Ultrasound-guided Aspiration Biopsy of Small Peripheral Pulmonary Nodules* Ang Yuan, M.D.; Pan-Chyr Yang, M.D., F.C.C.P.; Dun-Bing Chang, M.D.; Chong-]en Yu, M.D.; Yung-Chie Lee, M.D.;t Sow-Hsong Kuo, M.D., F.C.C.P.;* and Kwen-Tay Luh, M.D., F.C.C.P.*
We compared the diagnostic yields of ultrasound-guided aspiration biopsy, sputum cytology, and 6beroptic bronchoscopy with biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 em in diameter. Among them, there were 4 minute nodules with diameter less than 1.0 em, 12 between 1.1 to 2.0 em, and 14 between 2.1 to 3.0 em. The 6nal diagnoses in these 30 patients, as con6rmed by histologic 6ndings, microbiology, and clinical fOllow-up, revealed 24 malignant lesions and 6 benign. All of these 30 nodules received ultrasound-guided transthoracic Hoe-needle aspiration biopsy, and con6rmative diagnoses were obtained in 27 (90 percent). Twenty-two (92 percent) of 24 patients with malignant nodules bad positive cytology for malignancy and 5 (83 percent) of 6 patients
he etiologic diagnosis of small peripheral pulmoT nary nodules is difficult. The diagnostic yields of sputum cytology and fiberoptic bronchoscopy with biopsy are unacceptably low. 1-3 Most of the patients may need transthoracic needle aspiration biopsy under the guidance of fluoroscopy or computerized tomography, and even thoracotomy to confirm the diagnosis. 4 Recently, chest ultrasound has proved useful in the evaluation of pleural-based opacities, peridiaphragmatic and mediastinal lesions. s- 11 Ultrasound-guided thoracentesis is very helpful in minimal or loculated pleural effusions which cannot be tapped with conventional technique. 12- 14 The application of ultrasound in guiding the transthoracic aspiration biopsy of peripheral lung lesions and mediastinal tumors has been reported to have good sensitivity and specificity. 1s- 18 In this study, we assess the diagnostic value of ultrasound-guided aspiration biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 em in diameter, which may pose difficulty for histologic diagnosis because of their small size and peripheral location. We also compare the diagnostic yield with the results of sputum cytology and fiberoptic bronchoscopy with biopsy. MATERIALS AND METHODS Thirty patients with small peripheral pulmonary nodules were *From the Departments of Internal Medicine, tSurgery, and *Clinical Pathology, National Taiwan University Hospital, Thipei, Taiwan. Manuscript re(:eived April 22; revision accepted August 5. Reprint Tl1quests: Dr. Yang, National Taiwan University Hospital, No_ 1 Chang-te Stl'l1et, Taipei, Taiwan, Republic of China 926
with benign lesions bad diagnosis made by cytologic and microbiologic examinations. One patient developed asymptomatic pneumothorax after needle aspiration. The size of the lesions did not affect the diagnostic yield and oompHcation rate. None of the lesions was diagnosed by sputum cytology (O of 19; 0 percent). Two patients had diagnoses obtained by 6beroptic bronchoscopy with biopsy (2 of 10; 20 percent). We conclude that ultrasound-guided aspiratioo biopsy is a useful and safe method for diagnosis of peripheral pulmonary nodules, even when the size of the nodule is less than 3 em in diameter. The diagnostic yield far exceeds that which can be obtained by sputum cytology and 6berop(Chat 1992; 101:926-30) tic bronchoscopy with biopsy.
examined between March 1984 and January 1991. There were 19 men and 11 women. Age ranged from 31 to 87 years (mean:60 years). Patients were selected for ultrasound-guided transthoracic aspiration biopsy based on the following criteria: (1) roentgenographic evidence of peripheral pulmonary nodules located within 1 em near the visceral pleura; (2) pulmonary nodules smaller than 3.0 em in diameter; (3) patients did not have bleeding tendency, the platelet count was greater than 100,00Wp.L, and normal prothrombin time; and (4) patients were cooperative. All 30 patients received ultrasound-guided aspiration biopsy, 19
had at least three sputum cytology examinations, and ten underwent Gberoptic bronchoscopy with biopsy. The ultrasound examinations were performed with a real-time linear-array, or convex unit with 3.5 MHz and 5.0 MHz transducer. The location of the nodule was Grst judged from the chest roentgenogram. The transducer was then placed over the area where the nodule was located. The patient was asked to breathe deeply and slowly to expose the small nodules beneath the ribs. After the lesion was detected, both longitudinal and transverse images were obtained to assess the three dimensional conGguration. The skin was then prepared and a sterile puncture transducer equipped with a guiding channel was applied. The patient was asked to hold his/her breath while a 22-gauge needle was inserted through the guiding channel, and aspiration biopsy was carried out as has been described.•• A schematic illustration of the puncture device, needle, and the relationship to the lesion has been previously described.•• It typically took 10 to 15 s to complete an aspiration procedure. The aspirate was examined fur cytologic and microbiologic Gndings, which included Papanicolaou stain, Riu stain,., acid-fast stain, Gram stain, india ink stain, and bacterial and fungal cultures. After needle aspiration biopsy, a routine chest roentgenogram was taken on the next day to assess possible complications. Fiberoptic bronchoscopy was performed with a bronchoscope as described elsewhere_ The specimens obtained by transthoracic aspiration biopsy, bronchoscopic biopsy, and sputum cytology were examined and interpretated by two specialists.
Table 1-Ruulta qfUitrt111011nd-guiJed 1hlnsthoracie A1piraCion Biop8y, Sputum Cytology, Bronchoscopic BiopBfJ Nature of lesion
No. of cases
Aspimtion biopsy
Sputum cytology
Bronchoscopy with biopsy
Malignancy Squamous cell Ca Adenocarcinoma Small cell Ca Poorly differentiated Ca Bronchioloalveolar Ca Hepatocellular Ca Renal cell Ca Benign Tuberculosis Cryptococcosis Aspergillosis Organized thrombus Extmmedullary hemopoiesis Total
24 7 8 1 2 1 4 1 6 1 2 1 1 1 30
22 (92%) 6 7 1 2 1 4 1 5 (83%) 1 2 1
We compared the diagnostic yields of ultrasound-guided aspiration biopsy, sputum cytology, and 6beroptic bronchoscopy with biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 em in diameter. Among them, there were 4 minute nodules with diameter less than 1.0 em, 12 between 1.1 to 2.0 em, and 14 between 2.1 to 3.0 em. The 6nal diagnoses in these 30 patients, as con6rmed by histologic 6ndings, microbiology, and clinical fOllow-up, revealed 24 malignant lesions and 6 benign. All of these 30 nodules received ultrasound-guided transthoracic Hoe-needle aspiration biopsy, and con6rmative diagnoses were obtained in 27 (90 percent). Twenty-two (92 percent) of 24 patients with malignant nodules bad positive cytology for malignancy and 5 (83 percent) of 6 patients
he etiologic diagnosis of small peripheral pulmoT nary nodules is difficult. The diagnostic yields of sputum cytology and fiberoptic bronchoscopy with biopsy are unacceptably low. 1-3 Most of the patients may need transthoracic needle aspiration biopsy under the guidance of fluoroscopy or computerized tomography, and even thoracotomy to confirm the diagnosis. 4 Recently, chest ultrasound has proved useful in the evaluation of pleural-based opacities, peridiaphragmatic and mediastinal lesions. s- 11 Ultrasound-guided thoracentesis is very helpful in minimal or loculated pleural effusions which cannot be tapped with conventional technique. 12- 14 The application of ultrasound in guiding the transthoracic aspiration biopsy of peripheral lung lesions and mediastinal tumors has been reported to have good sensitivity and specificity. 1s- 18 In this study, we assess the diagnostic value of ultrasound-guided aspiration biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 em in diameter, which may pose difficulty for histologic diagnosis because of their small size and peripheral location. We also compare the diagnostic yield with the results of sputum cytology and fiberoptic bronchoscopy with biopsy. MATERIALS AND METHODS Thirty patients with small peripheral pulmonary nodules were *From the Departments of Internal Medicine, tSurgery, and *Clinical Pathology, National Taiwan University Hospital, Thipei, Taiwan. Manuscript re(:eived April 22; revision accepted August 5. Reprint Tl1quests: Dr. Yang, National Taiwan University Hospital, No_ 1 Chang-te Stl'l1et, Taipei, Taiwan, Republic of China 926
with benign lesions bad diagnosis made by cytologic and microbiologic examinations. One patient developed asymptomatic pneumothorax after needle aspiration. The size of the lesions did not affect the diagnostic yield and oompHcation rate. None of the lesions was diagnosed by sputum cytology (O of 19; 0 percent). Two patients had diagnoses obtained by 6beroptic bronchoscopy with biopsy (2 of 10; 20 percent). We conclude that ultrasound-guided aspiratioo biopsy is a useful and safe method for diagnosis of peripheral pulmonary nodules, even when the size of the nodule is less than 3 em in diameter. The diagnostic yield far exceeds that which can be obtained by sputum cytology and 6berop(Chat 1992; 101:926-30) tic bronchoscopy with biopsy.
examined between March 1984 and January 1991. There were 19 men and 11 women. Age ranged from 31 to 87 years (mean:60 years). Patients were selected for ultrasound-guided transthoracic aspiration biopsy based on the following criteria: (1) roentgenographic evidence of peripheral pulmonary nodules located within 1 em near the visceral pleura; (2) pulmonary nodules smaller than 3.0 em in diameter; (3) patients did not have bleeding tendency, the platelet count was greater than 100,00Wp.L, and normal prothrombin time; and (4) patients were cooperative. All 30 patients received ultrasound-guided aspiration biopsy, 19
had at least three sputum cytology examinations, and ten underwent Gberoptic bronchoscopy with biopsy. The ultrasound examinations were performed with a real-time linear-array, or convex unit with 3.5 MHz and 5.0 MHz transducer. The location of the nodule was Grst judged from the chest roentgenogram. The transducer was then placed over the area where the nodule was located. The patient was asked to breathe deeply and slowly to expose the small nodules beneath the ribs. After the lesion was detected, both longitudinal and transverse images were obtained to assess the three dimensional conGguration. The skin was then prepared and a sterile puncture transducer equipped with a guiding channel was applied. The patient was asked to hold his/her breath while a 22-gauge needle was inserted through the guiding channel, and aspiration biopsy was carried out as has been described.•• A schematic illustration of the puncture device, needle, and the relationship to the lesion has been previously described.•• It typically took 10 to 15 s to complete an aspiration procedure. The aspirate was examined fur cytologic and microbiologic Gndings, which included Papanicolaou stain, Riu stain,., acid-fast stain, Gram stain, india ink stain, and bacterial and fungal cultures. After needle aspiration biopsy, a routine chest roentgenogram was taken on the next day to assess possible complications. Fiberoptic bronchoscopy was performed with a bronchoscope as described elsewhere_ The specimens obtained by transthoracic aspiration biopsy, bronchoscopic biopsy, and sputum cytology were examined and interpretated by two specialists.
Table 1-Ruulta qfUitrt111011nd-guiJed 1hlnsthoracie A1piraCion Biop8y, Sputum Cytology, Bronchoscopic BiopBfJ Nature of lesion
No. of cases
Aspimtion biopsy
Sputum cytology
Bronchoscopy with biopsy
Malignancy Squamous cell Ca Adenocarcinoma Small cell Ca Poorly differentiated Ca Bronchioloalveolar Ca Hepatocellular Ca Renal cell Ca Benign Tuberculosis Cryptococcosis Aspergillosis Organized thrombus Extmmedullary hemopoiesis Total
24 7 8 1 2 1 4 1 6 1 2 1 1 1 30
22 (92%) 6 7 1 2 1 4 1 5 (83%) 1 2 1
