Study the Complications of Ct-guidance Fine Needle Biopsy in Intra-thoracic Masses
The purpose of this study was to observe the complications of needle biopsy of chest lesions guided by the CT scan among the patients studied. This is a descriptive epidemiologic study. All patients that referred to Imam Khomeini in Ahwaz from 2005 to 2007 and it was necessary to biopsy the chest lesions were studied. Snapshot files on lung CT scan lesion size and depth measurements and the biopsy samples obtained were sent to pathology. After the biopsy the patient CT scan was to act as the presence or absence of symptoms, proper action was made. Among 102 patients studied, 85 patients (83.4%) were uncomplicated, but 8 patients (7.9%) were suffered from pneumothorax. In the study were made between lesion size and depth of complications found no correlation, but between lesion location and complications caused there was statistically significant difference. The needle biopsy guided by CT scan due to low complications in many cases is a suitable diagnostic method.
Fine-needle aspiration (FNA) or core biopsy of intra-thoracic masses that performed
with ultrasound or Computed Tomography (CT) guidance, has become an increasingly
popular technique owing to its distinct advantages of being sensitive and specific,
expedient, economical and safe (Smith et al., 1985).
CT-guided sampling of thoracic lesions have been described and utilized in human
medicine (Steil et al., 2009; Geraghty
et al., 2003; Chojniak et al., 2006).
The specificity, sensitivity and accuracy of this technique vary depending on
the target organ and the type of needle used. The accuracy of CT-guided sampling
has been reported a values between 75 to 99% in patients (Kinoshita
et al., 2006; Wang et al., 2009; Priola
et al., 2007; Van Rijn and Bossuyt, 2004).
Imaging-guided percutaneous core-needle biopsy has become the modality of choice
for diagnosing mediastinal masses (De-Filippo et al.,
2008 ; Rodríguez-Fernandez et al., 2007).
The extrapleural parasternal approach with Computed Tomographic (CT) or ultrasonographic
guidance is most appropriate for lesions that extend to the anterior chest wall
lateral to the sternum (Gupta et al., 2005).
Many complications co-exist with FNA of trans-thoracic sampling. The most commonly
reported complications in humans, regardless of modality, are pneumothorax and
hemorrhage. Pneumothorax is the most frequently encountered complication during
CT-guided lung biopsy, with an incidence of 22-45% (Wallace
et al., 2002; Li et al., 1996; Gianfelice
et al., 2000). Higher pneumothorax rates up to 64% for lesions 1.0
cm or smaller have been reported (Gatenby et al.,
1984). Hemothorax, pericarditis, body wall bruising, subcutaneous emphysema,
air embolism and tumor or infection seeding along the needle tract have been
reported, but are uncommon (Steil et al., 2009;
Kinoshita et al., 2006).
This study aimed to evaluate the complication rate of FNA and CT-guided biopsy of intra-thoracic masses.
MATERIALS AND METHODS
Between November 2007 and August 2008, a total of 102 CT-guided trans-thoracic
diagnostic procedures (aspiration biopsy with fine or spinal needle or core
biopsy) were carried out. FNA biopsy was performed in 39 (38.2%) female and
63 (61.8%) male patients. The study population comprised all subjects who underwent
the surgical resection and non-surgical patients who had completed at least
12 months of follow-up (382 subjects). The population included 202 men and 180
women, with a mean age of 59.7 years (range 4-89 years). None of the patients
had a history of bleeding tendency or alterations in blood parameters or coagulation
profile. Subjects receiving anti-aggregant or anticoagulation agents discontinued
treatment for 7 days prior to the biopsy. The analyzed variables included the
age, chest wall thickness, lesion size and depth, type of the mass and the experience
of the radiologist performing the biopsies. The study was approved by the University
Hospital and Ahvaz Jundishapur University of Medical Sciences Ethics Committees
and all subjects granted informed consent to participate.
The patients with following criteria have been excluded from the study:
significant changes in blood-coagulation profile, contralateral pneumonectomy,
patients inability to maintain a lying position and/or to follow verbal
or visual instructions.
Needle Type and Caliber
In all procedures, we used either a single needle (20-gauge Chiba needle;
18-gauge cutting needle with coaxial technique) or, in the event of multiple
biopsies, a consecutive combination of different needles. The choice of the
type of needle was based on parameters such as lesion size, clinical history
and imaging data, operators preferences and the presence of the cytopathologist.
The radiologist briefly reviewed the patients history just before
the procedure. At the time of each biopsy, a previous diagnostic CT scan was
available for all patients. All biopsies were performed according to a standard
protocol by the same interventional radiologist under CT guidance with an X
vision/ EX Toshiba- CTS scanner. The patient reposed on the CT table in prone,
supine or lateral decubitus positions depending on lesion location. After having
established the entry site and selection of the proper needles, the needle entry
site was anaesthetized (2% lidocaine), the needle, positioned and the patient
instructed to hold his or her breath. At this point CT scans were obtained to
visualize the needle tip in relation to the lesion. Biopsies were carried out
by needle aspiration with a 20-gauge fine needle or by core biopsy with an 18-gauge
cutting needle. To assess the presence of possible complications (pneumothorax,
needle track bleeding), post-procedural CT scans were carried out 10-15 min
after the procedure.
Statistical analysis was conducted with the SPSS 15.0 and aimed at evaluating
the accuracy of the procedure. Differences between proportions were analyzed
with Chi-square tests or Students t test. Parameters considered significant
in determining diagnostic accuracy were further stratified and correlated to
accuracy with the aid of contingency graphs and tables. A p value<0.05 was
taken as significant in all cases.
The patients were divided randomly to 5 groups based on the age criteria (Table
1), the most frequent age was 66 to 80-year group with related frequency
of 42.2% (43/102). Of 102 CT-guided FNA biopsy procedures, 8(7.9%) were complicated
by pneumothorax, with 2(1.9%) patients requiring thoracostomy tube placement.
It showed subtle enhancement, which made the lesion indeterminate and a biopsy
was advised. Using the traditional technique, the needle could be placed only
along the side of the nodule; in some cases pneumothorax was presented (Fig.
1A, B) and mild parenchymal hemorrhage (Fig.
|| Frequency distribution of patients in different age groups
||(A) Needle biopsy from a sub-pleural lung nodule and (B) control
CT shows pneumothorax
Needle biopsy from a right lung mass and (B) Control CT shows mild parenchymal
|| Study of complications in patients
|| Distance to the chest wall lesion desired
In case of CT showing a right basal lung mass, needle biopsy confirmed bronchoalveolar
cell carcinoma involving the right lower lobe. The control CT showed mild parenchymal
hemorrhage (Fig. 2A, B).
The complications have been listed in Table 2, Chest wall thickness was varied in range from 0.75 to 10 cm (mean of 3.8 cm). The length between chest wall and lesion is summarized in Table 3; most frequent length was in range of 3.1- 6 cm among 52 patients (51%). There was no significant correlation between the size and depth of lesion with presence of the complications. In the case of the depth and position of the lesion, 53 (52%) of the patients have internal hemi-thorax and the rest 49 (48%) have external hemi-thorax. There was significant (p<0.05) correlation between the position of the lesion. Out of 53 cases of internal hemi-thorax 14 (13.7%) were complicated by pneumothorax. Only 3 (2.9%) patients out of 49 external hemi-thorax cases were complicated by pneumothorax. A final diagnosis could be obtained for all 102 patients: 65.68% (67/102) of lesions were found to be malignant, 25.49% (26/102) were benign, whereas no reliable judgment could be made among the 9 (8.82%) cases (Table 4).
Needle biopsy from a lung nodule and (B) Control CT shows pleural effusion
and mild parenchymal hemorrhage
|| Type of lesion obtained in patients under study
Review of the existing literature reveals variable rates of pneumothorax that
range from 8 to 64%. However, pneumothorax remains the most common complication
of CT-guided lung biopsy (Wallace et al., 2002;
Li et al., 1996; Gianfelice
et al., 2000). Wallace et al. (2002)
in a study on 61 patients (34 men and 27 women) 21-89 years old with lung nodules
underwent CT-guided trans-thoracic FNA biopsy, reported 38 (62%) patients had
pneumothorax, with 19 (31%) requiring thoracostomy tube placement. Recently,
Ng et al. (2008) in a study on 55 patients using
coaxial technique claimed that pneumothorax occurred in 29 (52.7%) patients,
with five (9.1%) requiring thoracostomy tubes. In the study made by Topal
and Ediz (2003), they have not found significant relationship between size
and depth of lesions with complications, but were found statistically significant
correlation between the location and complications. Our study show that lesions
less than 2 cm have pneumothorax rate 11 times more waste than 4 cm, which may
cause difficulty and increase exercise time of needle biopsy. Increasing depth
of lesion was revealed bleeding lesions communication distance of more than
2 cm from the surface of pleural lesions compared with 10 times the risk of
sticking to the pleural bleeding that can cause due to crowding and large vessels
is more central areas. So, in this study reduce the risk of pleural effusion
was accompanied with less bleeding. This is possible because of the negative
pressure inside the space next to the effects of effusion and tamponade by delayed
in diagnose the bleeding. This finding was in agreement with the results of
a study conducted by Gohari and Haramati (2004).
The use of core biopsies as the first line technique for assessing diagnoses
of pulmonary nodules is still debated. During the past 30 years, numerous studies
have proved the accuracy and safety of radio-graphically guided trans-thoracic
lung biopsy procedures (Tsukada et al., 2000;
Satoh et al., 2005; Laurent
et al., 2000). According to the Massachusetts group the FNA should
still be performed initially if a cyto-pathologist is available in the CT room
and malignancy is suspected (McLoud, 1998). However,
if a malignant diagnosis is obtained on review of the FNA, a core biopsy is
not needed. Furthermore, if it is non-diagnostic or suggestive of a benign process,
a core biopsy should then be performed (Boiselle et al.,
Many researches have been discussed the mortality due to applying this technique.
Reports of death in the literature are very rare. Greene
(1982), estimated mortality associated with fine needle aspiration to be
0.02%. Most deaths were attributed to fatal air embolism. Hirasawa
et al. (2008) reported a case of cerebral air embolism which occurred
during Computed Tomography (CT)-guided needle biopsy. In that case the air entering
the aorta is depicted on CT-fluoroscopy images of the procedure. There was no
reported death in our study as a complication of biopsy.
Hiraki et al. (2007) in study based on four
cases of systemic air embolism complicating CT scan-guided trans-thoracic needle
biopsy, which were encountered among 1010 procedures performed. In three patients
without cardiac or cerebral symptoms, the presence of systemic air was confirmed
on post-procedural CT scan images, which was resolved without causing morbidity
after the immediate therapy. In this study there was no reported air embolism
complicating CT scan-guided trans-thoracic needle biopsy.
Trans-thoracic CT-guided needle biopsy of pulmonary lesions is a highly accurate procedure, especially in malignant lesions. Considering the possible complications of anesthesia and thoracotomy and mediastenostomy admission and require several days of surgery mentioned above and the high cost biopsy guided by CT scan method is less invasive and the other hand, are cheaper and in many cases can be a suitable replacement for above mentioned surgeries.
The authors would like to thanks the patients and their family. The study was fully supported by the research deputy of Ahwaz Jondishapour University of Medical Sciences.
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