CT-guided cutting needle biopsy of lung lesions--safety and efficacy of an out-patient service

AIM: To determine the safety and efficacy of CT-guided cutting needle biopsy of lung lesions as an out-patient procedure. MATERIALS AND METHODS:A total of 185 consecutive biopsies were performed under CT guidance on 183 patients between January 1991 and December 1998 using 20-gauge (n= 33), 18-gauge (n= 151) or 14-gauge (n= 1) core biopsy needles. A chest radiograph was taken after observation in the Radiology department for 1 h and asymptomatic patients were discharged. RESULTS: The histology was malignant in 150 biopsies (81. 1%) and benign in 23 (12.4%) with 12 false-negative results (6.5%); there were no false-positive results. The sensitivity was 92.6%; specificity 100%; negative predictive value 65.7%; and overall accuracy 93.5%. Pneumothoraces occurred in 48 patients (25.9%); one required aspiration only and four required insertion of an intercostal drain. One patient developed a pneumothorax after discharge. Small haemoptyses occurred in 13 patients without pneumothorax (7.0%), one of whom was admitted. In-patient treatment was required in 10 patients (5.4%). CONCLUSION: Computed tomography-guided cutting needle biopsy of pulmonary lesions is a safe technique with a diagnostic accuracy and complication rate comparable to reported figures for fine needle aspiration biopsy. It can be safely performed on an out-patient basis.     

使用切割针行经皮纵隔肿块穿刺活检术

探讨ＣＴ引导下使用切割针行经皮纵隔肿块穿刺活检术的临床价值。材料和方法：对３２例纵隔肿块,使用１６～１９Ｇ切割针在ＣＴ引导下施行穿刺活检术,分别进行细胞学和组织学检查。结果：诊断准确性为９３．８％,假阴性率６．１％。并发症包括气胸（３例）、肺内出血（５例）、纵隔内出血（３例）,其发生与穿刺路径有关;总体发生率为３４．４％（１１／３２）,均无需特殊处理。结论：ＣＴ引导下经眼纵隔肿块切割活检术诊断准确     

Hilar masses: evaluation with CT-guided biopsy after negative bronchoscopic examination

Computed tomography (CT)-guided biopsies of 20 patients with hilar masses were performed after non-diagnostic bronchoscopic examination. Bronchoscopy included washings, brushings, routine biopsy, and, in many cases, transbronchial biopsy. In all but one case (95%), biopsy with a 22-gauge needle permitted a cytologic diagnosis of malignancy. In 14 of the 19 cases (74%), a diagnosis of primary lung carcinoma involving the hili was made, and in the remaining five of the 19 (26%), metastatic hilar adenopathy from an extrathoracic primary tumor was identified. A pneumothorax rate consistent with our average rate for CT-guided biopsies (25%) was obtained, and only one patient required chest tube placement. In this series, CT-guided biopsies of hilar masses were more consistently successful in obtaining tissue for diagnosis than were bronchoscopic biopsies. Transthoracic needle aspiration biopsy may be the preferred initial diagnostic procedure in many patients with hilar masses.     

Comparison of fully automated and semi-automated biopsy needles for lung biopsy under CT fluoroscopic guidance

Objective

The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for lung biopsy.

Methods

50 consecutive percutaneous lung biopsies using the Monopty needle between June 2006 and January 2007 and 66 consecutive lung biopsies for 1 nodule in each session using the Temno needle between February 2007 and August 2008 were performed under CT fluoroscopic guidance followed by histopathological evaluation.

Results

In 42/50 lung biopsies performed with the Monopty needle and 54/66 lung biopsies performed with the Temno needle, the final diagnosis was confirmed by independent surgical pathological findings or clinical follow-up. Sufficient samples for histopathological evaluation were obtained in all 50 (100%) biopsies using the Monopty needle and in 55 (83.3%) of the 66 biopsies using the Temno needle (p<0.01). Accurate diagnosis was achieved in 41 (97.6%) of 42 biopsies using the Monopty needle and in 45 (83.3%) of 54 biopsies using the Temno needle (p=0.04). Biopsy-induced complications were pneumothorax, haemoptysis and haemothorax in 44.0%, 10.0% and 6.0% of biopsies, respectively, using the Monopty needle and in 48.3%, 8.3% and 3.3%, respectively, using the Temno needle.

Conclusion

There is a possibility that a fully automated biopsy needle such as the Monopty is more useful for CT scan-guided lung biopsy than semi-automated biopsy needles.CT scan-guided needle biopsy of lung nodules has become a well-established diagnostic technique [1]. Most CT scan-guided lung biopsies cited in earlier reports [2,3] were performed with fine-needle aspiration for cytology and were useful in differentiating malignant from benign lesions. In addition, a tissue-core biopsy using a cutting needle, which enables histopathological evaluation of the samples obtained [4], has been implemented to enhance diagnostic ability. Owing to the development of the automated cutting needle, tissue-core biopsy can now be performed more easily and higher quality core specimens can be obtained for histopathological analysis [5-11].There are two types of automated cutting needles: the fully automated biopsy needle and the semi-automated biopsy needle. Comparisons have been made of the use of these needles for autopsy [12] or breast tissue biopsy [13]. To our knowledge, no investigation has been carried out to compare these two types of automated cutting needles for lung biopsy. The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for use in CT scan-guided lung biopsy.     

CT-guided needle biopsy of the lung: factors affecting risk of complications

PURPOSE: To analyze factors influencing the risk of complications associated with CT-guided percutaneous needle biopsy for lung lesions. MATERIALS AND METHODS: Sixty patients, aged 24-85 years (37 men and 23 women), underwent CT-guided needle biopsy. A definite diagnosis was made in 49 of 60 cases (81.7%), including 38 of 43 malignant lesions (88.4%) and 11 of 17 benign lesions (64.7%). Complications associated with biopsy were observed in 35 patients (58.3%). Major complications included pneumothorax (n = 26) and pulmonary hemorrhage (n = 20). Chest tube placement was needed in 5 (19.2%) of 26 pneumothorax cases (8.3% of all biopsies). RESULTS: The high frequency of pneumothorax (43.3%) in this series had several contributing factors, including the presence of pulmonary emphysema, lesion size, and traversal of aerated lung. Chest tube replacement was necessary more frequently in patients with pulmonary emphysema. The number of pleural passes, location of lesions, and size of needles were not correlated with the incidence of pneumothorax. CONCLUSION: The presence of pulmonary emphysema, lesion size, and traversal of aerated lung are the predominant risk factors for pneumothorax in patients with CT-guided lung biopsy.     

Variables affecting the risk of pneumothorax and intrapulmonal hemorrhage in CT-guided transthoracic biopsy

The influence of various variables on the rate of pneumothorax and intrapulmonal hemorrhage associated with computed tomography (CT)-guided transthoracic needle biopsy of the lung were evaluated retrospectively. One hundred and thirty-three patients underwent CT guided biopsy of a pulmonary lesion. Two patients were biopsied twice. Variables analyzed were lesion size, lesion location, number of pleural needle passes, lesion margin, length of intrapulmonal biopsy path and puncture time. Eighteen-gauge (18G) cutting needles (Trucut, Somatex, Teltow, Germany) were used for biopsy. Pneumothorax occurred in 23 of 135 biopsies (17%). Chest tube placement was required in three out of 23 cases of pneumothorax (2% of all biopsies). Pneumothorax rate was significantly higher when the lesions were located in the lung parenchyma compared with locations at the pleura or chest wall (P < 0.05), but all pneumothorax cases which required chest tube treatment occurred in lesions located less than 2 cm from the pleura. Longer puncture time led to an increase in pneumothorax rate (P < 0.05). Thirty-seven (27%) out of 135 biopsies showed perifocal hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage and pneumothorax (P < 0.05). Significantly more hemorrhage occurred when the pleura was penetrated twice during the puncture (P < 0.05). Lesion size <4 cm is strongly correlated with higher occurrence of perifocal hemorrhage (P < 0.05). Lesion margination showed no significant effect on complication rate. CT-guided biopsy of smaller lesions correlates with a higher bleeding rate. Puncture time should be minimized to reduce pneumothorax rate. Passing the pleura twice significantly increases the risk of hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage as well as pneumothorax.     

New suction guide needle designed to reduce the incidence of biopsy-related pneumothorax: experimental evaluation in canine model

In an attempt to remove air that enters the pleural space during computed tomography (CT)-guided coaxial transthoracic needle biopsy, the authors fashioned an 18-gauge experimental suction guide needle and evaluated the incidence of pneumothorax with this needle in comparison to the incidence of pneumothorax with a standard 18-gauge guide needle in a canine model. This experiment had animal care and use committee approval. Ten dogs underwent a biopsy of each lung, for a total of 20 lung biopsies. Half of the biopsies were performed by using the experimental needle (five right lungs, five left lungs), and half were performed by using a standard guide needle. CT revealed pneumothorax during the procedure and was performed to reveal pneumothorax 1 and 3 hours after the procedure. A significant reduction (P < .016) in intraprocedural lung biopsy-associated pneumothorax was found when the experimental guide needle was used.     

肺隐球菌病CT导向下经皮穿刺活检的诊断价值

目的：探讨CT导向下经皮穿刺肺活检对肺隐球菌的诊断价值。方法：回顾性分析11例经皮肺穿刺活检病理证实的肺隐球菌病的病例资料,所有病例均行CT检查,其中9例平扫,2例直接增强,11例行细针抽吸及切割活检送病理组织学检查。结果：CT显示单发肺结节4例,多发肺结节5例,2例呈实变样表现,11例经细针抽吸活检2例可疑隐球菌病,切割活检11例均确诊为隐球菌病,发生少量气胸1例。结论：对于肺部难以确诊的肺隐球菌病例,CT导向下经皮穿刺切割活检是一种安全有效的方法。     

Nonpulmonary thoracic biopsy

The aim of the present paper is to distinguish between thoracic pulmonary needle biopsy--which can be carried out under fluoroscopic guidance--and thoracic extrapulmonary needle biopsy, which requires a more accurate type of guidance, such as CT. Among the 500 thoracic punctures performed during the last 5 years, we considered only 90 biopsies of mediastinal (N = 58) or thoracic wall (N = 32) masses. We have thus excluded all parenchymal lesions of the lungs. For extrapulmonary thoracic masses, CT was the method of choice for biopsy guidance which provided diagnostic evidence of small-diameter mediastinal lesions that permitted analysis of the relationship to vascular structures and performance of extrapleural needle insertion, using larger-gauge needles to ensure accurate needle placement within the lesion. In both mediastinal and thoracic wall lesions an overall accuracy rate of 84% was obtained. In no case was thoracic drainage required for treatment of the moderate degree of pneumothorax that occurred in 1% of our patient population.     

CT-guided lung biopsy: incidence of pneumothorax after instillation of NaCl into the biopsy track

This study was conducted to evaluate whether instillation of NaCl 0.9% solution into the biopsy track reduces the incidence of pneumothoraces after CT-guided lung biopsy. A total of 140 consecutive patients with pulmonary lesions were included in this prospective study. All patients were alternatingly assigned to one of two groups: group A in whom the puncture access was sealed by instillation of NaCl 0.9% solution during extraction of the guide needle (n = 70) or group B for whom no sealing was performed (n = 70). CT-guided biopsy was performed with a 18-G coaxial system. Localization of lesion (pleural, peripheral, central), lesion size, needle-pleural angle, rate of pneumothorax and alveolar hemorrhage were evaluated. In group A, the incidence of pneumothorax was lower compared to group B (8%, 6/70 patients vs. 34%, 24/70 patients; P < 0.001). All pneumothoraces occurred directly post punctionem after extraction of the guide needle. One patient in group A and eight patients in group B developed large pneumothoraces requiring chest tube placement (P = 0.01). The frequency of pneumothorax was independent of other variables. After CT-guided biopsy, instillation of NaCl 0.9% solution into the puncture access during extraction of the needle significantly reduces the incidence of pneumothorax.     

CT导向经胸穿刺活检108例报告

CT导向经胸穿刺活检108例;纵隔,肺门36例,周围肺野66例,胸膜6例。经手术证实和临床随访,恶性肿瘤的穿刺活检正确率为96％、良性肿瘤为54.5％、非肿瘤性病变为36.4％。4例并发症:2例气胸、2例轻微出血。无空气栓塞及肿瘤扩张。本文讨论了CT导向与电视监视,超声导向的比较,认为CT导向对深部小病灶以及组织结构重叠部位病灶比电视监视、超声导向为好。另外也分析了穿刺针与并发症的关系以及产生并发症的其它因素。并且评价了CT导向穿刺活检在临床诊断的作用。     

直径3cm以下肺孤立性病灶的CT引导下经皮肺穿刺活检

目的:评价直径3cm以下肺孤立性病灶的CT引导下经皮肺穿刺活检的价值。方法:68例直径3cm以下肺孤立性病灶在CT引导下,采用抽吸式活检针,选择最佳穿刺层面及穿刺点获取标本。结果:本组病例共行84次穿刺活检,获得细胞学涂片检查者68例,获得组织学检查59例。总的诊断准确度为89.7%,其中细胞学和组织学标本诊断准确度分别为662%(45/68)和81.4%(48/59)。阳性预告值和阴性预告值分别为100%(51/51)和58.8%(10/17)。并发症:气胸16例(23.5%),出血5例(7.4%),咯血4例(5.9%)。结论:CT引导下经皮肺穿刺活检是一种创伤小而实用的定性诊断方法,对直径3cm以下肺孤立性病灶的诊断具有较高的临床应用价值。     

Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax.

PURPOSE: To analyze the influence of multiple variables on the rate of pneumothorax and chest tube placement associated with transthoracic needle aspiration biopsy of the lung. MATERIALS AND METHODS: In 346 patients, 331 computed tomographically (CT) guided and 24 fluoroscopically guided lung biopsies were performed. Variables analyzed were lesion size, depth, and location; number of pleural passes; needle size; presence of emphysema; and training level of the person who performed the biopsy. RESULTS: Pneumothorax occurred at 144 (40.4%) of 356 biopsies, including 139 (42.0%) CT-guided and five (21%) fluoroscopically guided biopsies. Chest tube placement was needed in 25 (17.4%) of 144 cases of pneumothorax (7% of all biopsies). An increased rate of pneumothorax was correlated with smaller lesion size (P = .001) and presence of emphysema (P = .01). Patients with emphysema were three times as likely to require chest tube placement. The pneumothorax rate was 15% (16 of 105) if no aerated lung was traversed and approximately 50% if aerated lung was penetrated. Lesion location, needle size, number of pleural passes, and level of training were not correlated with pneumothorax rate. CONCLUSION: Smaller lesion size and emphysema are strongly correlated with occurrence of pneumothorax. Pneumothorax was more than three times less frequent if no aerated lung was traversed. After pneumothorax, chest tube placements were related to the presence of emphysema.     

CT-guided percutaneous needle biopsy of intrathoracic lesions by using the transsternal approach: experience in 37 patients.

PURPOSE: To report our experience with computed tomography (CT)-guided coaxial needle biopsy of intrathoracic lesions by using the transsternal approach. MATERIALS AND METHODS: Medical records of 37 consecutive patients who underwent CT-guided transsternal biopsy of intrathoracic lesions were evaluated retrospectively. A coaxial needle technique was used in all patients; an 18-gauge needle was used for transsternal penetration, through which a 22-gauge needle was passed to obtain fine-needle aspirates. Five patients also underwent core-needle biopsy with a coaxially introduced 20-gauge needle. Medical records were reviewed for lesion size and location, needle path, number of needle penetrations, reasons for failure, biopsy results, and complications. RESULTS: The transsternal approach was used in mediastinal (n = 32) or intrapulmonary (n = 5) lesions. Transsternal needle sampling of the target lesion was successful in 35 patients. In the remaining two, adequate angling of the transsternal needle could not be achieved. Extrapleural access to the mediastinal lesions was achieved in all but one patient in whom the 22-gauge needle traversed the lung. Major vessels were avoided in most patients; the 22-gauge needle was safely passed through the brachiocephalic vein in one patient with a retrotracheal mass. Thirty-two (91%) of the 35 biopsies yielded diagnostic specimens. No major complications were encountered. Minor complications were pneumothorax in one patient and mediastinal hematoma in another. CONCLUSION: The CT-guided transsternal approach for coaxial core-needle biopsy allows safe access to masses in various locations in the mediastinum and anteromedial lung.     

Percutaneous needle evaluation of intradural extramedullary lesions of the lumbar spine

Summary A total of eight patients in whom five intradural extramedullary lesions and three epidural lesions were present were evaluated by percutaneous needle biopsy. In four patients the level of aspiration biopsy was determined using the initial myelogram and in those patients fluoroscopic guided percutaneous needle biopsies were performed. Three of these patients had large intradural extramedullary masses (above 1 cm); one patient had an epidural lesion. Diagnostic material was obtained in all cases (medulloblastoma, astrocytoma, small cell carcinoma, adenocarcinoma). Immediate post procedure CT and clinical followup showed no complications. In three patients with small lesions (below 1 cm), post myelographic CT was used to determine the level of aspiration. Post myelographic CT showed an intradural extramedullary mass in one patient and epidural lesions in two cases. Plain CT showed a high attenuation lesion in one patient. CT guided percutaneous needle biopsies in these four patients yielded diagnostic specimens (neurofibroma, uroepithelial carcinoma, hematoma, Thorotrast deposit). Clinical follow up showed no complications. Our experience indicates that percutaneous needle biopsy of intradural extramedullary and epidural lesions of the lumbar spine is safe and efficacious. Depending upon the size of the lesions, myelography or CT can be utilized to determine the level of aspiration.     

CT导向经皮肺部病变穿刺活检的临床效果

目的探讨CT导向经皮肺穿刺活检的临床应用和体会。方法 66例经CT导向做肺穿刺活检的患者,肺内肿块为62例,胸膜病变2例,肋骨及胸腺病变各1例,采用切割针和抽吸针。结果经一次穿刺成功诊断59例。穿刺后病理怀疑肺鳞状细胞癌,结果为肺脓肿1例;第一次穿刺假阴性6例,其中有2例再次穿刺成功诊断为肺腺癌和鳞状细胞癌。本组穿刺活检总的成功率为92.4%。结论 CT导向经皮肺穿刺活检是一项安全有效的诊断方法,CT的准确定位和良好的穿刺技术及病理科的配合和熟练的技术操作是提高活检成功率的重要因素。     

CT引导下肺实性结节切割活检术后出血与气胸的多因素分析

目的 探讨CT引导下经皮穿刺肺实性结节切割活检术后并发出血、气胸的危险因素.方法 回顾性分析肺实性结节(≤3 cm)320例经16 G半自动切割活检的临床及影像学资料,行单因素和多因素Logistic回归分析.结果 活检术后针道出血发生率33.1％,气胸发生率18.1％,良恶性诊断准确率约99.6％.针道长度是出血的独立危险因素,针道每增加3 cm,风险增加3.881倍,且风险也随穿刺时间(P=0.061)和穿胸膜次数(P=0.062)呈正相关.年龄、位置和针-胸膜夹角是气胸独立风险因素,年龄每增加10岁,风险增加2.102倍;上肺叶病灶显著低于下肺叶;针-胸膜夹角每增加20°,风险增加2.413倍,肺气肿以微弱差距(P=0.086)被排除方程之外.以出血、气胸概率值绘制ROC曲线,AUC值分别为0.753和0.725.结论 CT引导下肺实性结节切割活检术后出血、气胸的发生受多种因素影响,术前仔细评估,术中操作熟练度可以有效预判和降低出血、气胸的发生.     

CT引导下经皮肺穿刺活检:18G和20G穿刺针的比较

目的探讨应用18G、20G自动切割针行CT引导下经皮肺穿刺活检的诊断效率和并发症的差异。方法对比分析应用18G和20G自动切割针肺活检的2组各60例的诊断效率和并发症。结果18G组肺癌48例,穿刺确诊45例,确诊率93.8%,假阴性3例,假阴性率6.2%;良性病变12例,其中10例穿刺活检确诊。20G组肺癌46例,穿刺确诊42例,确诊率91.3%,假阴性4例,假阴性率8.7%;14例良性病变,其中10例穿刺活检确诊。18G组有20例发生气胸,2例需闭式引流处理,20G组有8例发生气胸,均是少量气胸,无需特殊处理。2组在确诊率、假阴性率、气胸发生率进行统计学处理,经χ2检验,P值>0.05,两者均无显著性差异。结论18G、20G2组在确诊率、假阴性率、气胸发生率均无显著差异,但18G组的气胸发生率及严重程度均高于20G组。     

CT导向经皮肺活检的临床应用

31例肺部肿块病人在CT导向下作了经皮针吸肺活检术,其中肺癌16例,肺穿刺活检准确率87.5%;良性病变15例,肺穿刺活检准确率93%、术后气胸3例(9.7%),小量出血1例(3.2%).CT扫描图像清晰.病灶定位准确.因此CT导向经皮肺活检术安全、准确、成功率高,在肺部肿块的诊断中有重要作用.     

CT-guided transthoracic needle biopsy using an ipsilateral dependent position

OBJECTIVE: We postulated that the pneumothorax rate of transthoracic needle biopsy might improve with an ipsilateral dependent position of the affected side. We tried to determine the feasibility, effectiveness, and safety of CT-guided biopsy with the patient in this position. SUBJECTS AND METHODS: CT-guided needle biopsy with the patient in an ipsilateral dependent position was performed in 23 patients with 17 lung lesions (15 posterior and two anterior) and six mediastinal lesions. Fine-needle aspiration was used in all patients, and core biopsy was also used in six patients. The technical difficulty of the procedure was classified into three grades compared with a routine transthoracic needle biopsy as follows: grade I, no more difficult; grade II, somewhat more difficult; and grade III, much more difficult. RESULTS: Adequate samples were obtained in 22 (96%) of 23 patients. A small asymptomatic pneumothorax occurred in two patients (8.7%). Difficulty was rated grades I, II, and III in 18 (78%), two (9%), and three (13%) procedures, respectively. Four of the five grades II and III procedures were biopsies of anterior lesions. Traversing the pleura was avoided in three of six mediastinal masses. CONCLUSION: Transthoracic needle biopsy of selected lung and mediastinal lesions using an ipsilateral dependent position is feasible, effective, and safe. The role of this technique for reducing the rate of pneumothorax as a result of the biopsy requires further investigation.