Needle Aspiration in Lung Cancer

Abstract

To the Editor: Several statements in the recent editorial by Drs. Hix and Aaron (Chest 1990; 97:516-517) deserve further comment. The radiologic literature supports the authors' statement that a lung needle aspiration which does not reveal malignant cells does not rule out lung cancer. The false negative rate for needle aspiration in patients with lung cancer is relatively high (5 to 10 percent).1Webb WR Radiologic evaluation of the solitary pulmonary nodule.AJR. 1990; 154: 701-708Crossref PubMed Scopus (113) Google Scholar, 2Khouri NF Stitik FP Erozan YS Gupta PK Kim WS Scott Jr, WW et al.Transthoracic needle aspiration biopsy of benign and malignant lung lesions.AJR. 1985; 144: 281-288Crossref PubMed Scopus (274) Google Scholar However, the radiologic literature does not support the authors' statement that a specific benign diagnosis of a lung tumor is very seldom made by needle aspiration. A bacterial diagnosis can be made in about 70 percent of solid infectious nodules. Drs. Khouri and Stitik et al made a specific, noninfectious, benign diagnosis in 67 percent (91 of 135 cases) of confirmed benign nodules.2Khouri NF Stitik FP Erozan YS Gupta PK Kim WS Scott Jr, WW et al.Transthoracic needle aspiration biopsy of benign and malignant lung lesions.AJR. 1985; 144: 281-288Crossref PubMed Scopus (274) Google Scholar The diagnosis of noninfectious benign disease is more difficult to establish by needle aspiration than the diagnosis of malignancy, for two reasons. Benign lesions often contain calcification and are difficult to penetrate with the needle tip. A specific benign diagnosis requires a large amount of tissue for histologic analysis. Drs. Hix and Aaron state that over one-half of lung tumors in smokers over 40 years of age are malignant. This means that nearly half of lung tumors in smokers over 40 must be benign. Which patients should have needle aspiration? Some expert chest radiologists would strongly recommend needle biopsy for all these patients (assuming prior chest radiographs were negative).2Khouri NF Stitik FP Erozan YS Gupta PK Kim WS Scott Jr, WW et al.Transthoracic needle aspiration biopsy of benign and malignant lung lesions.AJR. 1985; 144: 281-288Crossref PubMed Scopus (274) Google Scholar Other expert chest radiologists reserve needle aspiration for those patients who are not candidates for surgery because of age, complicating illness, unresectability of the lesion, or suspicion that the lesion is a metastatic deposit.1Webb WR Radiologic evaluation of the solitary pulmonary nodule.AJR. 1990; 154: 701-708Crossref PubMed Scopus (113) Google Scholar In fact, the decision regarding needle aspiration depends upon many other factors, including the patient's feelings about the growth in his/her lung, the philosophy of the patient's attending physician and surgeon, and the track record of the radiologist and pathologist in needle aspiration of benign and malignant lesions. In my experience, the rare chance of tumor cell implantation in the needle tract is not a significant factor in the decision process. One noninvasive diagnostic test which may obviate the need for needle aspiration or surgery is high resolution (thin-section) CT scan of the lung tumor. Granulomas account for the majority of benign lung tumors. A specific diagnosis of benign granuloma can be made if dense central calcification, laminated calcification, or diffuse calcification is identified within a lung tumor on chest radiography, spot films, or conventional tomography.3Levitt RG Thin-section CT and the solitary pulmonary nodule.Chest. 1988; 93: 451-452Crossref PubMed Scopus (3) Google Scholar CT scan is 10 to 20 times more sensitive to density differences than chest radiography. Using thin-section CT, 50 percent of solitary pulmonary nodules not seen to be calcified on chest radiographs or conventional tomograms can be shown to be diffusely calcified,4Zerhouni EA Stitik FP Siegelman SS Naidich DP Sagel SS Proto AV et al.CT of the pulmonary nodule: A cooperative study.Radiology. 1986; 160: 319-327Crossref PubMed Scopus (296) Google Scholar, 5Siegelman SS Khouri NF Leo FP Fishman EK Brauerman RM Zerhouni EA Solitary pulmonary nodules: CT assessment.Radiology. 1986; 160: 307-312Crossref PubMed Scopus (323) Google Scholar thereby avoiding invasive diagnostic procedures. Needle Aspiration in Lung CancerCHESTVol. 98Issue 6PreviewTo the Editor: Full-Text PDF