MR fluoroscopy-guided transthoracic fine-needle aspiration biopsy: feasibility

The purpose of this study was to evaluate the feasibility of using an open-configuration magnetic resonance (MR) imaging system with MR fluoroscopic guidance to perform percutaneous transthoracic fine-needle aspiration biopsy in patients with lung masses. Percutaneous transthoracic aspiration biopsies were performed with MR fluoroscopic guidance in 14 patients. The masses were 2-7 cm in diameter (mean, 4.1 cm). The needle was positioned by using a free-hand technique with MR fluoroscopic guidance. The needle tip reached the target lesion, and biopsy was performed. Analysis of the biopsy specimens facilitated a specific diagnosis in all patients. Pneumothorax was noted in two patients (14%) with chronic obstructive pulmonary disease. Study results showed that the described MR fluoroscopy-guided transthoracic biopsy technique can be used safely and successfully for lung masses. MR fluoroscopy can be used to reach the target lesion easily and accurately.     

Pneumothorax post CT-guided lung biopsy: a comparison between detection on chest radiographs and CT

Pneumothorax is reported to be a more common complication of lung biopsy performed under computed tomography (CT) than under fluoroscopic guidance. This may simply reflect the greater sensitivity of CT over chest radiographs (CXRs) in the detection of small pneumothoraces. This study aimed to determine the incidence of pneumothorax detected by CXR and by CT after CT-guided biopsy of non-pleurally based pulmonary masses, and to compare these incidences with previous reports in the literature of pneumothorax incidence post fluoroscopic biopsy. 88 consecutive CT-guided lung biopsies of masses not abutting the pleural surface were included. Immediate post-biopsy CT images, and 1 and 4 h CXRs were assessed independently by two observers for the presence and size of pneumothorax. 72 biopsies were fine needle aspirations (FNAs) performed with 22 G spinal needles only, seven were cutting needle biopsies (CNBs) performed with 18 G cutting needles only, and nine were both. 37 patients (42%) developed a pneumothorax. 35 were detected on CT (40%) and 22 on CXR (25%). None required tube drainage. Of the patients in whom CT demonstrated a pneumothorax, the average depth of this was significantly greater for those in whom CXR also detected a pneumothorax compared with those in whom CXR was negative (7.3 mm versus 3.4 mm, p < 0.05). The incidence of pneumothorax detected on CXR post CT-guided biopsy is similar to the reported incidence post fluoroscopic biopsy.     

Percutaneous Relief of Tension Pneumomediastinum in a Child

The purpose of this article was to describe the experience of relieving tension pneumomediastinum by a fluoroscopic-guided percutaneous method. We inserted a percutaneous drainage catheter with a Heimlich valve under fluoroscopic guidance to relieve the tension pneumomediastinum in a 2-year-old girl who suffered from dermatomyositis with lung involvement. This allowed immediate relief without the need for surgery. The procedure was repeated for relapsed tension pneumomediastinum. Good immediate results were achieved in each attempt. We conclude that percutaneous relief of pneumomediastinum under fluoroscopic guidance can be performed safely and rapidly in patients not fit for surgery.     

Percutaneous biopsy of paracardiac masses

Computed tomography was used to guide 55 biopsies on paracardiac masses. The authors' experience, gained with over 800 thoracic biopsies, points to CT as the method of choice for paracardiac masses, especially in those cases where the masses are located close to mediastinal and cardiovascular structures, which are not easily evaluated with fluoroscopy and, therefore, imply a greater bioptic risk. Furthermore, CT allows a more accurate needle trajectory to be selected than fluoroscopic guidance does. A diagnosis was reached in 47 of 55 cases, with 85% diagnostic accuracy. No complications such as hemoptysis, hemothorax, pericarditis and hemopericardium were observed. Only one patient required drainage after pneumothorax.     

Musculoskeletal biopsies using computed tomography fluoroscopy

OBJECTIVE: To determine the diagnostic yield, accuracy, and safety of computed tomography (CT) fluoroscopy guidance for musculoskeletal biopsies. MATERIALS AND METHODS: A retrospective analysis of musculoskeletal biopsies performed with CT fluoroscopy guidance over a 2-year period was made. Data collected were biopsy sites, CT fluoroscopic times, and biopsy results. Results were categorized as the following: positive, negative (but diagnostic), or nondiagnostic. Reference standard consisted of 5 years of follow-up to verify results. RESULTS: Ninety-five CT fluoroscopy-guided musculoskeletal biopsies were performed. Bone biopsies comprised 83% (79/95), and soft tissue biopsies comprised 17% (16/95). The mean age was 54 years (range, 16-90 years); 40.0% (38/95) were male subjects, and 60.0% (57/95) were female subjects. For all subjects, CT fluoroscopic times ranged from 2 to 310 seconds, with a mean time of 63 seconds and a median time of 34 seconds. The diagnostic yield was 96% (91/95), with a nondiagnostic result in 4% (4/95) of subjects. Diagnostic biopsy specimens showed a positive result in 63% (60/95) of subjects and a negative but diagnostic result in 33% (31/95) of subjects. There were no major complications. CONCLUSIONS: Computed tomography fluoroscopic-guided musculoskeletal biopsies show a high diagnostic yield and are accurate and safe. The biopsy results are similar or superior to other published reports using conventional CT guidance with only a small overall fraction being nondiagnostic. The benefits of real-time imaging are at the cost of operator exposure to ionizing radiation and the risk of potentially high exposures to both patient and operator. The impact on indications for which lesions are most amenable to percutaneous biopsy using CT fluoroscopy and procedure time has yet to be determined.     

Limitations of fibre-optic bronchoscopy under fluoroscopy in the investigation of peripheral lung lesions

Transbronchial lung biopsy under fluoroscopic guidance was attempted in 14 patients with discrete peripheral lesions and histological evidence of pathology was obtained in five (37.7%). The difficulties and limitations of the procedure are discussed. The radiation hazard to both patient and bronchoscope are assessed. From this study it is concluded that aspiration needle biopsy is preferred in the investigation of patients with peripheral lung lesions.     

Percutaneos pancreaticobiliary biopsies in 173 patients using primarily ultrasound or fluoroscopic guidance

Two hundred and one biopsies of the pancreas and/or extrahepatic bile ducts were performed in 173 patients using primarily ultrasound (US) or fluoroscopic guidance. Computed tomographic (CT) guidance was used twice. The success rate for detecting malignancy was 82.4%. Patients with primary ductal carcinoma had the lowest success rate. Seven complications occurred: five vasovagal reactions, one fever, and one acute pancreatis in a patient with a normal variation, which resembled a mass. In this large series, aspiration biopsy of the pancreas and extrahepatic bile ducts proved to be a safe and reliable procedure that often can be performed on an outpatient basis. Fluoroscopic and US guidance are satisfactory for the majority of biopsies. CT guidance probably should be reserved for patients who undergo a repeat biopsy, or when US fails to adequately demonstrate the pancreas. Presented at the Annual meeting of the American Roentgen Ray Society, April, 1986, Washington, DC.     

Image-directed percutaneous biopsies with a biopsy gun

Core tissue for histologic study is believed by many pathologists to be more diagnostic than material from needle aspiration. Recently, a biopsy "gun" has been introduced, which simplifies core biopsies. With this device, 182 biopsies of multiple anatomic sites were performed with ultrasonic, computed tomographic, and fluoroscopic guidance and 18-gauge needles. High-quality histopathologic specimens were obtained in 177 of the biopsies, and diagnostic target tissue was obtained in 167. Only three significant complications occurred: one bleeding complication that required transfusion and two cases of pneumothorax that necessitated placement of chest tubes. The biopsy gun eliminated the disjointed movements of conventional "skinny" needle biopsies, and none of the samples demonstrated significant "crush" artifact or obscuring blood, problems that are commonly associated with manual biopsy techniques. Patient discomfort was decreased with this system compared with that of manual biopsies, and the total procedure time was reduced. Because of these distinct advantages, the authors now use the biopsy gun exclusively for all percutaneous biopsies and recommend that other institutions consider the use of this biopsy method.     

Patient and operator exposure during percutaneous vertebroplasty

Purpose

The purpose of this study was to compare exposure of patient and operator to ionising radiation during percutaneous vertebroplasty performed under combined computed tomography (CT) and fluoroscopic guidance or fluoroscopic guidance alone.

Materials and methods

With the collaboration of our physics department, we measured exposure on ten patients undergoing vertebroplasty with combined CT and fluoroscopic guidance and on ten undergoing vertebroplasty with fluoroscopic guidance alone.

Results

Mean operator dose was approximately 0.8 microSv during vertebroplasty done with combined CT and fluoroscopic guidance and 5.8 microSv in procedures with fluoroscopic guidance alone. Mean patient dose was approximately 6 mSv for combined guidance and 8 mSv for fluoroscopic guidance, a difference that was not found to be statistically significant.

Conclusions

Although combined CT and fluoroscopic guidance is normally preferred for difficult areas such as the cervical and upper thoracic vertebrae, to ensure operator radiation protection, the technique should also be considered for areas normally treated under fluoroscopic guidance alone. However, a larger patient series is needed to correctly evaluate the real contribution of low-dose CT to patient exposure.     

CT fluoroscopy--guided interventional procedures: techniques and radiation dose to radiologists.

PURPOSE: To determine the radiation dose to radiologists who perform computed tomographic (CT) fluoroscopic interventional procedures by using a quick-check method and a low-milliampere technique. MATERIALS AND METHODS: Two hundred twenty CT fluoroscopy--guided interventional procedures were performed in 189 patients. Procedures included 57 spinal injections, 17 spinal biopsies, 24 chest biopsies, 20 abdominal aspirations, 44 abdominal biopsies, and 58 abdominal drainages. Procedure details were prospectively recorded and included site, depth, target diameter, milliampere value, kilovolt peak, fluoroscopic time, and CT technique (continuous CT fluoroscopy, quick-check method, or a combination of these techniques). An individual collar and finger radiation detector were worn by each radiologist during each procedure to determine the dose per procedure. RESULTS: The quick-check technique was performed in 191 (87%) of 220 procedures. Four procedures were performed with continuous CT fluoroscopy, and a combination technique was used for 25 (11%) procedures. The overall mean CT fluoroscopic time was 17.9 seconds (range, 1.2--101.5 seconds). The mean milliampere value was 13.2 mA (range, 10--50 mA). The overall mean radiologist radiation dose per procedure was 2.5 mrem (0.025 mSv) (whole body). Individual procedure doses ranged from 0.66 to 4.75 mrem (0.007--0.048 mSv). The finger radiation dose was negligible. CONCLUSION: By using a low-milliampere technique and the quick-check method, CT fluoroscopic time and radiation exposure can be minimized.     

Transperitoneal percutaneous retroperitoneal lymph node aspiration biopsy.

Percutaneous aspiration biopsies of opacified retroperitoneal lymph nodes, and retroperitoneal, intraperitoneal and paraspinal masses were successfully accomplished in 14 of 17 patients. A 23-guage needle was utilized for the procedure which is performed under fluoroscopic guidance. Metastatic carcinoma, sarcoma and melanoma were readily identified by aspiration biopsy while the diagnosis of lymphoma, especially as to type, was more difficult. No significant complications have resulted from the passage of the needle through the peritoneal cavity.     

Fluoroscopically guided thin needle aspiration biopsy of the abdomen and retroperitoneum.

The results of 49 transabdominal and translumbar thin needle percutaneous aspiration biopsies in patients suspected of having malignant disease are reported. A correct diagnosis was obtained in 40 cases. Placement of the Chiba needle was accomplished by fluoroscopically controlled biplane radiography during constrast examinations. No complications were encountered. The technique allows cytologic diagnosis of malignancy without high risk exploratory surgery, prolonged hospitalization, or delay of treatment. Use of fluoroscopic needle guidance and biplane radiography for confirmation of position using various contrast examinations as markers is felt to be superior to either CT or ultrasound. The technique is readily available in all radiology departments.     

球囊扩张及内支架成形术治疗气管良恶性狭窄的临床应用

目的 评价X线监视下内支架成形术和球囊扩张术治疗良恶性气管狭窄的临床意义.方法 回顾分析45例气道狭窄患者,其中恶性气管狭窄37例,包括纵隔淋巴结转移14例、食管癌13例、肺癌4例、支气管腺癌3例、淋巴瘤2例、喉癌1例;良性气管狭窄8例,包括支气管内膜结核6例、胸骨后甲状腺腺瘤1例、气管插管后1例.对其中38例患者行气道内支架成形术,7例患者行球囊扩张术.所有操作均在X线透视下完成.结果 38例患者共放置53枚支架,除1例死于痰液窒息外,其他患者术后临床症状均即刻缓解,随访无支架移位;4例患者发生再狭窄,分别行再次内支架成形术和球囊扩张术.7例患者共行19次球囊扩张术,术后症状明显缓解,无复发.平均随访24.5个月(0～124个月),31例因疾病死亡,无与支架或球囊扩张相关死亡病例.结论 X线透视下行内支架成形术和球囊扩张术是治疗良恶性气管狭窄的安全、快速、有效方法.     

Fluoroscopy-guided percutaneous biopsies: value of real-time guidance with image fusion software

Based on our preliminary experience with fluoroscopy-guided biopsy using a real-time 3D image fusion software, several biopsies may be performed in the interventional radiology suite as opposed to under CT guidance: percutaneous lung and bone biopsies are easily performed for lesions larger than 15 mm.     

Percutaneous biopsy of the musculoskeletal system: a review of 77 cases.

OBJECTIVE: To analyze the accuracy of percutaneous bone and soft-tissue biopsies. METHODS: A total of 77 percutaneous biopsies performed under computed tomographic or fluoroscopic guidance over a 24-month period were reviewed. The biopsies were performed in 74 patients, 32 male and 42 female, with a mean age of 60.3 years. RESULTS: Sixty-three bone and 14 soft-tissue biopsies were performed. No follow-up information was available for 8 patients, and 1 patient died before an accurate diagnosis could be made. There were 44 true-positive, 17 true-negative, 8 false-negative and no false-positive results. The correct diagnosis was obtained in 57 of 68 cases (83.8%). For bone biopsies, the accurate diagnosis was obtained in 47 of 55 cases (85.5%). For soft-tissue biopsies, the correct diagnosis was obtained in 10 of the 13 cases (76.9%). Diagnostic accuracy was slightly better for osteolytic than for osteosclerotic lesions. Accuracy also varied with lesion site and needle type. Cytology and pathology specimens were almost equally useful in contributing to the correct diagnosis. CONCLUSION: The accuracy of percutaneous biopsy achieved in this series is similar to that found in other series. Although diagnostic accuracy varied, accuracy is improved if both cytologic and pathologic specimens are analyzed.     

Percutaneous laser disk decompression under CT and fluoroscopic guidance: indications, technique, and clinical experience.

The aim of percutaneous laser disk decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disk, thereby reducing the volume and pressure of a diseased disk. This minimally invasive technique can be performed in patients who need surgical intervention for disk herniation with leg pain. PLDD is usually performed under fluoroscopic guidance with or without diskoscopy. However, it can also be performed under dual computed tomographic (CT) and fluoroscopic guidance as an outpatient procedure. CT and fluoroscopic guidance increases the safety and accuracy of PLDD, with high precision of instrument guidance, direct visualization of nucleus pulposus vaporization, and reduced risk of complications. Of 119 patients with lumbar disk herniation treated with PLDD under CT and fluoroscopic guidance, 91 (76.5%) had a good or fair response. PLDD performed with CT and fluoroscopic guidance appears to be a safe and effective treatment for herniated intervertebral disks.     

Percutaneous lymph node aspiration biopsy: experience with a new technique

Experience with post-lymphographic percutaneous fine needle aspiration lymph node biopsy is described in 13 patients with suspected metastatic malignant disease. All aspirations were performed using an anterior transabdominal approach under local anaesthesia with fluoroscopic guidance. In most patients more than one lymph node was biopsied. Four patients with confirmed metastatic disease had a positive biopsy in the appropriate lymph node. Seven patients with negative biopsies had the absence of metastatic disease confirmed by surgery or follow-up roentgenograms. One patient with a negative biopsy was lost to follow-up. There were two patients with negative biopsies in whom representative lymphoid tissue was not aspirated. No evidence of metastasis was found in these patients at surgery. No serious complications were encountered.     

CT-guided percutaneous biopsy in orthopedics. Indications--planning--technic--personal experiences, with special reference to the spine

Computed tomography, though few previous reports have dealt with this aspect of it, is an excellent aid when percutaneous skeletal biopsies have to be taken, especially in critical skeletal regions. Our own series consists of 48 CT-guided musculoskeletal biopsy procedures, mainly concerning the spine and pelvis. We used biopsy needles with calibers between 22 G and 14 G; specifically, the sure-cut needle was used in most cases. There were no complications. The results were conclusive in 29 cases, semiconclusive in 10 cases, and inconclusive in 9 cases. The advantages of CT guidance are most obvious in the case of lesions of the axial skeleton and pelvis: it allows precise planning of an adequate biopsy approach, better location of small cortex leaks for intraosseous entry of the puncture needle, and more sensitive selection of the best place for tissue sampling. Therefore, with CT guidance intraosseous lesions are more accessible, even to less highly invasive instruments. The risk of complications is low, and the accuracy similar to that obtained with fluoroscopic guidance.     

Comparison of CT and PET/CT for biopsy guidance in oncological patients

Purpose

To compare FDG PET/CT and CT for the guidance of percutaneous biopsies with histological confirmation of lesions.

Methods

We prospectively evaluated 323 patients of whom 181 underwent FDG PET/CT-guided biopsy (total 188 biopsies) and 142 underwent CT-guided biopsy (total 146 biopsies). Biopsies were performed using the same PET/CT scanner with a fluoroscopic imaging system. Technical feasibility, clinical success and complication rates in the two groups were evaluated.

Results

Of the 188 biopsies with PET/CT guidance, 182 (96.8%) were successful with conclusive tissue samples obtained and of the 146 biopsies with CT guidance, 137 (93.8%) were successful. Therefore, 6 of 188 biopsies (3.1%) with PET/CT guidance and 9 of 146 (6.1%) with CT guidance were inconclusive (p?=?0.19). Due to inconclusive histological results, 4 of the 188 lesions (2.1%) were rebiopsied with PET/CT guidance and 3 of 146 lesions (2.0%) were rebiopsied with CT guidance. Histology demonstrated that 142 of 188 lesions (75.5%) were malignant, and 40 (21.2%) were benign in the PET/CT-guided group, while 89 of 146 lesions (60.9%) were malignant and 48 (32.8%) were benign in the CT-guided group (p?=?0.004 and 0.01, respectively). Patients with a histological diagnosis of benign lesion had no recurrence of disease with a minimum of 6 months follow-up. Of the 188 PET/CT-guided biopsies, 6 (3.1%) were repeat biopsies due to a previous nondiagnostic CT-guided biopsy performed in a different diagnostic centre. The interval between the two biopsies was less than a month in all cases. Histology revealed five malignant lesions and one benign lesion among these. The complication rate in the PET/CT-guided biopsy group was 12.7% (24 of 188), while in the CT-guided group, was 9.5% (14 of 146, p?=?0.26). Therefore, there was no significant difference in complication rates between PET/CT and CT guidance.

Conclusion

PET/CT-guided biopsy is already known to be a feasible and accurate method in the diagnostic work-up of suspected malignant lesions. This prospective analysis of a large number of patients demonstrated the feasibility and advantages of using PET/CT as the imaging method of choice for biopsy guidance, especially where FDG-avid foci do not show corresponding lesions on the CT scan. There were no significant differences in the ability to obtain a diagnostic specimen or in the complication rates between PET/CT and CT guidance.

     

Percutaneous needle biopsy of lung nodules under CT fluoroscopic guidance with use of the "I-I device"

The aim of this study is to evaluate the feasibility and safety of CT fluoroscopic-guided needle biopsy with the use of the "I-I device", which was developed to assist in precisely advancing the needle while avoiding irradiation to the operator's hand. Using the "I-I device" under CT fluoroscopic guidance, 131 percutaneous needle lung biopsies were performed followed by histopathological evaluation. The final diagnosis was confirmed by independent surgical pathological findings or clinical follow-up. The rate of success in obtaining specimens adequate for histopathological analysis was 100% (131/131). For the 104 lesions that we were able to follow up, sensitivity, specificity and accuracy in diagnosing malignancy were 93.8%, 100% and 95.2%, respectively. In 51 lesions for which surgery was performed, the specific cell type was characterized in 98.0% (50/51; malignant, n = 38; benign, n = 12). The specific cell type was precisely diagnosed and confirmed after surgery in 36 malignant lesions and 8 benign lesions. Biopsy-induced complications were pneumothorax in 34.0% (44/131) and haemoptysis in 9.9% (13/131). None of the patients had serious complications. In conclusion, CT fluoroscopic-guided lung biopsy with use of the "I-I device" provides a high degree of diagnostic accuracy, allows specific characterization of lung nodules and can be performed safely.