Percutaneous lung biopsies have been performed for more than a century and are commonly performed in the evaluation of solitary or multiple pulmonary lesions.1 Computed tomography (CT) has rapidly become the guidance modality of choice for performing transthoracic lung biopsy due to technical advances in CT and its better detection of pulmonary lesions than chest radiograph and ultrasound.2
Lung biopsies can be performed by fine-needle aspiration (FNA), providing a specimen for cytological examination, or using an automated cutting needle, providing a specimen for histologic examination. FNA is a reasonably simple and safe technique with an accuracy of about 95% for malignant lesions.3 However, in cases of benign lesions, the diagnostic accuracy of automated cutting needle biopsies is in fact higher than that of aspiration biopsies, ranging from 71% to 100%, and is particularly useful in making specific diagnoses.4-7 The cap between FNA and automated cutting needle biopsy in benign lesions can be avoided by the presence of a cytopathologist during the biopsy.8 However, well-trained cytopathologists are not available to immediately interpret FNA specimens in many institutions. As a result, several institutions have advocated the use of automated cutting needles to obtain core tissue for histologic evaluation.4,5 Recently, it was demonstrated that CT-guided lung biopsy could be particularly valuable in defining organizing pneumonia, Langerhans cell histiocytosis, and fungal infection.9-11
Pneumothorax and bleeding are two of the most common complications of percutaneous lung biopsies. The reported incidence of pneumothorax varies widely from 8% to 64%. The rate of chest tube placement varies from 2% to 18%.12-14 Bleeding occurs less often (2% to 10%) but is more frequently fatal. Several risk factors are considered to be related to the incidence of pneumothorax and bleeding; including needle size, chest wall thickness, lesion size, lesion depth, angle of the needle trajectory, presence of emphysema, gender of patients.15-18 Meanwhile, studies have been done to determine improvements to reduce the complication rate. Kinoshita et al19 demonstrated that the puncture site-down positioning technique was an effective choice to lower the incidence of complication. Kang et al20 reported CT perfusion imaging guided biopsy of pulmonary lumps using multi-detector row CT to be useful. Unfortunately, the results of risk analysis reported by existed studies are variable and even contradictory.
Our institute has performed CT-guided transthoracic cutting needle lung biopsy on inpatients for more than ten years. We carried out this retrospective study to analyze the clinical significance and complication rate of CT-guided cutting needle lung biopsy.
From January 2000 to October 2010, CT-guided percutaneous cutting needle lung biopsies were performed on 1014 consecutive patients. There were 744 men and 270 women, with a mean age of 59.1 years (range 16-91 years). We retrospectively reviewed the patients' charts, pathologic diagnoses, final diagnoses, and complications secondary to the lung biopsy; pneumothorax and bleeding.
All patients who had focal lung lesions presenting as a nodule, a mass, or a mass-like consolidation, and could not be diagnosed by non-invasive examinations were considered for a lung biopsy. Patients should have normal platelet counts and activated prothrombin time within one week before biopsy. An informed consent was signed after the benefits, necessities, and risks of cutting needle lung biopsy were explained to the patients or family members.
All biopsies were performed by four experienced respiratory physicians or residents under their supervision. Immediately before biopsy, the operator explained to patients the importance of patients' cooperation and patients were trained several times in regular breathing and breath-holding before the biopsy.
All patients had undergone diagnostic CT of the chest before biopsy. At the time of biopsy, preliminary helical CT images were obtained in 5-mm-thick sections through the lesion. From a review of these preliminary images, patient's position, level of the entry needle site, and directions of approach for biopsy were planned to provide the most direct route for biopsy, to traverse the least amount of aerated lung, and to avoid bullae and fissures. Patients were placed in a prone, a supine, or a lateral decubitus position, allowing penetration of the lesion from a position closest to the body surface.
After local anesthesia, a coaxial needle guide was inserted under intermittent CT guidance with its trajectory pointing toward the lung lesion. A final quick pierce of the pleural surface was made. Almost all biopsies were performed with a single pleural puncture. Each physician could choose the needle size, ranging from 18 to 16-gauge according to the lesion size. The depth from the skin to the pleura and from the pleura to the edge of the lesions was calculated from CT images. At least two core specimens were obtained by cutting a fixed 1-1.5 cm long specimen via a coaxial needle guide that was inserted at least 5 mm into the focal lung lesions. The specimens were kept in 10% formaldehyde solution. If infection was suspected, a tiny fragment of the obtained specimen was injected into 1.0 ml of nonbacteriostatic saline for staining and culture. Pathological examinations were performed by a pathologist with experience in pulmonary disease.
After removal of the biopsy needle, patients were immediately placed in a supine position and completion images were obtained to detect any post-biopsy complication. Talking and coughing were discouraged. The patients were requested to stay supine for more than four hours and they were only allowed to get off the bed 24 hours later. Asymptomatic individuals with pneumothorax who showed no pneumothorax progression were discharged after one night of observation. In the event of severe pneumothorax symptoms that required treatment, a chest tube was inserted. We did not perform FNA in the study period because it was difficult to coordinate the visit of an on-site cytologist to the CT suite in our institution.
Data collection and statistical analysis
The basic information of patients (age and sex) and date from biopsies were collected. The diagnoses from biopsies were compared with the final diagnoses (combination of the clinical and pathologic information or diagnoses from surgery). The biopsies that failed to get to the core of the lung lesions or diagnoses that were inconsistent with the final diagnoses were considered to be inefficient biopsies. The appearance of complications secondary to the biopsies, pneumothorax (especially those requiring insertion of chest tubes) and bleeding, were recorded and the complication rate was calculated.
Data from a total of 1014 biopsies were collected and an average of 101 biopsies were performed per year. We had increasing numbers of patients who underwent CT-guided lung biopsy over time. Table 1 shows the details of the basic patient information.
The final diagnoses determined by lung biopsy are shown in Table 2. Among the 1014 lesions, 639 lesions (63.0%) were diagnosed as malignant, including 55 lesions as metastases from primary malignant tumors in other organs, such as kidney, stomach, breast, and bone. The diagnoses were validated by the clinical symptoms, cytological diagnoses, or surgical resections. Three hundred and thirty-three lesions (31.8%) were diagnosed as benign (such as inflammation, tuberculosis, aspergillosis, and cryptococcosis) and were confirmed through surgical resection, lesion stabilization, diminution or disappearance. Three typical pathologic images of benign lesions are shown in Figure 1, and the specimens were diagnosed as aspergillosis, cryptococcosis, and acute chest syndrome. However, there were still 53 patients for whom we could not get exact diagnoses from the CT-guided lung biopsy. The diagnostic efficiency of CT-guided lung biopsy in our institution was 94.8%.
Two CT images seen during the biopsy are shown in Figure 2. The lesions were blocked by bone or were only about 1.0 cm at their greatest diameter. After discussing the necessity of the procedure and possible complications with the patients and family members, we finally performed the lung biopsy and we got final diagnoses three days later. However, we should admit that CT guided lung biopsy is still not free from complications. In our study, post-biopsy pneumothorax occurred in 131 (12.9%) of the 1014 cutting needle lung biopsy procedures. In 15 cases (1.5%), chest tube placement was necessary. Small hemoptysis occurred in 41 (4.0%) patients and mild parenchymal hemorrhage, that required intravenous hemostatic drugs, occurred in 16 (1.6%) patients. The overall complication rate was 18.5%. Unfortunately, there was a 45-year-old patient who died from the complications of lung biopsy. He got severe pneumothorax and hemoptysis. We performed endotracheal intubation, inserted a chest tube, and gave intravenous hemostatic drugs, but the patient finally died from respiratory failure and hypoxic encephalopathy.
CT-guided lung biopsy was first described in 1976.21 Since then, there has been great progress in this diagnostic technology. On one hand, the modalities we chose to guide the biopsy are greatly improved, from the one dimensional X-ray, and superficial ultrasound to CT; which is better at detecting pulmonary lesions. Additionally, the needles we use in the biopsy have changed from fine needles to cutting needles. These improvements have significantly improved the accuracy of biopsy and diagnosis.
The diagnostic efficiency in our patients was 94.8%. There were 53 patients who did not get a final diagnosis from lung biopsy because of the following situations: (1) We failed to get the core of the lesions and only recovered some skin or muscle, or only some neutrophils. (2) The diagnoses made from the lung biopsies were found to be wrong following surgical resection. (3) Some lesions that were diagnosed as benign were found to progress in a short time and were further confirmed as malignant lesions. The size and the site of the lesions, the skill of the operator, the difficulty in making a pathological evaluation might be sources of the discordance of the diagnostic efficiency.
There is a trend that lung biopsy is more often performed on the patients who are considered to have malignant lesions. In our study, about 30% patients were finally diagnosed with benign lesions. Pathology diagnoses are also important for such patients, especially those with infection. A cutting needle lung biopsy showed greater potential in diagnosing benign lesions than FNA.6 Three patients we provided in Figure 1 convalesced within half a year. The prompt diagnosis from lung biopsy shortened their time to recovery from the disease.
The usually mentioned exclusion criteria of lung biopsy are as follows: (1) patients who were very elderly, infirm or dyspnoeic at rest, (2) patients who were not able to lie horizontally and maintain suspended inspiration, (3) lung lesions <1.0 cm in greatest diameter, (4) lung lesions which were blocked by bone, (5) patients or family members who could not accept procedure-related risks. However, the exclusion criteria are generalizations and some patients can still get a diagnosis by lung biopsy after evaluation of their situation. The oldest patient in our study was 91 years old. Further more, as shown in Figure 2, patients with lesions blocked by bones or small lesions also got their diagnoses from lung biopsies.
For a pathologic diagnosis, the diagnostic accuracy of lung biopsy is much less doubtful. While there are concerns about risk factors of complications, especially pneumothorax. Yeow et al15 found that the risk factors for the highest pneumothorax rate are lesion size ≤2.0 cm, a subpleural lesion depth of 0.1 to 2.0 cm, and a less experienced radiologist. Choi et al17 identified female gender and the absence of an emphysematous change as risk factors for delayed pneumothorax. And Saji et al18 considered the angle of needle route to be a novel predictor of pneumothorax. In our institution, pneumothorax occurred in 131 patients and 15 required insertion of an intercostals drain. Small hemoptysis occurred in 41 patients and mild parenchymal hemorrhage occurred in 16 patients. The overall complication rate was 18.5%. And we found that accurate positioning before biopsy and enough rest after biopsy were very important to reduce the complication rate.
Even though there were only a few patients who suffered complications from lung biopsy, it is still not free from hazards. Besides pneumothorax and bleeding mentioned above, several rare but severe complications have been reported.22-24 And there was one patient who died from lung biopsy in our institution. The patient was referred to our division on May 4, 2010, with a high fever, chest distress, and cough. He was diagnosed with a pulmonary infection with asthma exacerbations. We performed the following treatment: broad-spectrum antibiotic therapy with imipenem and tinidazole, and prophylactic budesonide and salbutamol to prevent asthma. The symptoms were relieved and the CT scan subsequently showed a mass in the left lung. We considered it necessary to get a pathologic diagnosis of the mass as different diagnoses would affect treatment. Unfortunately, the patient developed a severe hemoptysis during the biopsy. Blood was swallowed and the patients felt asphyxiated. We performed endotracheal intubation, inserted a chest tube, and gave intravenous hemostatic drugs. However, the patient finally died from respiratory failure and hypoxic encephalopathy. The death of this patient reinforces that comprehensive assessment of the patient's condition is of first importance before the biopsy. Physicians who perform the procedure should be aware of the known complications and be prepared to treat them appropriately.
We found that over time, there were more patients who were undergoing lung biopsy in our institution, and the range of age of our patients had also expanded. There are several reasons to explain this phenomenon. Firstly, there were a flood of papers to confirm the diagnostic accuracy and safety of CT-guided lung biopsy, so it became widely accepted by clinicians and they were willing to persuade the patients to have this examination. A second reason was that doctors and patients demand more information for making the diagnosis. Taking malignant lesions as an example, it is no longer enough to distinguish non small cell lung cancer and small cell lung cancer by cast-off cells. The development of molecular targeted therapy and molecular pathology has brought greater demands to histologic diagnosis. Patients have become much more willing to get the exact diagnosis to insure proper treatment.
In conclusion, our study describes a large consecutive series of patients in a Chinese population who underwent transthoracic cutting needle biopsies of the lung. In line with the previous publications, CT-guided cutting needle lung biopsy was found to be a diagnostic technology with a high diagnostic efficiency and a low complication rate.
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Keywords:© 2011 Chinese Medical Association
diagnostic efficiency; complication rate; CT-guided; lung biopsy; retrospective study