Percutaneous computed tomography-guided biopsy of the lung: data from a hospital

Abstracts

OBJETIVO: Apresentar a experiência do serviço de radiologia do Hospital Santa Cecília, São Paulo, SP, no manejo das biópsias pulmonares por aspiração através de agulha fina e biópsias por fragmentos guiadas por tomografia computadorizada e a análise de sua importância e associação com suas complicações. MATERIAIS E MÉTODOS: Foram analisadas 168 biópsias guiadas por tomografia, sendo 84 em homens e 84 em mulheres. Utilizou-se a técnica de biópsia por aspiração por agulha fina em 64 pacientes, a técnica de biópsia por fragmento em 68 pacientes e ambas as técnicas em 36 pacientes. RESULTADOS: Pneumotórax ocorreu em 38 pacientes e a hemorragia pulmonar, em dez pacientes. As dimensões das lesões biopsiadas variaram de 0,5 cm até 15 cm. O diagnóstico foi realizado na primeira tentativa em 132 casos e na segunda tentativa em dez casos. CONCLUSÃO: A acurácia das biópsias aspirativas por agulha fina e por fragmento de lesões pulmonares depende do tamanho da lesão e da colaboração do paciente. Essas técnicas são relativamente seguras e têm acurácia diagnóstica elevada quando feitas por um profissional experiente.

Biópsia; Câncer; Tomografia computadorizada

ORIGINAL ARTICLE

Percutaneous computed tomography-guided biopsy of the lung: data from a hospital^*

Emílio Humberto Carazzai^I; Maristela Andreosi^II; Fábio Mota Gonzalez^III; Sandra de Quadros Uzêda Gonzalez^IV; Olger de Souza Tornin^V; Marcelo D'Andrea Rossi^VI

^IMD, Radiologist at Maximagem, Hospital São Luís and Hospital Santa Cecília

^IIMD, Radiologist, Assistant for the Sector of Ultrasound at Medimagem – Hospital Beneficência Portuguesa de São Paulo

^IIIMaster's Degree in Sciences of Health at Hospital Heliópolis

^IVMaster's Degree in Morphology at Universidade Federal de São Paulo-Escola Paulista de Medicina

^VMaster's Degree Student in Sciences of Health at Hospital Heliópolis, Professionalizing Practice in Magnetic Resonance Imaging at Universidade de São Paulo

^VIClinical Director at Maximagem, MD, Radiologist at Hospital São Luís

^{Mailing address}

ABSTRACT

OBJECTIVE: To present the experience of Santa Cecília Hospital (São Paulo, SP, Brazil) radiology service in the handling of computed tomography-guided fine-needle aspiration biopsy and percutaneous core biopsy of pulmonary lesions, analyzing their importance and associated complications.

MATERIALS AND METHODS: One hundred and sixty-eight computed tomography-guided biopsies were performed in 84 men and 84 women. Sixty-four patients underwent fine-needle aspiration biopsy, 68 underwent percutaneous core biopsy and 36 patients underwent both techniques.

RESULTS: Pneumothorax occurred in 38 patients, and pulmonary hemorrhage in then cases. The biopsied lesions ranged in size from 0.5 to 15 cm. The diagnosis was achieved at the first attempt in 132 cases and at the second attempt, in ten cases.

CONCLUSION: The accuracy of fine-needle aspiration and percutaneous core biopsies depends both on the size of the lesion and the patient's cooperation. These techniques are relatively safe and present a high diagnostic accuracy when performed by an experienced professional.

Keywords: Biopsy; Cancer; Computed tomography.

INTRODUCTION

Computed tomography (CT)-guided, either fine-needle aspiration or percutaneous core biopsies of lung, are procedures routinely performed in European countries, United States and Japan with proved specificity, accuracy and sensitivity for the diagnosis of pulmonary lesions^(1–5).

Main complications related to these methods are pneumothorax and perilesional hemorrhage, respectively. The frequency reported in the literature for pneumothorax following these types of procedures ranged between 11.5% and 62%^(1–12), the majority of cases being of small volume and not requiring specific treatment.

In Brazil, there are few studies published reporting the utilization of CT-guided percutaneous biopsy aimed at evaluating pulmonary lesions^(4,13,14). Additionally, despite the wide acceptance and importance of this diagnostic method in the international literature, and the facility to be performed after training, this procedure is performed with a relatively low frequency in our country, usually remaining as a routine procedure in a restricted number of institutions.

The objective of the present study is to provide professionals with guidance on techniques and main complications resulting from CT-guided biopsies of lung, besides presenting epidemiologic data - something rare in the Brazilian literature.

MATERIALS AND METHODS

We have analyzed results from 168 CT-guided biopsies of chest performed in the period between September 1997 and April 2003, at Hospital Santa Cecília (São Paulo, SP, Brazil). The group of patients included 84 men and 84 women. The patients' ages ranged between 14 and 81 years (mean age 57.9 years).

We have employed the fine-needle aspiration biopsy in 64 patients, percutaneous core biopsy in 68, and both techniques in 36 patients.

All the biopsies were CT-guided with the following devices: Toshiba X-speed, CT scanner and Toshiba Medical System.

Before performing the biopsy, the radiologist explained to the patient about the procedure, trying to calm him/her. Possible complications were mentioned and explained in the moment of informed consent signature.

Previously to the procedure, the patient received training for controlling the respiration rhythm and was asked to avoid deep inspiration during the procedure, keeping the most constant possible inspiratory volume to reduce stress on the site of pleura to be perforated. Some images of the lesion were made to give us certainty about the efficacy of respiratory movements performed by the patient.

The skin marker was positioned on the site where we had obtained the shortest route between skin and lesion aiming at not reaching important structures during the needle insertion.

Later, an image was made on the marker to confirm its relation with the lesion. Once the needle entry site had been marked with ink, the marker was removed, asepsis was made with iodine or iodine-alcohol solution and the sterile field was placed. Local anesthetic (about 8 ml xylocaine at 2%) was injected, leaving the anesthetic needle itself in place as a guide for eventually changing the biopsy route position or angulation.

As regards the technique choice, we have opted for percutaneous core biopsy of lesions in contact with pleura and fine-needle aspiration biopsy for more distant lesions, aiming at reducing the probability of pneumothorax. In larger lesions, provided they were in contact with pleura, the combined technique was employed.

Gallini SRL automatic guillotine needle (16- and 18-gauge) and Shiba cytological aspiration needle (22-gauge), both with 10 cm or 15 cm, were employed.

The needle was inserted trying not to affect the pleura at that moment. Then, a new image was obtained for assurance on trajectory direction and measurement of the lesion depth, and the needle was inserted up to the desired point for a new tomographic control.

Once the needle positioning into the lesion was confirmed, the fragment was withdrawn and immediately preserved, or material was aspirate for smear preparation, and sent to the laboratory for anatomopathological examination.

Control images must be acquired during and after the procedure, with the patient lying directly on the puncture site.

In case of pneumothorax, the following conduct is adopted (Chart 1):

Chart 1 - click here to enlarge

RESULTS

The mean duration of procedures analyzed was 19 minutes, the fastest one being performed in 10 minutes, and the longest one, in 46 minutes, considering the time interval between the first image for localizing the skin marker and the control image obtained after the procedure.

Fine-needle aspiration biopsy was performed in 64 patients (38.1%), percutaneous core biopsy in 68 patients (40.48%) and both techniques combined in 36 cases (21.42%).

Lesions dimensions ranged between 0.5 cm and 15 cm (average 4.5 cm). Fourty lesions measured 2.0 cm or less.

The majority of lesions were adjacent to the pleura (134 from a total of 168). The distance between the pleura and the lesion ranged between 0.5 cm and 5.0 cm (mean distance 2.45 cm).

The higher number of pleura biopsy-related injuries in one procedure was six and the lower, one (mean 1.44)

Diagnosis was achieved at the first attempt in 132 cases, and at the second in ten cases.

The number of inconclusive biopsies was 26, 20 of them being fine-needle aspiration biopsies and six, percutaneous core biopsies.

Thirty-eight patients presented pneumothorax during or right after the procedure (Figure 4). Of these patients, only two were submitted to aspiration with a 14-gauge intravenous catheter into the second intercostal space, in the midclavicular line, without the need of posterior thoracic drain placement.

Figure 4 - click here to enlarge

Only ten patients (5.9%) presented hemorrhage adjacent to the lesion, without major complications (Figure 5). There was no report on significant postbiopsy hemoptysis.

Figure 5 - click here to enlarge

The number of neoplastic lesions diagnosed in the anatomopathological examination was of 128 (76.15%), benign lesions were 14 (8.33%) and inconclusive/non-specific biopsies were 26 (15.47%), corresponding to 84.52% of diagnostic biopsies. Of the lesions measuring 2.0 cm or less (40), 28 yielded sufficient material for diagnosis. Eight were benign and 20 were malignant.

Neoplasms histological types were: adenocarcinoma (24 cases), small-cell carcinoma (22 cases), large-cell carcinoma (20 cases), spinocellular carcinoma (nine cases), bronchoalveolar carcinoma (three cases), neuroendocrine carcinoma (two cases), bronchogenic carcinoma (the subtype could not be defined in two cases), primitive neuroectodermal tumor (four cases), melanoma (two cases), metastases (12 cases), lymphoma (two cases), thymoma (two cases), neurofibrosarcoma (two cases) and Kaposi's sarcoma (two cases) (Figures 1 to 4).

Figures 1-4 - click here to enlarge

Chondroid hamartoma (five cases), tuberculous granuloma (five cases), sarcoidosis (one case) and abscess (three cases) were found in the group of benign lesions.

DISCUSSION

In cases where nodules or masses have been detected, the main objective is to determine if the lesion is benign or malignant. CT-guided percutaneous biopsy of lung is fundamental for this purpose.

In the present study, we have observed that the diameter of the lesion was of paramount importance for determining an accurate diagnosis. The smaller the lesion, the lower the accuracy. Some studies have already described these findings, like that of vanSonnenberg et al.⁽¹⁾, reporting a 90% diagnostic accuracy for lesions between 3.1 and 4.0 cm in diameter, 89.3% for lesions between 2.1 and 3.0 cm, 83.9% for lesions between 1.1 and 2.0 cm, and 73.9% for lesions between 0.3 and 1.0 cm. On the other hand, for Li et al.⁽¹²⁾, the accuracy was 74% for lesions with < 1.5 cm and 96% for lesions > 1.5 cm. The later has reported an overall accuracy of 84.5%, not taking into consideration the lesion size.

Considering only lesions with < 2.0 cm, the accuracy decreases to approximately 70%. This rate would decrease even more if we had taken into consideration only the fine-needle aspiration biopsies performed in the absence of a pathologist at the moment of the procedure. Additionally, as regards the accuracy in the absence of a pathologist during the procedure, Klein et al.⁽¹⁵⁾ have reported an accuracy of 88% for lesions with 2.9 cm in average diameter; Haramati & Austin⁽¹⁶⁾ have reported 81% for 4.0 cm lesions and Lucidarme et al.⁽⁸⁾ have reported 88% accuracy for lesions with 3.36 cm in average.

Another important data reported in previous studies is that the accuracy will increase if the number of needle passes through the lesions is higher. With the conventional technique this would imply a higher number of pleura biopsy-related injuries, increasing the risk for complications. With the coaxial technique, the number of pleura biopsy-related injuries is limited to one because, after the pass of the guide-needle (external), the necessary amount of material is withdrawn without displacing it, by means of a finer needle passing through the guide-needle. We have not employed this technique in the present study because of the unavailability of appropriate material that has later been acquired.

It is important to observe that, in sites where real time CT (CT fluoroscopy) is available, the accuracy can be even higher. Katada et al.⁽¹⁷⁾ have reported 100% accuracy for CT fluoroscopy-guided fine-needle aspiration biopsies for lesions with more than 1.1 cm, and 67% for lesions with less than 1.0 cm. Major problems are the exposure of the professional hands to the radiation and unavailability of real time CT equipment in most facilities.

Other techniques presently being employed in an attempt to improve accuracy is the freezing of the biopsy specimen and immediate evaluation by the pathologist⁽¹¹⁾ and the respiratory gating technique. Both techniques increase the cost of the procedure, making it impossible for the greatest majority of institutions in the country. Besides, additional studies are necessary for confirming the real diagnostic value of these techniques.

The choice of the biopsy method to be utilized still remains controversial and there is no consensus in the literature regarding the method appropriateness for each situation related to the size of the lesion and the distance between pleura and lesion, among others. The fine-needle aspiration biopsy presents as major disadvantages the lower diagnostic accuracy specifically for non-neoplastic lesions⁽⁴⁾ and the necessity of the presence of a cytopathologist during the procedure for the specimen analysis, which is indispensable to reduce the number of inconclusive biopsies^(5,12). Theoretically, the great advantage of fine-needle aspiration biopsy over the core biopsy would be the lower incidence of complications, a fact that is controversial in the literature^(1–12).

Most frequent complications are pneumothorax and perilesional hemorrhage. Main factors related to the increase the risk for pneumothorax are: the size of the lesion (small lesions present higher risk), the presence of emphysema and the contact between lesion and pleura (the higher the contact, the lower the risk of pneumothorax)⁽⁷⁾.

When pneumothorax occurs in the moment of the needle pass through the pleura, there is a partial lung collapse and the initial position of the lesion changes in relation to the skin marking, difficulting the access to the lesion, particularly in cases of small lesions. In the present study, such situation has occurred for three times and, in one of them there was no problem because of the lesion diameter (0.5 cm).

None of the cases of pneumothorax analyzed in this study presented a need for thoracic drain. Only two patients were submitted to aspiration with a 14-gauge intravenous catheter due to its higher caliber.

Perilesional hemorrhage has occurred in tem patients, with no reports on significant hemoptysis or other complications mentioned in other studies^(4,11,17).

Since respiratory movements affect the nodules positioning, the patients' cooperation was essential for the success of the procedure as well as his/her training and guidance before the procedure is performed. Additionally, the procedure itself and possible complications must be explained to the patients, since this usually calms them and facilitates the examination.

CONCLUSION

The accuracy of fine-needle aspiration and percutaneous biopsies of pulmonary lesions depends on the size of the lesion and the patient's cooperation. When performed by an experienced professional, these procedures have shown to be relatively safe, presenting satisfactory accuracy levels.

REFERENCES

Received September 2, 2005.

Accepted after revision December 16, 2005.

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*

Study developed at Hospital Santa Cecília, São Paulo, SP, Brazil.

Publication Dates

• Publication in this collection
  26 Sept 2006
• Date of issue
  Aug 2006

History

• Accepted
  16 Dec 2005
• Received
  02 Sept 2005