Transthoracic CT-guided biopsy with multiplanar reconstruction image improves diagnostic accuracy of solitary pulmonary nodules

doi:10.1016/S0720-048X(03)00216-X

European Journal of Radiology

Volume 51, Issue 2, August 2004, Pages 160-168

https://doi.org/10.1016/S0720-048X(03)00216-X Get rights and content

Abstract

Objective: To evaluate the utility of multiplanar reconstruction (MPR) image for CT-guided biopsy and determine factors of influencing diagnostic accuracy and the pneumothorax rate. Materials and methods: 390 patients with 396 pulmonary nodules underwent transthoracic CT-guided aspiration biopsy (TNAB) and transthoracic CT-guided cutting needle core biopsy (TCNB) as follows: 250 solitary pulmonary nodules (SPNs) underwent conventional CT-guided biopsy (conventional method), 81 underwent CT-fluoroscopic biopsy (CT-fluoroscopic method) and 65 underwent conventional CT-guided biopsy in combination with MPR image (MPR method). Success rate, overall diagnostic accuracy, pneumothorax rate and total procedure time were compared in each method. Factors affecting diagnostic accuracy and pneumothorax rate of CT-guided biopsy were statistically evaluated. Results: Success rates (TNAB: 100.0%, TCNB: 100.0%) and overall diagnostic accuracies (TNAB: 96.9%, TCNB: 97.0%) of MPR were significantly higher than those using the conventional method (TNAB: 87.6 and 82.4%, TCNB: 86.3 and 81.3%) (P<0.05). Diagnostic accuracy were influenced by biopsy method, lesion size, and needle path length (P<0.05). Pneumothorax rate was influenced by pathological diagnostic method, lesion size, number of punctures and FEV1.0% (P<0.05). Conclusion: The use of MPR for CT-guided lung biopsy is useful for improving diagnostic accuracy with no significant increase in pneumothorax rate or total procedure time.

Introduction

Transthoracic needle biopsy of pulmonary lesions is performed under fluoroscopic, computed tomographic (CT) or even sonographic guidance. CT is particularly useful for localizing small solitary pulmonary nodules (SPNs) which can be difficult under fluoroscopic or sonographic guidance [1], [2], [3]. Although CT is fast, less costly and generally accomplished with high accuracy, pneumothorax remains the most frequent complication of this procedure. Diagnostic accuracy is limited because of the obscure location of the needle tip, by the partial volume effect and positional changes of the SPN in the cranio-caudal direction by respiratory motion [4], [5], [6], [7]. Recently, CT-fluoroscopic biopsy has been proposed as a new technique for assessing pulmonary lesions as it overcomes the limitations of diagnostic accuracy and complication of CT-guided biopsy [8], [9]. However, development of devices and skills for reducing radiation exposure to patients and operators are required [10], [11]. Limitations of CT-guided biopsy and CT-fluoroscopic biopsy are mainly caused by the fact that the localization of the needle tip and the SPN is performed only in the transverse section.

The development of new CT-techniques, such as helical scan and multidetector-row system, and workstations help to reduce examination time and to allow for multiplanar reconstruction (MPR) images for evaluation in the arbitrary section [12], [13], [14]. Therefore, we propose a new MPR assisted CT-guided biopsy technique using a single-detector spiral CT system and a newly developed multidetector-row CT system for the evaluation of the relationship between the needle tip and the SPN on the arbitrary section.

The purpose of this study was to evaluate usefulness of MPR image for transthoracic CT-guided biopsy in comparison with the conventional CT-guided biopsy technique and the CT-fluoroscopic biopsy regarding success rate, diagnostic accuracy, pneumothorax rate and total procedure time. Determination of factors affecting diagnostic accuracy and the frequency of pneumothorax of transthoracic biopsy with CT-guidance were also assessed using a multi-variable analysis.

Section snippets

Patients

Three hundred ninety patients with 396 SPNs, 221 male and 169 female aged 16–86 years (mean, 63.3±16.8 (standard deviation) years), underwent transthoracic CT-guided or CT-fluoroscopic needle biopsies of SPNs in our hospital between January 1995 and December 2002. Detail of patient was shown in Table 1.

Out of 396 SPNs, conventional CT-guided biopsy (conventional method; between January 1995 and September 1998) was performed in 250 cases (170 aspiration biopsies and 80 core biopsies);

Results

Out of the 396 SPNs, 266 SPNs diagnosed as malignant and 80 SPNs diagnosed as benign by transthoracic needle biopsy were TP and TN cases. The remaining 50 SPNs were false positive and false negative cases, and were diagnosed as follows; 50 cases (30 malignant, 20 benign) were diagnosed by video-assisted thoracic surgery (VATS), sputum cytology or open lung biopsy. Success rate, overall diagnostic accuracy, pneumothorax rate and total procedure time are shown in Table 2.

On TNAB, success rates of

Discussion

Since Haaga and Aifridi reported the first CT-guided biopsy in 1976 [1], improved techniques have expanded the scope of thoracic lesions amenable to transthoracic biopsy [3], [4], [15], [16]. Many investigators have reported accuracies of CT-guided biopsy ranging from 64 to 97%, and major complications are rare [1], [3], [4], [5], [6], [7], [15], [16], [17], [18], [19], [20], [21], [22], [23]. Pneumothorax is the most common complication after TNAB, with reported rates of 19–44%; the range of

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Cited by (40)

Transthoracic Computed Tomography–Guided Lung Nodule Biopsy: Comparison of Core Needle and Fine Needle Aspiration Techniques
2016, Canadian Association of Radiologists Journal
Citation Excerpt :
Some papers have defined hemorrhage using hemoptysis [14] while others have used hemoptysis and ground glass opacity on postbiopsy CT [26]. Consistent with previous studies [4–6,8,9,27] we found no difference between FNA and CN on hemoptysis and our hemoptysis rate was concordant with previous data [5,14]. In this study, pneumothorax and pulmonary hemorrhage were more common in small lesions.
To determine if there is a statistically significant difference in the computed tomography (CT)–guided trans-thoracic needle biopsy diagnostic rate, complication rate, and degree of pathologist confidence in diagnosis between core needle biopsy (CNB) and fine needle aspiration biopsy (FNAB).
A retrospective cohort design was used to compare the diagnostic biopsy rate, diagnostic confidence, and biopsy-related complications of pneumothorax, chest tube placement, pulmonary hemorrhage, hemoptysis, admission to hospital, and length of stay between 251 transthoracic needle biopsies obtained via CNB (126) or FNAB (125). Complication rates were assessed using imaging and clinical follow-up. Final diagnosis was confirmed via surgical pathology or clinical follow-up over a period of up to 10 years.
CNB provided diagnostic samples in 91% and FNA in 80% of biopsies, which was statistically significant (P < .05). The sensitivities for CNB and FNAB were 89% (85 of 95) and 95% (84 of 88), respectively. The specificity of CNB was 100% (21 of 21) and for FNAB was 81% (2 of 11) with 2 false positives in the FNAB group.
The differences in complication rate was not statistically significant for pneumothorax (50% vs 46%; determined by routine postbiopsy CT), chest tube (2% vs 4%), hemoptysis (4% vs 6%), and pulmonary hemorrhage (38% vs 47%) between FNAB and CNB, respectively. Seven patients requiring chest tube were admitted to hospital, 2 in the FNAB cohort for an average of 2.5 days and 5 in the CNB cohort for an average of 4.6 days.
CNB provided more diagnostic samples with no statistical difference in complication rate.
Déterminer s'il existe un écart statistiquement significatif entre la biopsie au trocart et la cytoponction (aspiration à l'aiguille) en ce qui a trait aux taux de diagnostic par biopsie transthoracique à l'aiguille guidée par tomodensitométrie (TDM), aux taux de complication et au degré de confiance diagnostique du pathologiste.
Un examen de cohorte rétrospectif a permis de comparer le taux de diagnostic, la confiance diagnostique et les complications (pneumothorax, insertion d'un drain thoracique, hémorragie pulmonaire, hémoptysie, admission et durée du séjour à l'hôpital) associés à 251 biopsies transthoraciques à l'aiguille, dont 126 biopsies au trocart et 125 cytoponctions. Les taux de complication ont été déterminés grâce au suivi en imagerie et au suivi clinique. Le diagnostic définitif a pour sa part été confirmé au moyen de résultats pathologiques chirurgicaux ou d'un suivi clinique pouvant s’échelonner sur 10 ans au plus.
91 % des échantillons prélevés par biopsie au trocart ont été utilisés à des fins diagnostiques, contre 80 % des échantillons prélevés par cytoponction (écart statistiquement significatif; P < 0,05). Le degré de sensibilité des biopsies au trocart a été établi à 89 % (85 sur 95), alors que celui des cytoponctions a été établi à 95 % (84 sur 88). Les biopsies au trocart ont affiché une spécificité de 100 % (21 sur 21) et les cytoponctions, une spécificité de 81 % (2 sur 11) avec deux résultats faussement positifs au sein du groupe.
En ce qui concerne les taux de complication, les écarts entre les cytoponctions et les biopsies au trocart ne se sont pas avérés significatifs sur le plan statistique au chapitre des pneumothorax (50 % contre 46 %; déterminés par la TDM postbiopsie d'usage), de l'insertion d'un drain thoracique (2 % contre 4 %), de l'hémoptysie (4 % contre 6 %) et de l'hémorragie pulmonaire (38 % contre 47 %). Enfin, des 7 patients qui ont été hospitalisés en raison de l'insertion d'un drain thoracique, 2 avaient subi une cytoponction et ont passé en moyenne 2,5 jours à l'hôpital, alors que 5 avaient subi une biopsie au trocart et ont passé en moyenne 4,6 jours à l'hôpital.
La biopsie au trocart prélève davantage d’échantillons diagnostics que la cytoponction. Toutefois, les deux interventions n'affichent aucun écart statistiquement significatif au chapitre des taux de complication.
How should pulmonary nodules be optimally investigated and managed?
2016, Lung Cancer
Citation Excerpt :
Ten retrospective case series each with at least 50 patients were identified with a total of 1568 patients. Sensitivities ranged from 77 to 97% and specificities from 72 to 100% [53–62]. Whilst accepting the wide heterogeneity in the inclusion criteria between studies, combined analysis of the 1445 patients for whom follow-up data were available revealed an overall sensitivity of 90%, specificity of 95% and negative likelihood ratio of 0.10 [4].
Pulmonary nodules are a common incidental finding on CT and the inexorable rise in the use of CT (10% increase per year in the UK over the last decade) means that the frequency of their detection is likely to increase over coming years. This may be augmented further if CT screening is implemented. Management has previously been influenced by North American guidelines, with the most widely used resource to date being the Fleischner Society guidelines published in 2005. These predominantly focus on the timing of CT scans arranged to survey small pulmonary nodules (≤8 mm), and the guideline authors chose not to offer specific recommendations regarding larger nodules. More recently, the society published specific guidelines for sub-solid nodules, reflecting the different prognosis that this subtype of nodules confers. The American College of Chest Physicians have published two guidelines on pulmonary nodules—the latest was completed in 2012 and published in Chest the following year.
However, the investigation and management of pulmonary nodules is a rapidly evolving subject largely driven by evidence from the large CT screening studies. In 2012, The British Thoracic Society (BTS) convened a guideline development group to address the topic of pulmonary nodule investigation and management, with publication of the guideline in July 2015. One third of the 359 references included in the guideline date from 2012 onwards, and many of the differences between the recommendations made and previous guideline recommendations reflect this recent evidence. This article reviews specific evidence considered in formulating the BTS guidelines, and summarises the main guideline recommendations.
Image-guided percutaneous transthoracic biopsy in lung cancer - Emphasis on CT-guided technique
2012, Journal of Infection and Public Health
Citation Excerpt :
Pneumothorax after CT-guided percutaneous lung biopsy has been reported from 8 to 54%, with an average of around 20% in most large series as CT imaging can detect even very small pneumothorax that may not even be visible on chest radiograph. However, the rate for pneumothoraces requiring treatment with chest tube varies from 5 to 18% [10,35,37–47]. Pneumothorax can occur during or immediately after the procedure, which is why it is important to perform a CT scan of the region following removal of the needle.
Image-guided percutaneous transthoracic core biopsy especially with CT guidance is playing an increasing role in the diagnosis and management of lung cancer. The recent advances in the specific chemotherapy and novel targeted therapy and the increasing need for specific diagnosis of tumor histopathologic subtypes have direct impact on the radiologists performing lung biopsy and important implications for the biopsy technique. Close cooperation between radiologists and referring physicians with understanding of the technical aspects of the biopsy procedure can help clinicians make appropriate referrals for this procedure and understand the significance and limitations of the results. Additionally, the appropriate management of complications can limit morbidity related to the biopsy procedure.
How accurate are measurements of skin-lesion depths on prebiopsy supine chest computed tomography for transthoracic needle biopsies?
2012, European Journal of Radiology
Citation Excerpt :
Thus, accurate targeting in biopsies is all the more important to obtain adequate samples and to avoid major complications, such as potentially fatal hemorrhage [11–14]. CT or CT fluoroscopy can provide image guidance for TNB of small and central pulmonary lesions with higher diagnostic accuracy and safety than conventional fluoroscopy [9,15–18], but fluoroscopy is still useful for image guidance in TNB, considering its advantages of lower radiation exposure to the patient and the operator [2,19,20]. Considering that large-gauge cutting needles usually have a 2-cm cutting segment and that the maximum change in skin-lesion depth in the prone position was about 2 cm, we recommend CT-guided TNB, or additional prebiopsy prone CT before fluoroscopy-guided TNB for nodules that are small (<2 cm) and that will be biopsied in the prone position.
To evaluate the accuracy of depth measurements on supine chest computed tomography (CT) for transthoracic needle biopsy (TNB).
We measured skin-lesion depths from the skin surface to nodules on both prebiopsy supine CT scans and CT scans obtained during cone beam CT-guided TNB in the supine (n = 29) or prone (n = 40) position in 69 patients, and analyzed the differences between the two measurements, based on patient position for the biopsy and lesion location.
Skin-lesion depths measured on prebiopsy supine CT scans were significantly larger than those measured on CT scans obtained during TNB in the prone position (p < 0.001; mean difference ± standard deviation (SD), 6.2 ± 5.7 mm; range, 0–18 mm), but the differences showed marginal significance in the supine position (p = 0.051; 3.5 ± 3.9 mm; 0–13 mm). Additionally, the differences were significantly larger for the upper (mean ± SD, 7.8 ± 5.7 mm) and middle (10.1 ± 6.5 mm) lung zones than for the lower lung zones (3.1 ± 3.3 mm) in the prone position (p = 0.011), and were larger for the upper lung zone (4.6 ± 5.0 mm) than for the middle (2.4 ± 2.0 mm) and lower (2.3 ± 2.3 mm) lung zones in the supine position (p = 0.004).
Skin-lesion depths measured on prebiopsy supine chest CT scans were inaccurate for TNB in the prone position, particularly for nodules in the upper and middle lung zones.
Risk of pleural recurrence after computed tomographic-guided percutaneous needle biopsy in stage i lung cancer patients
2011, Annals of Thoracic Surgery
Citation Excerpt :
The possibility of pleural seeding causing pleural dissemination after a percutaneous needle biopsy procedure has been noted, although survival analyses are lacking [18]. Diagnostic imaging techniques have been developed to obtain accurate clinical diagnosis, such as positron emission tomography in addition to conventional or thin-slice CT, whereas percutaneous CT-guided needle biopsy methods have been reported, along with CT fluoroscopy or multi-planar reconstruction imaging techniques [19, 20]. Thus, we reconsidered the efficacy of CTGNB and the proper indications for its use with lung cancer diagnoses.
A computed tomographic-guided percutaneous needle biopsy (CTGNB) is useful as an option for pathologic diagnosis of lung cancer, especially in patients with peripheral small-sized nodules. We aimed to assess the risk of pleural seeding of cancer cells, leading to postoperative relapse with dissemination caused by the procedure.
We investigated the clinical outcomes of 447 stage I lung cancer patients. Survival analysis was performed using the Kaplan-Meier method and a log-rank test. Pleural recurrence rates were also determined. Furthermore, propensity score matching analysis was used to reduce background bias from patient characteristics.
The 5-year, disease-free survival rate was 89.1% in patients diagnosed with CTGNB, and 85.5% in those diagnosed using a transbronchial biopsy or open lung biopsy procedure. Local recurrence with pleural dissemination was found in 8 of 13 recurrence cases (61.5%) in the CTGNB group, which was higher as compared with the transbronchial biopsy or open lung biopsy group (p < 0.01). Subset analyses of p stage IB cases and those with subpleural lesions showed that local recurrence with dissemination was significantly more frequent in the CTGNB group (p = 0.02 and p < 0.01, respectively). In patients with subpleural lesions diagnosed with CTGNB, the rate of local recurrence with dissemination was 15.4%. Propensity score matching analysis confirmed the significantly increased frequency of pleural dissemination after CTGNB.
The CTGNB procedure might increase the risk of pleural implantation in stage I lung cancer patients, especially p stage IB cases with subpleural lesions, whereas the overall disease-free survival rate was not affected by this small population of patients with recurrence.
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2024, Current Medical Imaging

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^☆: We have no grants in conflict with this study.

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Transthoracic CT-guided biopsy with multiplanar reconstruction image improves diagnostic accuracy of solitary pulmonary nodules☆

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Radiol. Clin. North Am.

J. Vasc. Intervent. Radiol.

Precise biopsy localization by computer tomography

Radiology

CT assistance for fluoroscopically guided transthoracic needle aspiration biopsy

J. Comput. Assisted Tomogr.

Technical aspects of needle aspiration lung biopsy: a personal perspective

Radiology

Direct percutaneous needle aspiration of localized pulmonary lesions: result in 422 patients

Radiology

Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung

Radiology

Use of spirometry to predict risk of pneumothorax in CT-guided needle biopsy of the lung

J. Comput. Assisted Tomogr.

Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules

Am. J. Roentgenol.

Guidance with real-time CT fluoroscopy: early clinical experience

Radiology

Radiation dosimetry at CT fluoroscopy: physician's hand dose and development of needle holders

Radiology

Image analysis in multislice spiral CT of the lung with MPR and MIP reconstructions

Radiology

CT diagnosis of solitary pulmonary nodule

Nippon Igaku Hoshasen Gakkai Zasshi

Diagnostic potential of virtual bronchoscopy: advantages in comparison with axial CT slices, MPR and mIP

Eur. Radiol.