Percutaneous Transthoracic Biopsy Research Articles

Predicting lung nodules malignancy

BackgroundIt is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting. MethodsThe authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy. ResultsFrom a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573. ConclusionsThe prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.

Should We Perform Transthoracic Trucut Lung Biopsies of Pleural-Based Lung Masses Under Ultrasound Guidance or Computed Tomography Guidance?

We aimed to emphasize which method should be prioritized by comparing the ultrasound and computed tomography (CT) guidance for percutaneous transthoracic biopsy of pleural-based lung lesions in terms of comorbidity, diagnostic success, time, and costs.Approximately 700 biopsy procedures performed between 2014 and 2018 were retrospectively reviewed. The files of these patients and picture archiving and communication system were scanned.Size and localization of the lesion, pathological diagnosis, comorbidity status, pneumothorax complications at the end of the procedure, and whether or not a thoracic tube was placed due to pneumothorax were recorded. Fisher exact test and Pearson χ test were used for statistical analysis.A total of 181 patients who underwent the pleural-based biopsy procedure, the subject of study, were included in the study. One hundred (55.2%) of the biopsy procedures of these patients were performed under the guidance of tomography, and 81 (44.8%) were performed under the guidance of ultrasound (US). Median size of the lesions is 38 mm (25%-75%, 33-55 mm). Pneumothorax complications were observed in 6 patients (6%) who had CT-guided procedures and 4 patients (4.9%) who had US-guided procedures. Of the patients who developed pneumothorax, 2.8% were inserted thoracic tubes owing to the complication. Diagnostic efficacy of our procedures is 99.8% in US-guided procedures and 97% in CT-guided transthoracic biopsy. The average duration of US-guided transthoracic biopsy procedures is 17 minutes, and the average duration of CT-guided biopsy procedures is 35 minutes.

ELECTROMAGNETIC NAVIGATIONAL (EMN) BRONCHOSCOPY AND EMN PERCUTANEOUS TRANSTHORACIC NEEDLE BIOPSY OF THE CHEST LESION: THE FIRST 102 CONSECUTIVE EARLY EXPERIENCE CASES

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: The recent advent of electromagnetic navigation (EMN) systems can be used to facilitate both bronchoscopic and transthoracic access for biopsy in a single operative setting. We report our early experience with EMN bronchoscopy and percutaneous transthoracic needle biopsy by a single surgeon. METHODS: The present study is a retrospective cohort analysis of the first 102 patients to undergo navigational bronchoscopy and /or percutaneous transthoracic interventions utilizing EMN system guidance between January 2018 and March 2019. Indications, success rate and complications were reviewed. RESULTS: A total 102 EMN procedures were performed by a single surgeon without fluoroscopy and radial endobronchial ultrasounds. Indications for EMN included biopsy of lung lesions 94, pleural lesions 7, and one for chest wall lesion. Of the ninety-four lung lesions, two underwent EMN percutaneous biopsy as the initial procedure without navigational bronchoscopy. Eighty-eight cases 95.6% (88/92) successfully reached the target by bronchoscopy under image guidance. The diagnostic yield for EMN bronchoscopy biopsy for nodules was 72.8 % (67/92). Twenty cases 22% (20/92) were converted to the percutaneous transthoracic core needle biopsy. The diagnostic yield for the patients who had percutaneous transthoracic biopsy was 90% (18/20). The combined diagnostic yield rate for EMN bronchoscopic and percutaneous lung biopsy was 92.3% (85/92). Diagnostic yield for pleural-based lesions by percutaneous transthoracic biopsy was 75% (6/8) with pleura thickness of 16±2 mm (16-20 mm). The only complication encountered in this series was pneumothorax after percutaneous transthoracic biopsy for the lung lesions requiring chest tube in 2 patients (10%). CONCLUSIONS: In our initial series of 102 cases by a single surgeon, EMN guided endobronchial and transthoracic needle biopsy for the chest lesions showed an acceptable diagnostic yield and minimal complications. The diagnostic yield rate was raised approximately 20 % by concurrent percutaneous transthoracic needle biopsy for the lung lesion. CLINICAL IMPLICATIONS: Performance in a single operative setting as an alternative diagnostic procedure has the potential to decrease time to diagnosis and numbers of procedural visits, ultimately streamlining care for the patient. DISCLOSURES: no disclosure on file for Raphael Bueno; No relevant relationships by Michael Jaklitsch, source=Web Response No relevant relationships by Ciaran McNamee, source=Admin input No relevant relationships by Carolyn Moore, source=Web Response no disclosure on file for Hisashi Tsukada; No relevant relationships by Brian Whang, source=Web Response no disclosure on file for Daniel Wiener

1407P - "Liquid withdraw" technique in CT-guided cutting needle lung biopsy: Decreased incidence of complications and increased tissue amount for lung cancer molecular testing

BackgroundCT-guided percutaneous biopsy is a minimally invasive technique used for obtaining enough tissue samples in the diagnosis of pulmonary lesions. The common complications of CT-guided percutaneous lung biopsy include pneumothorax, hemoptysis. Coaxial technique makes it much easier to repeat sampling and obtain adequate specimens, still it makes no change to the high incidence of pneumothorax. Basic on the research De Filippoet al. had done about complications, we hypothesis that when the inner chuck of coaxial guiding needle was removed and the cutting needle was placed inside the guiding needle, the injection of a small amount of liquid (a mixture of lidocaine and hemocoagulase) through the syringe while withdraw of the guiding needle may help to prevent the incidence of pneumothorax for which close the needle track with liquid. MethodsFrom August 24th, 2018 to April 1th ,2019, a total of 32 CT-guided percutaneous transthoracic biopsy procedures performed in 32 patients were retrospectively evaluated. The patients were divided into groups regarding the lesion from pleural surface: <30mm or≥30mm. The rates of complications such as pneumothorax and pneumorrhagia were analyzed. And the complications were graded as mild/very mild, moderate, and severe. Different complications between the two groups were analyzed using Pearson’s Chi-squared test for categorical values. ResultsPathology results were malignant in 28 patients (17 cases were adenocarcinoma), benign in 4 patients.7 cases (21.9%) happened pneumothorax (4 very mild pneumothorax, 2 mild pneumothorax, 1 moderate pneumothorax),13 cases (40.6%) happened pneumorrhagia (12 mild pneumorrhagia, 1 very mild pneumorrhagia). And there was no statistically significant between pneumothorax and the depth of lesion to pleural surface (P>0.05). ConclusionsCompared to co-axial technique only, CT-guided percutaneous lung biopsy using co-axial combined with "liquid withdraw" significantly reduced the incidence of pneumothorax, which has been confirmed what we found in earlier retrospective study. The new technique provided an more accurate, secure and reliable way to obtain adequate tissue samples in the diagnosis. Legal entity responsible for the studyComprehensive Cancer Center of Drum-Tower Hospital. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

EP1.05-01 "Liquid Withdraw” Technique in CT-Guided Cutting Needle Lung Biopsy Decrease Incidence of Complications: Prospective Study

CT-guided percutaneous biopsy is a minimally invasive technique used for obtaining enough tissue samples in the diagnosis of pulmonary lesions and genetic testing related to drug efficacy. The common complications of CT-guided percutaneous lung biopsy include pneumothorax, hemoptysis etc. Coaxial technique makes it much easier to repeat sampling and obtain adequate specimens, still it makes no change to the high incidence of pneumothorax. For all this, it is particularly urgent to find some technique to reduce the incidence of pneumothorax. Basic on the research De Filippoet al. had done about complications of the biopsy technique, we hypothesis that when the inner chuck of coaxial guiding needle was removed and the cutting needle was placed inside the guiding needle, the injection of a small amount of liquid (a mixture of lidocaine and hemocoagulase) through the syringe while withdraw of the guiding needle may help to prevent the incidence of pneumothorax for which close the needle track with liquid. From August 24th, 2018 to April 1th ,2019, a total of 32 CT-guided percutaneous transthoracic biopsy procedures performed in 32 patients were retrospectively evaluated. The patients were divided into groups regarding the lesion from pleural surface: <30 mm or ≥30 mm. The rates of complications such as pneumothorax and pneumorrhagia were analyzed. And the complications were graded as mild/very mild, moderate, and severe. Different complications between the two groups were analyzed using Pearson’s Chi-squared test for categorical values. Pathology results were malignant in 28 patients (17 cases were adenocarcinoma, in which10 patients consented EGFR mutation test ), benign in 4 patients.7 cases (21.9%) happened pneumothorax (4 very mild pneumothorax, 2 mild pneumothorax, 1 moderate pneumothorax), 13 cases (40.6%) happened pneumorrhagia (12 mild pneumorrhagia, 1 very mild pneumorrhagia). No infection, tumor implantation or aeroembolism happened. And there was no statistically significant between pneumothorax and the depth of lesion to pleural surface (P>0.05). Compared to co-axial technique only, CT-guided percutaneous lung biopsy using co-axial combined with "liquid withdraw” significantly reduced the incidence of pneumothorax, which has been confirmed what we found in earlier retrospective study. The new technique provided a more accurate, secure and reliable way to obtain adequate tissue samples in the diagnosis.

Chest wall implantation of lung cancer following percutaneous transthoracic biopsy

A 75-year-old man had an incidental finding of a 1.7 cm spiculated lung nodule over the left lower lobe on thoracic CT scan (figure 1). He underwent CT-guided percutaneous thoracic...

The Diagnostic Value of CT-guided Percutaneous Co-axial Trans-thoracic Biopsy (PCTTB) and Evaluation of the Pathologic Examination.

We investigated thoracic masses with Computed Tomography (CT)- guided Percutaneous Co-Axial Trans-Thoracic Biopsy (PCTTB). The retrospective data of 86 patients to whom CT-guided PCTTB had been applied were obtained. Eighty-four cases and their pathologic results were included in the study. Localization and appearance of the lesions, pathologic results, and complications were evaluated. Diagnostic sensitivity of CT-guided PCTTB was 97.6%. In 60.7% of the cases, malign lesions and, in 39.3% of the cases, benign lesions were diagnosed. The mass size was on average greater than 2 cm, and one mass was detected as being more than ≥2 masses. Mainly, irregular contours were observed. Most of the malign tumors were primary malign tumors on both sides (91.7% on the right side and 88.9% on the left side). Squamous Cell Carcinoma (SCC) was the most often detected malign tumor on the right side, and adenocarcinoma was the most often detected malign tumor on the left side. In masses localized on the left inferior lobe, metastasis was often detected. When the number of the mass was ≥2 and the mass had the appearance of consolidation, metastasis was usually detected. Small and large masses were mainly localized on right and left upper lobes. In the small mass group, 75.0% of the cases were benign, and, in the large mass group, 64.5% of the cases were malign (p=0.031, χ2=4.666). Pneumothorax was the most commonly occurring complication (23.8%). In masses localized on the right lower lobe, the pneumothorax ratio increased in benign masses compared to malign masses. The hemorrhage detection rate was 13.0%, and hemoptysis occurred in 14.2% of the cases. Hemorrhage was detected during 11.8% of the large mass biopsies. In females, hemorrhage occurred more often than in males (p=0.026, r= 0.244). CT-guided PCTTB is a safe method to utilize for lung biopsies. Co-axial method increased the diagnostic accuracy of CT-guided percutaneous trans-thoracic biopsies. A single cut also decreased the complication rates.

Inhibitory effects of pirfenidone on fibroblast to myofibroblast transition in rheumatoid arthritis-associated interstitial lung disease via the downregulation of activating transcription factor 3 (ATF3)

ObjectivePirfenidone (PFD) is an oral anti-fibrotic drug used for idiopathic pulmonary fibrosis (IPF) therapy. We determined the role of activating transcription factor 3 (ATF3) and the effect of PFD on fibroblast to myofibroblast transition (FMT) in rheumatoid arthritis-associated interstitial lung disease (RA-ILD). MethodsRA-ILD lung specimens were obtained by CT-guided percutaneous transthoracic biopsy. A pulmonary fibrosis mouse model was established by the intratracheal injection of bleomycin. Pathological variation and the expression of α-SMA and ATF3 were observed by H&E, Masson and immunofluorescence staining. Primary human lung fibroblasts (pHLFs) were isolated from lung tissues that were pathologically confirmed to be normal by pneumonectomy. Cell viability was detected using an MTT assay. Cell migration and invasion were detected using a Transwell chamber. The protein levels of α-SMA, ATF3, Smad3 and p-Smad3 were measured by Western blot. HLFs were infected with lentiviruses expressing ATF3 or scrambled shRNA. ResultsATF3 was dramatically upregulated in lung tissues from both bleomycin-induced mice and patients with RA-ILD compared with controls. The upregulation of ATF3 and the accumulation of collagen in the lung tissues of mice with pulmonary fibrosis were reduced by PFD. PFD significantly inhibited increases in the proliferation, invasion and migration of pHLFs stimulated by TGF-β1. Moreover, we observed the inhibitory effect of PFD on FMT via the downregulation of ATF3, which was further confirmed in ATF3 knockdown (KD) pHLFs. ConclusionsThis work shows the inhibitory effect of PFD on FMT in pHLFs, which is mediated by the downregulation of ATF3. Our findings suggest that PFD might have therapeutic potential for the treatment of RA-ILD.

Application of laser navigation system in percutaneous transthoracic needle biopsy based on a SPECT/CT platform

Objective To evaluate the value of a novel laser navigation system (LNS) designed for a SPECT/CT platform in improving efficiency of molecular imaging-guided percutaneous transthoracic needle biopsy (PTNB). Methods From January 2017 to October 2017, a total of 25 patients (17 males, 8 females, age (58.9±10.8) years) with thoracic lesions suspicious for malignancy underwent 99Tcm-methoxyisobutylisonitrile (MIBI) SPECT/CT-guided PTNB, and the hyperactivity areas were chosen as the sampling areas. Thirteen patients underwent traditional free hand puncture (control group), and 12 patients had LNS-assisted puncture (LNS group). The operation time, CT-guided times, average effective radiation dose of the two methods were compared. Two-sample t test was used to analyze the data. Results Comparing to control group, LNS-assisted PTNB puncture significantly reduced operation time ((7.6±2.2) vs (24.2±9.8) min; t=5.693, P<0.001), CT-guided times (1.9±0.9 vs 4.0±1.5; t=4.108, P<0.001) and average effective radiation dose ((7.7±0.9) vs (10.5±2.1) mSv; t=4.306, P<0.01). Conclusion The novel LNS is helpful in improving efficiency of molecular imaging-guided PTNB based on a SPECT/CT platform. Key words: Lung neoplasms; Biopsy, needle; Tomography, emission-computed, single-photon; Tomography, X-ray computed; Lasers; Technetium Tc 99m sestamibi

Does Ipsilateral-Dependent Positioning During Percutaneous Lung Biopsy Decrease the Risk of Pneumothorax?

The purpose of this study is to determine whether placing patients in an ipsilateral-dependent position during percutaneous CT-guided transthoracic biopsy reduces the pneumothorax rate. Between July 2013 and August 2017, a total of 516 patients (317 men and 199 women; mean age, 66.4 years) underwent core needle biopsies performed using 17- and 18-gauge needles. The overall pneumothorax rate and the rate of pneumothorax requiring drainage catheter insertion were compared between group A (patients placed in an ipsilateral-dependent position) and group B (patients placed in a position other than the ipsilateral-dependent position), with use of a chi-square test or Fisher exact test, as appropriate. Linear regression analysis and multiple regression analysis were performed for risk factors of pneumothorax, including patient characteristics (e.g., emphysema along the needle track), lesion characteristics (e.g., size and position), and biopsy technique characteristics (e.g., needle path length, needle-pleura angle, and fissure crossing). For patients in group A and group B, the overall pneumothorax rate (21/94 [22.3%] and 95/422 [22.5%], respectively; p = 0.97) and the rate of pneumothorax requiring drainage catheter insertion (6/94 [6.4%] and 28/422 [6.6%], respectively; p = 0.90) were not statistically different. After multiple regression analysis, the only independent risk factors for pneumothorax and insertion of a drainage catheter were needle path length (p < 0.001 and p = 0.02, respectively), emphysema along the needle track (p = 0.01 and p < 0.001, respectively), and fissure crossing (p = 0.04 and p < 0.001, respectively). Even though the pneumothorax rate does not appear to be reduced, with the limits of a retrospective evaluation considered, other advantages of the ipsilateral decubitus position exist, including protection of the contralateral lung in patients with severe hemoptysis.

SPECT/CT-guided percutaneous transthoracic needle biopsy of thoracic masses

Objective To investigate a real-time imaging guided percutaneous transthoracic needle biopsy (PTNB) for thoracic masses with SPECT/CT. Methods From March to June 2016, a total of 12 patients (7 males, 5 females; average age: (59.2±13.2) years) with thoracic lesions suspicious for malignancy underwent 99Tcm-methoxyisobutylisonitrile (MIBI) SPECT/CT-guided PTNB. The hot spot areas were chosen from the thorax 99Tcm-MIBI SPECT/CT images as the sampling targets. Subsequent guiding CT scans were repeatedly fused with the prior SPECT images to realize the real-time guiding of the biopsy needle puncture step by step, until reaching to the target margin. Masses were sampled after confirming that the needle tips reached planned areas. Pathological results, total time of examination, time of PTNB procedure, complication, CT radiation dosage were recorded. Results Based on 99Tcm-MIBI SPECT/CT results, biopsies targeted the most suspicious areas within lesions. All biopsy procedures yielded diagnostic results. Eleven patients had positive results of malignancy, and 1 patient with inflammation. There were no severe complications. Total time of examination was (74.3±10.4) min, and (33.5±9.1) min for PTNB. Radiation dosage of CT was (6.1±1.7) mSv, 36% of which was caused by CT-guiding ((2.2±1.0) mSv). Conclusion Multimodal of SPECT/CT fusion imaging is useful for thorax biopsy planning and guiding, and can increase overall performance of safety and feasibility. Key words: Thoracic neoplasms; Biopsy, needle; Tomography, emission-computed, single-photon; Technetium Tc 99m sestamibi

Pulmonary emphysema is a predictor of pneumothorax after CT-guided transthoracic pulmonary biopsies of pulmonary nodules

PurposePneumothoraces are the most frequently occurring complications of CT-guided percutaneous transthoracic pulmonary biopsies (PTPB). The aim of this study was to evaluate the influence of pre-diagnostic lung emphysema on the incidence and extent of pneumothoraces and to establish a risk stratification for the evaluation of the pre-procedure complication probability.Material and methodsCT-guided PTPB of 100 pre-selected patients (mean age 67.1±12.8 years) were retrospectively enrolled from a single center database of 235 PTPB performed between 2012–2014. Patients were grouped according to pneumothorax appearance directly after PTPB (group I: without pneumothorax, n = 50; group II: with pneumothorax, n = 50). Group II was further divided according to post-interventional treatment (group IIa: chest tube placement, n = 24; group IIb: conservative therapy, n = 26). For each patient pre-diagnostic percentage of emphysema was quantified using CT density analysis. Emphysema stages were compared between groups using bivariate analyses and multinomial logistic regression analyses.ResultsEmphysema percentage was significantly associated with the occurrence of post-interventional pneumothorax (p = 0.006). Adjusted for potential confounders (age, gender, lesion size and length of interventional pathway) the study yielded an OR of 1.07 (p = 0.042). Absolute risk of pneumothorax increased from 43.4% at an emphysema rate of 5% to 73.8% at 25%. No differences could be seen in patients with pneumothorax between percentage of emphysema and mode of therapy (p = 0.721).ConclusionThe rate of lung emphysema is proportionally related to the incidence of pneumothorax after CT-guided PTPB and allows pre-interventional risk stratification. There is no association between stage of emphysema and post-interventional requirement of chest tube placement.

Intravascular tumour embolism from chondrosarcoma

A 48-year-old woman with a history of sternal chondrosarcoma that had been completely resected 3 years previously presented with a 7-month history of cough and progressive dyspnoea. On admission she had blood oxygen saturation of 88%. Pulmonary CT angiography showed a large tumour embolus in the main pulmonary artery bifurcation that extended into the left pulmonary artery and all the left lobar and segmental arterial branches and caused a large left lower lobe parenchymal consolidation (fi gure). Percutaneous transthoracic biopsy of the consolidation showed metastatic chondrosarcoma. She underwent a left pneumonectomy. Macroscopic examination of the resected lung (fi gure) showed a translucent myxoid tissue fi lling the pulmonary arteries in an arboreous pattern. Microscopic analysis confi rmed that the metastatic chondrosarcoma was confi ned to the vasculature, even inside the parenchymal consolidation. The patient died 4 months later from respiratory insuffi ciency from right-sided pleural and pulmonary infection associated with rapid metastatic spread to the right lung. Pulmonary intravascular tumour embolism is often underdiagnosed at imaging; it is reported in 4–30% of all patients with malignancy on post-mortem examination. It is most common in cancers of the kidney, liver, breast, and lung. Chondrosarcomas are the third most common primary bone malignancy. They often metastasise to the lung parenchyma, but intravascular pulmonary tumour embolism has rarely been reported in chondrosarcoma. Distribution depends on the size of the initial tumour embolus. Small tumour emboli initially lodge distally and propagate towards the centre, gradually aff ecting larger pulmonary vessels, whereas larger tumour aggregates that embolise in more proximal vessels spread both centrally and peripherally. The clinical signs of pulmonary tumour embolism are variable, and often mimic those of acute or chronic pulmonary thromboembolism; unlike thrombo emboli, tumour emboli typically continue to grow despite anticoagulation. Pulmonary tumour embolism can show various patterns on chest CT (fi gure). It can present with a tree-in-bud pattern—a pattern that is more commonly seen in other diseases such as bronchiolar infl ammation or infection— when small tumour emboli cause fi lling and dilatation of the small peripheral centrilobular pulmonary arteries, occasionally leading to a pulmonary infarct. The most characteristic appearance of tumour embolism is enlargement of more central beaded pulmonary arteries, caused by larger tumour emboli. Extensive dissemination can also result in parenchymal consolidation, a cause that should be considered in a patient with a known malignancy.

Diagnostic Accuracy and Safety of CT-Guided Percutaneous Transthoracic Needle Biopsies: 14-Gauge versus 22-Gauge Needles

PurposeTo compare the diagnostic accuracy and safety of a 14-gauge core needle versus a 22-gauge fine needle in the evaluation of thoracic lesions by CT–guided percutaneous transthoracic needle biopsy (TTNB). Materials and MethodsMedical charts of all patients who underwent CT-guided percutaneous transthoracic core-needle biopsies (CNBs) with a 14-gauge Spirotome device (99 patients, 102 procedures) and fine-needle biopsies (FNBs) with a 22-gauge Rotex needle (92 patients, 102 procedures) between 2007 and 2013 at a single academic institution were retrospectively reviewed. Variables that could influence diagnostic accuracy and safety were collected. ResultsThe overall and cancer-specific diagnostic accuracy rates were 90% and 94%, respectively, with CNB, versus 82% and 89% with FNB. Precise cancer type/subtype was provided by 97% of CNBs versus 65% of FNBs (P < .001). In patients with lung cancer considered for targeted therapy, biomarker analyses were feasible in 80% of CNBs versus 0% of FNBs (P < .001). The rate of pneumothorax was significantly higher with CNB versus FNB (31% vs 19%; P = .004), but chest tube insertion rates were similar (10% vs 11%, respectively). Major bleeding complications occurred in 1% of CNBs versus 2% of FNBs and were associated with one death in the CNB group. ConclusionsPercutaneous transthoracic CNB with a 14-gauge Spirotome needle provided better characterization of cancer lesions and allowed biomarker analyses without a significant increase in major procedural complications.

The diagnostic value of ultrasound-guided percutaneous transthoracic core-needle biopsy versus computed tomography-guided biopsy in peripheral intrathoracic lesions

Transthoracic ultrasound has become an important diagnostic tool in peripheral intrathoracic lesions. Transthoracic needle biopsy is a relatively safe and easy procedure under real-time ultrasound (US) guidance, and may provide adequate tissue sampling of lesions for cytological, histological, or microbiological analysis. The aim of the present study was to compare the diagnostic yield, accuracy, and complications of thoracic US-guided core-needle biopsy versus computed tomography (CT)-guided biopsy in peripheral intrathoracic lesions, including pleural, peripheral pulmonary, and mediastinal lesions. US-guided biopsy and CT-guided biopsy were performed in Chest and Radiology Departments during the period from February 2011 to June 2014 on 100 patients (50 patients for each group) using core-biopsy needle, with needle size (16–18–20 G), needle length (20 cm), and core length (1–1.5–2 cm) according to the size and type of lesion. The histopathological examination and complications were reported. The diagnostic value of chest US was compared with CT; chest US had sensitivity 91.7%, specificity 89.4%, positive predictive value 73.3%, negative predictive value 97.1%, and accuracy 90% in detecting pleural lesions; 90.7, 91.4, 95.1, 84.2, and 91%, respectively, in detecting pulmonary lesions; and 72.7, 88.7, 44.4, 96.3, and 87%, respectively, in detecting mediastinal lesions compared with chest CT. After taking transthoracic biopsy, chest US-guided biopsy revealed four benign (8%), 30 malignant (60%), 10 inflammatory(20%), and six undiagnosed (12%) cases, whereas CT group revealed two (4%), 33 (66%), 10 (20%), and five (10%) cases, respectively, with a complication rate [pneumothorax: two (4%) cases for US group and three (6%) cases for CT group and pulmonary hemorrhage: two (4%) cases and three (6%) cases respectively]. Chest US-guided biopsy is safe, reliable, and a fast procedure with lower cost and fewer complications than is CT-guided biopsy, provided that the lesions have favorable acoustic window and abut the visceral pleura.

Predictors of False-Negative Results from Percutaneous Transthoracic Fine-Needle Aspiration Biopsy: An Observational Study from a Retrospective Cohort.

PurposeWe investigated factors predictive of false-negative pulmonary lesions with nonspecific benign cytology results on percutaneous transthoracic fine-needle aspiration biopsy (FNAB).Materials and MethodsWe included 222 pulmonary lesions that had a nonspecific benign result from percutaneous transthoracic FNAB between March 2005 and December 2012, and were confirmed by subsequent pathologic results or adequate clinical follow up over at least 2 years. Clinical, imaging, and biopsy procedure-related findings were compared between lesions with a final diagnosis of malignancy (false-negative) and lesions with a benign diagnosis (true-negative). Multivariate logistic regression analysis was performed to identify significant predictors of false-negatives.ResultsOf 222 lesions, 115 lesions were proved to be false-negatives, and 107 were true-negatives. Compared with the true-negatives, false-negative lesions showed significantly older age (p=0.037), higher maximum standardized uptake value (SUVmax) on positron emission tomography (p=0.001), larger lesion size (p=0.007), and lesion characteristics of a subsolid nodule (p=0.007). On multivariate logistic regression analysis, SUVmax, lesion size, and lesion characteristics were significant predictors of false-negative results.ConclusionAmong the clinical, radiologic, and procedure-related factors analyzed, high SUVmax, large lesion size, and subsolid lesions were useful for predicting malignancy in pulmonary lesions with nonspecific benign cytology results on FNAB.

A Case of Intrathoracic Ectopic Liver in a Patient without Diaphragmatic Defect

Intrathoracic ectopic liver is a rare condition (1-4). In most patients, it is found incidentally during chest radiography as a mass usually located in the right lower area of the thorax adjacent to right the diaphragm, although ectopic liver on the left side of the thoracic cavity is also reported (4). Intrathoracic ectopic liver is usually associated with congenital diaphragmatic defect, mimicking a lung mass on CT scan (5). In these patients, percutaneous transthoracic biopsy or surgery is necessary to exclude bronchogenic cancer. A finding of intrathoracic ectopic liver in the presence of an intact, normal diaphragm is an extremely rare congenital anomaly, with only 18 reports to date in the English literature (6). However, there are no radiologic reports of intrathoracic ectopic liver without diaphragmatic defect using dynamic chest CT. We described a patient with intrathoracic ectopic liver without diaphragmatic defect that appeared as a subpleural mass abutting the diaphragm with isodense enhancement to liver tissue during arterial and delayed phase images on dynamic chest CT.

CT-guided transthoracic biopsy: histopathologic results and complication rates.

We aimed to investigate the effectiveness and complications of transthoracic CT-guided biopsy techniques. A total of 94 CT-guided percutaneous transthoracic biopsy procedures performed in 85 patients were retrospectively evaluated. Core biopsy technique was used in 87 procedures and transthoracic fine-needle aspiration biopsy was used in seven procedures. Diagnostic results were achieved in 79 of 94 biopsy procedures. Pathology results were malignant in 54 patients, suspicious for malignancy in three patients, benign in five patients, and benign nonspecific in 17 patients. Specific diagnoses were obtained in 59 patients (62.8%) using core biopsy, but no specific diagnosis could be reached with transthoracic fine-needle aspiration biopsy. Complications included pneumothorax in 27 patients (28.7%) and parenchymal hemorrhage during and after the procedure in eight patients (8.5%). CT-guided percutaneous transthoracic needle biopsy is a highly accurate procedure for histopathological diagnosis of thoracic masses. In addition, percutaneous transthoracic biopsy has an acceptably low complication rate and it reduces the need for more invasive surgical procedures.

A 40-Year-Old Woman With Multiple Pulmonary Nodules

A 40-year-old woman (a nonsmoker) with history of idiopathic thrombocytopenic purpura and a platelet count > 90,000 cells/μL without specific medication was referred to pulmonary clinic for evaluation of multiple pulmonary nodules. The patient presented to an outside hospital with fatigue, lack of energy, and dyspnea on exertion for 2 years. She denied fever, cough, chest pain, or weight loss. An initial chest radiograph showed bilateral multiple pulmonary nodules. A chest CT scan revealed multiple nodular lesions, varying in size, in all lobes of both lungs. There was no mediastinal lymphadenopathy or pleural effusion. There was no significant hypermetabolic activity on a subsequent fluorodeoxyglucose PET scan/CT scan, and there had been no significant change. She underwent CT scan-guided percutaneous transthoracic biopsy and bronchoscopy with transbronchial biopsies, all of which were inconclusive. An open lung biopsy was considered.

Success and failure rates of tumor genotyping techniques in routine pathological samples with non-small-cell lung cancer

IntroductionIdentification of some somatic molecular alterations in non-small-cell lung cancer (NSCLC) has become evidence-based practice. The success and failure rate of using commercially available tumor genotyping techniques in routine day-to-day NSCLC pathology samples is not well described. We sought to evaluate the success and failure rate of EGFR mutation, KRAS mutation, and ALK FISH in a cohort of lung cancers subjected to routine clinical tumor genotype. MethodsClinicopathologic data, tumor genotype success and failure rates were retrospectively compiled and analyzed from 381 patient-tumor samples. ResultsFrom these 381 patients with lung cancer, the mean age was 65 years, 61.2% were women, 75.9% were white, 27.8% were never smokers, 73.8% had advanced NSCLC and 86.1% had adenocarcinoma histology. The tumor tissue was obtained from surgical specimens in 48.8%, core needle biopsies in 17.9%, and as cell blocks from aspirates or fluid in 33.3% of cases. Anatomic sites for tissue collection included lung (49.3%), lymph nodes (22.3%), pleura (11.8%), bone (6.0%), brain (6.0%), among others. The overall success rate for EGFR mutation analysis was 94.2%, for KRAS mutation 91.6% and for ALK FISH 91.6%. The highest failure rates were observed when the tissue was obtained from image-guided percutaneous transthoracic core-needle biopsies (31.8%, 27.3%, and 35.3% for EGFR, KRAS, and ALK tests, respectively) and bone specimens (23.1%, 15.4%, and 23.1%, respectively). In specimens obtained from bone, the failure rates were significantly higher for biopsies than resection specimens (40% vs. 0%, p=0.024 for EGFR) and for decalcified compared to non-decalcified samples (60% vs. 5.5%, p=0.021 for EGFR). ConclusionsTumor genotype techniques are feasible in most samples, outside small image-guided percutaneous transthoracic core-needle biopsies and bone samples from core biopsies with decalcification, and therefore expansion of routine tumor genotype into the care of patients with NSCLC may not require special tissue acquisition or manipulation.