414
Fortschr. Röntgenstr. 129, 4
Fortschr. Röntgenstr. 129, 4 (1978) 414-418
Precautions and management of complications By B. Nordenström and W. N. Sinner't 3 Figures Department of Diagnostic Radiology, Karolinska Siukhuset, Stockholm, Sweden
This review is based on 5300 needle biopsies. Complications and their precaution are discussed. Pneumothorax seldom has to be treated. Hemoptysis and small local bleeding are of no clinical significance. Tumor cell spread and air embolism may occur but extremely rarely. Indications, contraindications equipment, and biopsy technique are treated. A recent technical improvement in needle biopsy is described. A technique of television guided needle biopsy of lung lesions was developed 14 years ago. The first results with this technique were reported on the basis of 843 needle biopsies in 1966
(1). No serious complications occurred in this material, the most significant one being pneumothorax which seldom had to be treated. Hemoptysis and small local bleedings were encountered in a few cases but usually did not require any manage-
Die vorliegende Ubersicht basiert auf 5300 Nadelbiopsien. Es werden die Komplikationen und ihre Verhütung besprochen. Pneumothorax erfordert nur in seltenen Fällen eine Behandlung. Hämoptoe und kleinere örtliche Blutungen sind ohne klinische Bedeutung. Eine Ausbreitung von Tumorzellen sowie Luftembolie treten äußerst selten auf. Der Artikel behandelt die Indikationen, Kontraindikationen, die erforderliche Ausrüstung und die Technik der Biopsie. Eine neuere technische Verbesserung der Nadelbiopsietechnik wird beschrieben.
Pathologist or cytologist. Their skill in the evaluation of the obtained material is also of fundamental importance for the whole procedure. An experienced and able cytologist may reduce the necessity to perform repeated sampling of material. The total frequency of
pneumothorax increased from 20.6 per cent at one needle insertion to 35.2 per cent at two insertions and to 42.9 per cent
ment.
at three insertions of a needle at the same examination.
The present report is based on the same technique performed with 5300 needle biopsies in 2726 patients. Particular emphasis will be given to precautions, complications and their management. Pneumothorax, bleeding, infections, mortality, air embolism and tumor cell spread following sampling of cell
Repeated biopsies are sometimes unavoidable. If no malignant cells are found repeat samplings up to at least three times from different parts of the lesion have to be taken. In this way the number of false results were reduced to about 2.5 per cent in the present material.
and tissue material have been reported by several authors. Extensive bibliography is given by Dahlgren and Nordenström (1), Sinner (14) and Sinner and Zajicek (15). Complications as well as diagnostic achievements vary considerably with different techniques, instrumentation and experi-
Patient. The patient should be properly informed about the examination by the examiner as a certain cooperation is required. This reduces anxiety and tension of the patient. A slight sedation
ence.
The actual precautions and managements of complications
and an antitussive agent is recommended 15 minutes before the examination. Children or uncooperative patients may require
now discussed are only valid for the applied technique. A short review of the factors of importance in its application is therefore made.
general anaesthesia. It would be unwise to try to perform a needle biopsy in an uncooperative patient or in a patient not having given a proper consent after having been informed
Examiner,
A certain experience and technical ability are undoubtly of fundamental significance for a good diagnostic result and a minimum of complications. The specific training must be built on an appropriate knowledge of chest radiology and radiologie techniques. The needle biopsies have to be practiced regularly and not too infrequently. Trainees in this department having
performed only 20 needle biopsies had a mean incidence of pneumothorax of 44.5 per cent while those having performed 80 needle biopsies had only 20 per cent. Trainees should be guided by experienced radiologists. Needle biopsies of more difficult cases (e.g. small deeply situated lesions in higher risk patients) should be avoided until experience has been achieved.
Needle biopsies of the lung do not have to be performed only in a few large hospitals, It would be desirable if in the future at
about its scope, how it is done and about possible risks. Rarely a patient denies the examination when is explained to him that the result of the examination is necessary for adequate treatment.
Contraindications Needle biopsy should be avoided in unconscious patients or patients with poor general condition. Patients with high fever, or uncontrollable cough should not be punctured before the acute symptoms have regressed. In a symptomatic patient with a history of recent myocardial infarction, angina pectoris, asthma, allergy or hypertension, the examination can be performed after premedication. The potential risks of complications have to be weighed against the potential value of information. In patients over 70 years of age, a higher incidence of symptomatic pneumothorax may be expected because of emphy-
least one radiologist in every radiologie department where special procedures are performed could have a sufficient training in needle biopsies. This should include not only biopsy of
lungs and mediastinum but also other deep biopsies of the skeleton, the kidneys, the liver, etc. 0340-1618/78
1032-0414
$ 05.00 © 1978
Present address: W. N. S., Professor of Radiology, Department of Radiology (R130), University of Miami, School of Medicine, P.O. Box 016960, Miami Florida 33101, USA.
Georg Thieme Publishers
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Nadelbiopsien pulmonärer Lasionen Vorbeugung und Behandlung von Komplikationen
Needle biopsies of pulmonary lesions
Comparison of needle biopsy performed in supine or prone position. A) Supine position, anterior approach. The interlobarfissure has not to be passed in puncturing lesions situated in the upper lobe. Fig. 1
B) Prone position, posterior approach. The interlobar fissure has often to be passed in puncturing lesions situated in the upper lobe.
sema or lung fibrosis. In this age group, 43 per Cent obtained a
pneumothorax against 27.2 in the group 60 to 69 years. The percentage of symptomatic pneumothorax which has to be treated also increases with increasing age. On the other hand, the age is never an absolute contraindication. Certain patients with a low "biological age" may be successfully examined and also operated upon at ages far over 70. If the lung function does not permit a surgical removal of a lesion a biopsy is usually not performed. Borderline cases should first be studied with cardiorespiratory function tests. Several of these cases may be suitable for radiotherapy which
415
Fig. 2 Approach in transthoracic needle biopsy. In peripherally situated lesions the shortest distance to the lesion is not always chosen (B); often a more tangential approach (A) is preferred. At least 4 cm of lung tissue should be interposed between the puncture site in the pleura and the surface of the lesion. In this way it is thought that tumor cells or infectious material from a lesion will be kept in the lung when the needle is removed.
Cu a c., k) - C CO C
o, CM a C9 r.j - O
also requires a cytologic diagnosis.
In some cases with inflammatory diseases a biopsy may be indicated for obtaining a differential diagnosis. The presence of
an obliteration of the pleural space is then of advantage because of a decreased risk for pneumothorax. Equipment
Modern equipment for roentgen television screening is indispensable. By means of a direct visual control of direction and depth of the instrument, unnecessary injury can be avoided both to the normal and pathological tissue and consequently diminish the risk for complications. Usually a single plane fluoroscopic installation is sufficient. For biopsy of deeply situated and small lesions a bi-plane installa-
tion may be of considerable value. The equipment should preferably be flexible enough to direct the radiation beam in an axial and perpendicular direction with the chosen direction of the needle. Some kind of a C-arm arrangement has proven to be suitable. The position of the patient should not be changed
after the insertion of the needle, which means that a new direction of the beam must be obtained by moving the equipment.
The biopsy needle has in the present material been 12 to 16 cm
long with an O.D. of 0.9-1.0 mm and obliquely bevelled tip. The diameter of the needle is stable enough to be guided to the correct place for the biopsy.
Fig. 3 Instrument set for percutaneous needle biopsy. A) Screw needle inserted into cannula and fixed at the instrument holder. B) Detail appearances of tip of screw needle and cannula.
influenced upon the results as roughly 20 radiologists have
performed the procedures. Their individual training and radiologic experience has varied considerably. All patients are examined recumbent with the arms over their heads in supine, prone or oblique positions. The most suitable projection is chosen from preliminary chest films and at a final TV-fluoroscopy.
The needle is inserted at the upper margin of a rib to avoid intercostal arteries. The shortest distance to a peripheral lesion
is not always the best as lung tissue should always be interposed between the lesion and the pleura in order to avoid tumor cell implantation into the pleura. The anterior and antero-lateral portions of the chest is as a rule to be preferred for the insertion of the needle. On the back the
muscle layers are thicker and the patient may contract the muscles making the guidance of the needle difficult. Therefore, the posterior approach more easily produces a larger trauma to
Biopsy technique The technique (1) has been practically unchanged in the entire
the lung parenchyma. The needle also more often passes
series. Small differences in the technical handling may have
fissures with increasing risk for pneumothorax (Fig. 1). In
through more than one pleural space due to the location of the
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Fortschr. Röntgenstr. 129,4
Needle biopsies of pulmonary lesions
B. Nordenström und W. N. Sinner
Fortschr. Röntgenstr. 129, 4
addition the intercostal spaces are more narrow in the back than in the front and partly overlapped by the transverse
puncture needles which have been used in the present material
processes and the scapula, which diminishes the possibilities to select the ideal puncture site. The selected puncture site should be marked at the skin. After careful washing of the skin, local anaesthesia (Lidocaine l%) is applied at the puncture site and the underlying pleura. A puncture hole is made in the skin with a thick sharp needle
between the atmosphere and a lung vein during quiet respira-
(16 gauge) which facilitates the introduction of the biopsy needle (18-20 gauge). The latter is introduced in a straight direction towards the chosen point of biopsy by means of a well collimated beam adjusted parallel with the needle. The needle may then be introduced by means of a wooden clamp or
hemostat in order to prevent unnecessary radiation to the hands of the radiologist. The patient should not be asked to hold his breath during the procedure. Quiet ordinary respiration is better than a temporary respiratory arrest followed by vigorous respiratory movements. At the puncture site the needle is rotated in order to loosen cell material before aspiration which is made with an ordinary 10 or 20 ml syringe. No extra jiggeling or jerking movements should be made at the biopsy place. Before the removal of the needle the negative pressure in the syringe should be slowly equalized in order to avoid that the cell material in the needle disappears into the syringe. The material obtained is then handed over to the cytologist, who preferably should be able to make a preliminary microscopy in an adjacent room. This reduces the number of needle insertions considerably. In the case of non-diagnostic material at the first attempt the second or the third will as a rule give a conclusive result.
have an I.D. of 0.5-0.6 mm. The low pressure gradient tion, with the patient in recumbent position, makes it very unlikely that an appreciable amount of air should enter the vein through the needle lumen. The time for removing the obturator of the needle and attaching a syringe to the hub is also short. A more likely route would be the puncture hole in a vein and in an adjacent alveoli after the removal of the needle. Air may then pass into the vein especially if the patient starts to cough. This easily occurs when blood flows into the bronchi. In the entire material only two possible cases of air embolism have been observed. They both occurred approximately 2 min after the removal of the needle and in connection with rather forceful coughing. After 10 to 20 seconds of unconsciousness spontaneous recovery occurred without sequelae in one of the patients. A permanent brain damage occurred in the other one who in the right lung had an infiltration of tumor appearance. After the removal of the needle the patient coughed forcefully but
was otherwise unconcerned and was allowed to leave the examination room. She rose rapidly from the examination table and walked five steps after which she fell unconscious to the floor. In spite of oxygen ventilation in recumbent position and supply of vasodilating agents, the patient finally presented
signs of injury to the frontal lobe and brain stem. It was considered that this patient had contracted cerebral air embolism.
At the moment, no other recommendations can be given to prevent air embolism than to use thin needles and to prevent elevation of the intrabronchial pressure, e.g. by coughing. The antitussive agent given as premedication serves this purpose.
Complications Pneumothorax is the most common complication. Mean f requency in 2726 patients was 27.2 per cent; in 7.7 per cent of these pleural air was exsufflated. In emphysematous and aged patients the development of a pneumothorax should always be expected, which may require exsufflation. The air may leak very slowly and produce a clinically significant pneumothorax several hours after the biopsy. The patient should therefore be under adequate observation during the first 24 hours. Chest pain and occasionally more or less severe dyspnea may occur. Increasing respiratory or circulatory distress indicate a possible pneumothorax. If necessary a chest tube is percutaneously
inserted into the pleural cavity and a continuous negative pressure is applied until a stable expansion of the lung is obtained. A tube of 5 mm internal diameter is usually sufficient. Occasionally a total collapse of the lung may occur rapidly. Therefore, pleural tubes and a suction device with sufficient capacity should always be available in the examination room. With facilities available for a rapid exsufflation of a pneumothorax this complication is easily controlled. Needle biopsy of both the right and the left lung should never be made at the same occasion. In this department a card is sent with the patient informing the
staff in the ward that the responsible radiologist should be contacted without delay if respiratory distress or other complications after the biopsy appear.
Hemoptysis may occur but has not been of clinical signifi-
Mortality One case of lethal outcome has recently occurred. A 31-year-old male had an osteogenic sarcoma operatively
removed from the right leg and was after that treated with extraordinary large doses of Methotrexate (approximately 1000 times the regular dose) and Interferon for several months. One 1.5 cm large infiltration was present in the right lung and two smaller ones in the left, probably metastases. In connection with diagnostic sampling of cell material from the larger lesion, an in situ electrocoagulation was planned in
the case that malignant cells were found at the biopsy. The same procedure was then planned for the two smaller tumors in the left lung. The technique for this combined diagnostic and therapeutic procedure is described elsewhere (7-9).
Premedication with one 0mg of Oxicone-Scopolamine and
local anaesthesia was used. Cell material was aspirated through a needle with an OD. of 1.0 mm, Microscopy, immediately performed showed an osteogenic metastasis. Three new needles with an 0.D. of 1.0 mm each in a thin teflon tube, were introduced into the tumor whereupon the needles were replaced by three electrocoagulation electrodes. During
radiography to control the position of the electrodes and before the electrocoagulation was starkd, cardiac and respiratory arrest suddenly occurred. EGG showed, in spite of absence
of heart contractions, large ventricular complexes at a frequency of 60 per min. Artificial ventilation, external heart massage and intracardiac injection of Epinephrine were unable to rescue the patient.
cance. At the most 20 ml of blood has been expelled by coughing. No treatment has been necessary in any case. Air embolism is often discussed as a potential complication in lung biopsy. If a direct communication is created between a
lung vein and a cannula air may pass into the vein. The
At a subsequent autopsy only a small local bleeding was observed around the tumor and a minor amount of blood in a bronchus. No evidence of pneumothorax, air embolism, bleeding or other reasons for the fatality could be found. In retros-
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416
Needle biopsies of pulmonary lesions
is thought that the patient had contracted an air
embolism.
Local seeding of tumor cells is rarely of importance as the surrounding lung tissue will be removed at a subsequent operation.
In the entire material one case of implantation of tumor cells in
the chest wall was found (15). In two more cases a possible implantation of tumor cells in the chest wall have been observed although they may have been spontaneous metas-
tases. In four patients pleurisy occurred after puncture of infectious lesions. These were effectively treated with antibiotics.
In order to avoid seeding of tumor cells to the pleura and the chest wall the following rule has been introduced. At least 4 cm of lung tissue should be interposed between the puncture site in the pleura and the surface of the lesion (Fig. 2). The intention is
that tumor cells or infectious material from a lesion will be kept in the lung when the needle is removed.
417
Some of the advantages with the new instrument may be summarized:
The sampling time is considerably diminished, jiggeling
motions are avoided as compared with the old aspiration technique which seems to minimize the risk to develop pneumothorax. Sampling is made from the tissue over at least the distance of the spiral part of the screw needle, which means a 15 mm
distance instead of only a region close to the tip of the instrument as in aspiration biopsy. Not only cell material but also connective tissue may be obtained in the grooves of the screw needle, which is of value in the diagnosis of inflammatory fibrous lesions. Firm, organized tissues as in hamartomas, neurinomas,
bronchial chondromas, as well as certain granulomas are effectively biopsied which is often not possible at simple aspiration biopsy.
The dilution of the sample by blood is considerably
be extremely low as almost the entire material has been
diminished improving cytologic handling and diagnosis. From the screw needle concentrated inoculations can be
examined without the recommended precautions.
made directly on culture media for bacteriologic examina-
Seeding to the blood stream. It is known that in malignant
tion.
tumor diseases a more or less continuous seeding to the blood stream takes place (10-13). As long as the patient's resistance
This technique has been used in more than 400 cases. On the
to the disease is unbroken permanent metastases will flot develop (2, 3, 6, 12). Needle biopsy should therefore be
compared with the needle aspiration biopsy can be expected.
performed on broad indications when the patients are in good conditions. The number of circulating cells likely increases at needle biopsy as well as after other trauma against a tumor (5, 10-13). A needle biopsy is an extremely small trauma to the tumor as compared with an eventual operative removal of the tumor. For that reason the possible seeding of the tumor cells to the blood stream in needle biopsy is a minor problem as long as operation is accepted as treatment.
described earlier in this article are also applicable for the screw needle biopsy. An evaluation of this new biopsy technique has recently been performed by House and Thomson (4). They found the technique superior to the now common needle aspiration technique.
The risk for local seeding to the pleura and the chest wall must
basis of this experience a decrease in complication rate as
The precautions and the management of complications
Abundant cell material could at times be obtained with histological detail not only from malignant tumors but also from firm fibrous lesions, connective tissue and inflammatory tissue. The incidence of complications was similar to those reported for conventional fine needle aspiration biopsy.
Recent technical improvements Although the previous technique has proven to be efficient in the diagnosis of pulmonary lesions, a further improved technique of biopsy has recently been introduced (8). This technique offers a still more efficient sampling of cytologic material but involves also other advantages for avoiding complications and unnecessary radiation to the examiner's hands. The instrument consists of a stainless steel screw needle, 0.D. 0.55 mm and 220 mm in length, a 160 mm long stainless stell cannula with OD. of 1.0 mm and an instrument holder (Fig,
Conclusion
3). The construction and use of the instrument has been described in detail elsewhere (8) and is here only briefly
mothorax, hemoptysis, and local bleeding are minor inci-
reported.
The cannula and indwelling screw needle is inserted by means of the instrument holder under television control until the tip of the cannula has reached the edge of the lesion. The instrument is held in firm position with the instrument holder while
the screw needle is rotated clockwise until its tip is brought into the lesion or 15 mm distal to the tip of the cannula. The cannula is then rotated counterclockwise using slight forward pressure until the screw needle is completely protected by the cannula. The screw needle and cannula are then pulled out together. The screw needle is pushed out without delay to
prevent drying of obtained material. The cell material is smeared and stained in the usual manner for cytologic examination. The material may also be examined as a bacteriological sample. The new instrument may be obtained from Ursus Konsult AB, Grey Turegatan 2, S-114 35 Stockholm, Sweden.
Needle biopsy of pulmonary lesions can now be performed routinely under the guidance of television screening with a high
degree of precision. The average diagnostic accuracy is high
and the number of complications can be kept low. Careful planning with consideration taken to indications and contraindications, general precautions and risk factors is essential in this connection. A certain number of complications as pneudences which usually only require observation. Some pneumothoraces may be symptomatic and require exsufflation
treatment. Very rarely air embolism may occur, but it constitutes the most important complication. It may even lead to cerebral symptoms and lethality. In spite of that, needle biopsy is indispensable in the diagnosis of pulmonary lesions. In this work the recently developed screw needle instrument seems to offer even better results than the now commonly used needle aspiration technique.
References Dahlgren, B., B, Nordenström: Transthoracic needle biopsy. Year Book Med. PubI., Chicago, 1966.
Engell, H. C.: Cancer cells in the circulating blood. Acta chir. scarid. Suppl. 201 (1955) 1
aspiration biopsy. Acta radio!. Diagnosis 10 (1971) 385 House, A. J. S., K. R, Thomson:
Evaluation of a new transthoracic needle for biopsy of benign and malig-
nant lung lesions. Amer. J.
Roent-
Engzell, U., P. L. Esposti, C. Rubio, A. Sigurdson, J. Za)icek: investigation
genol. 129 (1977) 215 (S) Moore, G. E., A. A, Sandberg, J. R. Schubarg: Clinical and experimental
on tumour spread in connection with
observations of the occurrence and
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
pect it
Fortschr. Röntgenstr. 129,4
Fortschr. Röntgenstr. 129,4
fate of tumor cells in the blood stream. Ann. Surg. 147 (1957) 580 Nordenström, B.: Needle biopsy of
pulmonary tumours under roentgen television guidance. Communication at the November meeting 1961 of the Swedish Association Radiology.
of
Medical
Nordenström, B.: Therapeutic roentgenology. Acta radiol. Diagnosis 3 (1965) 115 Nordenström, B.: New instruments for biopsy. Radiology 117 (1975) 474 Nordenström, B.: Electrocoagulation of small lung tumors, in Potchen, E. J., editor: Current concepts in
P. Mäkeläu. Mitarb.
radiology, Saint Louis, 1977, C. V. Mosby Company, vol. Ill, p, 331. Roberts, S., O. Jonasson, L. Long, E. A. MacGrew, R. MacGrath, W. H. Cole: Relationship of cancer
Metastasenstraßen, in Schinz, H. R., R. Glauner, A. Rüttiman, Herausgeber: Ergebnisse der medizinischen
aspiration biopsy. Acta radiol. Diagnosis 17 (1976) 813
Strahlenforschung, Stuttgart, 1964,
tation metastasis after percutaneous
Georg Thieme Verlag, Band I, Neue
cells in the circulating blood to operation. Cancer 15 (1962) 232 Sandberg. A. A., G. E. Moore, J. R. Schubarg: Atypical" cells in the blood of cancer patients - differentiation from tumor cells. J. Nat. Cancer Inst. 22 (1959) 555
Folge, S. 415
transthoracic needle aspiration biopsy. Acta radiol. Diagnosis 17 (1976)
Sinner,
W.
N.:
Wert und
Bedeutung des Tumorzellnachweises im strömenden Blut. Praxis 44 (1963) 1343
Sinner, W. N., H. R. Schinz:
Sinner, W. N.: Complications of percutaneous transthoracic needle
Sinner, W. N., J. Zajicek: Implan-
473
Prof. Björn Nordenström Department of Diagnostic Radiology Karolinska Sjukhuset S-104 01 Stockholm 60, Sweden.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
418
Fortschr. Röntgenstr. 129, 4
Fortschr. Röntgenstr. 129, 4 (1978) 414-418
Precautions and management of complications By B. Nordenström and W. N. Sinner't 3 Figures Department of Diagnostic Radiology, Karolinska Siukhuset, Stockholm, Sweden
This review is based on 5300 needle biopsies. Complications and their precaution are discussed. Pneumothorax seldom has to be treated. Hemoptysis and small local bleeding are of no clinical significance. Tumor cell spread and air embolism may occur but extremely rarely. Indications, contraindications equipment, and biopsy technique are treated. A recent technical improvement in needle biopsy is described. A technique of television guided needle biopsy of lung lesions was developed 14 years ago. The first results with this technique were reported on the basis of 843 needle biopsies in 1966
(1). No serious complications occurred in this material, the most significant one being pneumothorax which seldom had to be treated. Hemoptysis and small local bleedings were encountered in a few cases but usually did not require any manage-
Die vorliegende Ubersicht basiert auf 5300 Nadelbiopsien. Es werden die Komplikationen und ihre Verhütung besprochen. Pneumothorax erfordert nur in seltenen Fällen eine Behandlung. Hämoptoe und kleinere örtliche Blutungen sind ohne klinische Bedeutung. Eine Ausbreitung von Tumorzellen sowie Luftembolie treten äußerst selten auf. Der Artikel behandelt die Indikationen, Kontraindikationen, die erforderliche Ausrüstung und die Technik der Biopsie. Eine neuere technische Verbesserung der Nadelbiopsietechnik wird beschrieben.
Pathologist or cytologist. Their skill in the evaluation of the obtained material is also of fundamental importance for the whole procedure. An experienced and able cytologist may reduce the necessity to perform repeated sampling of material. The total frequency of
pneumothorax increased from 20.6 per cent at one needle insertion to 35.2 per cent at two insertions and to 42.9 per cent
ment.
at three insertions of a needle at the same examination.
The present report is based on the same technique performed with 5300 needle biopsies in 2726 patients. Particular emphasis will be given to precautions, complications and their management. Pneumothorax, bleeding, infections, mortality, air embolism and tumor cell spread following sampling of cell
Repeated biopsies are sometimes unavoidable. If no malignant cells are found repeat samplings up to at least three times from different parts of the lesion have to be taken. In this way the number of false results were reduced to about 2.5 per cent in the present material.
and tissue material have been reported by several authors. Extensive bibliography is given by Dahlgren and Nordenström (1), Sinner (14) and Sinner and Zajicek (15). Complications as well as diagnostic achievements vary considerably with different techniques, instrumentation and experi-
Patient. The patient should be properly informed about the examination by the examiner as a certain cooperation is required. This reduces anxiety and tension of the patient. A slight sedation
ence.
The actual precautions and managements of complications
and an antitussive agent is recommended 15 minutes before the examination. Children or uncooperative patients may require
now discussed are only valid for the applied technique. A short review of the factors of importance in its application is therefore made.
general anaesthesia. It would be unwise to try to perform a needle biopsy in an uncooperative patient or in a patient not having given a proper consent after having been informed
Examiner,
A certain experience and technical ability are undoubtly of fundamental significance for a good diagnostic result and a minimum of complications. The specific training must be built on an appropriate knowledge of chest radiology and radiologie techniques. The needle biopsies have to be practiced regularly and not too infrequently. Trainees in this department having
performed only 20 needle biopsies had a mean incidence of pneumothorax of 44.5 per cent while those having performed 80 needle biopsies had only 20 per cent. Trainees should be guided by experienced radiologists. Needle biopsies of more difficult cases (e.g. small deeply situated lesions in higher risk patients) should be avoided until experience has been achieved.
Needle biopsies of the lung do not have to be performed only in a few large hospitals, It would be desirable if in the future at
about its scope, how it is done and about possible risks. Rarely a patient denies the examination when is explained to him that the result of the examination is necessary for adequate treatment.
Contraindications Needle biopsy should be avoided in unconscious patients or patients with poor general condition. Patients with high fever, or uncontrollable cough should not be punctured before the acute symptoms have regressed. In a symptomatic patient with a history of recent myocardial infarction, angina pectoris, asthma, allergy or hypertension, the examination can be performed after premedication. The potential risks of complications have to be weighed against the potential value of information. In patients over 70 years of age, a higher incidence of symptomatic pneumothorax may be expected because of emphy-
least one radiologist in every radiologie department where special procedures are performed could have a sufficient training in needle biopsies. This should include not only biopsy of
lungs and mediastinum but also other deep biopsies of the skeleton, the kidneys, the liver, etc. 0340-1618/78
1032-0414
$ 05.00 © 1978
Present address: W. N. S., Professor of Radiology, Department of Radiology (R130), University of Miami, School of Medicine, P.O. Box 016960, Miami Florida 33101, USA.
Georg Thieme Publishers
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Nadelbiopsien pulmonärer Lasionen Vorbeugung und Behandlung von Komplikationen
Needle biopsies of pulmonary lesions
Comparison of needle biopsy performed in supine or prone position. A) Supine position, anterior approach. The interlobarfissure has not to be passed in puncturing lesions situated in the upper lobe. Fig. 1
B) Prone position, posterior approach. The interlobar fissure has often to be passed in puncturing lesions situated in the upper lobe.
sema or lung fibrosis. In this age group, 43 per Cent obtained a
pneumothorax against 27.2 in the group 60 to 69 years. The percentage of symptomatic pneumothorax which has to be treated also increases with increasing age. On the other hand, the age is never an absolute contraindication. Certain patients with a low "biological age" may be successfully examined and also operated upon at ages far over 70. If the lung function does not permit a surgical removal of a lesion a biopsy is usually not performed. Borderline cases should first be studied with cardiorespiratory function tests. Several of these cases may be suitable for radiotherapy which
415
Fig. 2 Approach in transthoracic needle biopsy. In peripherally situated lesions the shortest distance to the lesion is not always chosen (B); often a more tangential approach (A) is preferred. At least 4 cm of lung tissue should be interposed between the puncture site in the pleura and the surface of the lesion. In this way it is thought that tumor cells or infectious material from a lesion will be kept in the lung when the needle is removed.
Cu a c., k) - C CO C
o, CM a C9 r.j - O
also requires a cytologic diagnosis.
In some cases with inflammatory diseases a biopsy may be indicated for obtaining a differential diagnosis. The presence of
an obliteration of the pleural space is then of advantage because of a decreased risk for pneumothorax. Equipment
Modern equipment for roentgen television screening is indispensable. By means of a direct visual control of direction and depth of the instrument, unnecessary injury can be avoided both to the normal and pathological tissue and consequently diminish the risk for complications. Usually a single plane fluoroscopic installation is sufficient. For biopsy of deeply situated and small lesions a bi-plane installa-
tion may be of considerable value. The equipment should preferably be flexible enough to direct the radiation beam in an axial and perpendicular direction with the chosen direction of the needle. Some kind of a C-arm arrangement has proven to be suitable. The position of the patient should not be changed
after the insertion of the needle, which means that a new direction of the beam must be obtained by moving the equipment.
The biopsy needle has in the present material been 12 to 16 cm
long with an O.D. of 0.9-1.0 mm and obliquely bevelled tip. The diameter of the needle is stable enough to be guided to the correct place for the biopsy.
Fig. 3 Instrument set for percutaneous needle biopsy. A) Screw needle inserted into cannula and fixed at the instrument holder. B) Detail appearances of tip of screw needle and cannula.
influenced upon the results as roughly 20 radiologists have
performed the procedures. Their individual training and radiologic experience has varied considerably. All patients are examined recumbent with the arms over their heads in supine, prone or oblique positions. The most suitable projection is chosen from preliminary chest films and at a final TV-fluoroscopy.
The needle is inserted at the upper margin of a rib to avoid intercostal arteries. The shortest distance to a peripheral lesion
is not always the best as lung tissue should always be interposed between the lesion and the pleura in order to avoid tumor cell implantation into the pleura. The anterior and antero-lateral portions of the chest is as a rule to be preferred for the insertion of the needle. On the back the
muscle layers are thicker and the patient may contract the muscles making the guidance of the needle difficult. Therefore, the posterior approach more easily produces a larger trauma to
Biopsy technique The technique (1) has been practically unchanged in the entire
the lung parenchyma. The needle also more often passes
series. Small differences in the technical handling may have
fissures with increasing risk for pneumothorax (Fig. 1). In
through more than one pleural space due to the location of the
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Fortschr. Röntgenstr. 129,4
Needle biopsies of pulmonary lesions
B. Nordenström und W. N. Sinner
Fortschr. Röntgenstr. 129, 4
addition the intercostal spaces are more narrow in the back than in the front and partly overlapped by the transverse
puncture needles which have been used in the present material
processes and the scapula, which diminishes the possibilities to select the ideal puncture site. The selected puncture site should be marked at the skin. After careful washing of the skin, local anaesthesia (Lidocaine l%) is applied at the puncture site and the underlying pleura. A puncture hole is made in the skin with a thick sharp needle
between the atmosphere and a lung vein during quiet respira-
(16 gauge) which facilitates the introduction of the biopsy needle (18-20 gauge). The latter is introduced in a straight direction towards the chosen point of biopsy by means of a well collimated beam adjusted parallel with the needle. The needle may then be introduced by means of a wooden clamp or
hemostat in order to prevent unnecessary radiation to the hands of the radiologist. The patient should not be asked to hold his breath during the procedure. Quiet ordinary respiration is better than a temporary respiratory arrest followed by vigorous respiratory movements. At the puncture site the needle is rotated in order to loosen cell material before aspiration which is made with an ordinary 10 or 20 ml syringe. No extra jiggeling or jerking movements should be made at the biopsy place. Before the removal of the needle the negative pressure in the syringe should be slowly equalized in order to avoid that the cell material in the needle disappears into the syringe. The material obtained is then handed over to the cytologist, who preferably should be able to make a preliminary microscopy in an adjacent room. This reduces the number of needle insertions considerably. In the case of non-diagnostic material at the first attempt the second or the third will as a rule give a conclusive result.
have an I.D. of 0.5-0.6 mm. The low pressure gradient tion, with the patient in recumbent position, makes it very unlikely that an appreciable amount of air should enter the vein through the needle lumen. The time for removing the obturator of the needle and attaching a syringe to the hub is also short. A more likely route would be the puncture hole in a vein and in an adjacent alveoli after the removal of the needle. Air may then pass into the vein especially if the patient starts to cough. This easily occurs when blood flows into the bronchi. In the entire material only two possible cases of air embolism have been observed. They both occurred approximately 2 min after the removal of the needle and in connection with rather forceful coughing. After 10 to 20 seconds of unconsciousness spontaneous recovery occurred without sequelae in one of the patients. A permanent brain damage occurred in the other one who in the right lung had an infiltration of tumor appearance. After the removal of the needle the patient coughed forcefully but
was otherwise unconcerned and was allowed to leave the examination room. She rose rapidly from the examination table and walked five steps after which she fell unconscious to the floor. In spite of oxygen ventilation in recumbent position and supply of vasodilating agents, the patient finally presented
signs of injury to the frontal lobe and brain stem. It was considered that this patient had contracted cerebral air embolism.
At the moment, no other recommendations can be given to prevent air embolism than to use thin needles and to prevent elevation of the intrabronchial pressure, e.g. by coughing. The antitussive agent given as premedication serves this purpose.
Complications Pneumothorax is the most common complication. Mean f requency in 2726 patients was 27.2 per cent; in 7.7 per cent of these pleural air was exsufflated. In emphysematous and aged patients the development of a pneumothorax should always be expected, which may require exsufflation. The air may leak very slowly and produce a clinically significant pneumothorax several hours after the biopsy. The patient should therefore be under adequate observation during the first 24 hours. Chest pain and occasionally more or less severe dyspnea may occur. Increasing respiratory or circulatory distress indicate a possible pneumothorax. If necessary a chest tube is percutaneously
inserted into the pleural cavity and a continuous negative pressure is applied until a stable expansion of the lung is obtained. A tube of 5 mm internal diameter is usually sufficient. Occasionally a total collapse of the lung may occur rapidly. Therefore, pleural tubes and a suction device with sufficient capacity should always be available in the examination room. With facilities available for a rapid exsufflation of a pneumothorax this complication is easily controlled. Needle biopsy of both the right and the left lung should never be made at the same occasion. In this department a card is sent with the patient informing the
staff in the ward that the responsible radiologist should be contacted without delay if respiratory distress or other complications after the biopsy appear.
Hemoptysis may occur but has not been of clinical signifi-
Mortality One case of lethal outcome has recently occurred. A 31-year-old male had an osteogenic sarcoma operatively
removed from the right leg and was after that treated with extraordinary large doses of Methotrexate (approximately 1000 times the regular dose) and Interferon for several months. One 1.5 cm large infiltration was present in the right lung and two smaller ones in the left, probably metastases. In connection with diagnostic sampling of cell material from the larger lesion, an in situ electrocoagulation was planned in
the case that malignant cells were found at the biopsy. The same procedure was then planned for the two smaller tumors in the left lung. The technique for this combined diagnostic and therapeutic procedure is described elsewhere (7-9).
Premedication with one 0mg of Oxicone-Scopolamine and
local anaesthesia was used. Cell material was aspirated through a needle with an OD. of 1.0 mm, Microscopy, immediately performed showed an osteogenic metastasis. Three new needles with an 0.D. of 1.0 mm each in a thin teflon tube, were introduced into the tumor whereupon the needles were replaced by three electrocoagulation electrodes. During
radiography to control the position of the electrodes and before the electrocoagulation was starkd, cardiac and respiratory arrest suddenly occurred. EGG showed, in spite of absence
of heart contractions, large ventricular complexes at a frequency of 60 per min. Artificial ventilation, external heart massage and intracardiac injection of Epinephrine were unable to rescue the patient.
cance. At the most 20 ml of blood has been expelled by coughing. No treatment has been necessary in any case. Air embolism is often discussed as a potential complication in lung biopsy. If a direct communication is created between a
lung vein and a cannula air may pass into the vein. The
At a subsequent autopsy only a small local bleeding was observed around the tumor and a minor amount of blood in a bronchus. No evidence of pneumothorax, air embolism, bleeding or other reasons for the fatality could be found. In retros-
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416
Needle biopsies of pulmonary lesions
is thought that the patient had contracted an air
embolism.
Local seeding of tumor cells is rarely of importance as the surrounding lung tissue will be removed at a subsequent operation.
In the entire material one case of implantation of tumor cells in
the chest wall was found (15). In two more cases a possible implantation of tumor cells in the chest wall have been observed although they may have been spontaneous metas-
tases. In four patients pleurisy occurred after puncture of infectious lesions. These were effectively treated with antibiotics.
In order to avoid seeding of tumor cells to the pleura and the chest wall the following rule has been introduced. At least 4 cm of lung tissue should be interposed between the puncture site in the pleura and the surface of the lesion (Fig. 2). The intention is
that tumor cells or infectious material from a lesion will be kept in the lung when the needle is removed.
417
Some of the advantages with the new instrument may be summarized:
The sampling time is considerably diminished, jiggeling
motions are avoided as compared with the old aspiration technique which seems to minimize the risk to develop pneumothorax. Sampling is made from the tissue over at least the distance of the spiral part of the screw needle, which means a 15 mm
distance instead of only a region close to the tip of the instrument as in aspiration biopsy. Not only cell material but also connective tissue may be obtained in the grooves of the screw needle, which is of value in the diagnosis of inflammatory fibrous lesions. Firm, organized tissues as in hamartomas, neurinomas,
bronchial chondromas, as well as certain granulomas are effectively biopsied which is often not possible at simple aspiration biopsy.
The dilution of the sample by blood is considerably
be extremely low as almost the entire material has been
diminished improving cytologic handling and diagnosis. From the screw needle concentrated inoculations can be
examined without the recommended precautions.
made directly on culture media for bacteriologic examina-
Seeding to the blood stream. It is known that in malignant
tion.
tumor diseases a more or less continuous seeding to the blood stream takes place (10-13). As long as the patient's resistance
This technique has been used in more than 400 cases. On the
to the disease is unbroken permanent metastases will flot develop (2, 3, 6, 12). Needle biopsy should therefore be
compared with the needle aspiration biopsy can be expected.
performed on broad indications when the patients are in good conditions. The number of circulating cells likely increases at needle biopsy as well as after other trauma against a tumor (5, 10-13). A needle biopsy is an extremely small trauma to the tumor as compared with an eventual operative removal of the tumor. For that reason the possible seeding of the tumor cells to the blood stream in needle biopsy is a minor problem as long as operation is accepted as treatment.
described earlier in this article are also applicable for the screw needle biopsy. An evaluation of this new biopsy technique has recently been performed by House and Thomson (4). They found the technique superior to the now common needle aspiration technique.
The risk for local seeding to the pleura and the chest wall must
basis of this experience a decrease in complication rate as
The precautions and the management of complications
Abundant cell material could at times be obtained with histological detail not only from malignant tumors but also from firm fibrous lesions, connective tissue and inflammatory tissue. The incidence of complications was similar to those reported for conventional fine needle aspiration biopsy.
Recent technical improvements Although the previous technique has proven to be efficient in the diagnosis of pulmonary lesions, a further improved technique of biopsy has recently been introduced (8). This technique offers a still more efficient sampling of cytologic material but involves also other advantages for avoiding complications and unnecessary radiation to the examiner's hands. The instrument consists of a stainless steel screw needle, 0.D. 0.55 mm and 220 mm in length, a 160 mm long stainless stell cannula with OD. of 1.0 mm and an instrument holder (Fig,
Conclusion
3). The construction and use of the instrument has been described in detail elsewhere (8) and is here only briefly
mothorax, hemoptysis, and local bleeding are minor inci-
reported.
The cannula and indwelling screw needle is inserted by means of the instrument holder under television control until the tip of the cannula has reached the edge of the lesion. The instrument is held in firm position with the instrument holder while
the screw needle is rotated clockwise until its tip is brought into the lesion or 15 mm distal to the tip of the cannula. The cannula is then rotated counterclockwise using slight forward pressure until the screw needle is completely protected by the cannula. The screw needle and cannula are then pulled out together. The screw needle is pushed out without delay to
prevent drying of obtained material. The cell material is smeared and stained in the usual manner for cytologic examination. The material may also be examined as a bacteriological sample. The new instrument may be obtained from Ursus Konsult AB, Grey Turegatan 2, S-114 35 Stockholm, Sweden.
Needle biopsy of pulmonary lesions can now be performed routinely under the guidance of television screening with a high
degree of precision. The average diagnostic accuracy is high
and the number of complications can be kept low. Careful planning with consideration taken to indications and contraindications, general precautions and risk factors is essential in this connection. A certain number of complications as pneudences which usually only require observation. Some pneumothoraces may be symptomatic and require exsufflation
treatment. Very rarely air embolism may occur, but it constitutes the most important complication. It may even lead to cerebral symptoms and lethality. In spite of that, needle biopsy is indispensable in the diagnosis of pulmonary lesions. In this work the recently developed screw needle instrument seems to offer even better results than the now commonly used needle aspiration technique.
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pect it
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Prof. Björn Nordenström Department of Diagnostic Radiology Karolinska Sjukhuset S-104 01 Stockholm 60, Sweden.
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418
