Radiol med DOI 10.1007/s11547-013-0360-1
CHEST RADIOLOGY
Trans-thoracic biopsy of lung lesions: FNAB or CNB? Our experience and review of the literature Emanuela Capalbo • Michela Peli • Maria Lovisatti • Maria Cosentino • Paola Mariani • Eisabetta Berti • Maurizio Cariati
Received: 26 July 2012 / Accepted: 13 May 2013 Ó Italian Society of Medical Radiology 2013
Abstract Purpose This study was performed to determine the type and incidence of complications of fine-needle aspiration biopsy (FNAB) and core biopsy (CNB) performed under computed tomography (CT) guidance to characterise lung lesions, and assess the diagnostic accuracy of the two techniques. Materials and methods In 2009–2011, we performed 124 lung biopsies (66 CNB and 56 FNAB) on 121 patients with a mean age of 72.4 years. Exclusion criteria were pulmonary resection, pleural lesions and/or effusions, and inadequate blood-coagulation profile. All examinations were acquired after contrast-agent administration in a craniocaudal direction from the lung apex to base during a single inspiratory breath-hold, with standardised parameters. Each lesion was scanned with 13–15 slices that could be repeated whenever necessary to document the needle track and for lesion centring, by positioning a metallic marker perpendicular to the centring light to indicate the point of needle access. Unless otherwise clinically indicated, 4 h after the procedure chest radiography was performed.
Results Age was found to be a factor influencing the complications: pneumothorax in young subjects (31 %) and parenchymal haemorrhage in the elderly (30 %), with CNB but not with FNAB. We had more complications with the right lung: 50 % of pneumothorax cases in the upper lobe with CNB and 40 % of cases of haemorrhage in the lower lobe with FNAB. The anterior approach gave rise to more complications with CNB, while the posterior approach with FNAB. CNB had more complications than FNAB for lesions B3.5 cm (31 vs. 18 % pneumothorax), and [3.5 cm (34 vs. 9 % haemorrhage). There was no significant correlation with lesion histology, needle calibre or number of passes (probably due to the small number of procedures done with needles other than 18 G in CNB or 22 G in FNAB or involving more than one needle pass). The diagnostic accuracy of FNAB, done with a pathologist’s extemporaneous assessment of sample adequacy, was 94.83 % against 81.82. % of CNB. Conclusions FNAB under CT guidance is subject to a lower rate of complications and, if performed in the presence of the pathologist, has a greater diagnostic accuracy compared to CNB.
E. Capalbo (&) M. Peli M. Lovisatti M. Cosentino School of Specialization of Diagnostic and Interventional Radiology, University of Milan, Via A. Di Rudinı`, 20142 Milan, Italy e-mail: [email protected]
Keywords Lung lesions Fine-needle aspiration biopsy (FNAB) Core-needle biopsy (CNB) Computed tomography guidance Diagnostic accuracy Complications
E. Capalbo M. Peli M. Lovisatti M. Cosentino P. Mariani M. Cariati Department of Diagnostic Sciences, UOC of Diagnostic and Interventional Radiology, San Carlo Borromeo Hospital, Via Pio II 3, 20153 Milan, Italy
Introduction
E. Berti Department of Diagnostic Sciences, UOC of Pathology, San Carlo Borromeo Hospital, Via Pio II 3, 20153 Milan, Italy
In the last few decades, there has been a significant increase in lung cancer incidence, especially in industrialised countries [1]. To reduce the high mortality characterising this disease, an early diagnosis is mandatory.
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Radiol med Table 1 General characteristics of the study population FNAB N (%) – mean ±[SD]
CNB N (%)– mean ±[SD]
Total N (%)– mean ±[SD]
56 (45.9)
66 (54.1)
122
18 G
54 (81.8)
54 (43.5)
20 G
10 (15.2)
10 (8)
No. of lesions Needle calibre
21 G
2 (3.5)
22 G
56 (96.5)
No. of passes 1 2
4 (3.2) 56 (45.2)
44 (78.5)
60 (90.9)
104 (85.2
12 (21.5)
4 (6)
16 (13.1)
2 (4)
2 (1.6)
1.12 [±15]
1.19 [±13]
3 Mean no. of passes
2 (3)
1.21 [±11]
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy, SD standard deviation
Today, diagnostic imaging and interventional radiology with lung biopsy have made it possible to achieve this aim. The first to perform a lung biopsy was Leyden in 1883, followed by Menetrier in 1886 [2]; later on, in 1970, with Porto, lung biopsy performed under fluoroscopic or radiographic guidance became widely disseminated [3]. The growing use of chest computed tomography (CT) has led to the detection of an increasing number of lung lesions, even of small dimension, which has heightened the interest in percutaneous CT-guided lung biopsies [4, 5]. The complication rate was initially very high, up to 61 % for pneumothorax [6], but over the years it has been reduced by optimising biopsy materials and imaging techniques [7], and is now 26.6 %, as described in a recent review [8]; moreover, the procedure carries relatively low mortality rates (0.07 %) [7, 9, 10]. When percutaneous biopsy is used to establish the diagnostic and therapeutic workup of a lung lesion, one must carefully evaluate the cost–benefit ratio as well as the most frequent complications—pneumothorax and parenchymal haemorrhage [5, 9, 11]. Although both complications usually resolve spontaneously, the occurrence of pneumothorax during the procedure may lead to an inconclusive result and, in a variable percentage of cases, worsening pneumothorax may require placement of a chest drain, whereas parenchymal haemorrhage may necessitate hospitalisation [12]. The first aim of this study was to assess the type and incidence of complications arising in CT-guided lung biopsies performed with fine-needle aspiration (FNAB) or cutting needle (CNB), by analysing the different variables related to the patient (age), the lesion (dimension, nature, side) and the procedure (number of passes, access and needle calibre). A secondary aim was to ascertain which technique has greater diagnostic accuracy, even in consideration of lesion size.
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Fig. 1 Lung biopsy with an 18-G trucut needle of a lesion of the dorsal segment of the right upper lobe, performed with a single pass with posterior access
Fig. 2 Fine-needle aspiration biopsy (FNAB) with a 22-G needle of a 1.2-cm nodule in the dorsal segment of right lung lower lobe with a single pass and posterior access
Materials and methods This retrospective study was performed by analysing a series of 121 patients, 15.3 % of them with known oncological disease, who underwent CT-guided lung biopsy using CNB or FNAB between 01-01-2010 and 31-12-2011. A total of 122 biopsies were performed in 76 men and 45
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Fig. 3 Core-needle biopsy (CNB) obtained with an 18-G needle and a single pass (a), postbiopsy computed tomography (CT) scan: occurrence of an anterior pneumothorax (b); chest radiograph at 2 h:
presence of apical pneumothorax (c); radiograph at 2 days: complete resolution of the pneumothorax without the need for surgical drainage (d)
Table 2 Complication rate based on complication type and sampling method
on history, objective and/or imaging features; in particular, CNB was selected for suspected benign, lymphoproliferative or sarcomatous lesions, while FNAB was used in known oncological patients and in all other cases, especially if the pathologist was on site. Exclusion criteria were previous surgery for lung resection (because postsurgical adhesions may protect against pneumothorax), pleural lesions, pleural effusions, and inadequate coagulation status (prothrombin time \1.4 and/or platelets \80,000/ml). Any platelet antiaggregant and anticoagulant treatment was suspended a few days prior to the procedure and subsequently resumed by the patient, in accordance with the haematologist’s indications. All patients had previously undergone a CT or highresolution CT (HRCT) examination which identified and defined the lesion. All the biopsies were carried out as inpatient or day-case procedures.
FNAB N (%)
CNB N (%)
Total N (%)
Pneumothorax
14 (21.2)
12 (21.4)
26 (21.3)
Haemorrhage
8 (12.1)
5 (8.9)
13 (10.6)
Pneumothorax ? haemorrhage Haemoptysis
6 (9) 4 (6.8)
2 (3.5) –
8 (6.5) 4 (6.8)
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
women (mean age 72.4 ± 13.8 years); one man repeated the biopsy (Table 1). The referring physician (oncologist and/or surgeon) had determined the indication for the procedure, which was subsequently evaluated by the radiologist who selected the biopsy technique according to the clinical suspicion based
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CT scan. Parenchymal haemorrhage was defined as an increased lung attenuation with preserved bronchial and vascular margins along the needle path. We recorded as pneumothorax any amount of air appearing between the lung and pleura. Expiratory chest radiography was performed in all patients 4–6 h after the procedure to assess the appearance or the growth of a pneumothorax previously detected on postprocedure CT. The evolution of the pneumothorax was further evaluated 2–4 h later. If it became stable or smaller, the patient was discharged, whereas if it increased the surgeon’s advice was sought for possible placement of a chest drain. In the event of complications arising in patients
All patients received verbal explanations about the biopsy procedure and its possible complications, and they subsequently read and signed the written informed consent form, which included consent for using their anonymised clinical data for scientific purposes. The possible complications of a CT-guided lung biopsy are pneumothorax, haemorrhage, haemothorax, haemoptysis, rarely seeding of neoplastic cells along needle path, cardiac effusion, and pulmonary infections (pneumonia, empyema), as well as risks attributable to the administration of the drugs used during the procedure. Pneumothorax and parenchymal haemorrhage were evaluated for about 5 min after the end of the procedure with a postprocedure Fig. 4 CNB age
CNB – Age. Hemoptysis
Hemoptysis
no
no
PNX
PNX
Suffusion
Suffusion
Suffusion+ PNX
Suffusion+PNX
46 4 (9%) 16 (35%)
20 10 (50%)
0 (0%)
100% 0%
100%
50%
35%
8 (17%)
30% 30%
6 (30%)
Young
100%
17%
14 (30%)
2 2 (10%) (10%)
9%
10% 4 (9%)
Elderly
10%
9%
Young
Elderly
CNB – Età. emottisi
emottisi
no
no
pnx
pnx
soffusione emorragica
soffusione emorragica
soffusione emorragica e pnx
46 4 (9%) 16 (35%)
20 10 (50%)
0 (0%)
giovane
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100%
50%
35%
8 (17%)
9%
17% 30%
14 (30%)
6 (30%) 2 2 (10%) (10%)
soffusione emorragica e pnx
100% 0%
30% 10%
4 (9%)
vecchio
10%
9%
giovane
vecchio
100%
Radiol med
who underwent the biopsy as a day-case procedure, the need for hospitalisation was assessed in relation to the clinical symptoms and signs. Biopsy protocol The examinations were performed on a 16-slice Lightspeed CT system (GE Medical System, Milwaukee WI, USA) and on a 128-slice SOMATOM Definition AS ? CT system (Siemens Healthcare, Erlangen, Germany). All examinations were acquired in a craniocaudal direction from the lung apex to base, during a single inspiratory breath-hold with the following standardised parameters: thickness 2.5 mm, collimation 10 mm, field of view 320–360 mm, pitch 1.75, 120 kV; automatic tube current modulation (mA); standard reconstruction filter; lung window. Patients received iodinated contrast agents: Ioversolo 350 (Covidien, Italy) and Iopromide 370 (Bayer Schering Pharma, Germany). According to lesion location, the ideal needle trajectory from the skin to the lesion was established. The lesion was scanned with 13–15 slices having a thickness of 2.5 mm, and this scan could be repeated whenever necessary to clearly document the needle track. Lesion centring was performed on the axial image of the image stack, in which the lesion presents the greatest extension and needle access is less hampered by the presence of anatomical structures. On the chosen image, a metallic marker is placed perpendicular to the centring light, which indicates the point that will be used for needle access. The needles used were Chibell (Biopsybell, Modena, Italy) with a calibre of 20 and 22 G, for FNAB
procedures, and Biomol (HP Service Hospital, Latina, Italy) with a calibre of 18, 20 and 21 G for CNB procedures. The biopsy procedures were carried out alternately by two radiologists with decades of experience. During the CNB procedures, no pathologist was present in the room, whereas during the FNAB procedures, a pathologist was on site to extemporarily evaluate the adequacy of the sample. Sample adequacy was assessed in real time alternately by two equally experienced pathologists, who subsequently performed also the final reading of the microscope slide. We used test tubes with and without fixative, skin disinfectant, bevelled glass slides, cover slips, racks, fixatives, haematoxylin–eosin staining scale, Papanicolaou stain, and a diagnostic room set up with a hood and an optical microscope. In relation to the pathological report, the result of each procedure was classified as diagnostic or nondiagnostic. Samples were defined nondiagnostic in the event of insufficient, cell-free, or strongly haematic material. Diagnostic samples were grouped by histological type. The CT images were assessed for the following parameters: needle access (anterior, posterior, lateral), lesion site (upper or lower right lobe, middle lobe, upper or lower left lobe), lesion size (large if [3.5 cm or small if B3.5 cm), patient’s age [\65 years (young) and C65 years (elderly)], needle gauge, number of needle passes, and lesion histology; all variables were correlated to the type and incidence of complications recorded with the two biopsy methods. In addition, we evaluated which technique had greater diagnostic accuracy, also in relation to lesion size.
Fig. 5 FNAB with an 18-G needle of a lesion of the right upper lung lobe with single pass and lateral access (a); at the end of the procedure, a small parenchymal detachment, and circumscribed haemorrhage along the needle track (b)
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Statistical analysis
Results
The baseline characteristics of the study population were expressed as mean ± standard deviation for continuous variables, and as percentages for categorical variables. Correlation between the variables considered and the presence of complications (pneumothorax, parenchymal haemorrhage, haemoptysis) was calculated using the Chisquare test. We represented the results obtained using histograms. In the graphs on the left, each histogram represents the number of observations classified according to the labels/classes placed under the columns, with an indication, within each label/class, of the type of complication (the various colours of the histogram). Conversely, the graph on the right does not consider the number of observations for each class, but only the percentage incidence of the different complications within the same class.
We performed 122 biopsies (66 CNB and 56 FNAB) of lung lesions having a mean size of 3.5 ± 2.3 cm (range 1.2–9.7); nodules sampled with CNB (Fig. 1) had a mean size of 3.8 ± 2.6 cm, whereas those sampled with FNAB (Fig. 2) were 2.9 ± 1.9 cm (Table 1). Complications occurred in 51 of the 122 biopsies (41 %). These included pneumothorax, haemorrhage, pneumothorax associated with haemorrhage, and haemoptysis. The most frequent complication was pneumothorax (Fig. 3), which required surgical placement of a chest drain in three patients (2.4 % of the entire population and 11.5 % of those with pneumothorax) (Table 2). There were no cases of late pneumothorax, since all cases were diagnosed by postprocedure CT or by radiography performed a few hours after the end of biopsy (Fig. 3). No case of parenchymal haemorrhage necessitated either hospitalisation (of the day cases) or additional treatments (of the inpatients).
FNAB – Age. 56 (100%)
32 (56%)
no
12 (20)
PNX
Suffusion Suffusion+ PNX
2 (4%)
10 (18%)
Eldery
FNAB – Età. 56 (100%)
no
32 (56%)
12 (20)
pnx
soffusione emorragica soffusione emorragica e pnx
2 (4%)
10 (18%)
vecchio
Fig. 6 FNAB: age
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Table 3 Fine-needle aspiration biopsy vs. core-needle biopsy for the development of pneumothorax and parenchymal haemorrhage Pneumothorax
Haemorrhage
Pneumothorax and haemorrhage
CNB N (%)
CNB N (%)
CNB N (%)
FNAB N (%)
FNAB N (%)
FNAB N (%)
Age C65 years
4 (17)
7 (30)
2 (9)
\65 years
3 (30)
1 (10)
1 (10)
Dimensions [3.5 cm
3 (17)
3 (27)
5 (28)
1 (9)
1 (6)
C3.5 cm
4 (27)
3 (18)
3 (20)
4 (24)
2 (13)
Anterior
3 (30)
1 (20)
4 (40)
Posterior
2 (12)
2 (22)
3 (18)
1 (11)
Lateral
2 (33)
3 (21)
1 (17)
4 (29)
Upper lobe
3 (30)
1 (17)
Middle lobe
2 (12)
Lower lobe
2 (33)
1 (9)
Needle access 1 (10) 2 (12)
1 (11)
4 (40)
1 (10)
1 (17)
3 (18)
2 (12)
Right lung
1 (20)
1 (17)
2 (40)
2 (22)
1 (17)
2 (22)
1 (17)
1 (14)
1 (11)
1 (14)
1 (11)
Left lung Upper lobe Lower lobe
1 (11)
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
Radiol med
pneumothorax (Fig. 5) had a higher incidence among young patients (30 vs. 17 %). Haemoptysis occurred in 9 % of elderly patients, either immediately or a few hours after the end of the procedure; no case of haemoptysis was recorded among the young patients. No patient younger
The patients were analysed in relation to age and type of biopsy. For CNB, the complication rate was 65 % among the elderly patients (Fig. 4) vs. 50 % among the young patients (p \ 0.005). In particular, haemorrhage was more frequent in elderly patients (31 vs. 10 %), whereas
Fig. 7 CNB: lesion size
CNB – Lesion size. Hemoptysis no PNX Suffusion Suffusion + PNX
Hemoptysis no PNX Suffusion Suffusion + PNX 36 2 (6%) 16 (44%)
6 (17%) 10 (28%) 2 (6%) Large
100% 6% 30 2 (7%)
44%
100% 7%
100%
33%
10 (33%) 8 (27%)
17%
6 (20%) 4 (13%)
28%
Small
6% Large
27%
20%
13% Small
CNB – Dimensione nodulo. emottisi no pnx soffusione emorragica soffusione emorragica e pnx 36 2 (6%) 16 (44%)
6 (17%)
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 100% 6%
30 2 (7%)
44%
100%
33%
10 (33%) 8 (27%)
17%
28%
2 (6%)
6 (20%) 4 (13%)
grande
piccolo
10 (28%)
100% 7%
6% grande
27%
20%
13% piccolo
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Radiol med Fig. 8 FNAB: lesion size
FNAB – Lesion size. no PNX Suffusion Suffusion+ PNX
no PNX Suffusion Suffusion+PNX
22
34
100%
100%
20 (59%)
55%
59%
6 (18%)
27%
18%
9% 9%
24%
Large
Small
100%
12 (55%) 6 (27%)
2 2 (9%) (9%)
0 (0%)
Large
8 (24%)
Small
0%
FNAB – Dimensione lesione. no PNX Soffusione Soffusione+ PNX
22
no PNX Soffusione Soffusione+PNX
34
100%
100%
20 (59%)
55%
59%
6 (18%)
27%
18%
9% 9%
24%
100%
12 (55%) 6 (27%)
2 2 (9%) (9%)
0 (0%)
Grande
Table 4 Complication rate based on complication type and lesion dimension
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
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Lesion dimension
8 (24%)
0%
Grande
Piccolo
FNAB N (%)
Piccolo
CNB N (%)
\3.5 cm
[3.5 cm
\3.5 cm
Pneumothorax
6 (18)
6 (27)
8 (27)
6 (17)
Haemorrhage
8 (24)
2 (9)
6 (20)
10 (28)
Pneumothorax ? haemorrhage
–
Haemoptysis
–
2 (9) –
[3.5 cm
4 (13)
2 (6)
2 (7)
2 (6)
3 (30)
2 (33)
lower lobe
1 (11)
Lower lobe
1 (11)
1 (17)
2 (12)
1 (10)
1 (10) 2 (12)
2 (13)
1 (6)
1 (10)
2 (9)
CNB core-needle biopsy, FNAB fine-needle aspiration biopsy, PNX pneumothorax
1 (17)
1 (17)
3 (18)
4 (40)
Upper lobe
1 (11)
2 (12)
Left lung
3 (30)
1 (17)
2 (33)
Middle lobe
4 (40) 3 (18)
Upper lobe
Right lung
Posterior
Anterior Lateral
3 (20)
5 (28)
1 (10)
7 (30)
3 (30) 2 (12)
4 (27)
C3.5 cm
Access
3 (17)
[3.5 cm
Dimension
4 (17)
C65 years
\65 years
Age
1 (11)
2 (12)
2 (12)
1 (7)
1 (6)
2 (9)
Haemoptysis N (%)
1 (14)
2 (22)
1 (20)
1 (17)
3 (21)
1 (20) 2 (22)
3 (18)
3 (27)
–
–
PNX N (%)
PNX ? haemorrhage N (%)
PNX N (%)
Haemorrhage N (%)
FNAB
CNB
1 (14)
2 (22)
4 (29)
1 (11)
4 (24)
1 (9)
–
–
Haemorrhage N (%)
Table 5 Variables determining the onset of complications and the complication rates for core-needle biopsy and fine-needle aspiration biopsy
2 (40)
(17)
1 (11)
–
1 (9)
–
–
PNX ? haemorrhage N (%)
–
–
–
–
–
–
– –
–
–
–
–
Haemoptysis N (%)
Radiol med
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Radiol med Fig. 9 CNB: needle approach
CNB – Needle approach. Hemoptysis no PNX Suffusion Suffusion+ PNX
Hemoptysis no PNX Suffusion Suffusion + PNX 34 4 (12%)
100% 0%
100% 0%
100% 100%
12%
20% 50%
16 (47%)
20 0 4 (0%) (20%) 6 (30%) 6 (40%) 2 (10%) Anterior
12
0 (0%) 6 (50%) 4 (33%) 0 (0%) 2
4 (12%)
30%
40%
47%
33%
6 (18%)
18%
4 (12%)
10%
Rear
Anterior
Lateral
12%
17%
12%
0% Lateral
Rear
CNB – Accesso ago. emottisi no pnx soffusione emorragica soffusione emorragica e pnx 34 4 (12%)
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 100% 0%
100% 0%
100% 100%
12%
20% 50%
16 (47%)
20 0 4 (0%) (20%) 6 (30%) 6 (40%) 2 (10%) anteriore
12
0 (0%) 6 (50%) 4 (33%) 0 (0%) 2 laterale
than 65 years underwent FNAB sampling (Fig. 6), so we were unable to assess whether the complications arising with this method were influenced by age (Table 3). With regard to lesion size (large if [3.5 cm and small if B3.5 cm), we found a higher complication rate for small lesions among patients undergoing CNB (67 %) (Fig. 7)
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4 (12%)
30%
40%
47%
33%
6 (18%)
12% 18%
4 (12%)
10%
posteriore
anteriore
17%
12%
0% laterale
posteriore
and for large lesions among those undergoing FNAB (45 %) (p \ 0.005) (Fig. 8; Table 4). A correlation was found between needle access (anterior, posterior or lateral) and complication rate (p \ 0.005) (Table 5) in both the CNB group (Fig. 9) and the FNAB group (Fig. 10).
Radiol med Fig. 10 FNAB: needle approach
FNAB – Needle approach. no pnx Suffusion Suffusion+PNX
no pnx Suffusion Suffusion+PNX 28
100%
14 (50%)
18
100%
100%
56%
50%
100
80% 10 (56%)
10 8 (80%) 2 (20%)
0 (0%) 0 (0%)
Anterior
4 (22%)
6 (21%) 2 (11%) 2 (11%)
Lateral
8 (29%)
21% 22% 11% 20%
0 (0%)
0% 0%
Rear
Anterior
29%
11% 0% Lateral
Rear
FNAB – Accesso ago. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 28
100%
14 (50%)
18
100%
100% 100%
56%
50%
80% 10 (56%)
10 8 (80%) 2 (20%)
anteriore
0 (0%) 0 (0%)
4 (22%)
laterale
In addition, we correlated complications with lesion location, in terms of side and lobe. For both biopsy methods (Table 5), we recorded a higher number of complications in the right lung (p \ 0.005) (Fig. 5). In the CNB group (Fig. 11), the complication rate was higher in the upper lobe, while in the FNAB group (Fig. 12) it was higher in the lower lobe. A higher complication rate was recorded in the left lung both for CNB (Fig. 13) and for FNAB (Fig. 14). Our study revealed no statistically significant correlation with the needle calibre (p [ 0.005). This may be in part explained by the small number of procedures done using needles with a calibre other than 18 G (Fig. 1) for CNB
6 (21%) 2 (11%) 2 (11%)
8 (29%)
21% 22% 11% 20%
0 (0%)
0% 0%
posteriore
anteriore
29%
11% 0% laterale
posteriore
(Fig. 15); for FNAB (Fig. 16), only two procedures (3.5 %) were performed with 20 G needles, the other 54 biopsies (96.5 %) were done with 22 G needles (Fig. 2; Table 1). Similarly, there was no statistically significant correlation with the number of passes (p \ 0.005). The reason for this is probably that only two of the CNB procedures (3 %) required three passes and four (6 %) required two passes (Fig. 17); as for FNAB, 12 cases (20.6 %) required two passes (Fig. 18; Table 1). Similar results were obtained with regard to lesion histology (p [ 0.005), both for lesions sampled with CNB (Fig. 19) and with FNAB (Fig. 20). We were unable to evaluate complications on the basis of either lesion nature (benign or malignant), as only six
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Radiol med Fig. 11 CNB: right lung
CNB– Right lung. Hemoptysis no PNX Suffusion Suffusion+PNX
Hemoptysis no PNX Suffusion Suffusion+ PNX 20
0 (0%)
4 (20%)
100% 0%
100%
20%
29%
2 (14%) 10 (50%)
4 (29%) 2 (14%) 4 (29%)
Lower
100% 0% 0% 0%
14%
14
2 (14%)
100%
2 0 2
0 (0%) 0 (0%) 0 (0%)
Middle
100%
14%
50%
29% 6 (30%)
30%
0 (0%)
Upper
14% Lower
0%
0%
Middle
Upper
CNB– Polmone destro. emottisi no pnx soffusione emorragica soffusione emorragica e pnx
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 20
0 (0%)
4 (20%)
14 10 (50%)
4 (29%) 2 (14%) 4 (29%)
inferiore
2 0 2
0 (0%) 0 (0%) 0 (0%)
medio
patients undergoing CNB had inflammatory disease, or lesion histology since the histological results were widely heterogeneous. The rate of nondiagnostic samples at definitive histological examination, assessed on the basis of the pathology reports, was 18.1 % for CNB and 10.7 % for FNAB (Table 6). We then calculated the diagnostic accuracy of the two methods. This evaluation revealed that FNAB, if
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100% 0% 0% 0%
14%
100% 0%
100%
20%
29%
2 (14%)
2 (14%)
100%
14%
100%
50%
29% 6 (30%) 0 (0%)
superiore
30%
14% inferiore
0%
0%
medio
superiore
performed with a pathologist on site who examines extemporaneously the accuracy of the samples, has an accuracy of 94.8 vs. 81.8 % for CNB. Finally, we found that FNAB accuracy, in relation to lesion size, is higher for lesions with a diameter between 1.8 and 3.5 cm (95.9 % accuracy), whereas CNB accuracy was higher for lesions between 2 and 4.2 cm (83.6 % accuracy) (Fig. 21).
Radiol med Fig. 12 FNAB: right lung
FNAB – Right lung. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX 12
100%
100% 0%
100% 100
10 40% 8 (67%)
4 (40%)
67% 20%
100%
2 (20%)
4 (40%)
2 2
0 (0%) Lower
0 (0%) 0 0 (0%)
Middle
2 (17%) 0 (0%) 2 (17%) Upper
17%
40%
0% 17%
0%
0% 0%
Lower
Middle
Upper
FNAB – Polmone destro. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 12
100%
100% 0%
100% 100%
10 40% 8 (67%)
4 (40%)
67% 20%
100%
2 (20%)
4 (40%)
2 2
0 (0%) inferiore
0 (0%) 0 0 (0%)
medio
Discussion In pulmonary lesions, it is very important to distinguish correctly between benign and malignant lesions, since the pathological diagnosis will determine the treatment to be applied [13]. One diagnostic method used in the evaluation of lung cancer is bronchoscopy, but when this is not sufficient for the diagnosis, particularly in peripheral pulmonary lesions or pleural lesions, a trans-thoracic biopsy is performed
2 (17%) 0 (0%) 2 (17%) superiore
17%
40%
0% 17%
0%
0% 0%
inferiore
medio
superiore
[14]. This procedure is characterised by a high diagnostic capability, but also by simplicity and a limited number of complications [13–15]. Our study shows that the diagnostic accuracy of both FNAB and CNB is relatively high for each technique. However, it is higher for the aspiration technique, reaching values equal to 94.8 %, while it is lower for CNB, with a rate of 81.8 %. All patients in our cohort were affected by primary or secondary malignancies, with the exception of six patients
123
Radiol med Fig. 13 CNB: left lung
CNB – Left lung. Hemoptysis no PNX Suffusion Suffusion+PNX
Hemoptysis no PNX Suffusion Suffusion+PNX
100%
18 2 (11%)
11%
100% 0%
100%
12 10 (56%)
0 (0%)
56%
67%
8 (67%) 2 (11%) 2 (11%)
2 (11%)
Lower
0 (0%) 2 (17%)
11% 2 (17%)
11%
11% Lower
Upper
0% 17%
17% Upper
CNB – Polmone sinistro. emottisi no pnx soffusione emorragica soffusione emorragica e pnx
emottisi no pnx soffusione emorragica soffusione emorragica e pnx
100%
18 2 (11%)
11%
100% 0%
100%
12 10 (56%)
0 (0%)
56%
67%
8 (67%) 2 (11%) 2 (11%)
2 (11%)
inferiore
0 (0%) 2 (17%)
2 (17%)
superiore
who had inflammatory disease. This did not allow us to evaluate diagnostic accuracy in relation to the benign or malignant nature of the lesion. The literature contains heterogeneous data on this topic. FNAB has a diagnostic accuracy that varies from 64 to 97 % [7]. According to Tarver et al. [16], this value is 95 % for malignant lesions, and lower (78.3 %) for benign lesions [6, 17]. This shows that the diagnostic classification of benign lesions, whether sampled by aspiration or cutting needle, is less
123
11%
0% 17%
11%
11% inferiore
17% superiore
accurate [6, 18]. This can in part be justified by the severity of the judgement to which the samples were subjected: material lacking malignant cells should not be considered negative for malignancy, unless it is possible to formulate a clear and specific diagnosis of a benign disease [19]. In some studies, diagnostic accuracy appears to be higher in the case of larger lesions and of FNAB performed in the presence of a pathologist to assess sample adequacy [4]. In many centres, however, the pathologist is not
Radiol med Fig. 14 FNAB: left lung
FNAB – Left lung. no PNX Suffusion
no PNX Suffusion 18
100%
100%
100%
14 10 (56%)
56% 71% 10 (71%)
4 (22%)
22% 2 (14%)
4 (22%) Lower
14% 2 (14%)
Upper
22% Lower
14% Upper
FNAB – Polmone sinistro. no pnx soffusione emorragica
no pnx soffusione emorragica
18
100%
100%
100%
14 10 (56%)
56% 71% 10 (71%)
4 (22%)
22% 2 (14%)
4 (22%) inferiore
superiore
available for extemporaneous evaluation of the samples. This may lead the operator to use cutting needles even when in the presence of small nodules [20, 21]. Charig and Phillips [20] have shown that the diagnostic accuracy of CNB is similar to that of FNAB, if performed with a pathologist on site. Other authors state that the diagnostic accuracy of CNB is lower for malignant lesions compared to that of FNAB [22, 23]. These latter data are consistent with the findings of the present study. Several published studies have also correlated diagnostic accuracy with lesion size. Tsukada [24] found a
14% 2 (14%)
22% inferiore
14% superiore
gradual and progressive decrease of diagnostic accuracy values with decreasing lesion size, from 100 % (for lesions \5 cm) to 67 % (for lesions \1 cm). Similar results were published by Priola [5], who reported an accuracy of 68 % for lesions \1.5 cm, 78 % if [5 cm and 87 % in the case of lesions measuring between 1.5 and 5 cm. Lucidarme [25] related diagnostic accuracy to lesion size as well as to the number of passes: for lesions [2 cm with an average of 2.5 passes per procedure, the diagnostic accuracy was 88 %; when one pass was performed, this
123
Radiol med
value decreased to 83 %. Yeow [19] described a mean of three passes per biopsy with a diagnostic accuracy of 84, 93 and 96 %, respectively, for lesions measuring \15, [5 cm
and between 1.5 and 5 cm. In small lesions, these data can be justified by sampling errors due to the increased technical difficulty during biopsy centring [26], but for large
CNB – Needle caliber. Hemoptysis Hemoptysis
no
no
PNX
PNX
Suffusion
Suffusion
Suffusion+ PNX
Suffusion + PNX 54 2 (4%)
100%
100% 0%
100%
4%
100%
20%
22 (41%)
41% 20% 0%
14 (26%)
10
12 (22%)
4 (40%)
4 (7%)
2 (20%) 2 (20%) 0 (0%) 2 (20%)
20 G
18 G
2 2 (100%)
0 (0%) 0 (0%) 0 (0%) 0 (0%)
100% 26%
40%
22% 20% 7%
0% 0% 21 G
20 G
18 G
21 G
0%
CNB – Calibro ago. emottisi emottisi
no
no
pnx
pnx
soffusione emorragica
soffusione emorragica
soffusione emorragica e pnx
soffusione emorragica e pnx 54 2 (4%)
100%
100%
4%
100% 0%
100%
20%
22 (41%)
41% 20% 0%
14 (26%)
12 (22%) 4 (7%) 18 G
Fig. 15 CNB: needle calibre
123
10 4 (40%) 20 G
2 (20%) 2 (20%) 0 (0%) 2 (20%)
2 2 (100%) 21 G
0 (0%) 0 (0%) 0 (0%) 0 (0%)
100% 26%
40%
22% 20% 7% 18 G
0% 0% 20 G
21 G
0%
Radiol med
the technique employed, a lower diagnostic accuracy in nodules measuring *1 cm or in large nodules. The reported rate of pneumothorax after CT-guided lung biopsies ranges from 4 % [26] to 62 % [27]. In the present study, where any air flap between the pleura and the lung was considered a pneumothorax, the incidence was 21.3 % and thus falls within the reported range (Table 2). Considering the two methods used, the pneumothorax rate was 21.2 % for CNB and 21.4 % for FNAB. Although with different rates, also Arakawa et al.
lesions it is understood if one considers the frequent finding of central necrosis [19]. Our study also found a correlation between lesion size and diagnostic accuracy, which appeared to be independent of the biopsy technique and higher for lesions between 1.8 and 4.2 cm. For nodules sampled with FNAB, the highest accuracy, equal to 95.9 %, was found for lesions between 1.8 and 3.4 cm. Conversely, for those sampled with CNB, the diagnostic accuracy was 83.6 % in lesions between 2 and 4.2 cm (Fig. 21). We therefore recorded, regardless of
Fig. 16 FNAB: needle calibre
FNAB – Needle Caliber. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX
100%
54
100%
30 (56%)
100%
56%
100%
2 2
0 (0%) 0 (0%) 0 (0%)
(100%)
12 (22%)
2 (4%)
22%
10 (19%)
19% 0%
4%
22 G
20 G
22 G
20 G
0%
0%
FNAB – Calibro ago. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 54
100%
100%
30 (56%)
100%
56%
100%
2 2 (100%) 20
0 (0%) 0 (0%) 0 (0%)
12 (22%)
2 (4%)
22%
10 (19%)
22
19% 0%
0%
20
0%
4%
22
123
Radiol med
[28] reported a higher percentage of pneumothorax with FNAB (40 %) than with CNB (24.3 %). Many cases of pneumothorax were completely resolved without any
need for surgical treatment (Fig. 8). Placement of a chest drain was required in 2.4 % of the total population, and in 11.5 % of the population with pneumothorax. These
CNB – Number of passes. Hemoptysis
Hemoptysis
no PNX
no
Suffusion
pnx
soffusione emorragica e pnx
Suffusion Suffusion e PNX
100% 13%
100% 0%
100% 0% 100% 0% 0%
75% 60 7 (100%) (12%) 8 (13%) 30 (50%)
7 (12%) 7 (12%) 8 (13%)
1
0%
50% 0 (0%) 1 (25%) 0 (0%) 3 4 (75%) (100%) 1 0 (25%) (0%) 2
0 (0%) 0 (0%) 0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100) 3
0%
0% 12%
25%
100%
2
3
12% 13% 1
CNB – Numero passaggi. emottisi
emottisi
no pnx
no
soffusione emorragica
pnx
soffusione emorragica e pnx
soffusione emorragica soffusione emorragica e pnx
100% 13%
100% 0%
100% 0% 100% 0% 0%
75% 60 (100%)) 8 (13%) 30 (50%) 7 (12%)
7 (12%) 8 (13%)
1
Fig. 17 CNB: number of passes
123
0% 0 (0%) 1 (25%) 0 (0%) 0 4 (0%) (100%) 3 0 (75%) (0%) 2
0 (0%) 0 (0%) 0 (0%) 0 2 (0%) (100%) 0 1 (0%) (50%) 3
50%
0%
0%
12%
12%
25%
100%
2
3
13%
1
Radiol med
results are consistent with the percentages reported in other studies [29]. The onset of pneumothorax was found to correlate with variables related to both the procedure and the patient (Table 3). In our study, we recorded a higher rate of pneumothorax for small lesions sampled with CNB (Table 4). Pneumothorax therefore correlated with both the biopsy type and lesion size (Fig. 5), as also reported by other authors, who described an increased risk for small
lesions [30, 31] or even a 4 % decrease in risk for each 10-mm increment in lesion diameter [5]. The percentage of parenchymal haemorrhage after CTguided lung biopsy is reported to vary from 4 % [19] to 27 % [32]. In our study, the results obtained in patients who underwent FNAB are consistent with those of Kahn et al. [32], who found a particularly significant relationship between small lesions and the appearance of haemorrhage (p \ 0.005) (Fig. 6).
Fig. 18 FNAB: number of passes
FNAB – Number of passes. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX
100%
44
24 (55%)
100%
55% 67%
12 (27%)
12
6 (14%)
2 (5%)
100%
1
8 (67%) 0 4 (0%) 0 (33%) (0%) 2
27%
0% 33%
14% 5%
0%
1
2
FNAB – Numero passaggi. no pnx soffusione emorragica soffusione emorragica e pnx
100%
44
24 (55%)
12 (27%) 6 (14%)
2 (5%) 1
no pnx soffusione emorragica soffusione emorragica e pnx 100%
100%
55% 67%
12 8 (67%) 0 4 (0%) 0 (33%) (0%) 2
27%
0% 33%
14% 5%
1
0%
2
123
Radiol med
CNB – Histologic type. 28 2 (7%)
Hemoptysis no
8 (29%)
PNX Suffusion Suffusion+PNX
10 (21%) 10 8 (29%)
0 (0%)
4 (14%)
0 (0%) 0 (0%)
2 2 (100%)
Bronchioloalveolar
Adenocarcionoma 100% 7%
0 2 2 (0%) 0 (20%) (40%) (0%) 2 0 (20%) (0%) 0 2 2 4 2 0 (0%) (20%) (40%) (40%) 1 (100%) 0 (0%) SCCL
100% 0% 0%
8 (67%)
4 (40%) 2 (20%) 2 (20%) Notevaluable
Squamos
100% 0%
12 2 (17%)
0 12 (0%)
0 (0%)
100% 100
17%
40%
29% 21%
40%
100% 100%
100%
20%
67% 20%
29% 40% 0%
Adenocarcinoma
0 (0%)
Inflammation
100% 0% 40%
100% 0%
2
0%
0%
Bronchioloalveolar
0% 17% 0%
0%
0%
Squamous
SCCL
Not evaluable
Inflammation
CNB – Istologia.
28 2 (7%)
emottisi no
8 (29%)
pnx soffusione emorragica soffusione emorragica e pnx
10 (21%) 10 8 (29%)
0 (0%)
4 (14%)
0 (0%) 0 (0%)
K adenocarcinoma 100% 7%
2 2 (100%)
0 2 2 (0%) 0 (20%) (40%) (0%) 2 0 (20%) (0%) 0 2 2 4 2 0 (20%) (0%) (40%) (40%) 1 (100%) 0 (0%)
K bronchioloalveolare 100% 0% 0%
K microcitoma 100% 0%
0 (0%)
4 (40%)
8 (67%)
100% 0% 40%
2 (20%) non valutabile
0 (0%)
2
0 (0%)
patologia infiammatoria 100% 100
17%
40%
29% 21%
100%
100% 100%
40% 20%
67% 20%
29% 40% 0%
0%
K adenocarcinoma K bronchioloalveolare
Fig. 19 CNB: histological type
123
12 2 (17%)
2 (20%)
k spinocellulare 100% 0%
12
0%
0%
K microcitoma
0% 17% 0%
0% k spinocellulare
non valutabile
patologia infiammatoria
Radiol med
FNAB – Histologic type. 26 no PNX Suffusion Suffusion+PNX
18 (69%)
16 8 (50%)
4 (15%) 2 2 (8%) (8%) Adenocarcinoma
100%
0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100%) Carcinoid
2 (100%) 2 (100%)
0 (0%) 0 (0%) 0 (0%)
SCCL
100%
0 (0%)
Carcinoid
0% 0%
0 (0%)
2
4
0 (0%)
Not evaluable
100% 0% 33%
50%
100%
0%
100%
0%
6
100%
50%
0% 0%
2 (50%) Metastasis
100%
100%
100%
Adenocarcinoma
2 (13%)
4
Squamous
69% 15% 8% 8%
6 (38%)
2 (50%) 0 (0%) 0 (0%)
0%
SCCL
67%
38%
50%
0% 13%
0%
0%
Squamous
Metastasis
Not evaluable
FNAB – Istologia.
26
no pnx Soffusione Soffusione +PNX
18 (69%)
16 8 (50%)
4 (15%) 2 2 (8%) (8%) K adenocarcinoma
100%
0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100%) k carcinoide
100%
2 (100%) 2 (100%)
0 (0%) 0 (0%) 0 (0%)
K microcitoma
2 (13%)
4 0 (0%)
k spinocellulare
100%
100%
50%
69% 100% 15% 8% 8%
6 (38%)
0% 0%
100%
0%
K adenocarcinoma k carcinoide
0% 0%
2 (50%)
2 (50%) 0 (0%) 0 (0%)
6 2
0 (0%)
0 (0%)
4
Metastasi
non valutabile
100%
100% 0% 33%
50%
100%
0%
0%
K microcitoma
38%
50%
0% 13%
0%
k spinocellulare
Metastasi
67% 0%
non valutabile
Fig. 20 FNAB: histological type
123
Radiol med
type of biopsy (Figs. 15, 16). This finding is ascribable to the small number of procedures carried out using needles with calibre other than 18 G in the case of CNB or 22 G in the case of FNAB. Even assessing the number of passes performed, we failed to find any statistically significant results (p [ 0.005), probably because most procedures were done with a single pass: 54 (93.1 %) FNAB and 52 (89.6 %) CNB (Figs. 19, 20). Other studies have justified a greater number of pneumothoraces by the number of passes, as these would increase the number of small traumas to the pleura [5]. We could not correlate the type and rate of complications with either lesion nature or histology because 95.1 % of lesions were malignant (Figs. 18, 19), and the histological findings were very heterogeneous. Rizzo et al. [5] reported that biopsies on metastatic lesions were more frequently associated with the occurrence of parenchymal haemorrhage. In contrast to other studies [33, 34], which described a lower percentage of inappropriate material for CNB than for FNAB, we performed FNAB with an on-site pathologist who immediately assessed the adequacy of the sample defining it appropriate or inappropriate (in which case an additional pass is needed) for the definitive histological examination, thereby obtaining a lower rate of nondiagnostic samples with FNAB than with CNB (Table 6).
Table 6 Nondiagnostic sampling in core-needle biopsy and fineneedle aspiration biopsy based on lesion dimension Lesion dimension
FNAB N (%)
CNB N (%)
B1.5 cm
0 (0)
0 (0)
1.6–3 cm
6 (10.7)
2 (3)
3.1–4.5 cm
0 (0)
6 (9.1)
C4.6
0 (0)
4 (6)
CNB core-needle biopsy, FNAB fine-needle aspiration biopsy
Accuratezza diagnostica
With regard to age (Table 5), the largest number of complications, such as haemorrhage and haemoptysis, was recorded in elderly patients undergoing CNB (Fig. 3). This can be ascribed to the fact that many of these patients normally took anti-aggregating or anticoagulant therapies and thus suffered from coagulation disorders, a finding in contrast with other authors’ reports [5]. As described in the literature [5], posterior access (Table 5) carries a greater risk of complications. This was reflected in the results we obtained with FNAB (Fig. 9) but not with CNB (Fig. 7); in fact, CNB was associated with a greater number of complications when the anterior approach was used (Fig. 8). This study did not reveal any statistically significant correlations with the needle gauge (p [ 0.005) in either
Accuratezza diagnostica di FNAB e CNB in base alle dimensioni delle lesioni. 120 100 80 60 40 20 0
FNAB CNB 1
1,5
2
2,5
3
3,5
4
4,5
5
5,5
6
6,5
7
Diagnostic accuracy
Dimensioni
120 100 80 60 40 20 0
Diagnostic accuracy of FNAB and CNB based on lesion dimension.
FNAB CNB 1
1,5
2
2,5
3
3,5
4
4,5
Dimensions
Fig. 21 Diagnostic accuracy of FNAB and CNB based on dimension of lesions
123
5
5,5
6
6,5
7
Radiol med
Conclusions FNAB seems to be burdened by a lower complication rate than CNB in terms of both absolute values and in relation to variables inherent to the patient, the procedure and the lesion. The diagnostic accuracy is higher for FNAB and, if this technique is performed in the presence of a pathologist, it is characterised by a lower rate of inadequate samples than CNB. We can therefore state that in lesions where both CNB or FNAB are an option, the latter is preferable in terms of both complication rate and diagnostic accuracy, provided that it is carried out by a pathologist on site. Conflict of interest Emanuela Capalbo, Michela Peli, Maria Lovisatti, Maria Cosentino, Paola Mariani, Eisabetta Berti, Maurizio Cariati declare that they have no conflict of interest related to the publication of this article.
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CHEST RADIOLOGY
Trans-thoracic biopsy of lung lesions: FNAB or CNB? Our experience and review of the literature Emanuela Capalbo • Michela Peli • Maria Lovisatti • Maria Cosentino • Paola Mariani • Eisabetta Berti • Maurizio Cariati
Received: 26 July 2012 / Accepted: 13 May 2013 Ó Italian Society of Medical Radiology 2013
Abstract Purpose This study was performed to determine the type and incidence of complications of fine-needle aspiration biopsy (FNAB) and core biopsy (CNB) performed under computed tomography (CT) guidance to characterise lung lesions, and assess the diagnostic accuracy of the two techniques. Materials and methods In 2009–2011, we performed 124 lung biopsies (66 CNB and 56 FNAB) on 121 patients with a mean age of 72.4 years. Exclusion criteria were pulmonary resection, pleural lesions and/or effusions, and inadequate blood-coagulation profile. All examinations were acquired after contrast-agent administration in a craniocaudal direction from the lung apex to base during a single inspiratory breath-hold, with standardised parameters. Each lesion was scanned with 13–15 slices that could be repeated whenever necessary to document the needle track and for lesion centring, by positioning a metallic marker perpendicular to the centring light to indicate the point of needle access. Unless otherwise clinically indicated, 4 h after the procedure chest radiography was performed.
Results Age was found to be a factor influencing the complications: pneumothorax in young subjects (31 %) and parenchymal haemorrhage in the elderly (30 %), with CNB but not with FNAB. We had more complications with the right lung: 50 % of pneumothorax cases in the upper lobe with CNB and 40 % of cases of haemorrhage in the lower lobe with FNAB. The anterior approach gave rise to more complications with CNB, while the posterior approach with FNAB. CNB had more complications than FNAB for lesions B3.5 cm (31 vs. 18 % pneumothorax), and [3.5 cm (34 vs. 9 % haemorrhage). There was no significant correlation with lesion histology, needle calibre or number of passes (probably due to the small number of procedures done with needles other than 18 G in CNB or 22 G in FNAB or involving more than one needle pass). The diagnostic accuracy of FNAB, done with a pathologist’s extemporaneous assessment of sample adequacy, was 94.83 % against 81.82. % of CNB. Conclusions FNAB under CT guidance is subject to a lower rate of complications and, if performed in the presence of the pathologist, has a greater diagnostic accuracy compared to CNB.
E. Capalbo (&) M. Peli M. Lovisatti M. Cosentino School of Specialization of Diagnostic and Interventional Radiology, University of Milan, Via A. Di Rudinı`, 20142 Milan, Italy e-mail: [email protected]
Keywords Lung lesions Fine-needle aspiration biopsy (FNAB) Core-needle biopsy (CNB) Computed tomography guidance Diagnostic accuracy Complications
E. Capalbo M. Peli M. Lovisatti M. Cosentino P. Mariani M. Cariati Department of Diagnostic Sciences, UOC of Diagnostic and Interventional Radiology, San Carlo Borromeo Hospital, Via Pio II 3, 20153 Milan, Italy
Introduction
E. Berti Department of Diagnostic Sciences, UOC of Pathology, San Carlo Borromeo Hospital, Via Pio II 3, 20153 Milan, Italy
In the last few decades, there has been a significant increase in lung cancer incidence, especially in industrialised countries [1]. To reduce the high mortality characterising this disease, an early diagnosis is mandatory.
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Radiol med Table 1 General characteristics of the study population FNAB N (%) – mean ±[SD]
CNB N (%)– mean ±[SD]
Total N (%)– mean ±[SD]
56 (45.9)
66 (54.1)
122
18 G
54 (81.8)
54 (43.5)
20 G
10 (15.2)
10 (8)
No. of lesions Needle calibre
21 G
2 (3.5)
22 G
56 (96.5)
No. of passes 1 2
4 (3.2) 56 (45.2)
44 (78.5)
60 (90.9)
104 (85.2
12 (21.5)
4 (6)
16 (13.1)
2 (4)
2 (1.6)
1.12 [±15]
1.19 [±13]
3 Mean no. of passes
2 (3)
1.21 [±11]
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy, SD standard deviation
Today, diagnostic imaging and interventional radiology with lung biopsy have made it possible to achieve this aim. The first to perform a lung biopsy was Leyden in 1883, followed by Menetrier in 1886 [2]; later on, in 1970, with Porto, lung biopsy performed under fluoroscopic or radiographic guidance became widely disseminated [3]. The growing use of chest computed tomography (CT) has led to the detection of an increasing number of lung lesions, even of small dimension, which has heightened the interest in percutaneous CT-guided lung biopsies [4, 5]. The complication rate was initially very high, up to 61 % for pneumothorax [6], but over the years it has been reduced by optimising biopsy materials and imaging techniques [7], and is now 26.6 %, as described in a recent review [8]; moreover, the procedure carries relatively low mortality rates (0.07 %) [7, 9, 10]. When percutaneous biopsy is used to establish the diagnostic and therapeutic workup of a lung lesion, one must carefully evaluate the cost–benefit ratio as well as the most frequent complications—pneumothorax and parenchymal haemorrhage [5, 9, 11]. Although both complications usually resolve spontaneously, the occurrence of pneumothorax during the procedure may lead to an inconclusive result and, in a variable percentage of cases, worsening pneumothorax may require placement of a chest drain, whereas parenchymal haemorrhage may necessitate hospitalisation [12]. The first aim of this study was to assess the type and incidence of complications arising in CT-guided lung biopsies performed with fine-needle aspiration (FNAB) or cutting needle (CNB), by analysing the different variables related to the patient (age), the lesion (dimension, nature, side) and the procedure (number of passes, access and needle calibre). A secondary aim was to ascertain which technique has greater diagnostic accuracy, even in consideration of lesion size.
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Fig. 1 Lung biopsy with an 18-G trucut needle of a lesion of the dorsal segment of the right upper lobe, performed with a single pass with posterior access
Fig. 2 Fine-needle aspiration biopsy (FNAB) with a 22-G needle of a 1.2-cm nodule in the dorsal segment of right lung lower lobe with a single pass and posterior access
Materials and methods This retrospective study was performed by analysing a series of 121 patients, 15.3 % of them with known oncological disease, who underwent CT-guided lung biopsy using CNB or FNAB between 01-01-2010 and 31-12-2011. A total of 122 biopsies were performed in 76 men and 45
Radiol med
Fig. 3 Core-needle biopsy (CNB) obtained with an 18-G needle and a single pass (a), postbiopsy computed tomography (CT) scan: occurrence of an anterior pneumothorax (b); chest radiograph at 2 h:
presence of apical pneumothorax (c); radiograph at 2 days: complete resolution of the pneumothorax without the need for surgical drainage (d)
Table 2 Complication rate based on complication type and sampling method
on history, objective and/or imaging features; in particular, CNB was selected for suspected benign, lymphoproliferative or sarcomatous lesions, while FNAB was used in known oncological patients and in all other cases, especially if the pathologist was on site. Exclusion criteria were previous surgery for lung resection (because postsurgical adhesions may protect against pneumothorax), pleural lesions, pleural effusions, and inadequate coagulation status (prothrombin time \1.4 and/or platelets \80,000/ml). Any platelet antiaggregant and anticoagulant treatment was suspended a few days prior to the procedure and subsequently resumed by the patient, in accordance with the haematologist’s indications. All patients had previously undergone a CT or highresolution CT (HRCT) examination which identified and defined the lesion. All the biopsies were carried out as inpatient or day-case procedures.
FNAB N (%)
CNB N (%)
Total N (%)
Pneumothorax
14 (21.2)
12 (21.4)
26 (21.3)
Haemorrhage
8 (12.1)
5 (8.9)
13 (10.6)
Pneumothorax ? haemorrhage Haemoptysis
6 (9) 4 (6.8)
2 (3.5) –
8 (6.5) 4 (6.8)
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
women (mean age 72.4 ± 13.8 years); one man repeated the biopsy (Table 1). The referring physician (oncologist and/or surgeon) had determined the indication for the procedure, which was subsequently evaluated by the radiologist who selected the biopsy technique according to the clinical suspicion based
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CT scan. Parenchymal haemorrhage was defined as an increased lung attenuation with preserved bronchial and vascular margins along the needle path. We recorded as pneumothorax any amount of air appearing between the lung and pleura. Expiratory chest radiography was performed in all patients 4–6 h after the procedure to assess the appearance or the growth of a pneumothorax previously detected on postprocedure CT. The evolution of the pneumothorax was further evaluated 2–4 h later. If it became stable or smaller, the patient was discharged, whereas if it increased the surgeon’s advice was sought for possible placement of a chest drain. In the event of complications arising in patients
All patients received verbal explanations about the biopsy procedure and its possible complications, and they subsequently read and signed the written informed consent form, which included consent for using their anonymised clinical data for scientific purposes. The possible complications of a CT-guided lung biopsy are pneumothorax, haemorrhage, haemothorax, haemoptysis, rarely seeding of neoplastic cells along needle path, cardiac effusion, and pulmonary infections (pneumonia, empyema), as well as risks attributable to the administration of the drugs used during the procedure. Pneumothorax and parenchymal haemorrhage were evaluated for about 5 min after the end of the procedure with a postprocedure Fig. 4 CNB age
CNB – Age. Hemoptysis
Hemoptysis
no
no
PNX
PNX
Suffusion
Suffusion
Suffusion+ PNX
Suffusion+PNX
46 4 (9%) 16 (35%)
20 10 (50%)
0 (0%)
100% 0%
100%
50%
35%
8 (17%)
30% 30%
6 (30%)
Young
100%
17%
14 (30%)
2 2 (10%) (10%)
9%
10% 4 (9%)
Elderly
10%
9%
Young
Elderly
CNB – Età. emottisi
emottisi
no
no
pnx
pnx
soffusione emorragica
soffusione emorragica
soffusione emorragica e pnx
46 4 (9%) 16 (35%)
20 10 (50%)
0 (0%)
giovane
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100%
50%
35%
8 (17%)
9%
17% 30%
14 (30%)
6 (30%) 2 2 (10%) (10%)
soffusione emorragica e pnx
100% 0%
30% 10%
4 (9%)
vecchio
10%
9%
giovane
vecchio
100%
Radiol med
who underwent the biopsy as a day-case procedure, the need for hospitalisation was assessed in relation to the clinical symptoms and signs. Biopsy protocol The examinations were performed on a 16-slice Lightspeed CT system (GE Medical System, Milwaukee WI, USA) and on a 128-slice SOMATOM Definition AS ? CT system (Siemens Healthcare, Erlangen, Germany). All examinations were acquired in a craniocaudal direction from the lung apex to base, during a single inspiratory breath-hold with the following standardised parameters: thickness 2.5 mm, collimation 10 mm, field of view 320–360 mm, pitch 1.75, 120 kV; automatic tube current modulation (mA); standard reconstruction filter; lung window. Patients received iodinated contrast agents: Ioversolo 350 (Covidien, Italy) and Iopromide 370 (Bayer Schering Pharma, Germany). According to lesion location, the ideal needle trajectory from the skin to the lesion was established. The lesion was scanned with 13–15 slices having a thickness of 2.5 mm, and this scan could be repeated whenever necessary to clearly document the needle track. Lesion centring was performed on the axial image of the image stack, in which the lesion presents the greatest extension and needle access is less hampered by the presence of anatomical structures. On the chosen image, a metallic marker is placed perpendicular to the centring light, which indicates the point that will be used for needle access. The needles used were Chibell (Biopsybell, Modena, Italy) with a calibre of 20 and 22 G, for FNAB
procedures, and Biomol (HP Service Hospital, Latina, Italy) with a calibre of 18, 20 and 21 G for CNB procedures. The biopsy procedures were carried out alternately by two radiologists with decades of experience. During the CNB procedures, no pathologist was present in the room, whereas during the FNAB procedures, a pathologist was on site to extemporarily evaluate the adequacy of the sample. Sample adequacy was assessed in real time alternately by two equally experienced pathologists, who subsequently performed also the final reading of the microscope slide. We used test tubes with and without fixative, skin disinfectant, bevelled glass slides, cover slips, racks, fixatives, haematoxylin–eosin staining scale, Papanicolaou stain, and a diagnostic room set up with a hood and an optical microscope. In relation to the pathological report, the result of each procedure was classified as diagnostic or nondiagnostic. Samples were defined nondiagnostic in the event of insufficient, cell-free, or strongly haematic material. Diagnostic samples were grouped by histological type. The CT images were assessed for the following parameters: needle access (anterior, posterior, lateral), lesion site (upper or lower right lobe, middle lobe, upper or lower left lobe), lesion size (large if [3.5 cm or small if B3.5 cm), patient’s age [\65 years (young) and C65 years (elderly)], needle gauge, number of needle passes, and lesion histology; all variables were correlated to the type and incidence of complications recorded with the two biopsy methods. In addition, we evaluated which technique had greater diagnostic accuracy, also in relation to lesion size.
Fig. 5 FNAB with an 18-G needle of a lesion of the right upper lung lobe with single pass and lateral access (a); at the end of the procedure, a small parenchymal detachment, and circumscribed haemorrhage along the needle track (b)
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Statistical analysis
Results
The baseline characteristics of the study population were expressed as mean ± standard deviation for continuous variables, and as percentages for categorical variables. Correlation between the variables considered and the presence of complications (pneumothorax, parenchymal haemorrhage, haemoptysis) was calculated using the Chisquare test. We represented the results obtained using histograms. In the graphs on the left, each histogram represents the number of observations classified according to the labels/classes placed under the columns, with an indication, within each label/class, of the type of complication (the various colours of the histogram). Conversely, the graph on the right does not consider the number of observations for each class, but only the percentage incidence of the different complications within the same class.
We performed 122 biopsies (66 CNB and 56 FNAB) of lung lesions having a mean size of 3.5 ± 2.3 cm (range 1.2–9.7); nodules sampled with CNB (Fig. 1) had a mean size of 3.8 ± 2.6 cm, whereas those sampled with FNAB (Fig. 2) were 2.9 ± 1.9 cm (Table 1). Complications occurred in 51 of the 122 biopsies (41 %). These included pneumothorax, haemorrhage, pneumothorax associated with haemorrhage, and haemoptysis. The most frequent complication was pneumothorax (Fig. 3), which required surgical placement of a chest drain in three patients (2.4 % of the entire population and 11.5 % of those with pneumothorax) (Table 2). There were no cases of late pneumothorax, since all cases were diagnosed by postprocedure CT or by radiography performed a few hours after the end of biopsy (Fig. 3). No case of parenchymal haemorrhage necessitated either hospitalisation (of the day cases) or additional treatments (of the inpatients).
FNAB – Age. 56 (100%)
32 (56%)
no
12 (20)
PNX
Suffusion Suffusion+ PNX
2 (4%)
10 (18%)
Eldery
FNAB – Età. 56 (100%)
no
32 (56%)
12 (20)
pnx
soffusione emorragica soffusione emorragica e pnx
2 (4%)
10 (18%)
vecchio
Fig. 6 FNAB: age
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Table 3 Fine-needle aspiration biopsy vs. core-needle biopsy for the development of pneumothorax and parenchymal haemorrhage Pneumothorax
Haemorrhage
Pneumothorax and haemorrhage
CNB N (%)
CNB N (%)
CNB N (%)
FNAB N (%)
FNAB N (%)
FNAB N (%)
Age C65 years
4 (17)
7 (30)
2 (9)
\65 years
3 (30)
1 (10)
1 (10)
Dimensions [3.5 cm
3 (17)
3 (27)
5 (28)
1 (9)
1 (6)
C3.5 cm
4 (27)
3 (18)
3 (20)
4 (24)
2 (13)
Anterior
3 (30)
1 (20)
4 (40)
Posterior
2 (12)
2 (22)
3 (18)
1 (11)
Lateral
2 (33)
3 (21)
1 (17)
4 (29)
Upper lobe
3 (30)
1 (17)
Middle lobe
2 (12)
Lower lobe
2 (33)
1 (9)
Needle access 1 (10) 2 (12)
1 (11)
4 (40)
1 (10)
1 (17)
3 (18)
2 (12)
Right lung
1 (20)
1 (17)
2 (40)
2 (22)
1 (17)
2 (22)
1 (17)
1 (14)
1 (11)
1 (14)
1 (11)
Left lung Upper lobe Lower lobe
1 (11)
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
Radiol med
pneumothorax (Fig. 5) had a higher incidence among young patients (30 vs. 17 %). Haemoptysis occurred in 9 % of elderly patients, either immediately or a few hours after the end of the procedure; no case of haemoptysis was recorded among the young patients. No patient younger
The patients were analysed in relation to age and type of biopsy. For CNB, the complication rate was 65 % among the elderly patients (Fig. 4) vs. 50 % among the young patients (p \ 0.005). In particular, haemorrhage was more frequent in elderly patients (31 vs. 10 %), whereas
Fig. 7 CNB: lesion size
CNB – Lesion size. Hemoptysis no PNX Suffusion Suffusion + PNX
Hemoptysis no PNX Suffusion Suffusion + PNX 36 2 (6%) 16 (44%)
6 (17%) 10 (28%) 2 (6%) Large
100% 6% 30 2 (7%)
44%
100% 7%
100%
33%
10 (33%) 8 (27%)
17%
6 (20%) 4 (13%)
28%
Small
6% Large
27%
20%
13% Small
CNB – Dimensione nodulo. emottisi no pnx soffusione emorragica soffusione emorragica e pnx 36 2 (6%) 16 (44%)
6 (17%)
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 100% 6%
30 2 (7%)
44%
100%
33%
10 (33%) 8 (27%)
17%
28%
2 (6%)
6 (20%) 4 (13%)
grande
piccolo
10 (28%)
100% 7%
6% grande
27%
20%
13% piccolo
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Radiol med Fig. 8 FNAB: lesion size
FNAB – Lesion size. no PNX Suffusion Suffusion+ PNX
no PNX Suffusion Suffusion+PNX
22
34
100%
100%
20 (59%)
55%
59%
6 (18%)
27%
18%
9% 9%
24%
Large
Small
100%
12 (55%) 6 (27%)
2 2 (9%) (9%)
0 (0%)
Large
8 (24%)
Small
0%
FNAB – Dimensione lesione. no PNX Soffusione Soffusione+ PNX
22
no PNX Soffusione Soffusione+PNX
34
100%
100%
20 (59%)
55%
59%
6 (18%)
27%
18%
9% 9%
24%
100%
12 (55%) 6 (27%)
2 2 (9%) (9%)
0 (0%)
Grande
Table 4 Complication rate based on complication type and lesion dimension
FNAB fine-needle aspiration biopsy, CNB core-needle biopsy
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Lesion dimension
8 (24%)
0%
Grande
Piccolo
FNAB N (%)
Piccolo
CNB N (%)
\3.5 cm
[3.5 cm
\3.5 cm
Pneumothorax
6 (18)
6 (27)
8 (27)
6 (17)
Haemorrhage
8 (24)
2 (9)
6 (20)
10 (28)
Pneumothorax ? haemorrhage
–
Haemoptysis
–
2 (9) –
[3.5 cm
4 (13)
2 (6)
2 (7)
2 (6)
3 (30)
2 (33)
lower lobe
1 (11)
Lower lobe
1 (11)
1 (17)
2 (12)
1 (10)
1 (10) 2 (12)
2 (13)
1 (6)
1 (10)
2 (9)
CNB core-needle biopsy, FNAB fine-needle aspiration biopsy, PNX pneumothorax
1 (17)
1 (17)
3 (18)
4 (40)
Upper lobe
1 (11)
2 (12)
Left lung
3 (30)
1 (17)
2 (33)
Middle lobe
4 (40) 3 (18)
Upper lobe
Right lung
Posterior
Anterior Lateral
3 (20)
5 (28)
1 (10)
7 (30)
3 (30) 2 (12)
4 (27)
C3.5 cm
Access
3 (17)
[3.5 cm
Dimension
4 (17)
C65 years
\65 years
Age
1 (11)
2 (12)
2 (12)
1 (7)
1 (6)
2 (9)
Haemoptysis N (%)
1 (14)
2 (22)
1 (20)
1 (17)
3 (21)
1 (20) 2 (22)
3 (18)
3 (27)
–
–
PNX N (%)
PNX ? haemorrhage N (%)
PNX N (%)
Haemorrhage N (%)
FNAB
CNB
1 (14)
2 (22)
4 (29)
1 (11)
4 (24)
1 (9)
–
–
Haemorrhage N (%)
Table 5 Variables determining the onset of complications and the complication rates for core-needle biopsy and fine-needle aspiration biopsy
2 (40)
(17)
1 (11)
–
1 (9)
–
–
PNX ? haemorrhage N (%)
–
–
–
–
–
–
– –
–
–
–
–
Haemoptysis N (%)
Radiol med
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Radiol med Fig. 9 CNB: needle approach
CNB – Needle approach. Hemoptysis no PNX Suffusion Suffusion+ PNX
Hemoptysis no PNX Suffusion Suffusion + PNX 34 4 (12%)
100% 0%
100% 0%
100% 100%
12%
20% 50%
16 (47%)
20 0 4 (0%) (20%) 6 (30%) 6 (40%) 2 (10%) Anterior
12
0 (0%) 6 (50%) 4 (33%) 0 (0%) 2
4 (12%)
30%
40%
47%
33%
6 (18%)
18%
4 (12%)
10%
Rear
Anterior
Lateral
12%
17%
12%
0% Lateral
Rear
CNB – Accesso ago. emottisi no pnx soffusione emorragica soffusione emorragica e pnx 34 4 (12%)
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 100% 0%
100% 0%
100% 100%
12%
20% 50%
16 (47%)
20 0 4 (0%) (20%) 6 (30%) 6 (40%) 2 (10%) anteriore
12
0 (0%) 6 (50%) 4 (33%) 0 (0%) 2 laterale
than 65 years underwent FNAB sampling (Fig. 6), so we were unable to assess whether the complications arising with this method were influenced by age (Table 3). With regard to lesion size (large if [3.5 cm and small if B3.5 cm), we found a higher complication rate for small lesions among patients undergoing CNB (67 %) (Fig. 7)
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4 (12%)
30%
40%
47%
33%
6 (18%)
12% 18%
4 (12%)
10%
posteriore
anteriore
17%
12%
0% laterale
posteriore
and for large lesions among those undergoing FNAB (45 %) (p \ 0.005) (Fig. 8; Table 4). A correlation was found between needle access (anterior, posterior or lateral) and complication rate (p \ 0.005) (Table 5) in both the CNB group (Fig. 9) and the FNAB group (Fig. 10).
Radiol med Fig. 10 FNAB: needle approach
FNAB – Needle approach. no pnx Suffusion Suffusion+PNX
no pnx Suffusion Suffusion+PNX 28
100%
14 (50%)
18
100%
100%
56%
50%
100
80% 10 (56%)
10 8 (80%) 2 (20%)
0 (0%) 0 (0%)
Anterior
4 (22%)
6 (21%) 2 (11%) 2 (11%)
Lateral
8 (29%)
21% 22% 11% 20%
0 (0%)
0% 0%
Rear
Anterior
29%
11% 0% Lateral
Rear
FNAB – Accesso ago. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 28
100%
14 (50%)
18
100%
100% 100%
56%
50%
80% 10 (56%)
10 8 (80%) 2 (20%)
anteriore
0 (0%) 0 (0%)
4 (22%)
laterale
In addition, we correlated complications with lesion location, in terms of side and lobe. For both biopsy methods (Table 5), we recorded a higher number of complications in the right lung (p \ 0.005) (Fig. 5). In the CNB group (Fig. 11), the complication rate was higher in the upper lobe, while in the FNAB group (Fig. 12) it was higher in the lower lobe. A higher complication rate was recorded in the left lung both for CNB (Fig. 13) and for FNAB (Fig. 14). Our study revealed no statistically significant correlation with the needle calibre (p [ 0.005). This may be in part explained by the small number of procedures done using needles with a calibre other than 18 G (Fig. 1) for CNB
6 (21%) 2 (11%) 2 (11%)
8 (29%)
21% 22% 11% 20%
0 (0%)
0% 0%
posteriore
anteriore
29%
11% 0% laterale
posteriore
(Fig. 15); for FNAB (Fig. 16), only two procedures (3.5 %) were performed with 20 G needles, the other 54 biopsies (96.5 %) were done with 22 G needles (Fig. 2; Table 1). Similarly, there was no statistically significant correlation with the number of passes (p \ 0.005). The reason for this is probably that only two of the CNB procedures (3 %) required three passes and four (6 %) required two passes (Fig. 17); as for FNAB, 12 cases (20.6 %) required two passes (Fig. 18; Table 1). Similar results were obtained with regard to lesion histology (p [ 0.005), both for lesions sampled with CNB (Fig. 19) and with FNAB (Fig. 20). We were unable to evaluate complications on the basis of either lesion nature (benign or malignant), as only six
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Radiol med Fig. 11 CNB: right lung
CNB– Right lung. Hemoptysis no PNX Suffusion Suffusion+PNX
Hemoptysis no PNX Suffusion Suffusion+ PNX 20
0 (0%)
4 (20%)
100% 0%
100%
20%
29%
2 (14%) 10 (50%)
4 (29%) 2 (14%) 4 (29%)
Lower
100% 0% 0% 0%
14%
14
2 (14%)
100%
2 0 2
0 (0%) 0 (0%) 0 (0%)
Middle
100%
14%
50%
29% 6 (30%)
30%
0 (0%)
Upper
14% Lower
0%
0%
Middle
Upper
CNB– Polmone destro. emottisi no pnx soffusione emorragica soffusione emorragica e pnx
emottisi no pnx soffusione emorragica soffusione emorragica e pnx 20
0 (0%)
4 (20%)
14 10 (50%)
4 (29%) 2 (14%) 4 (29%)
inferiore
2 0 2
0 (0%) 0 (0%) 0 (0%)
medio
patients undergoing CNB had inflammatory disease, or lesion histology since the histological results were widely heterogeneous. The rate of nondiagnostic samples at definitive histological examination, assessed on the basis of the pathology reports, was 18.1 % for CNB and 10.7 % for FNAB (Table 6). We then calculated the diagnostic accuracy of the two methods. This evaluation revealed that FNAB, if
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100% 0% 0% 0%
14%
100% 0%
100%
20%
29%
2 (14%)
2 (14%)
100%
14%
100%
50%
29% 6 (30%) 0 (0%)
superiore
30%
14% inferiore
0%
0%
medio
superiore
performed with a pathologist on site who examines extemporaneously the accuracy of the samples, has an accuracy of 94.8 vs. 81.8 % for CNB. Finally, we found that FNAB accuracy, in relation to lesion size, is higher for lesions with a diameter between 1.8 and 3.5 cm (95.9 % accuracy), whereas CNB accuracy was higher for lesions between 2 and 4.2 cm (83.6 % accuracy) (Fig. 21).
Radiol med Fig. 12 FNAB: right lung
FNAB – Right lung. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX 12
100%
100% 0%
100% 100
10 40% 8 (67%)
4 (40%)
67% 20%
100%
2 (20%)
4 (40%)
2 2
0 (0%) Lower
0 (0%) 0 0 (0%)
Middle
2 (17%) 0 (0%) 2 (17%) Upper
17%
40%
0% 17%
0%
0% 0%
Lower
Middle
Upper
FNAB – Polmone destro. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 12
100%
100% 0%
100% 100%
10 40% 8 (67%)
4 (40%)
67% 20%
100%
2 (20%)
4 (40%)
2 2
0 (0%) inferiore
0 (0%) 0 0 (0%)
medio
Discussion In pulmonary lesions, it is very important to distinguish correctly between benign and malignant lesions, since the pathological diagnosis will determine the treatment to be applied [13]. One diagnostic method used in the evaluation of lung cancer is bronchoscopy, but when this is not sufficient for the diagnosis, particularly in peripheral pulmonary lesions or pleural lesions, a trans-thoracic biopsy is performed
2 (17%) 0 (0%) 2 (17%) superiore
17%
40%
0% 17%
0%
0% 0%
inferiore
medio
superiore
[14]. This procedure is characterised by a high diagnostic capability, but also by simplicity and a limited number of complications [13–15]. Our study shows that the diagnostic accuracy of both FNAB and CNB is relatively high for each technique. However, it is higher for the aspiration technique, reaching values equal to 94.8 %, while it is lower for CNB, with a rate of 81.8 %. All patients in our cohort were affected by primary or secondary malignancies, with the exception of six patients
123
Radiol med Fig. 13 CNB: left lung
CNB – Left lung. Hemoptysis no PNX Suffusion Suffusion+PNX
Hemoptysis no PNX Suffusion Suffusion+PNX
100%
18 2 (11%)
11%
100% 0%
100%
12 10 (56%)
0 (0%)
56%
67%
8 (67%) 2 (11%) 2 (11%)
2 (11%)
Lower
0 (0%) 2 (17%)
11% 2 (17%)
11%
11% Lower
Upper
0% 17%
17% Upper
CNB – Polmone sinistro. emottisi no pnx soffusione emorragica soffusione emorragica e pnx
emottisi no pnx soffusione emorragica soffusione emorragica e pnx
100%
18 2 (11%)
11%
100% 0%
100%
12 10 (56%)
0 (0%)
56%
67%
8 (67%) 2 (11%) 2 (11%)
2 (11%)
inferiore
0 (0%) 2 (17%)
2 (17%)
superiore
who had inflammatory disease. This did not allow us to evaluate diagnostic accuracy in relation to the benign or malignant nature of the lesion. The literature contains heterogeneous data on this topic. FNAB has a diagnostic accuracy that varies from 64 to 97 % [7]. According to Tarver et al. [16], this value is 95 % for malignant lesions, and lower (78.3 %) for benign lesions [6, 17]. This shows that the diagnostic classification of benign lesions, whether sampled by aspiration or cutting needle, is less
123
11%
0% 17%
11%
11% inferiore
17% superiore
accurate [6, 18]. This can in part be justified by the severity of the judgement to which the samples were subjected: material lacking malignant cells should not be considered negative for malignancy, unless it is possible to formulate a clear and specific diagnosis of a benign disease [19]. In some studies, diagnostic accuracy appears to be higher in the case of larger lesions and of FNAB performed in the presence of a pathologist to assess sample adequacy [4]. In many centres, however, the pathologist is not
Radiol med Fig. 14 FNAB: left lung
FNAB – Left lung. no PNX Suffusion
no PNX Suffusion 18
100%
100%
100%
14 10 (56%)
56% 71% 10 (71%)
4 (22%)
22% 2 (14%)
4 (22%) Lower
14% 2 (14%)
Upper
22% Lower
14% Upper
FNAB – Polmone sinistro. no pnx soffusione emorragica
no pnx soffusione emorragica
18
100%
100%
100%
14 10 (56%)
56% 71% 10 (71%)
4 (22%)
22% 2 (14%)
4 (22%) inferiore
superiore
available for extemporaneous evaluation of the samples. This may lead the operator to use cutting needles even when in the presence of small nodules [20, 21]. Charig and Phillips [20] have shown that the diagnostic accuracy of CNB is similar to that of FNAB, if performed with a pathologist on site. Other authors state that the diagnostic accuracy of CNB is lower for malignant lesions compared to that of FNAB [22, 23]. These latter data are consistent with the findings of the present study. Several published studies have also correlated diagnostic accuracy with lesion size. Tsukada [24] found a
14% 2 (14%)
22% inferiore
14% superiore
gradual and progressive decrease of diagnostic accuracy values with decreasing lesion size, from 100 % (for lesions \5 cm) to 67 % (for lesions \1 cm). Similar results were published by Priola [5], who reported an accuracy of 68 % for lesions \1.5 cm, 78 % if [5 cm and 87 % in the case of lesions measuring between 1.5 and 5 cm. Lucidarme [25] related diagnostic accuracy to lesion size as well as to the number of passes: for lesions [2 cm with an average of 2.5 passes per procedure, the diagnostic accuracy was 88 %; when one pass was performed, this
123
Radiol med
value decreased to 83 %. Yeow [19] described a mean of three passes per biopsy with a diagnostic accuracy of 84, 93 and 96 %, respectively, for lesions measuring \15, [5 cm
and between 1.5 and 5 cm. In small lesions, these data can be justified by sampling errors due to the increased technical difficulty during biopsy centring [26], but for large
CNB – Needle caliber. Hemoptysis Hemoptysis
no
no
PNX
PNX
Suffusion
Suffusion
Suffusion+ PNX
Suffusion + PNX 54 2 (4%)
100%
100% 0%
100%
4%
100%
20%
22 (41%)
41% 20% 0%
14 (26%)
10
12 (22%)
4 (40%)
4 (7%)
2 (20%) 2 (20%) 0 (0%) 2 (20%)
20 G
18 G
2 2 (100%)
0 (0%) 0 (0%) 0 (0%) 0 (0%)
100% 26%
40%
22% 20% 7%
0% 0% 21 G
20 G
18 G
21 G
0%
CNB – Calibro ago. emottisi emottisi
no
no
pnx
pnx
soffusione emorragica
soffusione emorragica
soffusione emorragica e pnx
soffusione emorragica e pnx 54 2 (4%)
100%
100%
4%
100% 0%
100%
20%
22 (41%)
41% 20% 0%
14 (26%)
12 (22%) 4 (7%) 18 G
Fig. 15 CNB: needle calibre
123
10 4 (40%) 20 G
2 (20%) 2 (20%) 0 (0%) 2 (20%)
2 2 (100%) 21 G
0 (0%) 0 (0%) 0 (0%) 0 (0%)
100% 26%
40%
22% 20% 7% 18 G
0% 0% 20 G
21 G
0%
Radiol med
the technique employed, a lower diagnostic accuracy in nodules measuring *1 cm or in large nodules. The reported rate of pneumothorax after CT-guided lung biopsies ranges from 4 % [26] to 62 % [27]. In the present study, where any air flap between the pleura and the lung was considered a pneumothorax, the incidence was 21.3 % and thus falls within the reported range (Table 2). Considering the two methods used, the pneumothorax rate was 21.2 % for CNB and 21.4 % for FNAB. Although with different rates, also Arakawa et al.
lesions it is understood if one considers the frequent finding of central necrosis [19]. Our study also found a correlation between lesion size and diagnostic accuracy, which appeared to be independent of the biopsy technique and higher for lesions between 1.8 and 4.2 cm. For nodules sampled with FNAB, the highest accuracy, equal to 95.9 %, was found for lesions between 1.8 and 3.4 cm. Conversely, for those sampled with CNB, the diagnostic accuracy was 83.6 % in lesions between 2 and 4.2 cm (Fig. 21). We therefore recorded, regardless of
Fig. 16 FNAB: needle calibre
FNAB – Needle Caliber. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX
100%
54
100%
30 (56%)
100%
56%
100%
2 2
0 (0%) 0 (0%) 0 (0%)
(100%)
12 (22%)
2 (4%)
22%
10 (19%)
19% 0%
4%
22 G
20 G
22 G
20 G
0%
0%
FNAB – Calibro ago. no pnx soffusione emorragica soffusione emorragica e pnx
no pnx soffusione emorragica soffusione emorragica e pnx 54
100%
100%
30 (56%)
100%
56%
100%
2 2 (100%) 20
0 (0%) 0 (0%) 0 (0%)
12 (22%)
2 (4%)
22%
10 (19%)
22
19% 0%
0%
20
0%
4%
22
123
Radiol med
[28] reported a higher percentage of pneumothorax with FNAB (40 %) than with CNB (24.3 %). Many cases of pneumothorax were completely resolved without any
need for surgical treatment (Fig. 8). Placement of a chest drain was required in 2.4 % of the total population, and in 11.5 % of the population with pneumothorax. These
CNB – Number of passes. Hemoptysis
Hemoptysis
no PNX
no
Suffusion
pnx
soffusione emorragica e pnx
Suffusion Suffusion e PNX
100% 13%
100% 0%
100% 0% 100% 0% 0%
75% 60 7 (100%) (12%) 8 (13%) 30 (50%)
7 (12%) 7 (12%) 8 (13%)
1
0%
50% 0 (0%) 1 (25%) 0 (0%) 3 4 (75%) (100%) 1 0 (25%) (0%) 2
0 (0%) 0 (0%) 0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100) 3
0%
0% 12%
25%
100%
2
3
12% 13% 1
CNB – Numero passaggi. emottisi
emottisi
no pnx
no
soffusione emorragica
pnx
soffusione emorragica e pnx
soffusione emorragica soffusione emorragica e pnx
100% 13%
100% 0%
100% 0% 100% 0% 0%
75% 60 (100%)) 8 (13%) 30 (50%) 7 (12%)
7 (12%) 8 (13%)
1
Fig. 17 CNB: number of passes
123
0% 0 (0%) 1 (25%) 0 (0%) 0 4 (0%) (100%) 3 0 (75%) (0%) 2
0 (0%) 0 (0%) 0 (0%) 0 2 (0%) (100%) 0 1 (0%) (50%) 3
50%
0%
0%
12%
12%
25%
100%
2
3
13%
1
Radiol med
results are consistent with the percentages reported in other studies [29]. The onset of pneumothorax was found to correlate with variables related to both the procedure and the patient (Table 3). In our study, we recorded a higher rate of pneumothorax for small lesions sampled with CNB (Table 4). Pneumothorax therefore correlated with both the biopsy type and lesion size (Fig. 5), as also reported by other authors, who described an increased risk for small
lesions [30, 31] or even a 4 % decrease in risk for each 10-mm increment in lesion diameter [5]. The percentage of parenchymal haemorrhage after CTguided lung biopsy is reported to vary from 4 % [19] to 27 % [32]. In our study, the results obtained in patients who underwent FNAB are consistent with those of Kahn et al. [32], who found a particularly significant relationship between small lesions and the appearance of haemorrhage (p \ 0.005) (Fig. 6).
Fig. 18 FNAB: number of passes
FNAB – Number of passes. no PNX Suffusion Suffusion+PNX
no PNX Suffusion Suffusion+PNX
100%
44
24 (55%)
100%
55% 67%
12 (27%)
12
6 (14%)
2 (5%)
100%
1
8 (67%) 0 4 (0%) 0 (33%) (0%) 2
27%
0% 33%
14% 5%
0%
1
2
FNAB – Numero passaggi. no pnx soffusione emorragica soffusione emorragica e pnx
100%
44
24 (55%)
12 (27%) 6 (14%)
2 (5%) 1
no pnx soffusione emorragica soffusione emorragica e pnx 100%
100%
55% 67%
12 8 (67%) 0 4 (0%) 0 (33%) (0%) 2
27%
0% 33%
14% 5%
1
0%
2
123
Radiol med
CNB – Histologic type. 28 2 (7%)
Hemoptysis no
8 (29%)
PNX Suffusion Suffusion+PNX
10 (21%) 10 8 (29%)
0 (0%)
4 (14%)
0 (0%) 0 (0%)
2 2 (100%)
Bronchioloalveolar
Adenocarcionoma 100% 7%
0 2 2 (0%) 0 (20%) (40%) (0%) 2 0 (20%) (0%) 0 2 2 4 2 0 (0%) (20%) (40%) (40%) 1 (100%) 0 (0%) SCCL
100% 0% 0%
8 (67%)
4 (40%) 2 (20%) 2 (20%) Notevaluable
Squamos
100% 0%
12 2 (17%)
0 12 (0%)
0 (0%)
100% 100
17%
40%
29% 21%
40%
100% 100%
100%
20%
67% 20%
29% 40% 0%
Adenocarcinoma
0 (0%)
Inflammation
100% 0% 40%
100% 0%
2
0%
0%
Bronchioloalveolar
0% 17% 0%
0%
0%
Squamous
SCCL
Not evaluable
Inflammation
CNB – Istologia.
28 2 (7%)
emottisi no
8 (29%)
pnx soffusione emorragica soffusione emorragica e pnx
10 (21%) 10 8 (29%)
0 (0%)
4 (14%)
0 (0%) 0 (0%)
K adenocarcinoma 100% 7%
2 2 (100%)
0 2 2 (0%) 0 (20%) (40%) (0%) 2 0 (20%) (0%) 0 2 2 4 2 0 (20%) (0%) (40%) (40%) 1 (100%) 0 (0%)
K bronchioloalveolare 100% 0% 0%
K microcitoma 100% 0%
0 (0%)
4 (40%)
8 (67%)
100% 0% 40%
2 (20%) non valutabile
0 (0%)
2
0 (0%)
patologia infiammatoria 100% 100
17%
40%
29% 21%
100%
100% 100%
40% 20%
67% 20%
29% 40% 0%
0%
K adenocarcinoma K bronchioloalveolare
Fig. 19 CNB: histological type
123
12 2 (17%)
2 (20%)
k spinocellulare 100% 0%
12
0%
0%
K microcitoma
0% 17% 0%
0% k spinocellulare
non valutabile
patologia infiammatoria
Radiol med
FNAB – Histologic type. 26 no PNX Suffusion Suffusion+PNX
18 (69%)
16 8 (50%)
4 (15%) 2 2 (8%) (8%) Adenocarcinoma
100%
0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100%) Carcinoid
2 (100%) 2 (100%)
0 (0%) 0 (0%) 0 (0%)
SCCL
100%
0 (0%)
Carcinoid
0% 0%
0 (0%)
2
4
0 (0%)
Not evaluable
100% 0% 33%
50%
100%
0%
100%
0%
6
100%
50%
0% 0%
2 (50%) Metastasis
100%
100%
100%
Adenocarcinoma
2 (13%)
4
Squamous
69% 15% 8% 8%
6 (38%)
2 (50%) 0 (0%) 0 (0%)
0%
SCCL
67%
38%
50%
0% 13%
0%
0%
Squamous
Metastasis
Not evaluable
FNAB – Istologia.
26
no pnx Soffusione Soffusione +PNX
18 (69%)
16 8 (50%)
4 (15%) 2 2 (8%) (8%) K adenocarcinoma
100%
0 (0%) 0 2 (0%) (100%) 0 2 (0%) (100%) k carcinoide
100%
2 (100%) 2 (100%)
0 (0%) 0 (0%) 0 (0%)
K microcitoma
2 (13%)
4 0 (0%)
k spinocellulare
100%
100%
50%
69% 100% 15% 8% 8%
6 (38%)
0% 0%
100%
0%
K adenocarcinoma k carcinoide
0% 0%
2 (50%)
2 (50%) 0 (0%) 0 (0%)
6 2
0 (0%)
0 (0%)
4
Metastasi
non valutabile
100%
100% 0% 33%
50%
100%
0%
0%
K microcitoma
38%
50%
0% 13%
0%
k spinocellulare
Metastasi
67% 0%
non valutabile
Fig. 20 FNAB: histological type
123
Radiol med
type of biopsy (Figs. 15, 16). This finding is ascribable to the small number of procedures carried out using needles with calibre other than 18 G in the case of CNB or 22 G in the case of FNAB. Even assessing the number of passes performed, we failed to find any statistically significant results (p [ 0.005), probably because most procedures were done with a single pass: 54 (93.1 %) FNAB and 52 (89.6 %) CNB (Figs. 19, 20). Other studies have justified a greater number of pneumothoraces by the number of passes, as these would increase the number of small traumas to the pleura [5]. We could not correlate the type and rate of complications with either lesion nature or histology because 95.1 % of lesions were malignant (Figs. 18, 19), and the histological findings were very heterogeneous. Rizzo et al. [5] reported that biopsies on metastatic lesions were more frequently associated with the occurrence of parenchymal haemorrhage. In contrast to other studies [33, 34], which described a lower percentage of inappropriate material for CNB than for FNAB, we performed FNAB with an on-site pathologist who immediately assessed the adequacy of the sample defining it appropriate or inappropriate (in which case an additional pass is needed) for the definitive histological examination, thereby obtaining a lower rate of nondiagnostic samples with FNAB than with CNB (Table 6).
Table 6 Nondiagnostic sampling in core-needle biopsy and fineneedle aspiration biopsy based on lesion dimension Lesion dimension
FNAB N (%)
CNB N (%)
B1.5 cm
0 (0)
0 (0)
1.6–3 cm
6 (10.7)
2 (3)
3.1–4.5 cm
0 (0)
6 (9.1)
C4.6
0 (0)
4 (6)
CNB core-needle biopsy, FNAB fine-needle aspiration biopsy
Accuratezza diagnostica
With regard to age (Table 5), the largest number of complications, such as haemorrhage and haemoptysis, was recorded in elderly patients undergoing CNB (Fig. 3). This can be ascribed to the fact that many of these patients normally took anti-aggregating or anticoagulant therapies and thus suffered from coagulation disorders, a finding in contrast with other authors’ reports [5]. As described in the literature [5], posterior access (Table 5) carries a greater risk of complications. This was reflected in the results we obtained with FNAB (Fig. 9) but not with CNB (Fig. 7); in fact, CNB was associated with a greater number of complications when the anterior approach was used (Fig. 8). This study did not reveal any statistically significant correlations with the needle gauge (p [ 0.005) in either
Accuratezza diagnostica di FNAB e CNB in base alle dimensioni delle lesioni. 120 100 80 60 40 20 0
FNAB CNB 1
1,5
2
2,5
3
3,5
4
4,5
5
5,5
6
6,5
7
Diagnostic accuracy
Dimensioni
120 100 80 60 40 20 0
Diagnostic accuracy of FNAB and CNB based on lesion dimension.
FNAB CNB 1
1,5
2
2,5
3
3,5
4
4,5
Dimensions
Fig. 21 Diagnostic accuracy of FNAB and CNB based on dimension of lesions
123
5
5,5
6
6,5
7
Radiol med
Conclusions FNAB seems to be burdened by a lower complication rate than CNB in terms of both absolute values and in relation to variables inherent to the patient, the procedure and the lesion. The diagnostic accuracy is higher for FNAB and, if this technique is performed in the presence of a pathologist, it is characterised by a lower rate of inadequate samples than CNB. We can therefore state that in lesions where both CNB or FNAB are an option, the latter is preferable in terms of both complication rate and diagnostic accuracy, provided that it is carried out by a pathologist on site. Conflict of interest Emanuela Capalbo, Michela Peli, Maria Lovisatti, Maria Cosentino, Paola Mariani, Eisabetta Berti, Maurizio Cariati declare that they have no conflict of interest related to the publication of this article.
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