Fluoroscopy-guided Lung Biopsy Research Articles

Non–Small Cell Lung Cancer with Resistance to EGFR-TKI Therapy: CT Characteristics of T790M Mutation–positive Cancer

Purpose To evaluate the clinical and CT characteristics of T790M mutation-positive non-small cell lung cancer (NSCLC) after epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) therapy failure. Materials and Methods A retrospective study of 304 patients with NSCLC who underwent rebiopsy after first-line EGFR-TKI therapy was conducted. Rebiopsy methods included CT- or fluoroscopy-guided lung biopsies (n = 105), endobronchial US- or bronchofibroscopy-guided biopsies (n = 66), pleural fluid analysis (n = 47), other solid organ biopsies (n = 43), US-guided axillary or supraclavicular lymph node biopsies (n = 31), and cerebrospinal fluid analysis (n = 12). CT findings at the initial diagnosis and rebiopsy were analyzed. Progression-free survival, the duration from the start of TKI therapy to rebiopsy, and survival were calculated. Results At rebiopsy, 144 (47.4%) patients were T790M mutation positive. The percentages of T790M mutation-positive NSCLCs were similar in 106 patients with rebiopsy of the lungs (53 [50%] of 106) and in 77 patients with rebiopsy of the primary lung lesions (36 [47%] of 77). T790M mutation positivity was associated with peripheral tumors (odds ratio [OR], 2.6; P = .01), pleural tag (OR, 5.0; P < .001), and air bronchogram (OR, 4.0; P = .006) at CT after TKI failure. The duration from the start of TKI therapy to rebiopsy was longer in T790M mutation-positive than in T790M mutation-negative patients (20.5 vs 13.6 months; P < .001). Cumulative survival from the time of rebiopsy to the last follow-up was significantly longer in patients with T790M mutation-positive lung cancers (P = .014). However, median survival time after rebiopsy was not statistically different between patients with and those without T790M mutation. Conclusion Peripheral tumor location with vascular convergence, the presence of a pleural tag, and air bronchogram of lung lesions at CT at the time of rebiopsy were significantly associated with T790M mutation in patients with non-small cell lung cancer after first-line epidermal growth factor receptor-tyrosine kinase inhibitor therapy failure. © RSNA, 2018 Online supplemental material is available for this article.

3:18 PMAbstract No. 368 - Comparison of radiation dose, procedure time and diagnostic yield of conventional CT-guided lung biopsy with CT fluoroscopy-guided lung biopsy

3:18 PMAbstract No. 368 - Comparison of radiation dose, procedure time and diagnostic yield of conventional CT-guided lung biopsy with CT fluoroscopy-guided lung biopsy

MAGE Gene Expression in Bronchial Washing Fluid in Suspected Parenchymal Lung Cancer

Background: The main goal of this study was to evaluate the diagnostic efficacy of reverse transcription-nested polymerase chain reaction (RT-nested PCR) in bronchial washing fluid with MAGE A1-6 common primers for the detection of lung cancers invisible by bronchoscopy. Methods: To determine the expression of MAGE A1-6 gene in 189 lung cancers diagnosed by conventional fluoroscopy-guided lung biopsy and 89 cancer-free controls, RT-nested PCR was performed in bronchial washing specimens. We analyzed MAGE A1-6 RT-nested PCR data according to tumor histology, stage, size, and compared them with cytological data. Results: 189 patients (111 cases in adenocarcinoma, 47 cases in squamous cell carcinoma, 22 cases in small cell lung carcinoma, and 9 cases in other cancers) and 89 benign patients were investigated. The expression of MAGE was performed by nested RT-PCR using common MAGE primer. Among 189 cancer patients, the expression rate of MAGE was 49.2%, and the positive predictive value was 89.4%. However, the expression rate of MAGE in patients with benign lesions was 12.4%. In peripheral lung cancer, the positive rate of MAGE expression was 57.4% in squamous cell carcinoma, 44.1% in adenocarcinoma and 59.1% in small cell lung cancer. Whereas the expression rate of bronchial washing cytology in peripheral lung cancer was 9.0% (p=0.011). Conclusion: MAGE RT-PCR in bronchial washing fluid gave us promising data for the detection of peripheral lung cancer. It could be a useful method for selecting diagnostic tools for peripheral lesions.

CT fluoroscopy-guided lung biopsy versus conventional CT-guided lung biopsy: a prospective controlled study to assess radiation doses and diagnostic performance

We evaluated radiation doses, complication rates, and diagnostic accuracy for CT-guided percutaneous needle aspiration biopsy (NAB) procedures of pulmonary lesions performed with or without fluoroscopic guidance. A total of 142 patients were prospectively enrolled to receive CT-guided NAB with (Group I, n = 72) or without (Group II, n = 70) fluoroscopic guidance. Outcome measurements were patient and doctor radiation dose, and complication rate. Sensitivity, specificity and accuracy were calculated based on 123 NAB results. The mean estimated effective patient radiation dose was 6.53 mSv in Group I and 2.72 mSv in Group II (p < 0.001). The mean estimated effective doctor dose was 0.054 mSv in Group I and 0.029 mSv in Group II (p < 0.001). The complication rate was significantly different between the two groups (13.4% versus 31.4%, p = 0.012). Sensitivity, specificity and accuracy for diagnosing pulmonary lesions were 97.8%, 100% and 98.4% in group I and 95.3%, 100% and 89.5% in group II (p > 0.05). CT fluoroscopy-guided NAB of pulmonary lesions provides high diagnostic accuracy and can be performed with significantly fewer complications. However, radiation exposure to both patient and doctor were significantly higher than conventional CT-guided NAB.

Incidence of and Risk Factors for Pneumothorax and Chest Tube Placement After CT Fluoroscopy–Guided Percutaneous Lung Biopsy: Retrospective Analysis of the Procedures Conducted Over a 9-Year Period

The objective of our study was to retrospectively evaluate the incidence of and the risk factors for pneumothorax and chest tube placement after CT fluoroscopy-guided lung biopsy. We analyzed 1,098 CT fluoroscopy-guided lung biopsies conducted with 20-gauge coaxial cutting needles for 1,155 lesions in 1,033 patients. Apart from evaluating the incidence of pneumothorax and chest tube placement, the independent risk factors for pneumothorax and chest tube placement for pneumothorax were determined using multivariate logistic regression analysis. The overall incidence of pneumothorax was 42.3% (464/1,098). Chest tube placement was required for 11.9% (55/464) of pneumothoraces (5.0% [55/1,098] of the total number of procedures). The significant independent risk factors for pneumothorax were no prior pulmonary surgery (p = 0.001), lesions in the lower lobe (p < 0.001), greater lesion depth (p < 0.001), and a needle trajectory angle of < 45 degrees (p = 0.014); those for chest tube placement for pneumothorax were pulmonary emphysema (p < 0.001) and greater lesion depth (p < 0.001). Pneumothorax frequently occurred and placement of a chest tube was occasionally required for pneumothorax after CT fluoroscopy-guided lung biopsy. To reduce the risk of pneumothorax necessitating chest tube placement, physicians should adopt the shortest needle path to the lesion.

Core Needle Lung Biopsy Specimens: Adequacy for EGFR and KRAS Mutational Analysis

The purpose of this study was to prospectively compare the adequacy of core needle biopsy specimens with the adequacy of specimens from resected tissue, the histologic reference standard, for mutational analysis of malignant tumors of the lung. The first 18 patients enrolled in a phase 2 study of gefitinib for lung cancer in July 2004 through August 2005 underwent CT- or fluoroscopy-guided lung biopsy before the start of gefitinib therapy. Three weeks after gefitinib therapy, the patients underwent lung tumor resection. The results of EGFR and KRAS mutational analysis of the core needle biopsy specimens were compared with those of EGFR and KRAS mutational analysis of the surgical specimens. Two specimens were unsatisfactory for mutational analysis. The results of mutational assay results of the other 16 specimens were the same as those of analysis of the surgical specimens obtained an average of 31 days after biopsy. Biopsy with small (18- to 20-gauge) core needles can yield sufficient and reliable samples for mutational analysis. This technique is likely to become an important tool with the increasing use of pharmacotherapy based on the genetics of specific tumors in individual patients.

CT Fluoroscopy-Guided Lung Biopsy with Novel Steerable Biopsy Canula: Ex-Vivo Evaluation in Ventilated Porcine Lung Explants

The purpose was to evaluate ex-vivo a prototype of a novel biopsy canula under CT fluoroscopy-guidance in ventilated porcine lung explants in respiratory motion simulations. Using an established chest phantom for porcine lung explants, n = 24 artificial lesions consisting of a fat-wax-Lipiodol mixture (approx. 70HU) were placed adjacent to sensible structures such as aorta, pericardium, diaphragm, bronchus and pulmonary artery. A piston pump connected to a reservoir beneath a flexible silicone reconstruction of a diaphragm simulated respiratory motion by rhythmic inflation and deflation of 1.5 L water. As biopsy device an 18-gauge prototype biopsy canula with a lancet-like, helically bended cutting edge was used. The artificial lesions were punctured under CT fluoroscopy-guidance (SOMATOM Sensation 64, Siemens, Erlangen, Germany; 30mAs/120 kV/5 mm slice thickness) implementing a dedicated protocol for CT fluoroscopy-guided lung biopsy. The mean-diameter of the artificial lesions was 8.3 +/- 2.6 mm, and the mean-distance of the phantom wall to the lesions was 54.1 +/- 13.5 mm. The mean-displacement of the lesions by respiratory motion was 14.1 +/- 4.0 mm. The mean-duration of CT fluoroscopy was 9.6 +/- 5.1 s. On a 4-point scale (1 = central; 2 = peripheral; 3 = marginal; 4 = off target), the mean-targeted precision was 1.9 +/- 0.9. No misplacement of the biopsy canula affecting adjacent structures could be detected. The novel steerable biopsy canula proved to be efficient in the ex-vivo set-up. The chest phantom enabling respiratory motion and the steerable biopsy canula offer a feasible ex-vivo system for evaluating and training CT fluoroscopy-guided lung biopsy adapted to respiratory motion.

CT Fluoroscopy-Guided Biopsy of 1,000 Pulmonary Lesions Performed With 20-Gauge Coaxial Cutting Needles: Diagnostic Yield and Risk Factors for Diagnostic Failure

<h3>Background</h3> Although conventional CT scan-guided needle biopsy is an established diagnostic method for pulmonary lesions, few large studies have been conducted on the diagnostic outcomes of CT fluoroscopy-guided lung biopsy. We have conducted a retrospective analysis to evaluate the diagnostic outcomes of 1,000 CT fluoroscopy-guided lung biopsies performed with 20-gauge coaxial cutting needles. <h3>Methods</h3> We determined the diagnostic yield of CT fluoroscopy-guided lung biopsies performed with 20-gauge coaxial cutting needles for 1,000 lesions in 901 patients. Independent risk factors for diagnostic failure (<i>ie</i>, nondiagnostic, false-positive, and false-negative results) were determined with multivariate logistic regression analysis. <h3>Results</h3> The biopsy results were nondiagnostic in 0.6% of the lesions (6 of 1,000 lesions). The sensitivity and specificity for the diagnosis of malignancy was 94.2% (741 of 787 lesions) and 99.1% (211 of 213 lesions), respectively; diagnostic accuracy was 95.2% (952 of 1,000 lesions). For lesions measuring ≤ 1.0 cm, the diagnostic accuracy was 92.7% (140 of 151 lesions). The significant independent risk factors for diagnostic failure were as follows: the acquisition of two or fewer specimens (odds ratio [OR], 2.43; p=0.007), lesions in the lower lobe (OR, 2.50; p=0.003), malignant lesions (OR, 7.16; p=0.007), and lesions measuring ≤ 1.0 cm (OR, 3.85; p=0.016) and ≥ 3.1 cm (OR, 4.32; p=0.007). <h3>Conclusions</h3> CT fluoroscopy-guided lung biopsy performed with 20-gauge coaxial cutting needles resulted in a high diagnostic yield, even in the case of small lesions. Factors such as the acquisition of two or fewer specimens, lesions in the lower lobe, malignant lesions, and lesions measuring ≤ 1.0 cm or ≥ 3.1 cm significantly increased the rate of diagnostic failure.

Robotically assisted lung biopsy under CT fluoroscopy: Lung cancer screening and phantom study

Lung cancer is an important clinical problem and lung cancer screening may lead to an early diagnosis. CT fluoroscopy-guided lung biopsy is a popular method for obtaining a tissue sample for lung cancer diagnosis. However, the radiation exposure for the physician associated with CT fluoroscopy may limit more widespread adoption of this technique. The use of a robotic needle driver that can hold the needle in a steady and precise manner on the CT fluoroscopy scan plane may provide accurate needle placement without exposing the physician to radiation. This paper will provide background on lung cancer screening, review the CT fluoroscopy-guided lung biopsy procedure, and present the results of the first phantom study to use a robotic needle driver. An interventional radiologist used a robotic needle driver under joystick control to accurately place needles into a simulated lesion in a respiratory motion phantom under CT fluoroscopy guidance.

Fluoroscopy-Guided Percutaneous Transthoracic Biopsy: Comparison between Fine Needle Aspiration Biopsy and Core Biopsy with an Automated Cutting Needle

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.

Usefulness of New Automated Cutting Needle for Tissue-Core Biopsy of Lung Nodules Under CT Fluoroscopic Guidance

The goal of our study was to evaluate the efficacy and safety of a new type of automated cutting needle for tissue-core lung biopsy under real-time CT fluoroscopic guidance. Observational One hundred ten percutaneous needle tissue-core lung biopsies were performed with the Auto Surecut needle (Create Medic; Yokohama, Japan) under CT fluoroscopic guidance, and the specimens obtained underwent histopathologic evaluation. A final diagnosis was confirmed by independent surgical pathology. The rate of success for the diagnosis for specimens that were adequate for histopathologic analysis was 94.5% (104 of 110 specimens). The sensitivity, specificity, and accuracy in diagnosing malignancy were 95.1%, 100%, and 96.2%, respectively. A specific cell type could be characterized in 95.2% of those 104 lesions (99 lesions; malignant, 76 lesions; benign, 23 lesions). The specific cell type was precisely diagnosed, and was confirmed after surgery in 65 malignant lesions and 23 benign lesions. The biopsy-induced complications encountered were pneumothorax in 34.5% (38 of 110 patients) and hemoptysis in 6.4% (7 of 110 patients). No patient had a serious complication. CT fluoroscopy-guided lung biopsy using the Auto Surecut needle provides a high degree of diagnostic accuracy, allows for the specific characterization of lung nodules, and can be performed safely.

Combining fine-needle aspiration and core biopsy under CT fluoroscopy guidance: a better way to treat patients with lung nodules?

The goal of our study was to evaluate the efficacy of the combined use of fine-needle aspiration and tissue core biopsy under real-time CT fluoroscopy guidance. One hundred thirty-eight percutaneous needle lung biopsy samples were obtained by two methods. The samples obtained by tissue fine-needle aspiration underwent cytologic evaluation, and those obtained by core biopsy using an automated cutting needle underwent histologic evaluation. The final diagnosis was confirmed by independent surgical pathologic findings, independent culture results, or clinical follow-up. Rates of adequate specimens obtained and of precise diagnosis by combined use of fine-needle aspiration and core biopsy were 97.1% (134/138) and 94.2% (130/138) evaluated lung lesions, respectively, whereas those rates were 84.8% (117/138) and 79.7% (110/138) by fine-needle aspiration alone and 91.3% (126/138) and 89.1% (123/138) by core biopsy alone, respectively. Precise diagnosis was achieved by the combined use of the techniques in 30 (93.8%) of 32 lesions ranging from 3 to 10 mm in diameter, 42 (93.3%) of 45 lesions ranging from 11 to 20 mm, 43 (93.5%) of 46 lesions ranging from 21 to 30 mm, and 100% of 15 lesions ranging from 31 to 100 mm. In 89 of 90 lesions shown to be malignant by CT-guided lung biopsy and 30 of 44 shown to be benign, specific cell types could be proven from specimens obtained by the combined use of the two different types of needle biopsy. The combined use of fine-needle aspiration and core biopsy improves the diagnostic ability of CT fluoroscopy-guided lung biopsy, even in small lesions.

Dose evaluation and effective dose estimation from CT fluoroscopy-guided lung biopsy.

The development of computerized tomography (CT) has made CT fluoroscopy possible with real-time CT images. However examination are expected to have high medical and occupational exposures. Then, exposures to patients and operating and assisting physicians during the CT fluoroscopy-guided lung biopsy were estimated. And changes in the examination conditions to lower the dose were made. Patient exposure was measured using an anthropomorphic phantom by simulation of clinical examination conditions. The surface dose to the physician was measured during actual clinical examinations. The average effective dose for the patient was 34+/-22mSv. The highest surface dose amounted to 1.9 Gy, although this was in a very narrow field. Patient doses could be reduced by a factor of 2.5-3 by changing examination methods while still retaining diagnostic quality. The highest dose to the operating physician was 10mGy which was recorded on the back of the hand and the average effective dose was estimated as 5.99&mgr;Sv per 1-minute examination. Doses were reduced by about a factor of 50 by lowering the tube voltage from 120kV to 80 kV and using a supplementary tool. The doses for assisting physicians were not significant. The exposure for physicians and patients was much affected by lowering the tube voltage used for fluoroscopy. Using a supplementary tool was effective for reducing the dose for physicians.