Image-guided Needle Biopsy Research Articles

Risk of pneumothorax caused by computerized tomography-guided percutaneous core needle biopsy of the lung in elderly and young patients.

The incidences and risk factors caused by computed tomography (CT)-guided percutaneous computed tomography-guided needle biopsies (PCNBs) in elderly and young patients were not very clear. This study explored the different incidences of pneumothorax caused by PCNBs and related risk factors in elderly and young patients. The medical records of 1100 patients who underwent CT-guided PCNBs in a hospital from January 2018 to December 2019 were retrospectively reviewed. Data relating to the patients, lesions, techniques, and diagnoses were collected according to the ethical standards of the institutional research committee (registration number: KYLL-202008-145). The variables were significant by univariate analysis and further analyzed by multivariate logistic regression analysis. In the 1100 patients with PCNBs, the incidence of pneumothorax in groups ≥65 years old and <65 years old was 15.2% and 12.9%, respectively. There was no significant difference in the incidence of pneumothorax between the young and elderly patients. In elderly and young patients, emphysema along the needle path and dwell time was independent predictors. However, in young patients, lesion-abutting pleura was an independent risk factor for pneumothorax, but not in elderly patients. The risk of pneumothorax caused by CT-guided percutaneous core needle biopsy of the lung does not increase in elderly patients. Emphysema along the needle path and dwell time is independent predictors of pneumothorax in elderly and young patients.

Isolated prostatic tuberculosis mimicking prostatic carcinoma: a needle biopsy diagnosis

Genitourinary tuberculosis is uncommon and mostly involves kidneys, seminal vesicles and epididymis. Isolated prostatic tuberculosis is rarely reported and is an under recognized entity. Here, we report such a case which clinically mimicked prostatic carcinoma and was subsequently diagnosed on image guided needle biopsy.

Recurrence and disease-free survival outcomes after computed tomography-guided needle biopsy in stage IA non-small cell lung cancer patients in China: a propensity score matching analysis.

Whether preoperative biopsy before radical resection can lead to recurrence and impact patient survival in non-small cell lung cancer (NSCLC) remains controversial. In this study, we carried out a retrospective analysis to determine whether preoperative biopsy can cause disease recurrence and influence disease-free survival (DFS) in patients with stage IA NSCLC. Patients diagnosed with stage IA NSCLC (solid nodule) between January 2010 and December 2014 were identified from the databases of 7 Chinese medical centers and divided into two groups: a preoperative computed tomography (CT)-guided needle biopsy (CTNB) plus radical resection group, and a non-CTNB group. The propensity score matching (PSM) method was adopted to balance the observed covariates, and Kaplan-Meier estimates were used for survival analysis. Cox regression was used in a single-factor analysis to identify the factors affecting DFS in stage IA NSCLC. After initial screening, 730 patients were enrolled in this study, with 186 and 544 patients in the CTNB group and the non-CTNB group, respectively. After PSM, 186 patients were eventually included in each group. No significant differences in basic clinical features were identified between the two groups (P>0.05). The rates of recurrence were 17.2% and 14.0% in the CTNB and non-CTNB groups (χ2=0.735, P=0.391), respectively. No notable differences in DFS (χ2=1.895, P=0.173) or overall survival (OS, χ2=1.785, P=0.182) were observed. Lung adenocarcinoma [hazard ratio (HR), 0.167, P=0.001] and lesion size (>2 cm) (HR, 2.712, P=0.000) were identified as risk factors for DFS in stage IA NSCLC. CTNB does not increase the incidence of recurrence in stage IA NSCLC or affect patient survival; therefore, it is not a risk factor for DFS. Lung adenocarcinoma and lesion size are risk factors for DFS.

CT Guided Needle Biopsy of Peripheral Lesions-Lesion Characteristics That May Increase the Diagnostic Yield and Reduce the Complication Rate.

Computed tomography-guided needle biopsy (CT-GNB) has a high diagnostic yield for lung cancer but higher complication rates compared to those of other biopsy modalities. We sought to clarify in which thoracic lesions we could achieve a quick pathological diagnosis using CT-GNB, considering the risks and benefits. We retrospectively enrolled 110 patients who underwent CT-GNB and 547 patients who underwent transbronchial biopsy (TBB) for parenchymal lung lesions in clinical practice. The diagnostic rates of CT-GNB and TBB were 87.3% and 75.3%. After failed diagnosis with other biopsy modalities, 92.3% of patients were finally diagnosed using CT-GNB and 65.8% using TBB. In cases with a negative bronchial sign, there was a statistically higher diagnostic rate with CT-GNB than with TBB (p < 0.001: 89.4% vs. 0%). Complication rates were higher with CT-GNB (50.9%) than with TBB (16.3%). However, there were lower rates of complications in cases with inhomogeneous tumors, subpleural lesions, and when more than 15 mm of the punctured needle length was within the target. We conclude that CT-GNB is an effective biopsy modality with a high diagnostic rate that is especially recommended when the bronchus sign is negative. It can be safely performed if risk factors for complications are taken into account.

Percutaneous Image-guided Needle Biopsy of Musculoskeletal Tumors: Technical Tips.

With recent advances in imaging technology, the frequency of detecting musculoskeletal lesions has also increased. Percutaneous image-guided needle biopsy is occasionally required for the diagnosis of such lesions. Moreover, in the era of personalized cancer care, chances in histopathological diagnosis and the importance of histopathological diagnosis by percutaneous needle biopsy are increasing. However, as percutaneous needle biopsy is not a common procedure for musculoskeletal lesions, careful planning and the application of adequate techniques such as hydrodissection and the trans-osseous approach are occasionally required. In this review, we have summarized the indications and techniques for percutaneous image-guided needle biopsy for musculoskeletal lesions, including lymphatic lesions.

Intrapericardial Ectopic Thyroid Arising From the Ascending Aorta

A 68-year-old woman with dyspnea, recurrent chest pain, and paroxysmal atrial fibrillation had, as indicated by chest computed tomography, a 42 × 44 × 53 mm mediastinal solid lesion with fluid cystic areas compressing the right atrium (Figure 1 [Ao, ascending aorta; At, right atrium; M, intrapericardial mass]), with a maximum standard uptake value of 1.5 at positron emission tomography scan. Considering the site of the mass and the radiologic and metabolic features, transthoracic computed tomography-guided needle biopsy was not performed, and surgical removal of the mass through right video-assisted thoracoscopy was scheduled instead.

Effectiveness of Cytological Diagnosis with Outer Cannula Washing Solution for Computed Tomography-Guided Needle Biopsy

We evaluated the availability of cytological diagnosis with outer cannula washing solution (C-OCWS) as a clinical diagnostic tool for computed tomography (CT)-guided needle biopsy. We retrospectively assessed 109 consecutive patients (71 males, 38 females; median age 68 years), who underwent CT-guided needle biopsy. In all patients, the specimens sampled by the inner needle were used for histological diagnosis, and those taken from the outer cannula were rinsed with 0.9% saline solution: outer cannula washing solution for cytological diagnosis. The accuracy of C-OCWS in addition to histological diagnosis were compared with that of histological diagnosis alone. We used binary logistic regression analysis to determine the variables associated with diagnostic accuracy for malignancy and lesion characteristics. The C-OCWS method precisely diagnosed 7 (6.4%) malignant lesions (i.e., effective cases) in the 109 patients characterized as "negative for malignancy" via histological diagnosis alone. The accuracy of the combination of C-OCWS and histological diagnoses was significantly higher than that of histological diagnosis alone (0.95 vs. 0.89, respectively; p = 0.023). Multivariate logistic regression analysis showed that increasing only a marginal ratio (failure rate for proper position of biopsy needle within the tumor) was independently associated with a high rate of effective cases (p = 0.003). C-OCWS may be helpful for improving the quality of CT-guided needle biopsy, and is a simple method that may not necessarily increase the patients' physical burden.

Development of a mechatronic guidance system for targeted ultrasound-guided biopsy under high-resolution positron emission mammography localization.

Image-guided needle biopsy of small, detectable lesions is crucial for early-stage diagnosis, treatment planning, and management of breast cancer. High-resolution positron emission mammography (PEM) is a dedicated functional imaging modality that can detect breast cancer independent of breast tissue density, but anatomical context and real-time needle visualization are not yet available to guide biopsy. We propose a mechatronic guidance system integrating an ultrasound (US)-guided core-needle biopsy (CNB) with high-resolution PEM localization to improve the spatial sampling of breast lesions. This paper presents the benchtop testing and phantom studies to evaluate the accuracy of the system and its constituent components for targeted PEM-US-guided biopsy under simulated high-resolution PEM localization. A mechatronic guidance system was developed to operate with the Radialis PEM system and a conventional US system. The system includes a user-operated guidance arm and end-effector biopsy device, integrating a US transducer and CNB gun, with its needle focused on a remote center of motion (RCM). Custom software modules were developed to track, display, and guide the end-effector biopsy device. Registration of the mechatronic guidance system to a simulated PEM detector plate was performed using a landmark-based method. Testing was performed with fiducials positioned in the peripheral and central regions of the simulated detector plate and registration error was quantified. Breast phantom experiments were performed under ideal detection and localization to evaluate for bias in the end-effector biopsy device. The accuracy of the complete mechatronic guidance system to perform targeted breast biopsy was assessed using breast phantoms with simulated lesions. Three-dimensional positioning error was quantified, and principal component analysis assessed for directional trends in 3D space within 95% prediction intervals. Targeted breast biopsies with test phantoms were performed and an overall in-plane needle targeting error was quantified. The mean registration errors were 0.63mm (N=44) and 0.73mm (N=72) in the peripheral and central regions of the simulated PEM detector plate, respectively. A 3D 95% prediction ellipsoid shows an error volume <2.0mm in diameter, centered on the mean registration error. Under ideal detection and localization, targets <1.0mm in diameter can be sampled with 95% confidence. The complete mechatronic guidance system was able to successfully spatially sample simulated breast lesions, 4mm and 6mm in diameter and height (N=20) in known 3D positions in the PEM image coordinate space. The 3D positioning error was 0.85mm (N=20) with 0.64mm in-plane and 0.44mm cross-plane component errors. Targeted breast biopsies resulted in a mean in-plane needle targeting error of 1.08mm (N=15) allowing for targets 1.32mm in radius to be sampled with 95% confidence. We demonstrated the utility of our mechatronic guidance system for targeted breast biopsy under high-resolution PEM localization. Breast phantom studies showed the ability to accurately guide, position, and target breast lesions with the accuracy to spatially sample targets <3.0mm in diameter with 95% confidence. Future work will integrate the developed system with the Radialis PEM system toward combined PEM-US-guided breast biopsy.

Four cases of completion lobectomy for locally relapsed lung cancer after segmentectomy

BackgroundAlthough completion lobectomy is the treatment of choice for local recurrence of non-small cell lung cancer after segmentectomy, few cases have been reported. We report four patients who underwent completion lobectomies for staple line recurrence after segmentectomy for stage I non-small cell lung cancer.Case presentationThree women aged 65, 82, and 81 years underwent completion lower lobectomy after superior segmentectomy of the same lobe for local recurrence of stage I non-small cell lung cancer. A 67-year-old man, who had a tumor recurrence on the staple line after apical segmentectomy with superior mediastinal nodal dissection for stage I non-small cell lung cancer, underwent completion right upper lobectomy. These four patients underwent segmentectomy because of comorbidities or advanced age. Local recurrence was confirmed by computed tomography-guided needle biopsy. The interval between the two operations was 37, 39, 41, and 16 months, respectively. Although minimal hilar adhesion was seen for the three completion lower lobectomies, tight adhesions after apical segmentectomy made completion right upper lobectomy quite difficult to dissect, which led to injury of the superior pulmonary vein. No recurrence was recorded after completion lobectomies for 62, 70, 67, and 72 months, respectively.ConclusionsAlthough completion lobectomy is one of the most difficult modes of resection, among several completion lobectomies, completion lower lobectomy after superior segmentectomy without superior mediastinal nodal dissection was relatively easy to perform because of fewer hilar adhesions.

Percutaneous Spine Biopsy: A Review of the Current Literature.

Spine lesions are often the result of pathologic processes elsewhere in the body; prompt and accurate diagnosis are crucial to optimize treatment. Despite modern advances in imaging modalities, definitive diagnosis ultimately requires biopsy and histologic analysis. Although open surgical biopsy has traditionally been considered the benchmark, percutaneous image-guided needle biopsy of the spine has proven to be a safe and highly effective method in making a diagnosis. Choosing the optimal biopsy approach, instrumentation and modality of image guidance may depend on a number of factors including lesion type, location, and level within the spine. Knowledge of relevant anatomy, indications, contraindications, and potential complications are critical to a successful biopsy procedure.

Sobre biópsia por agulha guiada por tomografia computadorizada - o imperioso diagnóstico de massas em cabeça e pescoço

Sobre biópsia por agulha guiada por tomografia computadorizada - o imperioso diagnóstico de massas em cabeça e pescoço

Utility of Percutaneous Image-guided Needle Biopsy for Suspected Spinal Vertebral Osteomyelitis

Chaudhry, Nauman S MD; Brunozzi, Denise MD; Behbahani, Mandana MD; Neckrysh, Sergey MD Author Information

The importance of MRI review following the diagnosis of atypical cartilaginous tumour using image-guided needle biopsy.

To evaluate the role of pre-biopsy MRI for management planning in patients with atypical cartilaginous tumours (ACT) diagnosed on image-guided core needle biopsy (IGCNB). Retrospective review of patients diagnosed with ACT of the appendicular skeleton based on IGCNB who subsequently underwent surgical curettage or resection. Data collected included age, sex, skeletal location and surgical histology classified as ACT, high-grade chondrosarcoma (HG-CS) and dedifferentiated chondrosarcoma (DD-CS). Pre-biopsy MRI studies were reviewed independently by 2 radiologists blinded to surgical histology results and graded as ACT, HG-CS and DD-CS based on MRI features. The study included 24 males and 28 females (mean age 42.1years; range 9-76years). One patient had 2 lesions treated, making a total of 53 lesions. Tumours were located in the femur in 21 cases, humerus in 17, tibia in 9, radius in 4 and ulna and fibula in 1 each. Surgical histology was ACT in 41 cases, HG-CS in 10 and DD-CS in 2, indicating mismatch between IGCNB and surgical histology in 12/53 cases (22.6%). Predicted MRI grade for the 2 readers was ACT in 39 cases each, HG-CS in 13 and 14 cases and DD-CS in 1 and 0 cases. Sensitivity, specificity and accuracy of MRI for predicting HG-CS/DD-CS were 91%, 93% and 92%, respectively. Inter-observer correlation was very good (kappa = 0.94). Review of MRI findings in patients with ACT diagnosed on IGCNB is vital for identifying patients with a HG-CS/DD-CS and is recommended when planning surgical management or considering repeat IGCNB.

MON-445 A Rare and Unusual Presentation of Adenoid Cystic Carcinoma as Thyroid Mass with Metastasis to the Lung

Introduction: Adenoid cystic carcinoma is a rare form of cancer that most commonly originates within the secretory cells of the major and minor salivary glands. In rare and unusual cases, adenoid cystic carcinoma can present as Thyroid mass. Adenoid cystic carcinoma is described presenting in papillary carcinoma of thyroid and as poorly differentiated thyroid carcinoma with mixed or unclear histology. We describe the case of a patient diagnosed with poorly differentiated thyroid carcinoma with complete thyroidectomy later presenting with metastatic lung disease diagnosed as adenoid cystic carcinoma. Case Presentation: A 53-year-old male with history of palpable neck mass, lymphadenopathy, and hoarseness with a diagnosis of poorly differentiated thyroid carcinoma with unclear histology. He underwent total thyroidectomy with level 6 compartment neck dissection, laryngeal nerve sparing with tracheostomy tube. Patient presented 2 months’ post thyroidectomy with right facial swelling. Labs were significant for microcytic anemia with Hgb 10, MCV 71, TSH and metabolic panel within normal limits. Radiographic imaging demonstrated residual-recurrent malignancy in the thyroid bed, lymphatic disease, and compression of surrounding structures including trachea, distal right internal jugular, and right subclavian vein. Follow up radiographic studies showed a 1.7 x 4.6 x 5.5cm soft tissue mass behind the trachea at the level of previously resected mass. Multiple pulmonary nodules were noted. Image guided needle biopsy of largest left lung nodules carcinoma with adenoid cystic pattern. Final path report was metastatic adenoid cystic carcinoma. Conclusion: This case is unique in that it describes a rare and uncommon presentation of adenoid cystic carcinoma as metastatic thyroid carcinoma in a patient with prior history of thyroidectomy. Adenoid cystic carcinoma is a rare glandular malignancy that commonly presents as the second most common histologic subtype of salivary cancer. Adenoid cystic carcinoma as a histologic subtype has a high morbidity and mortality, if not identified and managed promptly. Prognosis and survival outcomes are poor with some studies comparing its prognosis to that of anaplastic carcinoma. This case also illustrates the complexity and diverse presentation of adenoid cystic carcinoma. The initial diagnosis in this patient was nonspecific with biopsy revealing poorly differentiated carcinoma. Adenoid cystic carcinoma was diagnosed later at time of disease progression to the lung. This case reviews the diagnostic workup, evaluation, and appropriate management of adenoid cystic primary thyroid carcinoma. In addition, it evaluates the appropriate differential diagnosis in patients enlarging neck mass and progressive thyroid cancer.

Is needle biopsy a risk factor of pleural recurrence after surgery for non-small cell lung cancer?

BackgroundTumor seeding, whereby malignant cells are deposited along the needle tract, is considered to be a potential hazard of needle biopsies. The aim of this study is to elucidate the relationship between needle biopsies for lung tumor, such as a preoperative computed tomography-guided needle biopsy (PCTGNB) or an intraoperative fine-needle aspiration biopsy (IFNAB), and ipsilateral pleural recurrence (PR) after lung cancer surgery.MethodsBetween 2008 and 2017, 1,047 patients with non-small cell lung cancer (NSCLC) underwent curative lung resection in our institution. They were divided into two groups: those in whom the first recurrent site was the ipsilateral pleural cavity (PR group) and the others (control group). Risk factors of PR were investigated retrospectively.ResultsRecurrence was observed in 191 patients (18.2%), 25 of whom were categorized to the PR group (17 malignant effusion, 10 dissemination). Pathological tumor [2–4], lymph nodes [1–2], pleural, lymphatic and vascular invasion (each ≥1) factors and patients who underwent PCTGNB were more frequently observed in the PR group than in the control group (each P<0.01) whereas the proportion of patients who underwent IFNAB was not significant. A multivariate analysis identified pathological lymph node factor and the frequency of PCTGNB as independent risk factors for PR with hazard ratios of 7.33 (95% CI, 2.93–19.8; P<0.01) and 6.92 (95% CI, 2.25–17.8; P<0.01), respectively.ConclusionsPCTGNB is a risk factor of PR but IFNAB is not. Indications for PCTGNB should be carefully determined.

Diagnostic Challenges in Primary Sacral Tumors and the Yield of Computed Tomography-Guided Needle Biopsy in the Modern Era

Primary sacral tumors pose unique challenges because of their complex radiographic appearances, diverse pathologic entities, and dramatically different treatment paradigms based on tumor type. Magnetic resonance imaging and computed tomography (CT) can provide valuable information; however, sacral lesions can possess unique radiographic features and pose diagnostic dilemmas. CT-guided percutaneous needle biopsy is a critical component of the diagnostic workup. However, limited data are available on its efficacy for primary sacral tumors. The data from patients with newly diagnosed primary sacral lesions during a 12-year period at our hospital were analyzed. The preoperative magnetic resonance imaging findings, biopsy results, and pathological data for patients who required surgery were analyzed. Unique cases in which the final pathologic result was unexpected from the preoperative imaging findings have been highlighted. Of 38 patients who underwent percutaneous needle biopsy, diagnostic tissue was obtained on the first attempt for 31 (82%). Five of the remaining 7 obtained diagnostic tissue on the second attempt, yielding 95% diagnosis, with only two requiring open biopsies. In 2 patients with diagnostic tissue on CT-guided biopsy, an open biopsy was still recommended because of the clinical scenario. In both patients, the open biopsy results matched those of the CT-guided biopsy. For the 18 patients who required surgery, we found 100% correlation between the percutaneous needle biopsy findings and the final pathological diagnosis. No biopsy-induced complications or extraspinal tumor seeding occurred. CT-guided biopsy is a safe and effective technique. It represents a critical component of the diagnostic algorithm, given the diverse pathological findings of primary sacral lesions and dramatic differences in treatment.

Desmoid tumor mimics local recurrence of extremity sarcoma on MRI.

The development of desmoid fibromatosis after tumor resection may mimic local recurrence. To our knowledge, this phenomenon has not been reported after extremity sarcoma resection. We report four cases of desmoid-type fibromatosis ("desmoid tumors") mimicking local recurrence after extremity sarcoma resection. We retrospectively reviewed the records of patients treated for extremity sarcoma by our orthopedic oncology service from 2014 to 2019 and identified four patients with biopsy-proven desmoid tumors. We extracted clinical, pathologic, radiographic, and operative data for the primary neoplasms and desmoid tumors. Four patients with postresection surveillance magnetic resonance imaging suspicious for local recurrence underwent further analysis showing desmoid tumors. Patients underwent image-guided needle biopsy, with specimens demonstrating fibromatosis-type histologic characteristics. Two cases were β-catenin positive. Desmoid tumors were managed with observation. No patient had experienced local or distant recurrence of the primary tumor at a mean follow-up of 30 months after resection (range, 23-34 months); none underwent surgery for symptoms of desmoid tumors. Desmoid tumors should be considered part of the differential diagnosis when assessing patients with radiographic concern for postresection local recurrence of extremity bone and soft-tissue sarcoma. An image-guided needle biopsy can inform diagnosis and management.

Development of a Handheld Volumetric Photoacoustic Imaging System With a Central-Holed 2D Matrix Aperture.

Photoacoustics has been evolving rapidly in the recent several decades. With the aim of clinical translation, a photoacoustic imaging platform with a portable system size, a miniaturized imaging probe, and convenient handheld capability is of great demand. In this work, by adopting an ultrathin central-holed matrix array and a compact coaxial photoacoustic design, a water-free handheld photoacoustic imager is developed (weight: 44 g). Optical Monte Carlo simulation and acoustic k-wave simulation are performed to confirm a relatively homogenous photoacoustic sensitivity distribution within a wide field of view (larger than 10 × 10 × 10mm3). Imaging resolution characterized by imaging two hairs is estimated to be about 0.80mm in the lateral direction and 0.73mm in the axial direction. To demonstrate the handheld capability in real time, handheld imaging guided needle biopsy in the rat's abdomen is performed at a rate of about 10 Hz (CNR ∼ 14.3dB). Furthermore, handheld imaging is also demonstrated on visualizing vasculature (mainly cephalic vein) in the human arm (CNR > 4.1dB). Results demonstrate that the volumetric photoacoustic imaging system using a central-holed 2D matrix array is an attractive choice for achieving convenient handheld operation in real time. Such a compact handheld design may promote the clinical translation of photoacoustic technique.

CT-guided transthoracic needle biopsy: advantages in histopathological and molecular tests.

Aim: The present study aimed to demonstrate that computed tomography-guided transthoracic needle biopsy (TTNB) is a safe procedure that gives a more accurate pre-operative tissue diagnosis for peripheral lung nodules than transthoracic needle aspiration, obtaining suitable samples for molecular test in lung adenocarcinomas. Patients & methods: Between December 2016 and March 2018 at Thoracic Surgery Department of the University of Palermo - Policlinico Paolo Giaccone hospital, TTNB was performed in 42 patients with computed tomography-detected peripheral lung nodules >10 mm, using 16-18-Gauge Tru-Cut needles. Results: With TTNB, we have estimated an accuracy for tissue diagnosis of 97.6%. At the molecular test, EGFR overexpression and ALK mutation resulted positive for 12/23 patients with lung adenocarcinoma. Conclusion: TTNB has showed a low rate of complications and it is adoptable as standard diagnostic procedure for peripheral lung nodules.

Factors leading to failure to diagnose pulmonary malignant tumors using endobronchial ultrasound with guide sheath within the target lesion

BackgroundThe diagnostic yield of peripheral pulmonary lesions has significantly increased with the use of radial endobronchial ultrasound with guide sheath within the lesion. Here, we retrospectively evaluated factors leading to misdiagnosis of pulmonary malignant tumors using endobronchial ultrasound with the guide sheath within the lesion.MethodsWe assessed the final histopathological diagnosis of biopsy samples taken from 130 patients with lung malignant tumors that underwent endobronchial ultrasound with guide sheath within the lesion.ResultsAmong 130 patients, 8 (6%) showed no definite malignant findings in biopsy samples but the presence of malignant cells (primary lung cancer 7, diffuse large B cell lymphoma 1) was subsequently confirmed by histopathological study of specimens taken by computed tomography-guided needle biopsy or surgery. Of the eight cases with diagnostic failure, the size of the biopsy sample was insufficient in five due to technical difficulties during the diagnostic procedure, and the diagnosis of malignant tumor was difficult in five cases because of extensive scarring tissue or central necrosis.ConclusionsThe results of this study showed that technical difficulties and/or pathological heterogeneity of the tumor might lead to failure to diagnose lung malignant tumor in cases using endobronchial ultrasound with guide sheath within the lesion.