The main indication for TTNA/CBN in both groups was the evaluation of a lung mass and suspected malignancy. There was no difference in the diagnostic yield or complications for both groups. Of the 35 TTNA and/or biopsy results, 16 were malignant, 7 were suggestive of an inflammatory, benign process, and 12 were nonspecific. The cell types of the 16 malignant specimens were as follows: adenocarcinoma, 6; squamous cell, 5; metastatic carcinoma, 2; small cell, 1: and others, 2. Adenocarcinoma and squamous cell carcinoma were the most common malignancies. The overall yield of the procedure was 66%, with malignancy being the most common diagnosis, seen in 70% of the diagnostic procedures (Table 3).
TTNA was the preferred procedure for pulmonologist compared with radiologists (79% vs. 50%). Twelve patients underwent CNB and TTNA, with 9 being positive; CBN was positive in all 9 patients (Table 4). The number of pleural passes for both groups was 2.4 (range: 1 to 3).
Follow-up Results and Complications
Seven patients had TTNA and/or CNB consistent with inflammatory or benign process; 2 of them underwent further diagnostic procedure confirming the diagnosis of a benign process. The 5 remaining patients had complete resolution of the pulmonary abnormalities after antibiotic treatment.
Ten of the 12 patients with nonconclusive TTNA and/or CBN underwent further diagnostic procedures; a benign etiology was confirmed in 1, and the remaining 9 patients all had malignancy. The most common diagnostic procedure performed was surgical biopsy (Table 5). Of the other 2 patients with a nonconclusive procedure, one died during hospital stay and the other refused further diagnostic procedures.
The most common complication noted was pneumothorax. Four patients (11%) developed a pneumothorax, 2 required chest tube placement.
This study, which compared diagnostic yield and complications of TTNA and/or CBN for pulmonologists versus IRs, demonstrated that there was no difference between these 2 groups.
TTNA has been used in the diagnosis of thoracic lesions for more than 100 years. Over the past 20 years, improvements in technology have led to an explosion in the procedures available for the diagnostic and therapeutic aspects of pulmonary medicine. Interventional pulmonology is an evolving field in pulmonary medicine that focuses on providing consultative and procedural services to patients with pulmonary disorders. The emergence of this discipline has been fueled by the surge in technology, and by the need to maintain procedural competency and expertise in an everexpanding specialty of pulmonary medicine. There are still numerous problems and obstacles to make these services available across the healthcare system. Important issues are expense of the technology and training and maintenance of competences. TTNA and CNB remain an orphan procedure, no longer required by ABIM for pulmonary certification and not consistently incorporated in the procedures under the direction of an interventional pulmonologist. The American College of Chest Physicians (ACCP), the European Respiratory Society, and the American Thoracic Society have published guidelines on interventional procedures with recommendations on the number of TTNA and CNB to be performed to achieve and maintain proficiency. The recommended number is 10 for each technique.1–3,6
The American College of Radiology requires a minimum of 35 image-guided TTNA and CNB to achieve competency.7 Currently, diplomates of the American Board of Radiology are expected to maintain their certification by completing the board's Maintenance of Certification program.8
The British Thoracic Society (BTS) in agreement with the Royal College of Radiologists and the British Society of Interventional Radiology recommends that operators who perform radiologically guided biopsies audit their own practice and monitor their complication rates. These should be similar to, or better than, those from national surveys: pneumothorax (20%), pneumothorax requiring drainage (3%), hemoptysis (5%), and death (<0.1%).9
In a large national survey of practicing pulmonologists, Ernst and collaborators2 reinforced the notion that the overall procedural skills of most pulmonologists are inadequate and or not uniform. Only one-quarter of practicing pulmonologists currently perform all procedures that are required for board certification in pulmonary medicine.2
A survey of 94 pulmonary and critical care fellowship programs in the United States which included university (89%) and community hospitals (11%) revealed that 33% of the programs offered training in TTNA/CNB with only 10% able to achieve the recommended competency number. All fellowships were of 3 years duration and had an average of 14 faculties per program. Forty-nine programs (53%) had a dedicated interventional pulmonologist and 9 had a single pulmonologist supervising more than half of the procedures.5
Our institution is the largest voluntary, not-for-profit healthcare system serving the South and Central Bronx in New York, with 865 acute care beds at 2 major hospital locations. The pulmonary and critical care division has 8 faculty members and 5 pulmonary fellows; 4 of the faculty have training in TTNA/CBN and perform these procedures. The average number of TTNA/CBN per faculty is 1 to 2/y, a number, much lower than recommended to achieve or maintain competence. In a community hospital like ours, it is not feasible to achieve the minimum requirements recommended by the ACCP. But, as recommended by the BTS, the yield and rate of complications is monitored.9 A recent survey of 139 thoracic radiologists practicing in academic (74%) and community based (26%) hospitals in the United States and Canada revealed that approximately 70% perform the procedure under CT guidance. Seventy percent of responders preferred TTNA, whereas 14% preferred CNB and 13% both. An on-site pathologist was available to 73% of responders.10 Another report from the UK again reveals a great variation in practice, with IR performing most of the procedures.11
The choice between TTNA and CNB is controversial and depends upon personal experience and the availability of a pathologist on site. Most of the pulmonologists, including our faculty, are more comfortable with TTNA and have an on-site pathologist.
Our study did not show any difference in the yield of TTNA or CBN when the procedure was performed by an IR without an on-site pathologist or a pulmonologist with an on-site pathologist. The yield for CNB was higher than TTNA alone in both groups, 61% versus 75%, but without reaching statistical significance. Some investigators suggest that when the most probable diagnosis is malignancy and an on-site pathologist is available, TTNA should be the first choice.12,13 However, CBN have been reported to provide higher yield in the specific diagnosis of benign lesions and lymphoma when compared with TTNA, even in the absence of an on-site pathologist.12,14
Some studies suggest that the combined use of TTNA and CNB improves the diagnostic ability of CT-guided lung biopsy, even in small, <10 mm lesions.15,16
The reported accuracy of TTNA and CNB for the diagnosis of pulmonary malignancy or malignant mediastinal lymphadenopathy ranges from 80% to 95%. Negative predictive values range from 84% to 96%, with false-positive rates of 2% to 4%. However, CNB can provide a specific benign diagnosis in 44% to 100% of cases, whereas TTNA has been shown to establish a specific benign diagnosis in only 12% to 47%.1,17,18
The reported diagnostic sensitivity for TTNA/CNB is 68% to 96%, with a specificity of 100%, and an accuracy of 74% to 96% in lesions of all sizes.19,20
In our study, all patients had lesions larger than 3 cm, but the diagnostic accuracy was closer to the accuracy reported for lesions smaller than 3 cm.4,21 One of the reasons could be the fewer procedures performed at our community hospital compared with university hospitals. In a report of 130 TTNAs, the sensitivity for small lesions (<3 cm) was 67% compared with 81% for lesions ≥3 cm.4 Other investigators have found no differences for the diagnostic yield of TTNA between small and larger lesions.19
The overall prevalence of malignancy in those patients with nonspecific TTNA/CNB results and after further surgical biopsy was 90% in our study, a rate similar to the 33% to 100% reported by others.4,22,23
Whereas some investigators found no difference in the complication rate of TTNA compared with CNB, others reported an increased rate of hemorrhage with CNB. The incidence of pneumothorax ranges widely from 6% to 60%, with higher rate if patients have moderate to severe emphysema or when CNB is performed. Hemoptysis is reported in 5% to 15% of cases. Tension pneumothorax and death are rare complications of TTNA.12,14,21,24
A report of 331 CT-guided and 24 fluoroscopically guided lung biopsies performed either by a trained radiologist or radiology residents at different levels of training, revealed that smaller lesion and presence of emphysema strongly correlated with occurrence of pneumothorax. Pneumothorax was reported to be less frequent in lesions abutting the pleura. Lesion location, needle size, number of pleural passes, and level of training did not correlate with rate of pneumothorax.25
In our study, no differences in complication rates were found between the groups.
The limitations of this study include its retrospective nature and absence of an on-site pathologist in the IR group. It is possible that the yield for IR could be increased by the presence of an on-site pathologist. Second, the number of cases was too small to find a significant difference for yield and complication rate. Further, larger prospective, randomized comparative studies with an on-site pathologist in both groups could help to validate our findings.
We could find no other study comparing the yield and complications of TTNA and CNB between a noninterventional pulmonologist and an IR in an inner-city community hospital. We have demonstrated that TTNA with or without CBN remains a useful and safe procedure in the hands of noninterventional pulmonologist and fellows in training. In the setting of community hospitals, neither the pulmonologist nor the IR can perform the required number of procedures to maintain proficiency. The diagnostic yield of the procedure is similar for the IR and the pulmonologist if the latter group uses assistance from an on-site cytopathologist.
The goal of fellowship programs is to ensure that trainees receive the best possible training in both the cognitive disciplines of pathophysiology and procedural skills that define their specialty. Although current consensus guidelines advocate competency numbers that may be too high for community programs, it is clear that a minimum number of procedures or a different competency system should be in place to achieve and maintain competency. Pulmonary training programs could consider limiting the number of faculty performing the procedure or teaming with radiologist to train pulmonary fellows and faculty if feasible. We recommend both TTNA and CNB to maximize the yield of the procedure.
We believe that pulmonary fellowship programs should continue to offer training in TPNA/CNB as long as the faculty has the expertise to do it. Many of our graduates will join small community hospital where there is no interventional radiology or pulmonologist and transferring or referral of patients may not be always possible. Obtaining expertise in CNB is of the outmost importance to maximize the yield of the procedure and decrease the need for further invasive diagnostic procedures. We suggest that if on-site cytologic examination is available pulmonologists can provide as good yield as the IR while performing TTNA and CNB.
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Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
transthoracic needle aspiration; core needle biopsy; resident training; interventional radiology