Abstract
Objectives:
To compare CT-guided transthoracic cutting needle biopsy (TCNB) with transthoracic aspiration needle biopsy (TANB) for pulmonary lesions with respect to the diagnostic accuracy and complication rate.
Methods:
Of the 859 cases that underwent consecutive CT-guided biopsy of pulmonary lesions, 713 cases confirmed by surgical pathology or clinical follow-up were enrolled. Of these, the first consecutive 275 cases underwent TANB, and the remaining 438 received TCNB. The final diagnosis determined the accuracy of biopsy. Based on the post-biopsy CT and clinical medical records, the presence or absence of biopsy-related complications was determined. The χ2 test was used to compare the differences between TCNB and TANB in terms of diagnostic accuracy and complication rate.
Results:
Among the 713 biopsy lesions, the final diagnosis was malignant in 411 cases and benign in 302 cases. As compared to TANB, the diagnostic accuracy of TCNB (98.9% vs 93.8%, χ2 = 14.35, p < 0.01), sensitivity to malignant lesions (97.8% vs 90.6%, χ2 = 10.58, p < 0.01), negative predictive value (97.6% vs 84.8%, χ2 = 19.03, p < 0.01), and specific diagnostic rate for benign lesions (73.4% vs 57.9%, χ2 = 7.29, p < 0.01) were improved. On the other hand, a statistical difference was detected between TCNB and TANB with respect to the incidence of pneumothorax (20.6% vs 13.1%, χ2 = 6.46, p = 0.01), hemorrhage (32.2% vs 13.1%, χ2 = 33.03, p < 0.01), and hemoptysis (8.2% vs 3.3%, χ2 = 6.87, p < 0.01). One patient died just several minutes after TCNB due to severe hemorrhage with hemoptysis.
Conclusions:
Compared to TANB, CT-guided TCNB improves the diagnostic accuracy of pulmonary lesions, but complication rate increases significantly.
Advances in knowledge:
In general, TCNB should be recommended, especially for highly suspicious benign lesions. For patients with small lesions adjacent to vessels or vessels within the lesion, TANB should be considered.
Introduction
For patients with a lung nodule or mass on chest radiography or CT, definite diagnosis is required before treatment. CT-guided transthoracic needle biopsy acts as a safe, minimally invasive method for the diagnosis and differential diagnosis of pulmonary lesions, and its value had been widely accepted. 1–6 Two CT-guided biopsy techniques currently being used are transthoracic cutting needle biopsy (TCNB) and transthoracic aspiration needle biopsy (TANB). The sensitivity and specificity of both techniques for diagnosing lung cancer have been reported to be high, with acceptable complication rates. 1,2,4,7 Whether one technique is better than another? To answer this question, the diagnostic value and safety of the two techniques must be compared.
To our knowledge, some studies had compared CT-guided TCNB and TANB for the evaluation of pulmonary lesions, but the results are somewhat conflicting. 7–21 Two recent initial meta-analyses showed that there were no differences between TANB and TCNB in identifying lung malignancies, 8,9 and TCNB did not result in a higher complication rate. 8 Some studies revealed TCNB yielded better results than TANB and that there was no significant increase in complication rate. 11,12 However, others stated CT-guided TANB has a greater diagnostic accuracy and lower complication rate compared to TCNB. 13,14
In our institution, aspiration needles were applied to all CT-guided lung biopsies before May 2016. Since TCNB can provide more adequate and high-quality tissue samples than TANB, it is advantageous to undergo further molecular pathological examinations and genetic detection to guide the clinical treatment. So, aspiration needles were replaced by cutting needles since June 2016. The present study was designed to evaluate the effect of aspiration needle and cutting needle on diagnostic accuracy and complication rate of CT-guided biopsy of pulmonary lesions by reviewing and summarizing the related data in recent years.
Methods and materials
Materials
From January 2014 to June 2017, a total of 859 cases underwent consecutive CT-guided biopsy of pulmonary lesions at the radiology department of our hospital. Of these, 146 cases without surgical pathology, clinical and imaging follow-up were excluded. 713 were enrolled in the present study. This study was approved by the ethics committee of our hospital. From January 2014 to May 2016, all 275 patients underwent biopsy using an 18G aspiration needle (COOK) without coaxial introducer needle. After June 2016, all 438 cases received cutting needle biopsy using 17G coaxial needle for guidance and 18G automated biopsy gun (Argon Medical Devices, Inc). All biopsies were performed by two radiologists who had experience in CT-guided biopsy for 22 and 3 years, respectively, together with a technician and a nurse. The general data of the two groups were shown in Table 1. There was no significant difference between the two groups in gender, age, lesion size, depth, and location.
Table 1.
Comparison of general data between TCNB group and TANB group
| Factor | TCNB group | TANB group | Statistical comparison |
|---|---|---|---|
| Gender | p = 0.79 | ||
| Male | 268 (61.2%) | 171 (62.2%) | |
| Female | 170 (38.8%) | 104 (37.8%) | |
| Age (y) | 60.05 ± 13.17 | 59.75 ± 14.21 | p = 0.81 |
| Lesion size (cm) | 2.56 ± 1.46 | 2.55 ± 1.63 | p = 0.92 |
| Location of lesion | p = 0.66 | ||
| upper lung field | 92 (21.0%) | 64 (23.3%) | |
| middle lung field | 179 (40.9%) | 104 (37.8%) | |
| lower lung field | 167 (38.1%) | 107 (38.9%) | |
| Distance from lesionto pleura (cm) | 1.30 ± 1.36 | 1.08 ± 1.19 | p = 0.06 |
| Emphysema | p = 0.47 | ||
| Presence | 42 (9.6%) | 22 (8%) | |
| Absence | 396 (90.4%) | 253 (92%) | |
Preparations before biopsy
Before the biopsy, the routine tests of coagulation time, platelet count, and prothrombin determination were performed, and CT-guided biopsy was conducted only after related results were confirmed as unremarkable. In patients receiving anticoagulant therapy, anticoagulants must be discontinued before biopsy. For patients taking asprin and/or clopidogrel, CT-guided biopsy was performed one week after discontinuation. Patients taking low-molecular weight Heparin should stop taking on the day of biopsy. Introduced the biopsy procedure, possible complications and precautions to the patient. All patients signed an informed consent, and intravenous trocar was placed before biopsy to preserve venous access.
Biopsy methods
The patient was laid in the supine or prone position based on lesion location. Toshiba Aquillion-one 16-slice whole-body spiral CT machine was used, and 100 kV, 120 mA routine CT scan of the lesion area was performed with a reconstructed slice thickness of 5 mm and an interval of 5 mm. These images were used by the operator to decide on a suitable approach to the lesion. In addition to avoidance bone tissues, the selection principles for the needle insertion path were followed: (1) avoiding the heart and large blood vessels; (2) as perpendicular to the pleura as possible; (3) the length through lung tissues should be as short as possible; (4) avoiding pulmonary bullae and emphysema area; (5) avoiding the interlobar fissure as much as possible; and (6) trying to be as close as possible to the upper edge of the rib. Subsequently, the skin puncture area underwent routine disinfection. 5 ml of 1% lidocaine was administered subcutaneously as local anesthesia. When TANB was performed, the 18G aspiration needle was inserted in the predetermined direction to the subcutaneous tissues. Local CT scan with a 2 cm range centered on the needle insertion plane was performed, and four images of 5 mm layer thickness and 5 mm interval obtained were used to verify and calibrate the actual needle direction before the needle tip reached the pleura. After the needle was further inserted to reach the lesion, the needle core was pulled out, and the lesion tissue was aspirated using a 20 ml syringe under negative pressure. The operator determined whether the specimen was sufficient. Cytopathology and histopathology were performed on the specimens. If the clinical history suggested an infectious etiology, specimens were submitted for microbiological analysis at same time. The procedure of TCNB was similar to TANB. The 17G coaxial needle tip reached the lesion, and the coaxial needle core was pulled out. Subsequently, the biopsy was performed using the 18G biopsy gun through the coaxial needle shell. 2 to 3 specimens with a length of 1 cm were usually obtained. The obtained specimens were placed in formalin and submitted for routine histopathology. Occasionally, if the clinical history suggested an infectious aetiology, specimens were submitted for microbiological analysis at same time. No pathologist was on site to extemporarily evaluate the adequacy of the sample, whether CT-guided TANB or TCNB.
Process after biopsy
Immediate post-biopsy CT scan of the lesion area was performed to observe the complications such as pneumothorax, pulmonary parenchymal hemorrhage around the lesions and the puncture needle tract. All patients had a chest radiograph at 4 h, or sooner if they became symptomatic. The decision to place a chest tube was based on the clinical status of the patient and the size of the pneumothorax. Asymptomatic patients with a pneumothorax involving less than 25% of lung volume were observed. Larger or symptomatic pneumothorax was drained using a percutaneously placed chest tube. In the case of patients with post-biopsy hemoptysis >20 ml, i.v. injection of hemocoagulase of spearhead viper was administered for hemostasis.
Determination of biopsy pathology
Based on the surgical pathology, clinical and imaging follow-up results, the final diagnosis for the lesion was obtained, and lesions were classified as malignant and benign. The lesion meeting one of the following conditions was defined as malignant: (1) The surgical pathology was malignant; (2) CT-guided biopsy pathology was malignant, and the lesion was significantly reduced by oncological treatment; and(3) Lesion was enlarged with distant organ and/or lymph node metastasis during follow-up. The lesion meeting one of the following conditions was defined as benign: (1) The surgical pathology was benign; (2) During follow-up, the lesion was significantly smaller or disappeared without treatment; (3) biopsy pathology confirmed the specific benign lesion; for example, tuberculosis, fungal infection, organizing pneumonia, showing marked improvement after targeted treatment; and (4) the lesion did not enlarge during follow-up for a period of at least 2 years. Biopsy pathology suspicious malignancy and malignancy are regarded as positive for statistical purposes. Biopsy pathologies were divided into true positive (both biopsy pathology and final diagnosis were malignant), false positive (biopsy pathology was malignant, but the final diagnosis was benign), true negative (both biopsy pathology and final diagnosis were benign), and false negative (biopsy pathology was benign, but the final diagnosis was malignant). True-negative biopsy pathologies were divided into specific benign diagnosis (biopsy pathology suggested clear benign results, such as tuberculosis, fungal infection, organizing pneumonia, and hamartoma) and non-specific benign diagnosis (biopsy pathology showed no malignant signs, but specific benign diagnosis could not be made). The diagnostic accuracy, sensitivity, specificity, positive and negative predictive values for malignant lesions between TCNB and TANB were compared.
The definition of complications
Pneumothorax was defined as any amount of air between the lung and pleura shown on post-biopsy CT or chest radiograph. The needle-tract hemorrhage was defined as newly found opacity with increased density and width >0.5 cm along the needle track. The lesion area hemorrhage was defined as a new density increase in the lesion or around the lesion after biopsy as demonstrated by CT. Hemoptysis included the newly developed hemoptysis and self-limited sputum with blood after the biopsy. Any of the needle tract hemorrhage, hemorrhage in the lesion area, and the post-biopsy hemoptysis would be identified as biopsy-related hemorrhage.
Complications were classified as minor or major according to the Society of Interventional Radiology (SIR) Guidelines. 22 Minor complications consisted of pneumothorax without need for intervention, small amount of pulmonary hemorrhage, and transient hemoptysis. Major complications consisted of pneumothorax requiring chest tube placement, hemothorax, hemoptysis requiring intervention, air embolism, needle tract seeding, and death.
Statistical analyses
Statistical analyses were performed using the SPSS software, v.17.0. The enumeration data between TCNB and TANB groups were compared using χ2 test, and the measurement data between the two groups were compared using independent sample t-test; p values < 0.05 were considered statistically significant.
Results
Diagnostic accuracy of CT-guided biopsy of pulmonary lesions
Biopsy pathological results and final diagnosis of biopsy lesions
Biopsy pathological results were shown in Table 2 and the comparison between biopsy pathological results and final diagnosis was shown in Table 3. Among 713 patients, 375 exhibited malignant lesions by biopsy pathology, of which 198 were adenocarcinomas (Figures 1 and 2a), 67 squamous cell carcinomas, 32 small cell lung cancers, 11 lymphomas, six neuroendocrine tumors (Figure 3), four sarcomas, and 37 lung cancers without tissue typing, 20 metastases (Figure 4) (breast cancer with lung metastasis in 13 cases, thyroid cancer with lung metastasis in six cases, and kidney cancer with lung metastasis in one case). Biopsy pathology suspected malignancy in 14 cases. The final diagnosis was malignant in all of 389 cases which were diagnosed or suspected malignancy by biopsy pathology. Of them, 129 cases had surgical verification, remaining 260 cases confirmed by CT and clinical follow-up.
Table 2.
CT-guided biopsy pathology in 713 cases
| Diagnosis | Total number | Number of TCNB | Number of TANB |
|---|---|---|---|
| Malignant lesions | 375 | 219 | 156 |
| Lung primary | 355 | 208 | 147 |
| Adenocarcinoma | 198 | 123 | 75 |
| Squamous cell carcinoma | 67 | 39 | 28 |
| Small cell lung cancer | 32 | 18 | 14 |
| No pathological type | 37 | 15 | 22 |
| Lymphoma | 11 | 7 | 4 |
| Neuroendocrine tumors | 6 | 4 | 2 |
| Sarcoma | 4 | 2 | 2 |
| Metastases | 20 | 11 | 9 |
| Breast cancer | 13 | 8 | 5 |
| Thyroid cancer | 6 | 2 | 4 |
| Kidney cancer | 1 | 1 | 0 |
| Suspicious for malignancy | 14 | 7 | 7 |
| Specific benign lesions | 209 | 154 | 55 |
| Organizing pneumonia | 57 | 43 | 14 |
| Tuberculosis | 50 | 39 | 11 |
| Pneumonia | 33 | 20 | 13 |
| Fungal infection | 25 | 19 | 6 |
| Vasculitis | 9 | 7 | 2 |
| Abscess | 9 | 6 | 3 |
| Inflammatory pseudotumor | 8 | 4 | 4 |
| Pulmonary infarction | 8 | 6 | 2 |
| Sarcoidosis | 4 | 3 | 1 |
| Pneumoconiosis nodules | 4 | 3 | 1 |
| Hamartoma | 2 | 2 | 0 |
| No specific benign lesions | 115 | 58 | 57 |
Table 3.
Comparison of CT-guided biopsy pathological results with final diagnosis
| Final diagnosis | Biopsy pathology | Total | ||
|---|---|---|---|---|
| Malignant | Specifically benign | Non-specifically benign | ||
| Malignant | 389 (54.6%) | 2 (0.3%) | 20 (2.8%) | 411 (57.6%) |
| Benign | 0 (0%) | 207 (29.0%) | 95 (13.3%) | 302 (42.4%) |
| Total | 389 (54.6%) | 209 (29.3%) | 115 (16.1%) | 713 (100%) |
Figure 1.
A 74-year-old female patient underwent TCNB for small ground-glass nodule at the left upper lobe, and biopsy pathology diagnosed invasive adenocarcinoma. The needle was inserted obliquely from the anterior chest wall to the lesion (arrow).
Figure 2.
A 55-year-old female patient with left upper lung mass, and TCNB pathology showed adenocarcinoma. The needle path passed through the interlobar fissure (a). The patient suffered from chest tightness and blood pressure drop post-biopsy, chest radiograph showed left hemothorax (b), and the patient recovered after ultrasound-guided aspiration and transfusion.
Figure 3.
A 55-year-old male patient with a nodule at the right lower lung underwent TCNB, and biopsy pathology revealed neuroendocrine carcinoma.
Figure 4.
A 43-year-old female patient with multiple nodules of both lungs underwent CT-guided TCNB, and biopsy pathology showed breast cancer with lung metastasis.
A total of 209 cases were diagnosed as specific benign lesions by biopsy pathology, including 57 organizing pneumonia (Figure 5), 50 with pulmonary tuberculosis (Figure 6), 33 with pneumonia, 25 with fungal infection (Figure 7), nine with vasculitis, nine with lung abscess, eight with inflammatory pseudotumor, eight with pulmonary infarction, four with sarcoidosis, four with pneumoconiosis nodules, and two with hamartoma. Among them, 207 cases were true negative (confirmed by surgical pathology, clinical treatment and CT follow-up in 10, 193, and 4 cases, respectively). The remaining two cases which were diagnosed as pneumonia by TANB were false negative (one was diagnosed as adenocarcinoma by bronchoscopy biopsy, and another one was diagnosed as malignancy owing to bone metastasis during follow-up).
Figure 5.
A 68-year-old male patient underwent TCNB for the lesion at the right lower lung, and biopsy pathology showed organizing pneumonia.
Figure 6.
A 48-year-old male patient of right upper lung nodules with cavitation. The needle was vertically inserted under supine position from the anterior chest wall to the lesion, and biopsy pathology suggested tuberculosis.
Figure 7.
A 58-year-old female patient with 1.2 cm lesion in the left lung underwent TCNB. Enhanced CT showed the lesion (arrow) surrounded by blood vessels and bronchi (a). The needle trajectory was close to blood vessels (b). The patient had severe hemoptysis and loss of consciousness after leaving CT scanning bed, and the chest radiograph showed massive bleeding (arrow) in right lung (c). The patient died immediately, although the emergency rescue was underwent.
In 115 cases, no malignant signs were observed and no specific benign diagnosis was made by biopsy pathology. Among them, 18 had strong clinical and imaging features of malignancy and underwent a surgery. The surgical pathology diagnosed malignancy in 13 cases and benign in five cases. In the remaining 97 cases, according to clinical course and imaging follow-up, the final diagnosis was benign in 90 cases and malignant in seven cases.
Comparison of the diagnostic accuracy between TCNB and TANB (Tables 4 and 5)
Table 4.
Comparison of biopsy pathology between TCNB and TANB
| True positive | False positive | True negative | False negative | Total | |
|---|---|---|---|---|---|
| TCNB | 226 | 0 | 207 | 5 | 438 |
| TANB | 163 | 0 | 95 | 17 | 275 |
| Total | 389 | 0 | 302 | 22 | 713 |
Table 5.
Comparison of the diagnostic values between TCNB and TANB
| Diagnostic accuracy | Sensitivity for malignant lesions | Diagnostic specificity | Positive predictive value | Negative predictive value | Specific diagnosis rate for benign lesions | |
|---|---|---|---|---|---|---|
| TCNB | 98.9% (433/438) | 97.8% (226/231) | 100% (207/207) | 100% (226/226) | 97.6% (207/212) | 73.4% (152/207) |
| TANB | 93.8% (258/275) | 90.6% (163/180) | 100% (95/95) | 100% (163/163) | 84.8% (95/112) | 57.9% (55/95) |
| Statistical comparison | χ2 = 14.35, p < 0.01 | χ2 = 10.58, p < 0.01 | χ2 = 19.03, p < 0.01 | χ2 = 7.29, p < 0.01 |
As compared to TANB, TCNB showed an increase with respect to qualitative diagnostic accuracy (98.9% vs 93.8%, χ2 = 14.35, p < 0.01), sensitivity to malignant lesions (97.8% vs 90.6%, χ2 = 10.58, p < 0.01), negative predictive value (97.6% vs 84.8%, χ2 = 19.03, p < 0.01), and specific diagnostic rate for benign lesions (73.4% vs 57.9%, χ2 = 7.29, p < 0.01).
Comparison of complications between TCNB and TANB
Among 713 CT-guided biopsies of lung lesions, pneumothorax, hemorrhage, and hemoptysis occurred in 126, 177, and 45, respectively. 18 cases had major complications, including massive pneumothorax with chest duct drainage in 12 cases (eight in TCNB group and four in TANB group), hemothorax in two patient (one was in TCNB group and another was in TANB group, the case in TCNB group had more bleeding volume) (Figure 2b), transient loss of consciousness after TCNB in two cases, TCNB-related pericardial tamponade in one patient (Figure 8), death after TCNB in one case. The dead patient had small lesion surrounded by blood vessels and bronchi, occurred severe hemoptysis and died immediately after TCNB, although the emergency rescue was underwent (Figure 7). In 713 biopsy cases, no needle tract seeding, lung torsion, and air embolism were detected. Comparison of complications between the two groups was shown in Table 6. The TCNB group showed a higher incidence of pneumothorax, pulmonary hemorrhage, and hemoptysis than the TANB group. The major complications in the TCNB group were higher than those in the TANB group (3.0% vs 1.8%), but the difference was not statistically significant due to the small number of cases. All the three patients with severe complications were in TCNB group, and one of them died.
Figure 8.
A 32-year-old female patient with lesion (arrow) in the lingual segment of left upper lobe underwent TCNB. Post-biopsy CT revealed pneumothorax (white stars) and pericardial tamponade (black stars).
Table 6.
Comparison of complications between TCNB and TANB
| Pneumothorax | Hemorrhage | Hemoptysis | Major complications | |||||
|---|---|---|---|---|---|---|---|---|
| Number | Occurrence rate | Number | Occurrence rate | Number | Occurrence rate | Number | Occurrence rate | |
| TCNB | 90 | 20.65% | 141 | 32.2% | 36 | 8.2% | 13 | 3.0% |
| TANB | 36 | 13.1% | 36 | 13.1% | 9 | 3.3% | 5 | 1.8% |
| Statistical results | χ2 = 6.45, p = 0.01 | χ2 = 33.02, P＜0.01 | χ2 = 6.87, P＜0.01 | χ2 = 0.94, p = 0.33 | ||||
Discussion
Comparison of diagnostic values between CT-guided TCNB and TANB for pulmonary lesions
This and previous studies had shown that CT-guided TCNB of pulmonary lesions significantly improved the specific diagnosis rate of benign lesions as compared to TANB. 7,8,17,19 However, there are conflicting data in the literature regarding the diagnostic sensitivity of malignant lesions between TCNB and TANB. Two recent meta-analyses 8,9 and the research by Sangha et al 21 showed that there were no differences between TANB and TCNB in identifying lung malignancies. Guimaraes et al 11 analyzed 362 cases undergoing CT-guided TANB and 97 cases undergoing TCNB for pulmonary lesions in a retrospective study, suggesting that the diagnostic sensitivity of TCNB to malignant lesions was higher than that of TANB (95.2% vs 81.8%). The findings by Arakawa et al, 15 Ocak et al, 16 and Beslic et al 18 were consistent with Guimaraes. In addition, study by Ocak et al 16 stated that TCNB carried out tissue typing accurately in 97% of lung cancers, which was significantly higher than that of TANB (65%). Meanwhile, TCNB could effectively perform gene detection. Conversely, some studies showed that TANB was superior to TCNB in the diagnostic accuracy of malignant lesions. 13,14 This study showed TCNB was superior to TANB in terms of qualitative diagnostic accuracy, sensitivity to malignant lesions, and negative predictive value. The sensitivity to malignant lesions was 97.8% for TCNB and 90.6% for TANB, which was higher than the data of meta-analysis (95% for TCNB and 90% for TANB). 9
Comparison of complications between TCNB and TANB
In addition to diagnostic value, safety is a common concern. Pneumothorax, hemorrhage, and hemoptysis are common complications of CT-guided lung biopsy. Heerink et al 10 conducted a meta-analysis of the complications of CT-guided transthoracic lung biopsy, involving 32 articles with a total of 8133 cases undergoing TCNB, and 17 studies encompassing a total of 4620 cases undergoing TANB. A statistically significant difference was detected between TCNB and TANB with respect to the overall incidence of complications (38.8% vs 24%), pneumothorax (25.3% vs 18.8%), hemorrhage (18.0% vs 6.4%), and hemoptysis (4.1% vs 1.7%). The findings by Ocak et al, 16 Beslic et al 18 were consistent with Heerink. Conversely, some studies showed the incidence of pneumothorax was significantly higher in TANB. 11,15 Meanwhile, some studies stated there was no significant difference in complication rate between TCNB and TANB. 8,21 In the present study, the rates of pneumothorax, hemorrhage, hemoptysis were 20.6%, 32.2%, 8.2% in TCNB group, and 13.1, 13.1, 3.3% in TANB group. The difference was statistically significant. The rates of hemorrhage and hemoptysis in both TCNB group and TANB group was significantly higher than the data of meta-analysis, 10 which might be related to our definition of hemorrhage and hemoptysis. In this study, hemoptysis included the newly developed hemoptysis and self-limited sputum with blood after the biopsy. Any of the needle tract hemorrhage, hemorrhage in the lesion area, and the post-biopsy hemoptysis was identified as biopsy-related hemorrhage.
Although CT-guided transthoracic needle biopsy is generally regarded as a safe procedure, rare but potentially fatal complications such as air embolism, severe pulmonary hemorrhage or hemoptysis, and tumor seeding can occur. According to a survey that included 9783 biopsy specimens collected from 124 centers in Japan, severe complications were observed in 62 cases (0.75%) and four cases died immediately after the CT-guided biopsy procedure. 23 In the present study, severe complications occurred in three cases (1 case of massive hemothorax, 1 case of pericardial tamponade, and 1 case of severe hemorrhage with hemoptysis). All three cases severe complications occurred in TCNB group. The case with severe hemorrhage and hemoptysis had small lesion surrounded by blood vessels and bronchi. The patient died of severe hemorrhage and hemoptysis. Two other patients with severe complications were recovered without sequela. Conclusion cannot be drawn from a single case, but we suggest that TCNB should be avoided for patients with small lesions adjacent to vessels or vessels within the lesion.
Comparison with similar studies
Several previous studies made a retrospective analysis and comparison between TANB and TCNB. A few studies 7,11,12,15 used either TANB or TCNB in the study period, and the specific selection in a particular case was subjectively determined by the operator. Aspiration needles were primarily used for lesions adjacent to blood vessels, smaller, and deeper lesions. The cutting needles were often used for peripheral and large lesions. 11 The lesion size is a critical factor affecting the diagnosis rate and the incidence of complications, 2,24–26 and the depth of the lesion is significantly associated with the incidence of pneumothorax and hemorrhage. 26,27 The selection bias inevitably affected the comparison results between the two groups in the diagnostic accuracy and incidence of complications. Greif et al 13 and Aviram et al 20 used a fully paired study (both TANB and TCNB sequentially performed on each lesion). Although their design completely eliminated the bias in lesion selection, the sequence of biopsy techniques had an impact on the comparison of the results, because complications such as paralesional hemorrhage or pneumothorax may occur after the first needle biopsy was completed. Once the complications appeared, it inevitably affected the reliability of the following biopsy; also, this method could not compare the effect of biopsy techniques on complications. In the present study and studies by Ocak et al, 16 Beslic et al, 18 and Sangha et al, 21 TCNB and TANB were performed in the same center at different periods. In the present study, the first 275 consecutive patients performed TANB during the first 29 months and 438 patients performed TCNB during the next 12 months. Statistical analyses did not reveal any marked difference with respect to the age, gender, lesion size, location, and depth between the two groups. Meanwhile, the biopsy was performed by the same radiologists, thereby avoiding the effects of operator’s level on results. Second, previous studies on TANB often used 20–22G aspiration needles, and the obtained specimens underwent cytopathological examination. In this study, 18G aspiration needles were used to obtain relatively sufficient specimens, and the obtained specimens were subjected to cytological and histopathological examinations. It may be related to the relatively good diagnostic results of TANB in this study.
The present study had several limitations. First, it was a single-center, retrospective study. Second, immediate assessment by an on-site pathologist can improve the overall diagnostic yield by providing information about adequacy of TANB sample. Whether CT-guided TANB or TCNB, no pathologist was on site in this study.
In summary, the current findings demonstrated that both TCNB and TANB could achieve desirable diagnostic accuracy with an acceptable complication rate. Compared to TANB, TCNB showed a significant improvement in the diagnostic sensitivity of malignant lesions and the definitive diagnosis rate of benign lesions. On the other hand, the incidence of biopsy-related complications, especially hemorrhage and hemoptysis were significantly higher in TCNB group than in TANB group. The selection of TANB or TCNB should be based on the biopsy purpose, and imaging characteristics of lesions. In general, TCNB is recommended, especially for highly suspicious benign lesions. For patients with small lesions adjacent to vessels or vessels within the lesion, TANB should be considered.
Contributor Information
Zhen-guo Huang, Email: zhuang680911@163.com.
Hong-liang Sun, Email: stentorsun@hotmail.com.
Cun-li Wang, Email: zhuanlongzhang@126.com.
Bao-xiang Gao, Email: gaobx@126.com.
He Chen, Email: chenhe0911@126.com.
Min-xing Yang, Email: mofw@163.com.
Xiao-liang Chen, Email: chenxlgo@126.com.
REFERENCES
- 1. Takeshita J, Masago K, Kato R, Hata A, Kaji R, Fujita S, et al. CT-guided fine-needle aspiration and core needle biopsies of pulmonary lesions: a single-center experience with 750 biopsies in Japan. AJR Am J Roentgenol 2015; 204: 29–34. doi: 10.2214/AJR.14.13151 [DOI] [PubMed] [Google Scholar]
- 2. Li H, Boiselle PM, Shepard JO, Trotman-Dickenson B, McLoud TC. Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules. AJR Am J Roentgenol 1996; 167: 105–9. doi: 10.2214/ajr.167.1.8659351 [DOI] [PubMed] [Google Scholar]
- 3. DiBardino DM, Yarmus LB, Semaan RW. Transthoracic needle biopsy of the lung. J Thorac Dis 2015; 7(Suppl 4): S304–16. doi: 10.3978/j.issn.2072-1439.2015.12.16 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Wang Y, Jiang F, Tan X, Tian P. CT-guided percutaneous transthoracic needle biopsy for paramediastinal and nonparamediastinal lung lesions: diagnostic yield and complications in 1484 patients. Medicine 2016; 95: e4460. doi: 10.1097/MD.0000000000004460 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Maxwell AWP, Klein JS, Dantey K, Mount SL, Butnor KJ, Leiman G. CT-guided transthoracic needle aspiration biopsy of subsolid lung lesions. J Vasc Interv Radiol 2014; 25: 340–6. doi: 10.1016/j.jvir.2013.11.037 [DOI] [PubMed] [Google Scholar]
- 6. Laspas F, Roussakis A, Efthimiadou R, Papaioannou D, Papadopoulos S, Andreou J. Percutaneous CT-guided fine-needle aspiration of pulmonary lesions: results and complications in 409 patients. J Med Imaging Radiat Oncol 2008; 52: 458–62. doi: 10.1111/j.1440-1673.2008.01990.x [DOI] [PubMed] [Google Scholar]
- 7. Poulou LS, Tsagouli P, Ziakas PD, Politi D, Trigidou R, Thanos L. Computed tomography-guided needle aspiration and biopsy of pulmonary lesions: a single-center experience in 1000 patients. Acta Radiol 2013; 54: 640–5. doi: 10.1177/0284185113481595 [DOI] [PubMed] [Google Scholar]
- 8. Yao X, Gomes MM, Tsao MS, Allen CJ, Geddie W, Sekhon H. Fine-Needle aspiration biopsy versus core-needle biopsy in diagnosing lung cancer: a systematic review. Curr Oncol 2012; 19: e16–27. doi: 10.3747/co.19.871 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Zhang H-F, Zeng X-T, Xing F, Fan N, Liao M-Y. The diagnostic accuracy of CT-guided percutaneous core needle biopsy and fine needle aspiration in pulmonary lesions: a meta-analysis. Clin Radiol 2016; 71: e1–10. doi: 10.1016/j.crad.2015.09.009 [DOI] [PubMed] [Google Scholar]
- 10. Heerink WJ, de Bock GH, de Jonge GJ, Groen HJM, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol 2017; 27: 138–48. doi: 10.1007/s00330-016-4357-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Guimarães MD, Marchiori E, Hochhegger B, Chojniak R, Gross JL. CT-guided biopsy of lung lesions: defining the best needle option for a specific diagnosis. Clinics 2014; 69: 335–40. doi: 10.6061/clinics/2014(05)07 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Anderson JM, Murchison J, Patel D. CT-guided lung biopsy: factors influencing diagnostic yield and complication rate. Clin Radiol 2003; 58: 791–7. doi: 10.1016/S0009-9260(03)00221-6 [DOI] [PubMed] [Google Scholar]
- 13. Greif J, Marmur S, Schwarz Y, Man A, Staroselsky AN. Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients. Cancer 1998; 84: 144–7. doi: [DOI] [PubMed] [Google Scholar]
- 14. Capalbo E, Peli M, Lovisatti M, Cosentino M, Mariani P, Berti E, et al. Trans-thoracic biopsy of lung lesions: FNAB or CNB? our experience and review of the literature. Radiol Med 2014; 119: 572–94. doi: 10.1007/s11547-013-0360-1 [DOI] [PubMed] [Google Scholar]
- 15. Arakawa H, Nakajima Y, Kurihara Y, Niimi H, Ishikawa T. CT-guided transthoracic needle biopsy: a comparison between automated biopsy gun and fine needle aspiration. Clin Radiol 1996; 51: 503–6. doi: 10.1016/S0009-9260(96)80191-7 [DOI] [PubMed] [Google Scholar]
- 16. Ocak S, Duplaquet F, Jamart J, Pirard L, Weynand B, Delos M, et al. Diagnostic accuracy and safety of CT-guided percutaneous transthoracic needle biopsies: 14-Gauge versus 22-Gauge needles. J Vasc Interv Radiol 2016; 27: 674–81. doi: 10.1016/j.jvir.2016.01.134 [DOI] [PubMed] [Google Scholar]
- 17. Thanos L, Galani P, Mylona S, Pomoni M, Mpatakis N. Percutaneous CT-guided core needle biopsy versus fine needle aspiration in diagnosing pneumonia and mimics of pneumonia. Cardiovasc Intervent Radiol 2004; 27: 329–34. doi: 10.1007/s00270-004-0043-3 [DOI] [PubMed] [Google Scholar]
- 18. Beslic S, Zukic F, Milisic S. Percutaneous transthoracic CT guided biopsies of lung lesions; fine needle aspiration biopsy versus core biopsy. Radiol Oncol 2012; 46: 19–22. doi: 10.2478/v10019-012-0004-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Greif J, Marmor S, Schwarz Y, Staroselsky AN. Percutaneous core needle biopsy vs. fine needle aspiration in diagnosing benign lung lesions. Acta Cytol 1999; 43: 756–60. doi: 10.1159/000331287 [DOI] [PubMed] [Google Scholar]
- 20. Aviram G, Greif J, Man A, Schwarz Y, Marmor S, Graif M, et al. Diagnosis of intrathoracic lesions: are sequential fine-needle aspiration (fna) and core needle biopsy (CNB) combined better than either investigation alone? Clin Radiol 2007; 62: 221–6. doi: 10.1016/j.crad.2006.11.003 [DOI] [PubMed] [Google Scholar]
- 21. Sangha BS, Hague CJ, Jessup J, O'Connor R, Mayo JR. Transthoracic computed Tomography-Guided lung nodule biopsy: comparison of core needle and fine needle aspiration techniques. Can Assoc Radiol J 2016; 67: 284–9. doi: 10.1016/j.carj.2015.10.005 [DOI] [PubMed] [Google Scholar]
- 22. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of interventional radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14(9 Pt 2): S199–202. doi: 10.1097/01.RVI.0000094584.83406.3e [DOI] [PubMed] [Google Scholar]
- 23. Tomiyama N, Yasuhara Y, Nakajima Y, Adachi S, Arai Y, Kusumoto M, et al. CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol 2006; 59: 60–4. doi: 10.1016/j.ejrad.2006.02.001 [DOI] [PubMed] [Google Scholar]
- 24. Yeow K-M, Tsay P-K, Cheung Y-C, Lui K-W, Pan K-T, Chou AS-B. Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures. J Vasc Interv Radiol 2003; 14: 581–8. doi: 10.1097/01.RVI.0000071087.76348.C7 [DOI] [PubMed] [Google Scholar]
- 25. Tsukada H, Satou T, Iwashima A, Souma T. Diagnostic accuracy of CT-guided automated needle biopsy of lung nodules. AJR Am J Roentgenol 2000; 175: 239–43. doi: 10.2214/ajr.175.1.1750239 [DOI] [PubMed] [Google Scholar]
- 26. Rizzo S, Preda L, Raimondi S, Meroni S, Belmonte M, Monfardini L, et al. Risk factors for complications of CT-guided lung biopsies. Radiol Med 2011; 116: 548–63. doi: 10.1007/s11547-011-0619-9 [DOI] [PubMed] [Google Scholar]
- 27. Lee H-Y, Lee IJ. Assessment of independent risk factors of developing pneumothorax during percutaneous core needle lung biopsy: focus on lesion depth. Iran J Radiol 2016; 13: e30929: e30929. doi: 10.5812/iranjradiol.30929 [DOI] [PMC free article] [PubMed] [Google Scholar]