloyl-1,5-quinolactone levels were lower in serum samples of lung cancer cases compared with those of healthy controls.

Conclusions

This study demonstrates evidence of early metabolic alterations that can possibly distinguish malignant ground glass opacity from benign ground glass opacity. Further studies in larger pools of samples are warranted.

Determining malignancy in CT guided fine needle aspirate biopsy of subsolid lung nodules: Is core biopsy necessary?

Purpose

To assess the success of determining malignancy in subsolid lung nodules by fine needle aspirate of CT-guided transthoracic needle biopsy.

Material and method

This IRB approved retrospective study analyzed CTguided transthoracic needle biopsy of 86 consecutive subsolid nodules (size 25 + 14 mm; Age 71 + 10 years: M: F, 27:59), with ground glass opacity of = 50% in 64 (74%) and size < 2 cm in 38 (44%). Fine needle aspirate was performed in all and additional core biopsy in 21 (24%). The biopsy results were correlated with resected surgical pathology in 59 (69%) and by long term clinical and imaging follow-up in 27 (31%). The statistical analysis was performed by Fischer exact test to determine the success rate in < 2cm and =2cm nodules and those with <50% and =50% ground glass opacity.

Results

The technical success of performing the biopsy was 94.7%. The sensitivity for making a diagnosis of malignancy in small and large subsolid nodules was 88.6 and 95.6% (p=>0.05), with a specificity 100% in both groups. Core biopsy altered the diagnosis only in 1/21 (4.8%). The nondiagnostic biopsy rate was 18 and 11% for lesions with =50% and <50% ground glass opacity (p=>0.05). The incidence of pneumothorax was 21%, none requiring chest tube, and mild hemoptysis in 8%.

Conclusion

CT-guided transthoracic needle biopsy of both small and large subsolid nodules is highly sensitive and very specific for making the diagnosis of malignancy with a low rate of complications. Additional core biopsy offered no significant advantage over fine needle aspirate biopsy alone.