European Journal of Radiology. 15 (1992) 49-53 0 1992 Elsevier Science Publishers B.V. All rights reserved. 0720-048X/92/$05.00

EURRAD

49

00277

Percutaneous

needle biopsy of lung nodules following failed bronchoscopic biopsy C.D. Collins”, E. Breatnach”

and P.H. Nathb

“Instituteof RadiologicalSciences, Mater Misericordiae Hospital,Dublin, Ireland bDepartment of Radiology, Universityof Alabama, Birmingham, AL, USA (Received

16 October

1991; accepted

Key words: Thorax, interventional

after revision 10 January

radiology; Thorax, neoplasm;

1992)

Neoplasm,

diagnosis

Abstract

Though transthoracic needle biopsy (TNAB) is a well established method for obtaining pathologic diagnosis in lung masses, very often the procedure is only performed after a previous negative bronchoscopic biopsy (BB) attempt. In this study we analyzed the results of TNAB in 129 consecutive patients where one or more inconclusive BB had been performed. TNAB was diagnostic in 115 of 129 lesions (89%) and the yield was not significantly affected by size, cell type or tumour location. In 97 patients who underwent thoracotomy, cytologic specimens obtained by TNAB accurately reflected histologic tumour type in all cases. A false negative rate for malignancy on TNAB was 5%. Awaiting inconclusive BB results caused an average delay of three in-hospital days before TNAB. In those patients in whom a biopsy is warranted, TNAB is most useful as an initial diagnostic procedure in masses that are peripheral and in pleural based tumours, in mediastinal adenopathy associated with a lung mass and instead of a repeat, previously failed bronchoscopy.

Introduction In patients with lung masses, transthoracic needle aspiration biopsy (TNAB) is an established alternative diagnostic procedure to bronchoscopic biopsy (BB) [ l-41. It is frequently used only as a second line of approach after negative BB. The results of TNAB in 129 consecutive patients with failed BB were analysed to see if the yield was influenced by location, size and cell type of the mass. In addition an attempt was made to identify the circumstances in which TNAB should be performed as the initial diagnostic procedure. Materials and methods The clinical records and chest radiographs of 129 consecutive patients, who underwent TNAB following a negative BB, were reviewed. In 14 patients more than one bronchoscopy with biopsies were performed. Correspondence to: Dr E. Breatnach, Dept. of Radiology, Mater Misericordiae

Hospital,

Eccles Street, Dublin 7, Ireland.

Patients (76 men and 53 women) were aged from 38 to 74 years. The following features were examined. (1) pathologic yield of TNAB ; (2) final surgical or clinical diagnosis; (3) size of lesion; (4) its location; (5) presence of metastases; (6) complications of TNAB and (7) interval between bronchoscopy and TNAB. Lesions were characterised as central or peripheral on poster0 anterior (PA) and lateral chest radiographs. Lungs were divided into vertical thirds with lesions located in the inner zone on the PA view and middle zone on the lateral view considered central. Masses in all other areas were classified as peripheral and were divided into sizes of less than 3 cm, 3-6 cm, and greater than 6 cm. In 114 patients tibreoptic bronchoscopy was performed under portable C/arm fluoroscopic guidance. In the remaining 15 patients fluoroscopy was not employed. At bronchoscopy an average of tive transbronchial biopsies were made. Endobronchial biopsy was performed for suitable lesions and bronchial washings carried out routinely. In 14 patients more than one bronchoscopy was performed before referral for TNAB.

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In 109 patients, TNAB was performed under fluoroscopic guidance by two experienced operators using a Greene coaxial 1Pgauge outer and 22 gauge inner biopsy needle combination (Cooke). Two passes were made on each patient with at least three vigorous suction aspirations being performed on each pass. Specimens were transported in saline for cytologic and cell block analysis. In 20 patients, with pleural based masses, a 10 cm 14 gauge Trucut cutting needle (Travernol) was used and samples sent in a formalin solution for histologic preparation. In 12 patients, where a lung mass was associated with mediastinal adenopathy, the lymph node mass was biopsied using a Greene needle in 10 and with Trucut biopsy technique in 2. For anterior mediastinal node biopsies a localising CT scan was first performed and biopsy was then carried out, or subsequently under fluoroscopic guidance. Expiratory chest radiographs were performed 30 min following biopsy for inpatients and again on the following morning. In five patients TNAB was performed as an outpatient procedure. In patients where the TNAB result was non-small cell carcinoma and the lesion resected, pathologic correlation of biopsy and surgical specimens was made. A TNAB diagnosis of small cell carcinoma was accepted when follow-up on appropriate chemotherapy showed an unequivocal reduction in the size of the primary tumour or metastatic deposits. TNAB diagnosis of nonsmall cell carcinoma, where resection was not performed, was accepted when there was progressive increase in mass or metastatic tumour size, or where the clinical course followed an unremitting deteriorating path, despite chemotherapy for small cell carcinoma. In all, apart from two patients where TNAB results were inconclusive, surgical biopsy was performed and firm pathologic diagnosis established. In the remaining two, a benign interpretation was accepted when repeated BBS and two TNABs, were negative for malignancy, and an unchanging radiological and clinical pattern were observed over a two year follow-up period. Results TNAB revealed a diagnosis in 115 patients (89%) and confirmed malignancy in 111, In 97 patients (75 %) who underwent surgical resection, histologic examination of the surgical specimen confirmed the prevailing TNAB diagnosis in all cases. In 4 patients an infectious aetiology was established. Diagnostic yield of TNAB biopsy vs. mass size, site and cell type are summarised in Tables l-3. In 60 patients lesions were from 1.5 to 3 cm in size, and in 29 greater than 6 cm. In the

TABLE 1 Correlation

of mass size and TNAB result

(cm)

Size

No. of masses

Positive pathology

Non-diagnostic aspirate

6

60 40 29

53 36 26

7 4 3

TABLE 2 Correlation

of mass location and TNAB result

Central Peripheral

No. of masses

Positive pathology

Non-diagnostic aspirate

40 89

38 il

2 12

TABLE 3 Correlation

of histologic cell type with TNAB result Total No.

Positive

Non-diagnostic

46

43

3

8

8

0

Adenocarcinoma

36

33

3

Undifferentiated large cell lung cancer

28

21

1

Squamous

cell carcinoma

Small cell carcinoma

remaining 40 the range was 3-6 cm. Forty lesions were central and 89 peripheral Of the 89 peripheral lesions, 8 were apical and 30 were pleural based. In 12 patients, where bulky mediastinal adenopathy was associated with a mass, a positive diagnosis was obtained in each by TNAB of the enlarged nodes. Of 14 non-diagnostic TNAB biopsies, three proved to be granulomata at surgery (two patients with blastomycosis, and one with non-specific granulomata). One patient had round atelectasis and three other lesions were presumed to be benign, exhibiting no change over a two-year follow-up period. The remaining seven patients were known to have malignancy at thoracotomy. Hence, 7 out of 129 (5%) of patients had a false negative TNAB which proved to be carcinoma at thoracotomy or autopsy. Following TNAB, 35 patients (27 %) had pneumothorax, 9 (7 %) requiring chest tube insertion. The remaining patients were treated by bed rest and further follow up radiographs at 7 d. Six patients had developed pneumothorax following BB. No transbronchial biopsy was performed in this group. Six patients had minimal, self-limiting haemoptysis fol-

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lowing TNAB. One patient died two days following TNAB due to massive haemoptysis. In five patients TNAB was performed as an outpatient procedure. There were no complications in this group. Thirty-two (25%) were considered surgically non-curable because of known primary cancer elsewhere, or because of metastases either to the mediastinum or an extrathoracic site. All remaining patients were considered surgical candidates at the time of biopsy. TNAB was performed on an average of 4.2 d after admission, and bronchoscopy 1.5 d after admission. A negative BB resulted in an average delay of 2.7 d from the time of bronchoscopy to performing TNAB.

Discussion Histological diagnosis of focal lung disease is usually made via a bronchoscopic approach or by percutaneous lung biopsy. Recent evidence has shown that the value of TNAB is limited in the specific instance of patients with suspected lung cancer who are otherwise operable [ 51. However, TNAB is of value in those patients who are not suitable for curative surgery because of local invasion, metastatic disease, poor lung function or general debility. In this sub-group TNAB has the potential to alter management and also allows patients to become aware of the prognosis. Few would argue but that central lesions showing clear cut endobronchial characteristics (i.e. obstructive segmental collapse or pneumonia) deserve a first biopsy attempt via bronchoscopy, or that in small pleural based peripheral lesions a percutaneous approach is the appropriate firstline method. In situations where lesions are not so easily classified the choice of biopsy method is not as clear cut. In these patients, because of established referral patterns, BB is usually attempted first, and it is only when the biopsies are found to be inconclusive that referral is made to a radiologist for TNAB. Advantages of BB include a potential to simultaneously inspect the proximal extent of tumour within the tracheobronchial tree and a low complication rate. In the former context CT has significantly improved radiographic staging of central tumours [6] but has the disadvantage of being unable to differentiate benign from malignant nodules. Furthermore, many surgeons prefer to perform their own routine rigid bronchoscopy prior to thoracotomy. Though the pneumothorax rate of BB is low [ 71, there are relative contraindications [ 81. The method does not always yield pathologically conclusive tissue, and is subject to a number of factors which reduce its diagnostic yield. Problems of size vs. BB yield were highlighted by

Radke [9] and Stringfield [IO]. Radke reported BB of lesions less than 2 cm as having been associated with only 28% success rate compared to rates in excess of 60% in lesions larger than 2 cm [ 91. In our series of failed bronchoscopies there was a predominance of lesions of less than 3 cm. Though there was a slightly higher non-diagnostic rate for TNAB of lesions less than 3 cm vs. masses of 3-6 cm (13.2% vs. 11.1%) size was not as significant a factor for TNAB results. Masses located in peripheral lung zones have also been found less suitable for BB [9, 1 l- 131. Cox et al. [ 121 made a diagnosis in only 36% of peripheral lesions by BB vs. 94% for central tumours. Similarly, in our series more than 50% of the non-diagnostic bronchoscopies were in respect of peripheral lesions. Though TNAB was marginally less successful in peripheral masses (Table l), location did not affect its yield to the same extent as that reported for BB. The explanation for non-diagnostic aspirates in such readily accessible lesions is not immediately clear, but the experience has also been reported elsewhere. [ 14,151. Both Shure and Fedullo [ 161 and Lundgren et al. [ 171 have reported that proximal lesions with a large submucosal or exobronchial element are difficult to biopsy via BB. Similarly, 40 of our inconclusive BB results were in central lesions. A positive result was obtained by TNAB in 38 of 40 such patients (Table 2). The relative success of TNAB in central vs. peripheral lesions has also been reported by others [ 181. The histologic nature of a mass may affect the reliability of transbronchial biopsy more than it does TNAB [ 12,19-211. Zisholtz [20] showed that, using BB, small cell carcinoma was associated with the highest biopsy yield (100 %) vs. adeno or large cell at 75 y0 success rate, and squamous cell carcinoma at 60% positive rate. Our results are similar to these findings. The difficulty found in cell typing specimens obtained by flexible bronchoscopy in lesions other than small cell carcinoma is highlighted by Radke’s recommendation [ 91, that pathologic descriptions of BB specimens should be limited to the distinction of small vs. non-small cell-type carcinoma, without attempts at more refined analysis. Only 8 of 118 patients with malignancy and inconclusive BB results had small cell disease. In all patients with small cell carcinoma a firm diagnosis was made by TNAB. The non-diagnostic rates by TNAB for squamous cell, adeno and poorly differentiated non-small cell carcinomas in our series were virtually identical, indicating that TNAB sensitivity was not discriminated against by any particular cell type. Of 11 patients with benign disease, the diagnosis was established by TNAB in only four. This correlates with others’ experience [22]. Better diagnostic rates of

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benignity (68%) have been reported by Khouri et al. [23] ; however, others have not been able to reproduce that degree of accuracy [ 241. Similarly poor results have been recorded from BB in benign disease [25]. Thus, biopsy results in benign disease are just as much a problem for BB as TNAB, and cannot be used to justify attempts at BB before TNAB. Percutaneous fine needle aspiration biopsy of mediastinal lesions is another area of advantage over BB [ 18, 25,271. In all 12 of our patients where this method was employed, a positive diagnosis was made. With this approach, on a single biopsy, besides the primary diagnosis, the nature of associated lymph node enlargement can be simultaneously assessed and a patient’s suitability for surgery planned. In 25% of our patients, surgery was not contemplated because of local extent of tumour or because of metastatic disease. In all of these a diagnosis was established by TNAB. In such circumstances the issue of pre-operative bronchoscopic staging does not arise. We accept, however, that as outlined by Calhoun et al. [l] indeterminate results from TNAB must never be trusted to the extent of dismissing a possible diagnosis of carcinoma. A 27% pneumothorax rate is in keeping with that recorded in other series [2,28,29]. This rate compares to 6 of 129 patients who a had small self-limiting pneumothorax following BB. The incidence of haemoptysis was approximately the same in both examinations, and in only one patient was intervention necessary. Death from haemoptysis following TNAB occurred in one patient. The biopsy was performed after three negative BBS and in the presence of known disseminated intravascular coagulopathy to isolate an organism in circumstances of life-threatening infection. When TNAB followed an unsuccessful BB, there was an average in-patient wait per patient of 2.7 d. In some patients delay extended to as much as 6 d, particularly when more than one bronchoscopy was performed. This causes hold-up in instituting therapy, with attendant increases in the cost of hospitalisation. Gobien et al. [ 30 ] have reported these logistics in detail. TNAB may also be performed on selected patients as an out-patient procedure [ 3 11. In the patients selected for out-patient TNAB in our series, no complication was recorded. In this study TNAB succeeded in establishing a diagnosis in the majority of cases after failed BB and the yield was not affected by size, cell type or tumour location. Current indications for its use are in peripheral or pleural based nodules including those in the lung apex, in mediastinal adenopathy associated with a lung mass and instead of a repeat previously failed bronchoscopy.

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Percutaneous needle biopsy of lung nodules following failed bronchoscopic biopsy.

Though transthoracic needle biopsy (TNAB) is a well established method for obtaining pathologic diagnosis in lung masses, very often the procedure is ...
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