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CT-guided percutaneous transthoracic biopsy in the evaluation of
undetermined pulmonary lesions.Rev
Port Pneumol. 2006 Sep-Oct;12(5):503-24.
CT-guided
Percutaneous Transthoracic Biopsies (PTB) performed in the Radiology
Department of Garcia de Orta Hospital between 2002 and 2004 to
evaluate undetermined pulmonary lesions were retrospectively analysed.
89 fine needle aspiration biopsies (FNAB) and 13 core needle biopsies
(CNB) were performed on 92 patients (67 men, mean age: 64.4 years). 82
lesions (89%) were nodular lesions (mean diameter: 3.8+/-1.7 cm, 65
peripheral). We did not observe complications among patients who
underwent CNB; minor complications and pneumothorax requiring drainage
occurred in 11 FNAB. 72 FNAB were considered adequate for cytology
diagnosis; 72% of them positive for malignancy. All CNB were adequate
and conclusive. From the 7 CNB performed on patients with previous
FNAB, 3 allowed a better histological characterization and in 3 cases
of inadequate FNAB, CNB was conclusive. All malignant lesions were
nodules: 20 adenocarcinoma, 13 non-small cell lung cancer (SCLC), 10
epidermoid tumours, 5 small-cell lung cancer, 2 carcinoids, 1
bronchiolo alveolar carcinoma, 1 malignant mesothelioma and 8
metastasis. Unspecific/inflammatory lesions (n=5) were the most
frequent benign lesions. Malignant lesions were more prevalent in
older patients (p=0.007) and were larger (p=0.006). Spiculated and
lobulated contour (p=0.05) were more prevalent in malignant lesions
while regular contour was more frequent among benign lesions
(p=0.0001). Gender, smoking, location, pleural tag, homogenous
attenuation, cavitation, calcification, necrosis and air bronchogram
did not differ significantly between benign and malignant nodules.
This study shows that CT-guided PTB is a safe and effective procedure
in the evaluation of undetermined pulmonary lesions.
CT-Guided transthoracic aspiration of peripheral pulmonary
nodules with a special bioptic needle.Pneumologie.
2005 Jun;59(6):369-75
Peripheral
pulmonary nodules are difficult to reach bronchoscopically, so for a
long time it has been tried, by the use of imaging techniques like
X-ray, ultrasound and computed tomography, to aspirate these nodules
for exact histological diagnosis. The computed tomography offers the
best spatial orientation for methodical reasons, thus this technique
is performed increasingly and with great accuracy in pulmonary
lesions. Complications like bleeding into lung parenchyma or small
pneumothorax after aspiration can be detected easier by computed
tomography. In this study we evaluated the use of a special bioptic
technique with the AUTOVAC(R) needle in 30 cases. Causing low
parenchymal damage to the lung, this bioptic needle enables
extraction of representative tissue samples for further pathological
examination. In 21 of 30 (70 %) cases the histological specimen led
to the diagnosis of malignancy, but 8 of those malignant specimen
could have been verified as primary or secondary malignancy by using
additional immunocytochemical techniques. In 2 of 30 cases (7 %)
harmless hemorrhage into lung parenchyma occured after aspiration.
In another 4 of 30 (13 %) cases pneumothorax occurred, requiring
chest tube placement. The ct-guided lung biopsy with the AUTOVAC(R)
needle represents a safe, low resilient diagnostic tool to obtain
large tissue samples of specimen in good quality. Even in patients
with compromised lung function because of severe chronic obstructive
lung disease and/or emphysema, the described aspiration technique
can be performed, if at the moment of aspiration procedure a
pneumologist with corresponding equipment and trained medical staff
is present, in order to place a chest tube in case of pneumothorax.
Percutaneous
image-guided cutting needle biopsy of the pleura in the diagnosis of
malignant mesothelioma.Chest.
2001 Dec;120(6):1798-802
STUDY
OBJECTIVES: Pleural fluid cytology and non-image-guided Abrams or
Cope biopsies have sensitivities of approximately 30% for detecting
malignant mesothelioma, and thoracoscopic biopsy has a sensitivity
of approximately 90%. The difference between these two probably
relates to obtaining adequate tissue. The use of immunohistochemical
stains allows a firm diagnosis to be made from relatively small
samples. This study explores whether percutaneous image-guided
cutting needle biopsy (CNB) combined with immunohistochemistry is
accurate in diagnosing pleural thickening due to mesothelioma.
DESIGN: Retrospective review of image-guided CNB of pleural
thickening performed on consecutive patients over 7 years by a
single radiologist. SETTING: Teaching hospital chest radiology
department. PATIENTS: Twenty-one adult patients with a final
diagnosis of malignant mesothelioma were identified from 53
consecutive patients who underwent percutaneous image-guided CNB.
All 21 patients had pleural thickening identified on
contrast-enhanced CT, and all had a final histologic diagnosis of
mesothelioma confirmed by postmortem examination or thoracoscopy.
INTERVENTIONS: Fourteen-gauge and 18-gauge cutting needles were
used. Biopsy guidance was by ultrasound in 6 patients and by CT in
15 patients. MEASUREMENTS AND RESULTS: A correct histologic
diagnosis of malignant mesothelioma was made by CNB in 18 patients
(86% sensitivity and 100% specificity). Complications included one
chest wall hematoma and a small hemoptysis. Four patients with a
pleural thickness of < or = 5 mm underwent biopsy, and all specimens
were diagnostic for mesothelioma. CONCLUSIONS: Image-guided
percutaneous CNB of pleural thickening is a safe procedure, with 86%
sensitivity for detecting malignant mesothelioma. Pleural thickening
of < or = 5 mm may be successfully sampled.
Tissue diagnosis
of suspected lung cancer: selecting between bronchoscopy,
transthoracic needle aspiration, and resectional biopsy.Respir
Care Clin N Am. 2003 Mar;9(1):51-76.
In pursuing
a tissue diagnosis of a suspected lung cancer, there is a range of
procedures to choose from. The principal goals are ideally to
diagnose and pathologically stage the patient's lung cancer at the
same time, preferably by using the safest, least invasive, and least
costly tests. If there is clinical or radiographic evidence of
extrapulmonary spread of disease, including supraclavicular N3 nodal
involvement or a malignant pleural effusion, then radiology-guided
or open biopsy will confirm tumor cell type and stage the patient as
unresectable. For patients with symptoms, such as increasing cough
or hemoptysis, that are suggestive of airways involvement. with or
without radiographic finding of central lesions, sputum cytology is
the least invasive study with a high specificity. A positive finding
of cancer is especially helpful if the patient is not a surgical
candidate because of anatomic location of the lesion or severe
physiologic limitations. The limited sensitivity of sputum cytology
and poor NPV may improve with improved sputum induction and
collection and processing techniques. Bronchoscopy with direct
examination of the visible airways is most often the preferred
invasive diagnostic procedure. Although the procedure should be
geared toward sampling the highest staged lesion to provide an
accurate tissue staging at the time of diagnosis, additional
procedures can be performed in sequence to sample different nodal
stations, is well as the primary lung mass. The incidental finding
of an unexpected central airways lesions or a synchronous second
endobronchial lung primary will also affect plans for treatment.
Autofluorescence bronchoscopy can improve the sensitivity for
detecting early intraepithelial neoplasia. Bronchoscopy for central
and peripheral lung masses that are suspected to be lung cancer
should be performed with ROSE whenever available. For visible
endobronchial lesions, given the similar yield of EBBX and EBNA,
EBNA may provide an immediate diagnosis, thus obviating additional,
possibly morbid, procedures such as BB or EBBX. For submucosal
lesions, EBNA is superior. For central cancers that are
peribronchial, TBNA performed as for regional nodal sampling should
have a yield that is comparable to TBNA for staging. TBBX and TBNA
of peripheral nodules that are smaller than 3 cm have a lower
diagnostic yield. Coming generations of thin bronchoscopes and
improved radiographic guidance systems may improve our ability to
biopsy these lesions with greater accuracy and safety. Under all
circumstances, immediate cytology feedback with ROSE will confirm
the adequacy of the retrieved specimen for a definitive tissue
diagnosis, thus avoiding the need for extra biopsies, or worse yet,
the need for a second invasive procedure because of insufficient
diagnostic material. ROSE is educational to the clinician and
fellow-in-training in getting immediate feedback on the procedural
techniques and in learning pulmonary pathology, as well. The
diagnostic sensitivity of TTNA is high, especially for the larger
peripheral-based lung lesion, and TTNA is a relatively rapid
procedure. TTNA's sensitivity falls for smaller or more central
lesions, where the false negative rate can approach 25% to 30%; the
risk of pneumothoraces and bleeding increases with central biopsies.
Furthermore, TTNA usually does not provide information about nodal
staging, unless the TTNA is initially directed toward central lymph
nodes. The central airways are not examined in the same appointment
to address issues of resection margins when there may be central
spread of disease. TTNA should, therefore, be held in reserve for
cases in which the sputum cytology and subsequent bronchoscopy are
negative, and the patient is not a surgical candidate or refuses
surgery, even if the cancer is potentially resectable. TTNA may then
provide the tissue diagnosis to permit initiation of cytotoxic
chemotherapy and radiotherapy. TTNA may also be helpful in cases
where the likelihood of cancer is only intermediate, such that a
specific benign diagnosis or an adequate sample without cancer will
greatly reduce the likelihood ratio of missing a cancer, and justify
to the patient and physician an approach of careful observation. To
maximize the yield of these diagnostic procedures, there must be
continued improvement in the hands-on teaching of clinical fellows
and pulmonary practitioners in the use of the various techniques of
TBNA and TBBX, as well as the applications of new endoscopic
technology, such as EBUS. Definitive curative surgery remains the
goal for patients with lung cancer, with accurate pathological
staging performed intraoperatively. Complete lobectomy or
pneumonectomy remains the standard resectional approach. Therefore,
for patients with sufficient cardiopulmonary reserve who can be
clinically staged as IA or IB, either by good quality CT with
contrast or increasingly with 18-FDG PET, the initial tissue
diagnosis may be at the time of surgery, when a frozen section
preceding a complete lobectomy with lymph node sampling will combine
diagnosis and therapy.
Percutaneous
needle biopsy of the lung and its impact on patient management.World
J Surg. 2001 Mar;25(3):373-9;
discussion 379-80. Epub 2001 Apr 11.
Percutaneous needle biopsy (PNB) of the lung is a commonly performed
procedure, mainly used for the investigation of solitary pulmonary
nodules. Developments in imaging, particularly computed tomography
(CT), have enable accurate preliminary assessment and targeting of
lesions. Improvements in needle design ensure the provision of
diagnostic samples for both cytologic and histologic assessment; and
the development of immunocytochemistry and immunohistochemistry have
allowed improved accuracy in diagnosis. A significant improvement in
diagnostic accuracy for benign lesions has been associated with the
use of cutting needles that provide cores for histologic diagnosis,
in contrast to cytologic analysis from fine-needle aspiration. The
complications of PNB are well recorded and have not changed
significantly with the newer imaging techniques and needles. The
preliminary assessment of solitary pulmonary nodules, and the
pretest likelihood of malignancy, has improved using
contrast-enhanced CT and positron emission tomography; the latter
modality is increasingly having a major impact on the investigation
of patients with suspected malignancy. The performance of PNB must
always be determined on an individual case basis and when the result
is likely to affect management. The complementary roles of PNB,
bronchoscopic biopsy, and video-assisted thoracoscopic biopsy
continue to evolve.
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