CT-guided biopsy of pulmonary nodules ≤10 mm: Diagnostic yield based on nodules' lobar and segmental distribution

PurposeThe aim of our study is to evaluate the diagnostic performance of CT-guided biopsy of lung nodules ≤10 mm based on their lobar and segmental location.Materials and methodsThis was a retrospective study performed on 193 CT-guided percutaneous transthoracic needle biopsies of lung nodules ≤10 mm in greatest dimension, between January 1, 2013 and April 30, 2019. Biopsies were classified as either diagnostic or non-diagnostic based on final cytology and surgical pathology reports. Diagnostic results were those that met parameters for malignancy or a specific benign diagnosis, whereas atypical cells, non-specific benignity, or insufficient specimen were considered non-diagnostic.ResultsA total of 1577 CT-guided percutaneous transthoracic needle biopsies were reviewed. Of these, 193 nodules (12.24%) measured ≤10 mm and were selected for further analysis. Of the 193 biopsies, 138 yielded diagnostic results while 56 yielded nondiagnostic results (71% vs 29%, respectively). When analyzed by nodule location, the superior segments of the lower lobes boasted the highest diagnostic yield compared to nodules located in the basal segments of the lower lobes which had the lowest diagnostic yield (84.2% vs 64.7%, respectively). Nodules in the upper lobes and in the middle lobes had a diagnostic yield of 70% and 66.7%, respectively.ConclusionThe diagnostic performance of CT-guided biopsy of lung nodules ≤10 mm in diameter may be affected by lobar and segmental location. While the overall performance was good (diagnostic yield of 71%), the yield varied nearly 20% depending on location.     

Is there an advantage to using computer aided detection for the early detection of pulmonary nodules within chest X-Ray imaging?

ObjectiveUsing published literature, this research examines whether Computer-aided Detection (CAD) identifies more Pulmonary Nodules (PN) within Chest X-ray (CXR) systems, compared to radiologist diagnosis without CAD.Key FindingsAlthough the primary papers were pointing to CAD being a beneficial system in the diagnosis of PN detection, a regression analysis of the data available within these papers showed no correlation between the higher sensitivity of CAD against the detrimental high False Positives (FP) of CAD. Findings of the studies were deemed inconclusive.ConclusionFurther research is recommended to review the potential of CAD on CXR PN detection.Implications for practiceCAD acting as a second reader could potentially reduce interpreter error rate.     

Computed tomography-navigated transthoracic core biopsy of pulmonary lesions: which factors affect diagnostic yield and complication rates?

RATIONALE AND OBJECTIVES: Only a few studies have systematically evaluated risk factors for pneumothorax and pulmonary hemorrhage in computed tomographically (CT)-guided transthoracic lung biopsy (TLB). We evaluated the diagnostic yield of CT-guided TLB and determined risk factors for pneumothorax and hemorrhage. METHODS: One hundred seventy-two CT-guided TLBs were performed on 159 patients (mean age 66 +/- 11 years; 72% male) using a 16-gauge core biopsy needle. Lesion and patient characteristics, lung function analysis, CT signs of emphysema, histopathologic diagnoses, and complications were recorded. Statistical analysis was performed with multivariate regression analysis. RESULTS: Histopathologic diagnosis was established in 153 cases (89%). Although lesion size was higher (47 +/- 29 vs. 43 +/- 35 mm, P = .191) and depth was lower (22 +/- 23 vs. 6 +/- 23 mm, P = .350) in procedures with histopathologic diagnosis, no parameter showed significant impact on diagnostic yield. Sensitivity and specificity for detection of malignancy were 93% and 100%, respectively, whereas positive and negative predictive values were 100% and 88%. Overall accuracy was 95%. Pneumothorax occurred in 45 procedures (26%). Hemorrhage was recorded in 17 procedures (10%). There was higher frequency of pneumothorax in smaller lesions (35 +/- 23 vs. 50 +/- 31 mm, P = .003; odds ratio = .96) and greater depth (29 +/- 29 vs. 20 +/- 19 mm, P = .05; odds ratio = 1.03). CT signs of emphysema revealed higher incidence of hemorrhage (35% vs. 23%; P = .04; odds ratio=41.03). Other parameters were nonsignificant. CONCLUSIONS: The high diagnostic yield of CT-guided TLB was not affected by lesion characteristics or emphysema. Pneumothorax rate was influenced by lesion size and depth. Hemorrhage was associated with CT signs of emphysema.     

CT-guided core biopsy and percutaneous fiducial seed placement in the lung: Can these procedures be combined without an increase in complication rate or decrease in technical success?

Objective

To determine if concomitant CT-guided biopsy and percutaneous fiducial seed placement in the lung can be performed in a selective patient population without increased complication or decreased success rates compared to either procedure alone.

Materials and methods

An IRB approved retrospective analysis of 285 consecutive patients that underwent CT-guided placement of fiducial seeds in the lung alone (N = 63), with concomitant core biopsy (N = 53) or only core biopsy (N = 169) was performed. Variables compared included: patient demographics, lesion size, depth from pleura, needle size, number of passes through pleura, number and size of core biopsies, number of seeds placed and technical success rates. Statistical analysis was performed using univariate and multivariate pair-wise comparisons.

Results

A pathologic diagnosis of malignancy was confirmed in all cases undergoing seed placement alone and seed placement with concurrent biopsy, and in 144 of the biopsy alone lesions. On univariate analysis, major complication rates were similar for all three groups as were lesion size, depth, number of pleural passes, and technical success. Pair-wise comparisons of the remaining variables demonstrated a significant younger age and smaller needle size in the biopsy only group, and less minor complications in the fiducial only group. Overall there were 80/285 (28.1%) minor and 29/285 (10.2%) major complications. All major complications leading to admission consisted of either pneumothorax or hemothorax, while minor complications included asymptomatic stable or resolving pneumothoraces, transient hemoptysis or small hemothoraces.

Conclusions

A combined procedure of percutaneous pulmonary core biopsy and stereotactic seed placement can be performed without additional risk of a major complication when compared to performing these separately.     

Acute upper gastrointestinal hemorrhage: is a radiological interventional approach an alternative to emergency surgery?

The aim of our study was to discuss the option of endovascular treatment compared to surgery for patients with endoscopically unmanageable nonvariceal hemorrhage of the upper gastrointestinal tract. From 2000 to 2006, 23 patients (male, 15 male; female, 8; mean age, 69 years) who failed endoscopic therapy for upper gastrointestinal hemorrhage were retrospectively evaluated. Twelve patients were operated on (SG), whereas 11 patients had an endovascular intervention (IG). Technical and primary clinical success rates and complications rates were calculated. Clinical parameters and comorbidities were related to outcome. The surgical group suffered less frequently from pre-existing pulmonary diseases (SG, 17%; IG, 55%; p = 0.05) and had a higher incidence of shock requiring catecholamines (p < 0.01) or plasma expander therapy (p < 0.01). There was no significant difference in the incidence of recurrent bleeding episodes (SG, 17%; IG, 27%; p = 0.35) and mortality rates (SG, 17%; IG, 27%, p = 0.35). Deaths in the IG were due to recurrent bleeding. In patients with unsuccessful endoscopic control of nonvariceal bleeding of the upper GI tract, surgery remains a very effective treatment. However, in patients with a high surgical risk due to unknown bleeding sources and/or severe pre-existing diseases/comorbidities, endovascular therapy offers an excellent treatment option. These patients should then be operated on as early as possible to minimize the risk of recurrent bleeding episodes, which are associated with high morbidity and mortality.     

Ultrasound-guided fine-needle liver biopsy:a multicentre survey of pre-procedure evaluation practices and complication rates

A survey report was conducted among 12 Italian centres experi-enced in fine-needle biopsy of the liver.The questions concerned:1.the per-formance of inpatient or outpatient fine-needle biopsy;2.the policy of routinehemostatic evaluation;3.the management of patients taking aspirin;4.thenumber of biopsies performed and the diagnoses obtained;5.the complicationsthat occurred in relation to coagulation tests values.The results were as follows:1.10 out of 12 centres performed biopsiesmainly on outpatients;2.in only 2 of the 12 centres was a history investigatingthe patient's hemostasis collected;all centres routinely performed coagulationtests;the most frequent combination included prothrombin time,partialthromboplastin time and platelet count.Among the centres a great variabilityconcerning the test values considered safe existed;3.in 10 of the 12 centresbiopsy was not deferred if the patient was taking aspirin;4.the amount ofbiopsies performed was 9156 on a total of 6261 patients,mainly in diagnosingmalignant focal liver lesions;5.in 2 out of 6261 patients(0.03%)bleedingcomplications were fatal and in 8 out of 6261(0.13%)non-fatal but significant.Besides hemostatic decompensation,factors involved in the risk of post-biopsybleeding were the type of the lesion(malignant or hemangiomatous)and the co-existence of cirrhosis.     

Magnetic resonance imaging of pulmonary nodules: accuracy in a granulomatous disease–endemic region

Objective

To estimate the diagnostic accuracy of signal intensity of the lesion-to-spinal cord ratio (LSR) and apparent diffusion coefficient (ADC) in diffusion-weighted (DW) magnetic resonance imaging of pulmonary nodules suspicious for lung cancer in granulomatous lung disease-endemic regions.

Methods

Forty-nine patients with indeterminate solitary pulmonary nodules detected by chest computed tomography and histopathologically confirmed diagnoses were included in the study. DW images were analysed semiquantitatively by focusing regions of interest on the lesion and spinal cord at the same level (for LSR calculation). ADCs were estimated from ratios of the two image signal intensities. Ratios of T1 and T2 signal intensity between nodules and muscle were calculated for comparison.

Results

Mean ADCs?±?standard deviations for lung cancer and benign lesions were 0.9?±?0.2 and 1.3?±?0.2?×?10^-3 mm²/s, respectively. Mean LSRs were 1.4?±?0.3 for lung cancer and 1?±?0.1 for benign lesions. ADCs and LSRs differed significantly between malignant and benign lesions (P?<?0.001). Mean T2 signal intensity ratios also differed significantly between benign and malignant lesions (0.8?±?0.2 vs. 1.6?±?0.2; P?<?0.05).

Conclusions

DWI can help to differentiate malignant from benign lesions according to ADC and the LSR with good accuracy.

Key Points

? DW imaging can help differentiate malignant from benign pulmonary nodules. ? ADC and LSR signal intensities had only small overlap between malignant and benign pulmonary nodules. ? Mean T2 signal intensity ratios differed significantly between benign and malignant lesions.

     

Are two-dimensional CT measurements of small noncalcified pulmonary nodules reliable?

PURPOSE: To evaluate the intra- and interreader agreement of two-dimensional computed tomographic (CT) measurements of pulmonary nodules less than 2 cm in diameter. MATERIALS AND METHODS: Three readers independently made three serial measurements of each of 54 pulmonary nodules measuring 3-18 mm that had been observed on standard-dose multisection CT images obtained in 24 patients who ranged in age from 36 to 81 years (mean age, 54.6 years). There were 14 women (58%), who ranged in age from 43 to 81 years (mean age, 58.9 years), and 10 men (42%), who ranged in age from 36 to 65 years (mean age, 48.5 years). The largest transverse cross-sectional diameter of each nodule was measured at picture archiving and communication system, or PACS, workstations by using high-spatial-resolution reconstructed CT images and identical window settings. Intra- and interreader agreement were determined by using methods described by Bland and Altman: the coefficient of repeatability for intrareader agreement, and methods derived from the 95% limits of agreement defined by Bland and Altman for interreader agreement. RESULTS: The repeatability coefficients were 1.70, 1.32, and 1.51 mm for readers 1, 2, and 3, respectively. The 95% limits of agreement for the difference among readers were -1.73 and 1.73. CONCLUSION: Two-dimensional CT measurements are not reliable in the evaluation of small noncalcified pulmonary nodules.     

When is a diagnosis of sclerosing adenosis acceptable at core biopsy?

PURPOSE: To determine concordance of imaging findings and diagnosis of sclerosing adenosis at histopathologic core biopsy and to establish the accuracy of core biopsy when cancer was coexistent. MATERIALS AND METHODS: From a database of 1,166 percutaneous biopsies in which sclerosing adenosis was reported, 88 (7.5%) lesions were identified, and imaging and histopathologic findings were reviewed for concordance. Sclerosing adenosis proved to be a minor component at core biopsy for 44 lesions, including one invasive ductal carcinoma, one ductal carcinoma in situ (DCIS), one focus of atypical ductal hyperplasia (ADH), and one atypical lobular hyperplasia. Sclerosing adenosis was a major (> or =50%) component for 44 lesions, including four malignancies, all DCIS manifested as clustered calcifications (pleomorphic [n = 2] or amorphous [n = 2]), and seven foci of ADH manifested as amorphous calcifications. In 30 patients with 33 lesions without atypia or malignancy, sclerosing adenosis was the major finding at core biopsy (21 lesions at 14-gauge core biopsy and 12 at 11-gauge vacuum-assisted biopsy); these patients formed the study population. Mammographic (33 lesions) and sonographic (18 lesions) features were recorded. Twenty-seven lesions had at least 20-month follow-up (n = 25) or excision (n = 2). RESULTS: One spiculated mass was considered discordant and was excised, showing a prospectively unrecognized radial sclerosing lesion with several 2-5-mm foci of invasive tubular and lobular carcinoma. Seventeen (53%) of 32 lesions manifested as masses; 10 (59%) were circumscribed, five (29%) were indistinctly marginated (one with punctate calcifications), and two (12%) were partially circumscribed and partially obscured (one with amorphous calcifications). Fifteen (47%) lesions manifested as clustered calcifications; nine (60%) were amorphous and indistinct, four (27%) were pleomorphic, and two (13%) were punctate. Of 27 lesions with acceptable follow-up, 26 (96%) were believed to have been accurately sampled at core biopsy. Of six radial sclerosing lesions associated with the original 88 lesions, only three (50%) were prospectively recognized. CONCLUSION: Sclerosing adenosis is an acceptable result at core biopsy of circumscribed masses and nonpalpable indistinctly marginated masses and for clustered amorphous, pleomorphic, and punctate calcifications. Recognition and reporting of coexistent radial sclerosing lesions is encouraged and may prompt excision. Malignancy can be seen with sclerosing adenosis; core biopsy was accurate in six (86%) of seven coexistent malignancies in this series.     

Lobular carcinoma in situ or atypical lobular hyperplasia at core-needle biopsy: is excisional biopsy necessary?

PURPOSE: To retrospectively determine frequency of invasive cancer or ductal carcinoma in situ (DCIS) at excisional biopsy in women with atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) at percutaneous core-needle biopsy (CNB). MATERIALS AND METHODS: Review of results in 6,081 consecutive patients who underwent CNB at two institutions revealed that in 35 (0.58%), LCIS (n = 15) or ALH (n = 20) was the pathologic finding with highest risk. Patient age range was 41-84 years (mean, 59 years). Of 35 patients, 26 (74%) underwent excisional biopsy and nine (26%) underwent mammographic follow-up for longer than 2 years. Lesions with a pathologic upgrade were noted when invasive cancer or DCIS occurred at the CNB site. CNB results in patients with a diagnosis of atypical ductal hyperplasia (ADH) (75 of 6,081 [1.2%]) were reviewed; these patients underwent subsequent excisional biopsy. Statistical comparison of frequency of upgrading of lesions in patients with a diagnosis of LCIS or ALH at CNB and in those with a diagnosis of ADH at CNB was performed (Pearson chi(2) test). RESULTS: In six (17%) of 35 (95% CI: 4.7%, 29.6%) patients, lesions were upgraded to DCIS (n = 4) or invasive cancer (n = 2). In 15 patients with LCIS diagnosed at CNB, lesions in four (27%) were upgraded to either DCIS or invasive cancer. In 20 patients with ALH diagnosed at CNB, lesions were upgraded to DCIS in two (10%). Lesions in nine patients who underwent mammographic follow-up were stable. No mammographic or technical findings distinguished patients with upgraded lesions from those whose lesions were not upgraded. In 12 (16%) of 75 (95% CI: 7.7%, 24.3%) patients with ADH, lesions were upgraded. Difference between the upgrade rate in patients with LCIS or ALH and that in those with ADH was not significant (P =.88). CONCLUSION: Lesions in 17% of patients with LCIS or ALH at CNB were upgraded to invasive cancer or DCIS; this rate was similar to the upgrade rate in patients with ADH. Excisional biopsy is supported when LCIS, ALH, or ADH is diagnosed at CNB.     

The classification of lymphomas: a new beginning or the end of an era?

The World Health Organisation Classification of Tumours of the Haematopoietic and Lymphoid Tissues has recently been published. This is the latest in a long line of classifications of haematological malignancies and will be the international standard. It is now possible to achieve high levels of diagnostic accuracy for the main types of lymphoma. However, many of the entities encompass a wide spectrum of clinical outcomes and this approach to classification may be insufficiently precise for the future needs of haematological oncology. Rapid progress in targeted therapies may require further developments in tumour classification based on pathogenic features rather than arbitrary morphological criteria.     

Diagnosing a parotid lump: fine needle aspiration cytology or core biopsy?

Fine needle aspiration cytology (FNAC) has been widely adopted for the cytological diagnosis of parotid lumps. FNAC does have drawbacks, even under optimum conditions and may be associated with poor levels of diagnostic accuracy, particularly outside the specialized clinic environment. Ultrasound-guided core biopsy (USCB) is a relatively recently described technique in the parotid gland which has been well tolerated and has demonstrated a high degree of diagnostic accuracy in several studies. This article discusses the merits and pitfalls of FNAC, together with the technique of USCB and also highlights the potential advantages benefit provided by USCB in parotid diagnosis.     

Sonographically detected subarachnoid hemorrhage: an independent predictor of neonatal posthemorrhagic hydrocephalus?

Blood from an intraventricular hemorrhage (IVH) can collect in the basilar cisterns and cause ventriculomegaly and eventual need for ventriculoperitoneal (VP) shunt. We looked for sonographic evidence of subarachnoid hemorrhage (SAH) in three basal cisterns and in the Sylvian fissure of 82 infants with IVH, 30 of whom had ventriculomegaly. We found that ultrasonographically diagnosed SAH and measurement of ventricular blood volume predict ventriculomegaly and need for VP shunt.