Diagnostic value of ultrasound guided transthoracic tru-cut biopsy in thorax malignancies

Background: Transthoracic fine needle aspiration biopsy (FNAB) is an important diagnostic method in the evaluation of lung malignancies. The incidence of chest wall implantation metastases after FNAB is extremely rare. However, we report a case of cancer seeding along needle track after a CT-guided transthoracic FNAB. Case report: We diagnosed squamous cell carcinoma of the lung, stage T3N0 in a 71-year old male, ex-smoker, by transthoracic FNAB. A small metastasis was discovered in the left humerus after PET-CT. The patient was treated by chemotherapy and irradiation of bone metastasis. Four months after initial evaluation we repeated CT scan of the thorax. A tumour progression with tumour growth from the primary site was found in the left upper lobe to the pectoral muscle along the needle biopsy track. Conclusions: Although the frequency of chestwall implantation metastasis after transthoracic FNAB of lung malignancies is very rare, attentive follow up is recommended. Early intervention with resection and irradiation is often curative in previously radically treated patients.

Objective To evaluate the diagnostic value of the contrast-enhanced ultrasound (CEUS) combined with ultrasound-guided fine needle aspiration biopsy (FNA) for thyroid carcinoma.Methods A retrospective analysis of the clinical data of 165 patients was finished,including 184 thyroid nodules confirmed by pathology (14 benign,170 malignant) and their preoperative FNA and CEUS data.According to the maximal diameter of thyroid nodules,the patients was divided into group A (≤ 1 cm) and group B (＞1 cm).According to the Bethesda System,＞grade Ⅳ was the malignant cytologic criteria for diagnosis of thyroid nodules,and uneven low-enhanced ultrasound was the standard diagnosis of malignant thyroid.Pursuant to which,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value of diagnosis for thyroid nodules by FNA,CEUS,and the combination were analyzed respectively.Results In group A,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value of single FNA were 93.8％,62.5％,92.0％,97.6％,38.5％,and CEUS diagnosis for thyroid cancer were 88.5％,37.5％,85.5％,95.8％,16.7％,respectively.After FNA and CEUS were combined,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value were 100％,25.0％,95.7％,95.6％,100％,respectively.When the combined diagnosis compared with single FNA and CEUS,the sensitivity and accuracy were statistically significant (P =0.013,0.000 and P =0.000,0.000).In group B,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value of single FNA were 100％,83.3％,97.8％,97.6％,100％,and CEUS diagnosis for thyroid cancer were 92.5％,83.3％,91.3％,97.4％,62.5％,respectively.After FNA and CEUS were combined,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value were 100％,66.7％,95.6％,95.2％,100％,respectively.For each pairwise comparison,the sensitivity,specificity,accuracy,positive predictive value and negative predictive value were not statistically different (P ＞0.05).Conclusions For thyroid nodules ≤ 1cm,the combined diagnosis of FNA and CEUS can significantly improve the diagnostic sensitivity and accuracy.While for thyroid nodules ＞ 1 cm,the combined diagnosis does not change the diagnostic accuracy,sensitivity and specificity. Key words: Ultrasonography; Microbubbles ; Biopsy, needle; Thyroid neoplasms

Mediastinal masses include a myriad of nonneoplastic and neoplastic conditions that may be benign or malignant, primary or metastatic. Although the clinical data, the location within the mediastinum, and the radiologic findings all help in narrowing the differential diagnosis, obtaining tissue for pathologic evaluation is often mandatory for choosing the appropriate treatment regimen. Tissue diagnosis is especially desirable for lesions that do not require surgical management. Transthoracic needle biopsy is a useful method for obtaining tissue diagnosis from mediastinal masses. Needle biopsy has several advantages compared with mediastinoscopy and mediastinotomy. Needle biopsy is faster and can be performed as an outpatient procedure, using local anesthesia, thereby avoiding the complications of surgery and general anesthesia. Additionally, needle biopsy is less costly compared with surgical procedures. The depth of the lesion does not influence sampling notably. All regions of the mediastinum are potentially accessible to needle biopsy, whereas certain mediastinal lymph node stations (e.g., anterior, posteroinferior subcarinal, para-aortic, and aortopulmonary nodes) are inaccessible to mediastinoscopy, sometimes requiring additional invasive diagnostic procedures such as mediastinotomy or thoracoscopy. We discuss the entities accounting for the majority of mediastinal masses and the merits of needle biopsy in their evaluation. Metastatic carcinoma to mediastinal or hilar lymph nodes accounts for 49 to 72% of mediastinal lesions, and is either the result of lung cancer or an extrathoracic malignancy. Malignant lymphoma and thymoma are the most frequent primary neoplasms in the mediastinum. Germ cell tumors, neurogenic tumors, cysts, benign lymphadenopathy, and inflammation are much less common. 1–3 The diagnostic accuracy of needle biopsy in these various lesions differs substantially and thus they are discussed separately. STAGING OF PRIMARY LUNG CANCER Metastatic carcinoma to the mediastinal lymph nodes is the most prevalent pathology within the mediastinum. Establishing the TNM staging of nonsmall cell lung cancer determines whether the cancer is operable. The status of mediastinal lymph nodes, however, cannot be assessed accurately by means of diagnostic imaging alone. According to Shields, 4 only 10 to 20% of patients with lung cancer have resectable mediastinal N2 lymph nodes (ipsilateral mediastinal and subcarinal lymph nodes). Patients with N3 disease (metastasis to contralateral mediastinal or hilar lymph nodes and to scalene and supraclavicular lymph nodes) are defined as having inoperable disease. It follows that the most common application for mediastinal transthoracic needle biopsy (or any other mediastinal staging procedure) is to prevent unnecessary surgery in patients with unresectable mediastinal lymph node metastases. Several imaging criteria that are used frequently to indicate “unresectability” include “bulky lymphadenopathy,” involvement of two or more lymph node stations, high paratracheal N2 disease, and superior vena caval obstruction. 5 Instead of relying on these nonspecific guidelines, mediastinal transthoracic needle biopsy, with or without biopsy of the primary lung cancer, can be used for definite staging (Fig. 1). High sensitivity and specificity of needle biopsy for the diagnosis of metastatic cancer to the mediastinum has been reported. Morrissey et al. 6 reported a sensitivity of 90% for metastatic carcinoma to the mediastinum using fine-needle aspiration (FNA), and a slightly higher sensitivity (96%) using core biopsy. Protopapas and Westcott 1 reported a sensitivity of 98% for the diagnosis of metastatic carcinoma in slightly to moderately enlarged lymph nodes. Weisbrod et al. 7 reported an accuracy of 90.3% in diagnosing mediastinal metastatic disease from lung and extrathoracic sites. Other investigators have also reported a high accuracy of needle biopsy for the diagnosis of metastatic mediastinal cancer. 2,3 Based on these results, several authors have recommended needle biopsy as the initial method for biopsy of suspected mediastinal cancer, manifested either as enlarged lymph nodes or as suspected mediastinal invasion.FIG. 1.: (A) Computed tomographic–guided needle biopsy of a subcarinal lymphadenopathy. The patient is in the prone position. The tip of the needle is seen within the subcarinal mass. (B) The aspiration biopsy of the subcarinal mass shows large clusters of markedly atypical epithelial cells with irregular nuclear membranes and prominent nucleoli (arrow), diagnostic of adenocarcinoma (Papanicolaou stain, original magnification ×1200).Figure 1: ContinuedDespite its many advantages, it should be emphasized that a negative needle biopsy of enlarged mediastinal lymph nodes should not be considered definitive evidence for benignity. A negative biopsy may be the result of sampling error resulting from incomplete neoplastic replacement of the sampled lymph node. A repeat biopsy may yield carcinoma in biopsies that were initially nondiagnostic. Protopapas and Westcott 8 addressed this issue recently in a study of 48 patients who underwent needle biopsy of enlarged mediastinal lymph nodes. In eight of these patients, a repeat biopsy was required, and five of the eight were positive for carcinoma on the second attempt. ANTERIOR MEDIASTINAL MASSES Establishing a diagnosis that distinguishes between lymphoma, thymoma, and germ cell tumor has major importance. Lymphoma is treated according to the type and stage of the disease with radiotherapy, chemotherapy, or a combination thereof in accordance with the precise diagnosis. Conversely, the primary treatment of thymoma and germ cell tumor is surgical resection. When diagnosing anterior mediastinal lesions with needle biopsy, the differential diagnosis depends on whether the predominant cell type is epithelial or lymphoid. When aspirates show a predominantly lymphoid cell population, the primary considerations are lymphoma (non-Hodgkin's lymphoma [NHL] and Hodgkin's disease [HD]) and thymic hyperplasia. When there is evidence for epithelial cell predominance the possibilities include epithelial thymoma, thymic carcinoma, germ cell tumor, metastatic carcinoma, and poorly differentiated carcinoma extending from the lung (Fig. 2). Lymphoma and thymoma are the most prevalent primary tumors of the mediastinum.FIG. 2.: (A) Computed tomographic–guided needle biopsy of an anterior mediastinal mass. A direct mediastinal approach has been used, avoiding transgression of the aerated lung. (B) The aspiration biopsy of this anterior mediastinal mass shows a biphasic cellular pattern, with small lymphocytes, scattered among prominent groups of bland benign epithelial cells, diagnostic of thymoma (Papanicolaou stain, original magnification ×600).Figure 2: ContinuedLymphoma The reported sensitivity of transthoracic FNA biopsy for the diagnosis of lymphoma ranges from 42 to 82%. Herman et al. 9 reported an overall sensitivity for diagnosing lymphoma of 42% in 26 patients. Their sensitivity for diagnosing HD was only 20%. 9 Weisbrod et al. 7 reported the accuracy of cytologic examination for lymphoma to be 66.7%, using FNA. Shaab et al., 10 who have also used FNA, have identified correctly six of seven cases of HD based on the presence of Reed–Sternberg cells in the specimen, and five of six cases of NHL based on the presence of lymphoid cells. FNA has a much lower accuracy for the diagnosis of mediastinal lymphoma compared with mediastinal carcinoma. Additionally, the combined number of reported FNA biopsies of mediastinal lymphoma is considerably lower compared with biopsies for carcinoma of the mediastinum. 1–3,8 Several investigators have reported a lower sensitivity of mediastinal needle biopsy for the diagnosis of HD, particularly the nodular sclerosis subtype, compared with NHL. The low yield of FNA in HD has been attributed to the paucity of Reed–Sternberg cells in the cellular aspirate. Subclassification of NHL into low and intermediate grades using FNA is also difficult or even impossible because it requires a histologic specimen to characterize the tissue architecture. 1,3 Silverman et al. 11 have reported their experience with transthoracic needle biopsy in 102 patients with lymphoma, which included 93 patients with NHL and 9 patients with HD. They used both FNA and core needle biopsy. Treatment was initiated in 72% of patients based on the results of image-guided needle biopsy alone. In patients with a prior diagnosis of lymphoma, treatment was initiated on the sole basis of needle biopsy in 91% of patients in their series. Ben-Yehuda et al. 12 reported their results with core needle biopsies in 100 patients with lymphoma, 79 of whom had NHL and 21 of whom had HD. A total of 86% of their patients were treated solely on the basis of results obtained by needle biopsy. The use of core needle biopsy in lymphoma allows sufficient tissue to be sampled for accurate histologic and immunohistochemical evaluation. It enhances the positive diagnostic rate as well as the percentage of patients treated on the basis of needle biopsy alone. Moulton and Moore 13 compared the use of aspiration versus core needle biopsy in 22 patients with lymphoma (21 NHL and 1 HD). FNA was positive for lymphoma in 68% of patients, but only in 53% was the information sufficient to institute therapy. In comparison, a correct diagnosis was established in 91% using core needle biopsy, allowing treatment in all of these patients. 13 Zinzani et al. 14 reported a sensitivity of 81% in diagnosing lymphoma using core biopsy. The diagnosed patients included 45 patients with NHL and 22 patients with HD. Specific classification of the histologic subtypes of NHL and HD was possible by means of immunohistochemical techniques. 14 It is clear that FNA has a much lower accuracy for lymphoma than for carcinoma. The use of core needle biopsies and immunohistochemical staining improves substantially the diagnostic accuracy of needle biopsy for the diagnosis of lymphoma (Fig. 3).FIG. 3.: Computed tomographic–guided needle biopsy of a large anterior mediastinal mass. The aspiration biopsy showed a rich population of large atypical cells. Immunocytostaining was positive for leukocyte common antigen and negative for cytokeratin, thereby establishing the diagnosis of large cell lymphoma.Thymoma Patients with thymoma are generally treated surgically, with radiotherapy reserved for patients with local invasion. In a series of 29 patients, Weisbrod 15 reported a sensitivity of 61% for the diagnosis of thymoma using FNA biopsy. Three cases of thymoma in this series were misdiagnosed by FNA, two as lymphoma and one as cystic thymoma. Herman et al. 9 reported a sensitivity of 71% for FNA biopsy in a series of 28 patients with thymoma. In an additional study by Weisbrod et al., 7 an accuracy of 82.4% for the cytologic diagnosis of thymoma was reported. It should be noted, however, that the cytologic evaluation was limited to the general diagnosis of thymoma, and did not differentiate between benign and malignant lesions. It appears that core needle biopsy can be beneficial in the diagnosis of thymoma, 6 but reports are limited, and even core needle biopsy cannot distinguish between benign and locally invasive disease. It is reasonable to conclude that, currently, the role of mediastinal needle biopsy for patients with thymoma is mainly to exclude other diagnoses for which treatment is nonsurgical, such as lymphoma and metastatic carcinoma. Patients with thymoma require surgery for an accurate diagnosis as well as for treatment. Nevertheless, a preoperative diagnosis may be of value when the tumor is large or when it is suspicious of being malignant. In these situations, a preoperative course of radiotherapy or chemotherapy may be useful. Mediastinal Germ Cell Tumors Mediastinal germ cell tumors account for 15% of anterior mediastinal masses. 16 Most series dealing with transthoracic needle biopsy for mediastinal germ cell tumors comprise only a small number of patients. The sensitivity for needle biopsy of mediastinal germ cell tumors has varied from 91% in a series of 11 patients described by Herman et al. 9 to 57% in a series of 10 patients described by Weisbrod. 15 Mature teratomas are predominantly cystic and can be very large. They may be calcified and are usually filled primarily with grumous material and hair. Most commonly, an aspiration biopsy yielding grumous material and squamous cells is sufficient to make the diagnosis. Seminoma is the most common malignant germ cell tumor in the mediastinum and it is sensitive to radiotherapy. It is therefore imperative to distinguish this germ cell tumor from those that require surgical excision or chemotherapy. Distinction from large cell lymphoma or HD can be difficult. Embryonal carcinoma may resemble poorly differentiated adenocarcinoma or large cell undifferentiated carcinoma. Core biopsies or cell-block preparations are superior to smears in making this distinction. NEUROGENIC TUMORS The most common cause of a posterior mediastinal mass is a neurogenic tumor. Weisbrod et al. 7 identified cells suggestive or consistent with neurogenic tumors in only 8 of 16 biopsies of posterior mediastinal masses. They found that some of these tumors underwent cystic changes as well as bleeding and fibrosis. Those associated features complicated their cytologic evaluation. Dahlgren and Ovenfors 17 described 16 biopsies of neurogenic mediastinal tumors, and concluded that such tumors, even when small, may be diagnosed relatively simply with combined radiographic features and aspiration biopsy. Neurogenic tumors in adults are usually of peripheral nerve sheath origin, most commonly schwannomas. 18 In children, most neurogenic tumors are malignant and arise from the sympathetic nervous system. Neurogenic tumors in children, which are typically highly cellular, include neuroblastoma and ganglioneuroblastoma, and are usually accompanied by increased levels of metabolites of catecholamines in the urine. Because needle biopsy in children poses difficulties that often make it impractical, these tumors in children are most easily diagnosed (and treated) using surgery. IMAGE GUIDANCE To perform a mediastinal needle biopsy, it is generally helpful to obtain a contrast enhanced computed tomographic (CT) scan before the procedure. The size of the mass as well as its characteristics, location, and proximity to mediastinal and vascular structures can be evaluated. This information can help avoid hitting a major vascular structure, and can assist in planning the appropriate needle path and patient positioning. Fluoroscopy is often inadequate to guide mediastinal biopsies because some lesions are poorly visualized and a safe needle path, avoiding vital cardiovascular structures, cannot be ensured. CT guidance is the preferred imaging used by most operators. 19 CT–fluoroscopy provides rapid image display and reconstruction allowing real-time visualization of the biopsy process. Procedures performed under standard CT guidance take longer than those performed using CT–fluoroscopy. White et al. 20 reported a decrease of 2 to 4 minutes per needle adjustment using CT–fluoroscopy. This method allows imaging of the needle as it advances, real-time visualization of positional changes resulting from respiration, and rapid detection of complications. Sonographic guidance is also used for mediastinal biopsies. 21–23 Sonography allows real-time imaging, with no exposure to ionizing radiation. Because an adequate sonographic window is required to achieve satisfactory sonographic imaging, this technique is suitable mainly for lesions abutting the chest wall. 23 Gupta et al. 24 report success with biopsies from right paratracheal and pretracheal lesions using suprasternal sonography. In this way, the soft tissue around the trachea and the great vessels provides an adequate sonographic window as well as anatomic guidance of the nearby structures. 24 A prebiopsy CT scan can be used to select patients in whom ultrasonic guidance for mediastinal biopsies is feasible. 25 In addition to transthoracic ultrasound, endosonographic guidance can also be used to perform mediastinal FNA. 26,27 DIFFERENT APPROACHES TO DIFFERENT LOCATIONS Direct Mediastinal Approach Using the direct mediastinal approach, the needle should be placed medial to the lung to avoid penetration of a pleural surface. This can be done easily when the mass in the anterior mediastinum is large enough and projects lateral to the sternum. Positioning the patient supine in an oblique lateral decubitus position may move the mass enough to enable direct mediastinal biopsy. With lateral decubitus positioning, the internal mammary artery and vein may be very close to the needle path. These vessels are clearly identified with CT and can be avoided by choosing a needle path that is immediately adjacent to the sternum. Bressler and Kirkham 28 reported two patients in whom the internal mammary vessels were punctured inadvertently, resulting in small, self-limiting extrapleural hematomas. Transpulmonary Approach The transpulmonary approach 28 for biopsy of mediastinal masses has been used especially under fluoroscopic guidance. This method has the attendant risk of pneumothorax as a common complication, which occurs in 20 to 30% of patients 2 because the needle must transgress two visceral pleural surfaces. This risk can be minimized by positioning the patients in the postbiopsy dependent position. 29,30 Suprasternal Approach The suprasternal approach is useful for lesions in the anterior 28 and the middle mediastinum. 31 Care should be taken when using this approach for middle mediastinal lesions to avoid puncturing the great vessels. Middle mediastinal lesions usually cause substantial anatomic distortion, which facilitates using the suprasternal approach and thus avoids the great vessels. Transsternal Approach The transsternal approach 32 enables sampling of most anteriorly located masses without passing lung parenchyma, while avoiding the hazard of puncturing the internal mammary vessels. The system includes a coaxial length-matched bone biopsy system, comprising an outer cannula and an inner eccentric drill bit. The sole complication we have encountered using this technique was minor patient discomfort while penetrating the sternum, which could be overcome by additional local anesthesia. Pleural Space Approach The pleural space approach 28 enables placement of the needle into the pleural space, which is widened by an effusion or a pneumothorax, avoiding puncture of the visceral pleura during the procedure. If the effusion is not big enough, patient positioning can help manipulate even a small amount of effusion to avoid visceral pleural puncture. If a pneumothorax is present as a complication of a failed prior biopsy attempt, subsequent attempts should be made using the existing pneumothorax to avoid further lung parenchymal puncture. In patients, with chest tubes ipsilateral to the lesion, an iatrogenic pneumothorax can be created, thus expanding the pleural space for a mediastinal mass biopsy. At the end of the procedure the pneumothorax is evacuated and the lung is reinflated. This approach should not be used if the patient develops dyspnea. BIOPSY NEEDLES Needles that are used for biopsy of mediastinal masses can generally be divided into two main categories: aspiration needles and cutting needles. Some needles yield tissue fragments that are suitable for histologic diagnosis as well as a cellular aspirate. Examples of such needles are the Westcott needle (Becton–Dickinson, Rutherford, NJ, USA) and the Turner needle (Cook Catheter, Bloomington, NJ, USA). In these two needle designs, modifications in the cutting edge have been made to improve the yield of tissue fragments. The Westcott needle has a beveled tip and a slotted opening adjacent to its tip, whereas the Turner needle has a sharpened 45° cutting edge along the circumference. 33,34 One of two techniques is generally used to obtain the biopsy specimen: the single-needle technique or the co-axial technique. In the latter, a thinner inner needle is inserted through a larger outer needle. The tip of the outer needle is placed at the edge of the lesion or within it, and multiple samples can be obtained using a single puncture. With the single-needle technique, multiple punctures are required to obtain multiple samples, but thinner, less traumatic needles can be used to obtain the same amount of specimen relative to the co-axial technique. 35 High diagnostic accuracy has been reported for aspiration biopsy of mediastinal metastatic carcinoma using thin aspiration needles that are 19 gauge or smaller. The reported sensitivity for mediastinal cancer ranges between 84 and 100%, and is comparable with needle biopsy results for pulmonary lesions. 1 However, the diagnostic accuracy of aspiration biopsy for noncarcinomatous lesions such as lymphoma, thymoma, and neurogenic tumors, is considerably lower. 1,2 In cases in which small tissue fragments with disorganized histology are insufficient (such as in noncarcinomatous and nonneoplastic masses), larger tissue fragments can be obtained using co-axial automated cutting needle devices. As stated earlier, in a study comparing aspiration versus core biopsy for the diagnosis of lymphoma, Moulton and Moore 13 reported an increase in sensitivity from 68 to 91%. Other studies have also shown superiority of Tru-Cut-type biopsies over FNA biopsies, particularly for the diagnosis of noncancerous malignant or benign mediastinal processes. 6,36 In automated devices, the core biopsy needle can be 18 or 20 gauge, but needles as large as 14 gauge have been used. 37 The larger the needle, the higher the risk for complication, but the ability to obtain sufficient tissue for diagnosis is higher as well. Balanced judgment regarding the biopsy needle to be used should be considered on a case-to-case basis, and should take into account the radiologic characteristics of the lesion. Biopsies of lesions with imaging suggestive of a carcinoma could be started with smaller gauge needles, whereas those of lesions suggestive of lymphoma or thymoma should be started with larger gauge needles. COMPLICATIONS The most frequently encountered complications of needle biopsy of the mediastinum are pneumothorax and mild mediastinal hemorrhage. The reported incidence of pneumothorax in several large series of needle biopsies of mediastinal lesions ranges from 0 to 34%, and is comparable with the reported rate in transthoracic biopsy of pulmonary lesions. 1–3,6,8,9 The risk factors for pneumothorax in transthoracic mediastinal biopsies include traversing the lung, the presence of emphysema, the depth of the lesion, the number of pleural surfaces traversed, and the number of needle passes. Therefore, the direct mediastinal, suprasternal, transsternal, and pleural space approaches, as described earlier, are preferred to the transpulmonary approach. The rate of hemorrhage after needle biopsy of the mediastinum ranges from 0 to 10%. 1 Even when mediastinal bleeding does occur, short hospitalization for observation is sufficient. 1,28 The incidence of serious complications resulting from needle biopsy of the mediastinum is very low, 1,28 even though major intrathoracic hemorrhage causing cardiac tamponade and death have been reported. 38,39 SUMMARY Image-guided needle biopsy of the mediastinum is rapid, safe, and inexpensive, and does not require general anesthesia. All regions of the mediastinum are potentially accessible using this technique. The depth of the lesion does not limit the feasibility of the biopsy procedure. Unnecessary surgery can often be avoided, thereby reducing patient morbidity and shortening hospitalization. The importance of establishing a diagnosis in a nonsurgical way in patients who are not surgical candidates is clear. Many mediastinal biopsies are performed for lung cancer staging. Needle biopsy, even when using thin aspiration needles, is highly accurate in diagnosing mediastinal carcinoma. Advances in biopsy needle technology, namely the use of core biopsy needles, have enabled the yield of large tissue fragments with minimally distorted histology, facilitating the diagnosis of lymphoma and helping to establish a diagnosis in patients in whom fine-needle biopsy was nondiagnostic. Advances in immunohistochemical staining have also contributed to the diagnostic accuracy of needle biopsy in the diagnosis of lymphoma. Innovations in CT imaging, particularly CT–fluoroscopy, which is more and more the of the needle biopsy procedure and its In cases of thymoma, the role of mediastinal needle biopsy is mainly to exclude other diagnoses for which treatment is nonsurgical, such as lymphoma and metastatic carcinoma. In needle biopsy of the mediastinum should be the procedure of to obtain tissue diagnosis for a of mediastinal particularly when the established diagnosis can surgery.

Policies and Reporting Guidelines for Small Biopsy Specimens of Mediastinal Masses

Background: Lung cancer is the number one cause of cancer-related death in the Western world. Intrapulmonary nodules are presenting either solitary or multiples. Primary bronchogenic carcinoma is the most common malignant tumor that presents as a solitary pulmonary nodule. Fine-needle aspiration (FNA) and Tru-cut biopsy are parts from several interventional procedures that need to reach to the final diagnosis. Aim: This study aims to assess the comparison between transthoracic FNA results and Tru-cut biopsy results in the diagnosis of peripheral pulmonary lesions and the possibility of depending on one of them in the diagnosis of these lesions. Materials and Methods: FNA and true cut biopsy under computed tomography scan guided were performed to patients had peripheral pulmonary lesion and sent to the cytological and histopathological laboratory for analysis. Results: All patients (20) that had pulmonary lesion were evaluated. Results of FNA were; 15/20 of them were adequate samples for diagnosis while 5/20 were inadequate. Results of Tru-cut biopsies were – 17/20 were adequate for histopathological assessment while 3/20 were inadequate. Thirteen out of 20 patients had malignancy, five patients diagnosed by both Tru-cut biopsy and FNA, other five diagnosed by Tru-cut biopsy only and three patients diagnosed by FNA only. One patient had benign lesion and diagnosed by both procedures. Six out of 20 patients had other results that diagnosed by both procedures. Squamous cells carcinoma was 5/13 patients (38.46%) and adenocarcinoma was the same percentage. The concordance of FNA results with Tru-cut biopsy results was 60%. Conclusion: The study demonstrated that Tru-cut biopsy is moderately superior to FNA in the evaluation of peripheral malignant lung lesions. Therefore, we advise not using the FNA alone in the evaluation of peripheral chest lesions that suspected of malignancy (except if large bullae or severe emphysema present) and Tru-cut biopsy is often required together to reach the diagnosis.

To determine the usefulness, limitations and diagnostic accuracy of fine needle aspiration biopsy (FNAB) in soft tissue tumours. Cross-sectional analytical (comparative) study. Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. A total of 78 soft tissue tumours were subjected to FNAB from May 2000 to April 2002. Adequate aspirate was obtained in 69 patients. The smears were stained with Haematoxylin and Eosin (HE) and May-Grunwald-Giemsa (MGG) stains. FNAB smears were put into three categories i.e. benign, borderline or malignant. A definite diagnosis was also given where possible. Tissue biopsies were received in 38 of these patients. Routine HE staining was done in each case along with special stains and immunohistochemistry where required. Out of 69 tumours, 30 were categorised as benign, 9 as intermediate and 30 as malignant. Lipomas were the most common benign tumour while small round blue cell tumours constituting 7 cases (23%) were the commonest malignancy. FNAB-histological correlation showed all tumours reported as benign on FNAB to be confirmed as such. There was only one false positive diagnosis on FNAB. All cases placed in intermediate category were found to be malignant on histopathology. Considering intermediate cases alternatively as benign and malignant revealed sensitivity of 80.6% and 100%, specificity of 85.7% and 85.7% and accuracy of 81.6% and 97.4% respectively. Majority of soft tissue tumours can be categorized on FNAB with high degree of accuracy. The tumours placed in intermediate category should be subjected to biopsy or excision as it is more likely that they turn out to be malignant.

Introduction: Transthoracic fine needle aspiration biopsy(TNAB) has shown to be a resonably safe, simple, and accurate procedure in diagnosis of intrathoracic lung lesions. We reviewed the results of 1,005 TNAB of chest lesions performed on 930 patients with 20 or 22-gauze needles over a period of 10 years. Methods: From November 1983 to June 1995, 1,005 cases in 930 patients with an undiagnosed lung lesion underwent TNAB at the Hanyang University Hospital: 66% were men and 34% were women. Most of the patients were 40~60 years old and the youngest patient was 3 years of age. Result: 540 patients had various malignant chest lesions and 322 patients had benign pulmonary lesions. The diagnostic accuracy of TNAB was 96.1 percent in malignant diseases with one false positive result and 90.1% in benign diseases. A definitive diagnosis was not obtained in the remaining 68 patients. The most common diagnoses among 519 malignancy chest lesions with TNAB were the following: squamous cell lung carcinoma, 31.7%; adenocarcinoma, 24.7%; small cell lung carcinoma, 16.7%; metastatic cancer, 14.2%; large cell lung carcinoma, 6.2% and so on. Complications included pneumothorax in 12.3% necessitating chest tube drainage in 0.6%. Minor hemoptysis occurred in 3.6%. There was no death directly attributable to the procedure. Conclusion: We concluded that TNAB permits a direct approach to all kinds of localized lung lesions with a high degree of accuracy and without major complications.

Objective To investigate the clinical value of detection of the BRAF V600E combined with ultrasound-guided fine needle aspiration cytology in the diagnosis of indeterminate thyroid nodules in elderly patients. Methods A total of 60 elderly patients with thyroid nodules admitted to our hospital from October 2014 to December 2015 underwent ultrasound-guided fine needle aspirations. The samples were sent for cytology examination and detection of the BRAF V600E mutation. Diagnoses based on cytology alone and those in combination with detection of the BRAF V600E mutation were retrospectively analyzed and compared with clinical follow-up results. Results The fine needle aspiration procedure was successfully performed in 95% (57/60) of the patients. Of the 57 patients, cytological diagnoses in 48 cases were consistent with the follow-up results, with an agreement rate of 84.2% (48/57). The 48 cases included 6 patients diagnosed with benign nodules and 42 patients with thyroid papillary carcinoma. The BRAF V600E mutation was found in 32 cases with thyroid papillary carcinoma, with a detection rate of 76.2%. Of the 9 cases with indeterminate thyroid nodules, 7 had the BRAF V600E mutation. In diagnoses based on the combination of fine needle aspiration biopsy with detection of the BRAF V600E mutation, 55 out of 57 cases were consistent with the follow-up results, achieving an agreement rate of 96.5%. The clinical diagnostic accuracy of the cytology procedure combined with BRAF V600E mutation detection was better than that of the cytology procedure alone (P<0.05). Conclusions Ultrasound-guided fine needle aspiration cytology combined with detection of the BRAF V600E mutation can increase the clinical diagnostic accuracy for thyroid nodules and is highly valuable in the diagnosis of cytologically indeterminate thyroid nodules in elderly patients. Key words: Ultrasonography; Lymph nodes; Immunohistochemistry

Objective In clinical practice,ultrasound-guided fine-needle aspiration biopsy (US-G FNAB) is the gold standard in diagnosing the pathological nature of undetermined thyroid nodules before operation.Re---sults of FNAB may vary substantially among operators with different skills.The aim of this study is to evaluate whether operator experience in US-G FNAB influences the rate of diagnostic procedures.Methods A total of 600 consecutive US-guided FNAB done by a single radiologist with 22-or 27-gauge needles from Feb.2008 to Apr.2012 were retrospectively analyzed.All specimens were prepared and fixed without the cytologist on site and were subsequently analyzed by 2 expert cytologists.The procedures were chronologically divided into 6 groups and further stratified according to the overall (A),solid nodules (B),mixed nodules (C),pure cystic nodules (D),acellular sample(E),heavily blood-stained sample(F),exclusively colloid material(G),incorrect slide fixation(H) and they were classified as diagnostic or no-diagnostic.Results The rate of no-diagnostic procedures for each group in learning curves were reported as:① Among A,34％ in group 1,15％ in group 2,18％in group 3,10％ in group 4,7％ in group 5,and 8％ in group 6.② Among B,4％ in group 1,1％ in group 2,0％ in group 3,0％ in group 4,0％ in group 5,and 0％ in group 6.② Among C,10％ in group 1,1％ in group 2,4％ in group 3,0％ in group 4,1％ in group 5,and 0％ in group 6.④ Among D,20％ in group 1,13％ in group 2,14％ in group 3,10％ in group 4,6％ in group 5,and 8％ in group 6.⑤ Among E,25％ in group 1,15％ in group 2,15％ in group 3,10％ in group 4,6％ in group 5,and 8％ in group 6.⑥ Among F,4％ in group 1,0％ in group 2,1％ in group 3,0％ in group 4,0％ in group 5,and 0％ in group 6.⑦ Among G,1％ in group 1,0％ in group 2,1％ in group 3,0％ in group 4,1％ in group 5,and 0％ in group 6.⑧ Among H,4％ in group 1,0％ in group 2,1％ in group 3,0％ in group 4,0％ in group 5,and 0％ in group 6.Among the 600 procedures,there were 2 cases of vertigo and 4 cases of moderate bleeding at the biopsy site,all of which resolved spontaneously.No major complications were recorded.Conclusions The rate of no-diagnostic US-guided FNAB is heavily dependent on the operator's experience.We estimate that at least 200 procedures are needed in order to achieve the levels of diagnostic accuracy reported in the literature.We therefore suggest operators to get specific training before routinely perform this procedure in clinical practice. Key words: Thyroid nodule; Fine needle aspiration biopsy; Ultrasound; Learning curve

Objective To investigate the value of Thyroid Imaging Reporting and Data System (TI-RADS) and The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) for thyroid nodules. Methods A total of 216 thyroid nodules were obtained from 207 patients with thyroid nodules under ultrasound-guided fine needle aspiration biopsy (US-FNAB) from November 2013 to April 2015 at the General Hospital of Tianjin Medical University. 170 nodules were confirmed by surgical pathology of Tianjin Medical University General Hospital and Tianjin Medical University Cancer Hospital, and 46 nodules were followed up for more than 6 months. The classifications of TI-RADS and TBSRTC were performed for all thyroid nodules. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of ultrasound TI-RADS and cytology TBSRTC in differential diagnosis of benign and malignant thyroid nodules were calculated using surgical pathological results and ultrasound follow-up results as the ″gold″ standard. Results 170 thyroid nodules were confirmed by operational pathology, including 146 malignant nodules, all of which were papillary thyroid carcinoma; and 24 benign nodules, which were 16 nodular goiters, 6 Hashimoto′s thyroiditis, and 2 follicular adenomas. The thyroid nodules were cytologically evaluated as TBSRTC class Ⅱ, and ultrasonically evaluated as TI-RADS class 3, and no significant changes in the size and morphology of the nodules at 6 to 15 months , which were considered benign. Among the 216 thyroid nodules, 8 were TI-RADS class 3, 19 were TI-RADS class 4a, 55 were TI-RADS class 4b, 130 were TI-RADS class 4c, 4 were TI-RADS class 5. Among them, there were 0, 5, 23, 114, and 4 malignant thyroid nodules, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of TI-RADS for differential diagnosis of benign and malignant thyroid nodules were 100%, 11.4%, 71.3%, 70.2%, and 100%, respectively. Of the 216 thyroid nodules, 57 were TBSRTC classⅡ, 24 were TBSRTC class Ⅲ, 3 were TBSRTC class Ⅳ, 83 were TBSRTC class Ⅴ, and 49 were TBSRTC class Ⅵ. Among them, there were 2, 16, 2, 77, 49 thyroid malignant nodules, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of TBSRTC for differential diagnosis of benign and malignant thyroid nodules were 98.4%, 90.2%, 95.8%, 95.5%, and 96.5%, respectively. In the subgroup of nodules with malignant classification on cytology TBSRTC, their ultrasound classifications were all TI-RADS 4a-5. Conclusions TI-RADS contribute to select the target nodule to puncture. TBSRTC has a high diagnostic capability, and provides an important basis for clinical treatment of nodules. The combination of the two methods will further improve the diagnosis of malignant nodules. Key words: Ultrasonography; Fine needle aspiration biopsy; Cytopathology; Thyroid nodules

Objective In this paper,we selected the ultrasound features of the malignant thyroid nodules to evaluate the preoperative diagnostic value of ultrasound-guided fine needle aspiration biopsy ( US-FNAB )in the preoperative evaluation of thyroid nodules.Methods Thirty-nine patients with thyroid nodules managed in the department of otolaryngology-head and neck surgery,Beijing Tongren Hospital,Captial Medical University from Dec.2010 to Aug.2011 were studied.All of them were undertaken the ultrasonic examination,ultrasound-guided fine needle aspiration biopsy and surgical treatment subsequently.The ultrasonic features,fine needle aspiration biopsy results and postoperative pathological results were analyzed to draw out the characteristics of sonographic features of thyroid malignant nodules.Results The sensitivity,specificity,misdiagnosis and missed diagnosis of fine needle aspiration biopsy were 80.0％,89.4％,11.0％ and 20.0％ respectively.Solid nodules,shape/dimension ratio ≥ 1,calcifications ＜ 2 mm,irregular shape,blurred margins,type Ⅲ vascularity were correlated significantly with the malignant nodules of thyroid.The specificity of shape to dimension ratio and outline of the nodules were relatively higher than others (90.5％and 85.7％ respectively).But there were no single ultrasound feature that could carry a high sensitivity and positive predictive value in the diagnosis of thyroid nodules.Conclusions Two ultrasonographic characteristics could be used together as a select indicator to screen malignant nodules which can reduce the chance of undertaking the fine needle aspiration biopsy in thyroid nodules. Key words: Thyroid; Nodule; Ultrasonography; Fine needle aspiration biopsy

Objective To determine the value of EUS- guided fine needle aspiration biopsy (FNAB)for the diagnosis of submucosal lesions. Methods We found 28 patients with upper gastrointestinal tract solid submucosal lesions by endoseopies. EUS was performed to assess the lesions arised from the specific layer of the wall and the lymph node metastasis. After excluding extrinsic normal tissues compressing the gastrointestinaltract, EUS guided FNAB were carried out. Results Among these patients, two were extrinsic normal tissues compressing the gastrointestinal tract and all other 26 patients were examined by EUS guided FNAB. EUS- guided FNAB failed in only 3 patients. Among the other 23 patients, cytology demonstrated malignant tumors in 4 patients (lymphoma, n=2; leiomyosarcoma, n=2) and benign lesions in 19 patients (leiomyoma, n=1;lipoma, n=1 ). The results of EUS-guided FNAB were validated by surgery (n=20), endoscopic treatment (n=1) or clinical follow-up (n=7). Conclusion EUS guided FNAB is a safe and accurate method for di-agnosis of submucosal lesions.

Purpose: To compare the diagnostic accuracy and complication rates of fluoroscopyguided percutaneous transthoracic fine needle aspiration biopsy (FNAB) and core biopsy (CB). Materials and Methods: Ninety-one fluoroscopy-guided lung biopsies were performed in 86 patients using a 22-gauge fine needle (n=52) or a 21-gauge automated cutting needle (n=39). The size of pulmonary lesions were 1-9 cm. Histologic diagnosis rates and complications rates of the two groups were compared. Results: The overall sensitivity of FNAB was 98% (51/52) which was higher than that of CB 89.7% (35/39) (p=0.160, Fisher's exact test). For the diagnosis of malignancy, sensitivities of FNAB and CB were 97.2% (35/36) and 89.7% (26/29), respectively (p=0.316). For the diagnosis of benignancy, sensitivities of FNAB and CB were 100% (16/16) and 90% (9/10), respectively (p=0.384). The specific histologic diagnosis rate of CB was 80% (8/10) in benignancy, which was higher than that of FNAB 56% (9/16) (p=0.398). The pneumothorax rates were 7.7% (4/52) for FNAB and 15.4% (6/39) for CB (p=0.316). Conclusion: Although not statistically significant, a higher overall sensitivity was found in fluoroscopy-guided FNAB in the diagnosis of both malignancy and benignancy, and FNAB also achieved lower complication rates. More specific histologic diagnoses were obtained with CB.

Objective To compare the diagnostic values of different endoscopic ultrasound guided fine needle aspiration (EUS-FNA) biopsy methods (dry suction technique and wet suction technique)for solid tumors. Methods A total of 22 cases diagnosed as having digestive malignant tumors were enrolled, in each case endoscopic ultrasound (EUS) guided dry-FNA and wet-FNA were simultaneously carried out. Samples were taken respectively for cytologic and histopathologic examination. Then the quality of tissue specimens and diagnostic accuracy between the two groups were compared. Results The positive diagnostic rates of dry-FNA and wet-FNA in cytologic pathology were 27.27%(6/22)and 45.45%(10/22) without significant difference (P>0.05). The positive diagnostic rates of dry-FNA and wet-FNA in histopathology were 40.91%(9/22)and 72.73%(16/22, P<0.05). The cell count in wet-FNA was higher than that in dry-FNA(45.5±11.5 VS 26.0±9.5, P<0.05). The puncture tissue scores in wet-FNA was higher than that in dry-FNA (4.3±1.5 VS 2.9±1.4, P<0.05). In 22 cases, the combined diagnostic positive rates of cytologic and histopathologic examination in dry-FNA and wet-FNA were 45.45%(10/22)and 81.82%(18/22, P<0.05), which were significantly higher than those in separate cytologic or histologic examination (P<0.05). Conclusion Wet-FNA method is simple and easy to operate, which provides high quality samples and good diagnostic positive rate. It has the superior value to dry-FNA in the diagnosis of solid tumors. Key words: Pathology; EUS-FNA; Dry-FNA; Wet-FNA

Objective To investigate the value of diagnostic for thyroid nodule by the ultrasound guided fine needle aspiration biopsy(USG-FNAB) cytology. Methods A retrospective analysis of 120 cases of USG-FNAB cell pathological report from December 2012 to August 2013 was made. Comparatively analyzed 42 cases of surgical histological pathology report at the same time. Took results of the USG-FNAB cytological examination to observe, and as well as analyzed its sensitivity, specificity, diagnostic coincidence rate and the misdiagnosis rate. Results Thirty-four cases of malignant and 77 cases of benign in 120 patients. Comparative cytological and histological pathology results: sensitivity was 97.06%, specificity was 98.70%, the diagnosis coincidence rate was 98.20%, the misdiagnosis rate was 1.30%. Conclusions Ultrasound guided fine-needle aspiration cytology is a simple operation in the identification of benign and malignant thyroid nodules with higher accuracy and is of great significance. Key words: Ultrasound guided fine-needle aspiration cytology; Pathological examination; Thyroid nodules