Diagnostic Radiology
Comparison of Bronchial Brushing and Percutaneous Needle Aspiration Biopsy in the Diagnosis of Malignant Lung Lesions 1 Silviu Landman, M.D.,2 Francis A. Burgener, M.D., and Gerald H. K. Lim, M.B., B.S. 3 The results of 100 bronchial brushings and 80 percutaneous needle aspiration biopsies of the lung performed in the same department were analyzed for their accuracy in the diagnosis of pulmonary neoplasms. While both procedures have a high degree of reliability, the aspiration needle biopsy appears to be the procedure of choice in smaller, more peripherallesions, in Pancoast tumors, and whenever a metastatic neoplasm is suspected. Biopsies, apparatus and equipment. Biopsies, complications • Bronchi, brushing • Lung Neoplasms, diagnosis
INDEX TERMS:
Radiology 115:275-278, May 1975
CARCINOMA has significantly increased in frequency throughout the world in recent years. The continuous search for earlier, accurate diagnosis of pulmonary densities has produced two significant advances in our radiologic capabilities. The selective catheterization of the tracheobronchial tree with collection of cytologic material by bronchial brushing has achieved considerable popularity in this country, largely due to the work of Fennessy and colleagues (4-6). Several reports have shown the value of this noninvasive biopsy technique, virtually free of complications, in the diagnosis of pulmonary neoplasms and other respiratory conditions (7,9, 14, 16,24,27). Percutaneous biopsy of pulmonary lesions has been tried for a number of years by thoracic surgeons and radiologists. Earlier methods using cutting and trephine techniques (1, 2, 26) were associated with a significant number of severe complications and did not become too popular. The use of needle aspiration, refined and popularized by Swedish workers (3, 18), has proved to be more acceptable clinically and has shown a high degree of accuracy (8, 11, 17, 19-21). Our aim in this retrospective analysis is to compare these two radiologic methods of diagnosis of pulmonary neoplasms and to assess, in a similar population in the same institution, the relative indications, reliability and complication rates of the two procedures. RONCHOGENIC
B
MA TERIAL AND METHODS
Over a three-year period, a total of 112 bronchial brushings and 80 needle aspiration biopsies of the lung were performed in our department. Twelve patients underwent brushing solely for the purpose of identifying the offending organism in cases 1 2
3 4
of suspected opportunistic infections. The remaining 100 patients were suspected of pulmonary malignancy and constitute the subject of this paper. The brushing technique is described at length in a different paper (13). The nylon brushes were introduced through a remote control catheter system" which had been advanced through the tracheobronchial tree into or as close as possible to the lesion under fluoroscopic control. Steel brushes and forceps techniques were not utilized. Eighty needle aspiration biopsies were performed in 77 patients suspected of having a pulmonary neoplasm. The technique used is essentially that of Nordenstrom and associates (3) and uses a thin-walled 20-gauge spinal needle. Biplane fluoroscopic control was used whenever possible for both procedures and was found very helpful. The accuracy of the cytologic diagnosis obtained through bronchial brushing and percutaneous needle aspiration biopsy was verified by checking the surgical reports, autopsy records and clinical course of the patients examined. RESULTS
Among the 100 patients brushed for the suspicion of bronchogenic carcinoma, 28 had surgical or clinical proof of benign lesions, while in 8 patients, the follow-up period was considered inadequate. The results of the bronchial brushings in the other 64 patients are shown in Table I. Bronchogenic carcinoma was diagnosed in 61 patients, while 3 had other pulmonary neoplasms not originating in the bronchus: pneumoblastoma, neurofibrosarcoma and metastatic soft-tissue sarcoma. Among the 80 percutaneous needle aspiration
From the Department of Radiology, University of Rochester Medical Center, Rochester, N. Y. Accepted for publication in November 1974. Present address: Department of Radiology, Lourdes Memorial Hospital, 169 Riverside Dr., Binghamton, N. Y. 13905. Present address: Department of Radiology, St. Vincent's Hospital, Sydney, N.S.W., 2010, Australia. Made by Medi-Tech, Inc., Watertown, Massachusetts. shan
275
276
May 1975
SILVIU LANDMAN AND OTHERS
Table I: Tumor
Results of Bronchial Brushings and Needle Aspiration Biopsies in Malignant Lung Tumors
- - - - - - - - - - - - B r u s h Results Suspicious Total Positive Number No. % No. % 61
Bronchogenic carcinoma Other malignant lung tumors Totals
72%
44
5
8%
3 64
44 Table II:
5
8%
Negative No. %
Total Number
Needle Results-----.., Positive No. %
12
20%
37
33
89%
3
100%
8
7
88%
15
23%
45
40
89%
Distribution of Lung Tumors Investigated by Size and Location ~-- Brush
Size and Location
Total No.
Results* Correct Diagnosis No. %
Total No.
Needle Results Correct Diagnosis No. %
Size
< 2 cm 2-6 cm > 6 cm
8
4
41 12
34
Lobar distribution Upper lobes lingula RML Lower lobes Topographical distribution Central Peripheral
+
13
11
11
50% 83% 92%
23 9
22 7
85% 96% 78%
39 4 18
29 4 16
74% 100% 89%
27 3 15
24 3 12
89% 100% 80%
17 44
16 33
94% 75%
14 31
12 28
86% 90%
* Suspicious brush results were included with the positives. Only bronchogenic tumors are tabulated. (See text.) Table III:
Cases with Negative Brush and Positive Needle Results
Case
Size
Location
Topography
Final Diagnosis
I II III IV V VI
Comparison of Bronchial Brushing and Percutaneous Needle Aspiration Biopsy in the Diagnosis of Malignant Lung Lesions 1 Silviu Landman, M.D.,2 Francis A. Burgener, M.D., and Gerald H. K. Lim, M.B., B.S. 3 The results of 100 bronchial brushings and 80 percutaneous needle aspiration biopsies of the lung performed in the same department were analyzed for their accuracy in the diagnosis of pulmonary neoplasms. While both procedures have a high degree of reliability, the aspiration needle biopsy appears to be the procedure of choice in smaller, more peripherallesions, in Pancoast tumors, and whenever a metastatic neoplasm is suspected. Biopsies, apparatus and equipment. Biopsies, complications • Bronchi, brushing • Lung Neoplasms, diagnosis
INDEX TERMS:
Radiology 115:275-278, May 1975
CARCINOMA has significantly increased in frequency throughout the world in recent years. The continuous search for earlier, accurate diagnosis of pulmonary densities has produced two significant advances in our radiologic capabilities. The selective catheterization of the tracheobronchial tree with collection of cytologic material by bronchial brushing has achieved considerable popularity in this country, largely due to the work of Fennessy and colleagues (4-6). Several reports have shown the value of this noninvasive biopsy technique, virtually free of complications, in the diagnosis of pulmonary neoplasms and other respiratory conditions (7,9, 14, 16,24,27). Percutaneous biopsy of pulmonary lesions has been tried for a number of years by thoracic surgeons and radiologists. Earlier methods using cutting and trephine techniques (1, 2, 26) were associated with a significant number of severe complications and did not become too popular. The use of needle aspiration, refined and popularized by Swedish workers (3, 18), has proved to be more acceptable clinically and has shown a high degree of accuracy (8, 11, 17, 19-21). Our aim in this retrospective analysis is to compare these two radiologic methods of diagnosis of pulmonary neoplasms and to assess, in a similar population in the same institution, the relative indications, reliability and complication rates of the two procedures. RONCHOGENIC
B
MA TERIAL AND METHODS
Over a three-year period, a total of 112 bronchial brushings and 80 needle aspiration biopsies of the lung were performed in our department. Twelve patients underwent brushing solely for the purpose of identifying the offending organism in cases 1 2
3 4
of suspected opportunistic infections. The remaining 100 patients were suspected of pulmonary malignancy and constitute the subject of this paper. The brushing technique is described at length in a different paper (13). The nylon brushes were introduced through a remote control catheter system" which had been advanced through the tracheobronchial tree into or as close as possible to the lesion under fluoroscopic control. Steel brushes and forceps techniques were not utilized. Eighty needle aspiration biopsies were performed in 77 patients suspected of having a pulmonary neoplasm. The technique used is essentially that of Nordenstrom and associates (3) and uses a thin-walled 20-gauge spinal needle. Biplane fluoroscopic control was used whenever possible for both procedures and was found very helpful. The accuracy of the cytologic diagnosis obtained through bronchial brushing and percutaneous needle aspiration biopsy was verified by checking the surgical reports, autopsy records and clinical course of the patients examined. RESULTS
Among the 100 patients brushed for the suspicion of bronchogenic carcinoma, 28 had surgical or clinical proof of benign lesions, while in 8 patients, the follow-up period was considered inadequate. The results of the bronchial brushings in the other 64 patients are shown in Table I. Bronchogenic carcinoma was diagnosed in 61 patients, while 3 had other pulmonary neoplasms not originating in the bronchus: pneumoblastoma, neurofibrosarcoma and metastatic soft-tissue sarcoma. Among the 80 percutaneous needle aspiration
From the Department of Radiology, University of Rochester Medical Center, Rochester, N. Y. Accepted for publication in November 1974. Present address: Department of Radiology, Lourdes Memorial Hospital, 169 Riverside Dr., Binghamton, N. Y. 13905. Present address: Department of Radiology, St. Vincent's Hospital, Sydney, N.S.W., 2010, Australia. Made by Medi-Tech, Inc., Watertown, Massachusetts. shan
275
276
May 1975
SILVIU LANDMAN AND OTHERS
Table I: Tumor
Results of Bronchial Brushings and Needle Aspiration Biopsies in Malignant Lung Tumors
- - - - - - - - - - - - B r u s h Results Suspicious Total Positive Number No. % No. % 61
Bronchogenic carcinoma Other malignant lung tumors Totals
72%
44
5
8%
3 64
44 Table II:
5
8%
Negative No. %
Total Number
Needle Results-----.., Positive No. %
12
20%
37
33
89%
3
100%
8
7
88%
15
23%
45
40
89%
Distribution of Lung Tumors Investigated by Size and Location ~-- Brush
Size and Location
Total No.
Results* Correct Diagnosis No. %
Total No.
Needle Results Correct Diagnosis No. %
Size
< 2 cm 2-6 cm > 6 cm
8
4
41 12
34
Lobar distribution Upper lobes lingula RML Lower lobes Topographical distribution Central Peripheral
+
13
11
11
50% 83% 92%
23 9
22 7
85% 96% 78%
39 4 18
29 4 16
74% 100% 89%
27 3 15
24 3 12
89% 100% 80%
17 44
16 33
94% 75%
14 31
12 28
86% 90%
* Suspicious brush results were included with the positives. Only bronchogenic tumors are tabulated. (See text.) Table III:
Cases with Negative Brush and Positive Needle Results
Case
Size
Location
Topography
Final Diagnosis
I II III IV V VI
