CT-guided Transthoracic Biopsy Research Articles

Optimizing Precision: A Trajectory Tract Reference Approach to Minimize Complications in CT-Guided Transthoracic Core Biopsy.

The advent of computed tomography (CT)-guided transthoracic needle biopsy has significantly advanced the diagnosis of lung lesions, offering a minimally invasive approach to obtaining tissue samples. However, the technique is not without risks, including pneumothorax and hemorrhage, and it demands high precision to ensure diagnostic accuracy while minimizing complications. This study introduces the Laser Angle Guide Assembly (LAGA), a novel device designed to enhance the accuracy and safety of CT-guided lung biopsies. We retrospectively analyzed 322 CT-guided lung biopsy cases performed with LAGA at a single center over seven years, aiming to evaluate its effectiveness in improving diagnostic yield and reducing procedural risks. The study achieved a diagnostic success rate of 94.3%, with a significant reduction in the need for multiple needle passes, demonstrating a majority of biopsies successfully completed with a single pass. The incidence of pneumothorax stood at 11.1%, which is markedly lower than the reported averages, and only 0.3% of cases necessitated chest tube placement, underscoring the safety benefits of the LAGA system. These findings underscore the potential of LAGA to revolutionize CT-guided lung biopsies by enhancing procedural precision and safety, making it a valuable addition to the diagnostic arsenal against pulmonary lesions.

Shape-Sensing Robotic-Assisted Bronchoscopy versus Computed Tomography-Guided Transthoracic Biopsy for the Evaluation of Subsolid Pulmonary Nodules

Introduction: Lung cancer remains the leading cause of cancer death worldwide. Subsolid nodules (SSN), including ground-glass nodules (GGNs) and part-solid nodules (PSNs), are slow-growing but have a higher risk for malignancy. Therefore, timely diagnosis is imperative. Shape-sensing robotic-assisted bronchoscopy (ssRAB) has emerged as reliable diagnostic procedure, but data on SSN and how ssRAB compares to other diagnostic interventions such as CT-guided transthoracic biopsy (CTTB) are scarce. In this study, we compared diagnostic yield of ssRAB versus CTTB for evaluating SSN. Methods: A retrospective study of consecutive patients who underwent either ssRAB or CTTB for evaluating GGN and PSN with a solid component less than 6 mm from February 2020 to April 2023 at Mayo Clinic Florida and Rochester. Clinicodemographic information, nodule characteristics, diagnostic yield, and complications were compared between ssRAB and CTTB. Results: A total of 66 nodules from 65 patients were evaluated: 37 PSN and 29 GGN. Median size of PSN solid component was 5 mm (IQR: 4.5, 6). Patients were divided into two groups: 27 in the ssRAB group and 38 in the CTTB group. Diagnostic yield was 85.7% for ssRAB and 89.5% for CTTB (p = 0.646). Sensitivity for malignancy was similar between ssRAB and CTTB (86.4% vs. 88.5%; p = 0.828), with no statistical difference. Complications were more frequent in CTTB with no significant difference (8 vs. 2; p = 0.135). Conclusion: Diagnostic yield for SSN was similarly high for ssRAB and CTTB, with ssRAB presenting less complications and allowing mediastinal staging within the same procedure.

Pre-procedure 18F-FDG PET/CT imaging improves the performance of CT-guided transthoracic biopsy.

To compare computed tomography (CT)-guided transthoracic lung biopsies (CTLB) with and without pre-procedure 18F-fluorodeoxgyglucose positron emission tomography (18F-FDG PET)/CT images in the diagnosis of pulmonary nodules/masses. This is a case-control study in a single center. The data of patients with a transthoracic lung biopsy guided by CT and pre-procedure 18F-FDG PET/CT (group 2, here called the "PETCTLB" group), including demographics, clinical characteristics, and biopsy-related parameters, were collected. The PET/CT scan was performed within 15 days before the biopsy. The data from patients with CTLB were used as controls (group 1). Biopsies for all patients were performed by the same physician between January 2019 and December 2021. The final diagnosis was based on surgical outcomes, or imaging findings, and the results of at least one 6-month follow-up. The demographics and clinical characteristics of patients, lesions and biopsy-related variables, diagnostic yields, and incidence of complications were compared between the two groups. Two-tailed t-tests were used to compare the mean values in the two independent groups, while categorical variables were compared using the Pearson chi-squared test, and P values < 0.05 were considered to be significant. A total of 84 patients were included, and 84 biopsies of 84 lung nodules/masses were analyzed. The demographics and clinical characteristics of group 2 (n = 39; 21 men; mean age, 63.2 ± 9.29 years) and group 1 (n = 45; 30 men; mean age, 61.2 ± 12.3 years) had no significant difference (P = 0.230 and 0.397, respectively). The procedure duration (11.1 ± 3.0 vs. 12.9 ± 3.3 minutes, P = 0.008), the number of samples (2.6 ± 0.5 vs. 3.1 ± 0.4, P < 0.001), diagnostic accuracy (97.4% vs. 82.2%, P = 0.033), and bleeding complication (25.6% vs. 42.2%, P = 0.034) of group 2 and group 1 were statistically different. A biopsy guided by CT plus pre-procedure 18F-FDG PET/CT (PETCTLB) is a safe procedure that can provide a precise diagnosis in the majority of lung nodules/masses. It has better diagnostic performance than CTLB.

Tumor seeding following CT- guided transthoracic needle biopsy in lung cancer. A case report

As a result of advances in the treatment of lung cancer, the life expectancy of lung cancer patients has improved significantly, but it remains the leading cause of cancer death worldwide. For decades, most of the initial tumor biopsies have been obtained by bronchoscopy or computed tomography (CT)-guided transthoracic lung biopsy without concerning reports of cancer seeding following the latter. In this case report we discuss the patient history of a 56-year old women with low-differentiated squamous cell lung cancer who developed tumor seeding following a CT-guided transthoracic biopsy 11 months after the intervention. This is put into context reviewing former and current literature.

Synchronous lung cancer presenting with small cell carcinoma and squamous cell lung carcinoma: a case report.

Synchronous multiple primary lung cancers are separate tumors presenting at the same time with different histology. We present a rare case of a 64-year-old patient with a combination of small-cell lung carcinoma (SCLC) and squamous carcinoma in two different sites with metastasis of SCLC in the mediastinal lymph node. The SCLC diagnosis was performed via bronchoscopy, and the other diagnosis via CT-guided transthoracic biopsy. It is often difficult to distinguish a synchronous tumor from intrapulmonary metastases. To date, there are no guidelines for the treatment of these cases. The management of synchronous multiple primary lung cancer (SMPLC), mainly surgical with chemotherapy or radiotherapy, must be studied according to the histological type, staging and molecular testing of the tumors. These rare cases of SMPLC require individual treatment and a multidisciplinary approach.

Еffectiveness of ct-guided transthoracic biopsy

Objective. To evaluate the effectiveness of CT-guided thoracic biopsy in the diagnosis of lung and mediastinal malignancies.Materials and methods. A retrospective analysis of 32 cases of CT-guided transthoracic biopsy was performed. Lung and mediastinal masses suspicious for malignancy with a size of more than 2.0 cm in the area available for manipulation were the indication for Cor-biopsy with additional examination of impression smears. A step-by-step procedure involved CT positioning of the object, marking by the radiation therapy program, and performing the procedure. The cytological and histological materials were evaluated and compared.Results. The analysis of manipulations performed in 32 patients with lung masses (75±7.7%) and mediastinal masses (25±7.7%) proved the technical effectiveness of the procedure, which lasted 37±9 minutes. The diagnosis was confirmed by cytological analysis of impression smears in 81.3±6.9% of cases, and using histological methods – in 71.9±8% (p&gt;0.05). The agreement between the results obtained by both methods was 53.1±8.8%. Immunohistochemical analysis of the material was performed in 69.6±9.6% of patients. Procedural complications (pneumothorax and hemoptysis) were observed in 21.9±7.3% of patients. Cytological examination allowed the results of a planned histological and immunohistochemical analysis to be foreseen with a high degree of probability.Conclusion. CT-guided transthoracic puncture is a highly effective method of diagnosing lung and mediastinal malignancies, which allows their morphological characterization to be done in 81% of cases.

NSCLC in the Era of Targeted and Immunotherapy: What Every Pulmonologist Must Know

The treatment of non-small cell lung cancer has dramatically changed over the last decade through the use of targeted therapies and immunotherapies. Implementation of these treatment regimens relies on detailed knowledge regarding each tumor's specific genomic profile, underscoring the necessity of obtaining superior diagnostic tissue specimens. While these treatment approaches are commonly utilized in the metastatic setting, approval among earlier-stage disease will continue to rise, highlighting the importance of early and comprehensive biomarker testing at the time of diagnosis for all patients. Pulmonologists play an integral role in the diagnosis and staging of non-small cell lung cancer via sophisticated tissue sampling techniques. This multifaceted review will highlight current indications for the use of targeted therapies and immunotherapies in non-small cell lung cancer and will outline the quality of various diagnostic approaches and subsequent success of tissue biomarker testing. Pulmonologist-specific methods, including endobronchial ultrasound and guided bronchoscopy, will be examined as well as other modalities such as CT-guided transthoracic biopsy and more.

THE LUNG POINT: AN ULTRASOUND FINDING IN THE DIAGNOSIS AND SEMI-QUANTIFICATION OF PNEUMOTHORAX AFTER CT-GUIDED TRANSTHORACIC BIOPSY

This study focused on evaluating the diagnostic performance of the lung point (LP)- a lung ultrasound (LUS) sign in detecting and semi-quantifying pneumothorax (PTX), using computed tomography (CT) as the reference standard. The study included 150 patients who underwent CT-guided transthoracic biopsy (TTB) for lung lesions. Two radiologists blinded to the participant’s prior information performed LUS post-biopsy. The results showed that PTX was present on CT in 49/150 (32.3%) cases. The LP was positive in 36/150 (24%) patients, with a substantial agreement between the two radiologists (Cohen κ statistics = 0.8). The sensitivity and specificity of the LP were 73.5% (95%CI 66.5% to 80.5) and 100% (95%CI 97.6% to 100%), respectively. Moreover, the positive and negative predictive values were 100% (95%CI 97.6% to 100%) and 67.3% (95%CI 59.8% to 78.4%), respectively. In the semi-quantification of PTX, the location of LP was described in 36/49 (73.5%) patients. The sensitivity and specificity of this sign were 87.5% (95%CI 82.2% to 92.8%) and 96.4% (95%CI 92.4% to 98.9%), respectively. The positive and negative predictive values were 87.5% (95%CI 82.2% to 92.8%) and 96.4% (95%CI 92.4% to 98.9%), respectively. In conclusion, LP is a susceptible and specific LUS sign for diagnosing and semi-quantifying PTX.

Solitary Lung Nodule: CT-Guided Transthoracic Biopsy vs Transbronchial Biopsy With Endobronchial Ultrasound and Flexible Bronchoscope, a Meta-Analysis of Randomized Controlled Trials.

Transbronchial lung biopsy with radial endobronchial ultrasound (rEBUS-TBB) and Computed tomography (CT) scan-guided transthoracic biopsy (CT-TTB) are commonly used to investigate peripheral lung nodules but high-quality data are still not clear about the diagnostic and safety profile comparison of these two modalities. We included all randomized controlled trials (RCT) comparing rEBUS-TBB with a flexible bronchoscope and CT-TTB for solitary lung nodules. Two reviewers extracted data independently on diagnostic performance and complication rates. 170 studies were screened, 4 RCT with a total of 325 patients were included. CT-TTB had a higher diagnostic yield than rEBUS-TBB (83.45% vs 68.82%, risk difference -0.15, 95% CI, [-0.24, -0.05]), especially for lesion size 1-2cm (83% vs 50%, risk difference -0.33, 95% CI, [-0.51, -0.14]). For malignant diseases, rEBUS-TBB had a diagnostic yield of 75.75% vs 87.7% of CT-TTB. rEBUS-TBB had a significant better safety profile with lower risks of pneumothorax (2.87% vs 21.43%, OR = 0.12, 95% CI [0.05-0.32]) and combined outcomes of hospital admission, hemorrhage, and pneumothorax (8.62% vs 31.81%, OR 0.21, 95% CI, [0.11-0.40]). Factors increasing diagnostic yield of rEBUS were lesion size and localization of the probe but not the distance to the chest wall and hilum. CT-TTB had a higher diagnostic yield than rEBUS-TBB in diagnosing peripheral lung nodules, particularly for lesions from 1 to 2cm. However, rEBUS-TBB was significantly safer with five to eight times less risk of pneumothorax and composite complications of hospital admission, hemorrhage, and pneumothorax. The results of this study only apply to flexible bronchoscopy with radial ebus without navigational technologies. More data are needed for a comparison between CT-TTB with rEBUS-TBB combined with advanced navigational modalities.

The additional diagnostic value of virtual bronchoscopy navigation in patients with pulmonary nodules – The NAVIGATOR study

BackgroundThe number of solitary pulmonary nodules to be evaluated is expected to increase and therefore we need to improve diagnostic and therapeutic tools to approach these nodules. To prevent patients from futile invasive procedures and receiving treatment without histological confirmation of cancer, we evaluated the value of virtual bronchoscopy navigation to obtain a diagnosis of the solitary pulmonary nodule in a real-world clinical setting. MethodsIn the NAVIGATOR single center, prospective, observational cohort study patients underwent a virtual bronchoscopy navigation procedure with or without guide sheet tunnelling to assess a solitary pulmonary nodule. Nodules were considered not accessible if a diagnosis could not be obtained by either by CT-guided transthoracic biopsy or conventional bronchoscopy. ResultsBetween February 2021 and January 2022 35 patients underwent the virtual bronchoscopy navigation procedure. The overall diagnostic yield was 77% and was dependent on size of the nodule and chosen path, with highest yield in lesions with an airway path. Adverse events were few and manageable. ConclusionVirtual bronchoscopy navigation with or without sheet tunnelling is a new technique with a good diagnostic yield, also in patients in whom previously performed procedures failed to establish a diagnosis and/or alternative procedures are considered not feasible based on expected yield and/or safety. Preventing futile or more invasive procedures like surgery or transthoracic punctures with a higher complication rate is beneficial for patients, and allowed treatment adaptation in two-third of the analyzed patient population.

Role of iodine density value on dual-energy CT for detection of high tumor cell proportion region in lung cancer during CT-guided transthoracic biopsy

ObjectiveThis study aimed to identify regions with at least 20% tumor cell content in lung cancer tumors by using spectral parameters from dual-layer spectral detector computed tomography (SDCT) to design the puncture path for transthoracic lung biopsy (TTLB). Materials and methodsThis prospective study recruited patients with suspected lung cancer. Forty-one patients were enrolled to identify the high tumor cell proportion region (HTPR) and then another 15 patients to validate the accuracy of the HTPR. In each of the 41 patients, the suspected regions with high or low tumor cell proportions were punctured according to local iodine density (IoD) values for separate biopsies. The tumor cell proportions of 82 specimens were assessed and classified into high and low tumor cell proportions based on the threshold value of 20 %. The performance of spectral parameters was analyzed to distinguish the HTPR (tumor cell proportion ≥ 20 %) from the low tumor cell proportion region (LTPR). The cutoff value of optimal spectral parameter was used to prospectively guide the biopsy of the HTPR in 15 cases for further validation, and then the accuracy was calculated. ResultsThe AUC values of spectral parameters were all higher than those of CTconventional in identifying the HTPR (all P < 0.05). The IoD with a cutoff value of 0.59 mg/mL in arterial phase (AP) yielded good performance (specificity: 97.10 %) in identifying the HTPR. It was applied to 15 cases for validation, and the accuracy rate was 100 %. ConclusionSpectral CT parameters can be used to identify regions with at least 20% tumor cell content in lung cancer for biopsies.

Safety, feasibility, and effectiveness of a CT-guided transthoracic lung and pleural biopsy - a single-centre experience with own low-dose protocol.

To assess the efficacy and safety of a low-dose, computed tomography (CT)-guided transthoracic biopsy of lung and pleural lesions. A total of 135 low-dose, CT-guided transthoracic lung and pleural lesions biopsies were performed. A cutting needle was utilized in 124 cases, and fine needle aspiration biopsy was performed in 14 cases. In all cases, 14- to 22-gauge biopsy needles were used. Diagnostic material was obtained in 111 (82.2%) patients. In 97 (71.8%) cases neoplastic lesions were found, predominantly adenocarcinoma and non-small cell carcinoma. In 14 (12.6%) cases non atypical cells were reported. Biopsy failed to obtain material suitable for histopathological examination in 24 (17.7%) cases. Complications occurred in 31 patients, including pneumothorax in 28 patients and haematoma in 3 cases. Based on the obtained results, it can be stated that low-dose, CT-guided transthoracic biopsy of lung and pleural tissues is an accurate and safe procedure. Also, it is linked to a low risk of complications such as a small pneumothorax.

Diagnostic performance of lung ultrasound in detecting pneumothorax after CT- Guided transthoracic biopsy

This study aimed to describe the diagnostic performance of lung ultrasound (LUS) in detecting and semi-quantifying pneumothorax (PTX), using computed tomography (CT) as the reference standard. The study included 150 patients who underwent CT-guided transthoracic biopsy (TTB) for lung lesions. Within 30 minutes, two radiologists blinded to the participant’s prior information performed LUS in asymptomatic patients. The results showed that PTX was present on CT in 49/150 (32.3%) cases. LUS was positive in 40/150 (26.7%) patients, with a substantial agreement between the two radiologists (Cohen κ statistics = 0.8). The sensitivity and specificity of LUS were 100% (95%CI 97.6% to 100%) and 91.8% (95%CI 87.4% to 96.2%), respectively. Moreover, the positive and negative predictive values were 87.5% (95%CI 82.2% to 92.8%) and 96.4% (95%CI 92.4% to 98.9%), respectively. In the semi-quantification of PTX by LUS, the location of lung point was described in 36/49 (73.5%) patients. The sensitivity and specificity of this sign were 87.5% (95%CI 82.2% to 92.8%) and 96.4% (95%CI 92.4% to 98.9%), respectively. The positive and negative predictive values were 87.5% (95%CI 82.2% to 92.8%) and 96.4% (95%CI 92.4% to 98.9%), respectively. In conclusion, LUS is a susceptible and specific diagnostic method for diagnosing and semi-quantifying PTX.

Cone beam CT-guided navigation bronchoscopy: a cost-effective alternative to CT-guided transthoracic biopsy for diagnosis of peripheral pulmonary nodules

ObjectivesTo determine if cone beam CT-guided navigation bronchoscopy (CBCT-NB) is a cost-effective diagnostic procedure in patients with a pulmonary nodule (PN) with an intermediate risk for lung cancer.Materials and methodsTwo...

Transtorasik Akciğer Biyopsisi: Tek Bir Merkezdeki İlk Deneyimlerin Retrospektif Değerlendirmesi

Background: To evaluate our first experience on computed tomography (CT)-guided transthoracic lung biopsy and compare our results including complication rates, etc. with the literature. Materials and Methods: Thirty-four CT-guided transthoracic biopsies in 33 consecutive patients with lung lesions using a 15 cm long 16 gauge semi-automatic (coaxial) biopsy needle were retrospectively evaluated. Age, gender, size of the lesion, location, distance to pleura, needle insertion angle, patient position, presence of emphysema and/or complications (pneumothorax and pulmonary hemorrhage), radiological findings before, during and after the biopsy,and pathological diagnosis were retrieved from patient files. The diagnostic success and failure of the method, and complication rates were noted. Results: Pneumothorax and pulmonary hemorrhage were observed in 9 and 7 patients, respectively, and 4 patients had both. Application of a chest tube was necessary in only 4 patients (4 of 9 patients wirth pneumothorax). None of the patients with pulmonary hemorrhage required additional procedures. The biopsy sample was adequate for histopathologic evaluation in 32 patients with a diagnostic accuracy rate of 96.6%. The most frequent diagnosis was squamous cell carcinoma (11/33), followed by other types of primary lung tumors in 14, breast carcinoma metastasis in 2, and B-cell lymphoma in 1 patient. Conclusions: Our rate of complication due to CT-guided transthoracic lung biopsy seems to be comparable with the literature. Pneumothorax and pulmonary hemorrhage may occur in up to one fifth/fourth but the management of these complications does not require additional procedures in the majority of patients, and the diagnostic accuracy rate is high.

Pneumothorax and Intrapulmonary Hemorrhage in CT-Guided Transthoracic Biopsy

Objective: To study the frequency of pneumothorax and intrapulmonary haemorrhage in computed tomography (CT) guided transthoracic needle lung biopsy (NLB) and the factors that affect the development of these complications in Pakistan through a representative limited data obtained from a tertiary care centre.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Armed Forces Institute of Radiology and Imaging, Rawalpindi, from Jan 2018 to Feb 2019.&#x0D; Methodology: A total of 68 patients who underwent CT-guided transthoracic biopsy were evaluated for intra- and immediate (within 04 hours) post-procedural pneumothorax and pulmonary haemorrhage. The factors affecting the development of these complications were evaluated.&#x0D; Results: Complications developed in 30 patients with the frequency of pneumothorax at 26.5 % and frequency of pulmonary haemorrhage at 19.1%. Significant risk factors for the development of pneumothorax were small lesions less than 2.5 cm in diameter (p-value &lt;0.05), increased needle track path within the lung tissue of more than 21 mm (p-value = 0.05), and presence of emphysema in the surrounding lung tissue (p-value &lt;0.05). In addition, smaller lesion size (p-value &lt;0.05) and increased traversed lung parenchyma (p-value &lt;0.05) were also significant factors in the development of intrapulmonary haemorrhage.&#x0D; Conclusion: Significant risk factors for pneumothorax and intrapulmonary haemorrhage are smaller lesion size and length of puncture path. The presence of emphysema is related to the development of pneumothorax.

Improving CT-guided transthoracic biopsy diagnostic yield of lung masses using intraprocedural CT and prior PET/CT fusion imaging

ObjectiveThe purpose of this study was to evaluate the usefulness of intraprocedural CT and prior PET/CT fusion imaging in improving the diagnostic yield of CT-guided transthoracic core-needle biopsy (CNB) in lung masses.MethodsIn total, 145 subjects with lung masses suspicious for malignancy underwent image-guided transthoracic CNB. According to imaging modality the subjects were divided into two groups. PET/CT images obtained no more than 14 days before the biopsy were integrated with intraprocedural CT images. The integrated or fused images were then used to plan the puncture sites. The clinical characteristics, diagnostic yield of CNB, diagnostic accuracy rate, procedure-related complications and procedure duration were recorded and compared between the two groups. Final clinical diagnosis was determined by surgical pathology or at least 6-months follow-up. The diagnostic accuracy of CNB was obtained by comparing with final clinical diagnosis.Results145 subjects underwent CNB with adequate samples, including 76 in fusion imaging group and 69 in routine group. The overall diagnostic yield and diagnostic accuracy rate were 80.3% (53/66), 82.9% (63/76) for fusion imaging group, 70.7% (41/58), 75.4% (52/69) for routine group, respectively. In addition, the diagnostic yield for malignancy in fusion imaging group (98.1%, 52/53) was higher than that in routine group (81.3%, 39/48). No serious procedure-related complications occurred in both two groups.ConclusionCNB with prior PET/CT fusion imaging is particularly helpful in improving diagnostic yield and accurate rate of biopsy in lung masses, especially in heterogeneous ones, thus providing greater potential benefit for patients.

CT-Guided Transthoracic Biopsy of Pulmonary Lesions: Diagnostic versus Nondiagnostic Results.

(1) Background: Despite the high accuracy of CT-guided transthoracic biopsy for diagnosis of pulmonary lesions, in a certain amount of cases biopsy results may indicate the presence of nonspecific findings or insufficient material. We aimed to investigate the effectiveness of CT-guided transthoracic biopsy of pulmonary lesions in providing a specific diagnosis and to analyze the variables affecting biopsy results. (2) Methods: In this retrospective study, a total of 170 patients undergoing 183 CT-guided transthoracic biopsies of pulmonary lesions were included. The clinical, radiological and pathological data were reviewed to classify biopsy results as diagnostic or nondiagnostic and to identify which variables were associated with the two groups. (3) Results: The biopsy results were diagnostic in 150 cases (82.0%), of which 131 (87.3%) positive for malignancy and 19 (12.7%) with specific benign lesions, and nondiagnostic in 33 cases (18.0%). Twenty-two of the thirty-three (66.7%) nondiagnostic cases were finally determined as malignancies and eleven (33.3%) as benign lesions. In the diagnostic group, all the 131 biopsies positive for malignancy were confirmed to be malignant at final diagnosis (87.3%); of 19 biopsies with specific benign lesions, 13 cases were confirmed to be benign (8.7%), whereas six cases had a final diagnosis of malignancy (4%). Multivariate analysis showed increased risk of nondiagnostic biopsy for lesions ≤ 20 mm (p = 0.006) and lesions with final diagnosis of benignity (p = 0.001). (4) Conclusions: CT-guided transthoracic lung biopsy is an effective technique for the specific diagnosis of pulmonary lesions, with a relatively acceptable proportion of nondiagnostic cases. Small lesion size and final benign diagnosis are risk factors for nondiagnostic biopsy results.

PULMONARY EPITHELIOID HEMANGIOENDOTHELIOMA: A RARE ENTITY WITH INSIDIOUS ONSET

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sarcomas are rare, malignant tumors of connective tissue origin. Epithelioid hemangioendothelioma (EHE) is an exceedingly rare vascular sarcoma of endothelial origin, with an incidence of less than one per one million. Patients are typically asymptomatic or manifest symptoms related to organ involvement. We present a case of an asymptomatic woman with an incidental discovery of pulmonary EHE. CASE PRESENTATION: A 26 year old woman with no smoking history presented with vague abdominal pain. Her exam and initial labs were unremarkable. Abdominal imaging revealed nodules at the lung bases, and subsequent thoracic imaging revealed innumerable nodules throughout the lung parenchyma without pleural involvement. CT-guided transthoracic biopsy revealed filling and distension of alveolar spaces by a neoplastic proliferation of small, bland cells with perinuclear vacuoles within a hyalinized stroma. Immunohistochemical staining showed the neoplastic cells to be positive for ERG and CD31. These imaging and pathology findings were consistent with stage IV metastatic pulmonary EHE. She was referred to a sarcoma center of excellence, and surveillance was recommended. DISCUSSION: EHE is a vascular subtype of sarcoma of low-grade malignancy most commonly involving the liver and lungs. Pulmonary EHE can be asymptomatic or present with non-specific symptoms of dyspnea, cough, hemoptysis, or weight loss. Diagnosis is made with histopathologic epithelioid morphology and immunohistochemical vascular characteristics. Our patient's biopsy tissue stained positive for markers of vascular differentiation. CD34 and Factor VIII-related antigen are additional markers that may be used to identify vascular features of EHE. Disease course is unpredictable, and factors associated with a poor prognosis include pleural effusion and hemoptysis. Disease rarity precludes established treatment guidelines. Surgical resection should be considered for solitary lesions. Past reports have shown some responsiveness to taxane, anthracycline, or IFN-2a therapy. Anti-VEGF therapies show promise for eliciting partial response or as maintenance therapy. Still, many cases are indolent and a surveillance strategy may be reasonable. In our patient, surveillance was supported by her asymptomatic disease without poor prognostic factors. The development of significant symptoms or progressive disease would prompt further consideration of treatment. CONCLUSIONS: EHE is an extremely rare sarcoma subtype most commonly affecting the liver or lungs. Diagnosis is made on immunohistopathology and treatment options include surgical resection, surveillance, or anti-angiogenic agents. It is an important, albeit uncommon diagnosis to consider for diffuse pulmonary nodules seen on imaging. REFERENCE #1: Semenisty V, Naroditsky I, Keidar Z, Bar-Sela G. Pazopanib for metastatic pulmonary epithelioid hemangioendothelioma—a suitable treatment option: case report and review of anti-angiogenic treatment options. BMC Cancer. 2015;15(1):402. doi:10.1186/s12885-015-1395-6 REFERENCE #2: Chevreau C, Le Cesne A, Ray-Coquard I, et al. Sorafenib in patients with progressive epithelioid hemangioendothelioma: A phase 2 study by the French Sarcoma Group (GSF/GETO). Cancer. 2013;119(14):2639-2644. doi:10.1002/cncr.28109 REFERENCE #3: Agulnik M, Yarber JL, Okuno SH, et al. An open-label, multicenter, phase II study of bevacizumab for the treatment of angiosarcoma and epithelioid hemangioendotheliomas. Ann Oncol. 2013;24(1):257-263. doi:10.1093/annonc/mds237 DISCLOSURES: No relevant relationships by Mohammad Ahmed, source=Web Response No relevant relationships by Gustavo Cumbo-Nacheli, source=Web Response No relevant relationships by Connor Kerndt, source=Web Response No relevant relationships by Ranuka Sinniah, source=Web Response

CT-Guided Transthoracic Biopsy of Lung Lesions Using a Non-Coaxial Biopsy Needle Technique: CT Characteristics Predictive for Diagnostic Accuracy and Pneumothorax.

Objectives:To analyze computed tomography (CT) characteristics predictive for diagnostic accuracy and pneumothorax in CT fluoroscopy-guided transthoracic biopsy (CTF-TTB) of lung lesions using non-coaxial biopsy needle technique.Methods:Retrospectively 274 lung lesion biopsies with confirmed histology were included in our study. CTF-TTB was done using an 18-gauge non-coaxial cutting needle. Diagnostic accuracy rates were calculated per lesion size and CT and procedural characteristics were evaluated for their predictive value regarding diagnostic accuracy and development of pneumothorax (maximal nodule diameter, distance to pleura, location per lung segment, nodule composition, benign versus malignant histology, and number of specimens).Results:Overall diagnostic accuracy of CTF-TTB was high (93%). Diagnostic accuracy for lesions ≤10 mm was 81%. Maximal nodule diameter was the only predictive CT characteristic for diagnostic success (p = 0.03). Pneumothorax occurred in 27%. Distance of lesion to pleura was the only risk factor for pneumothorax (p < 0.00001). Pneumothorax rates were significantly lower in subpleural lesions (14%) compared to those located 1–10 mm (47%), 10–20 mm (33%), and >20 mm from pleura (29%).Conclusions:High diagnostic accuracy rates were achieved with CTF-TTB using non-coaxial biopsy technique, even for lesions ≤10 mm. Pneumothorax rates were comparable with other studies. Lesion size was the only predictive CT characteristic for diagnostic accuracy. Distance to pleura was the only risk factor for pneumothorax.