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Year : 2004  |  Volume : 14  |  Issue : 4  |  Page : 395-400
Computed tomography (Ct) guided transthoracic needle aspiration cytology in difficult thoracic mass lesions-not approachable by USG


Mohan Dai Oswal Cancer Hospital G.T.Road, Sherpur By Pass, Ludhiana. (Punjab), India

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   Abstract 

Objectives : To evaluate the diagnostic accuracy and complications of Computed tomography (CT) guided aspiration cytology in thoracic masses and to know the pathological spectrum of thoracic masses along with the correlation of CT findings with cytopathological reports. Material and Methods : 34 patients underwent CT-guided FNAC of thoracic lesions using a 20-gauge spinal needle. The diagnostic accuracy, sensitivity, specificity, positive and negative predictive values of the FNAC procedure were calculated. Results : Of these 34 patients 22 presented with pulmonary parenchymal lesions, 6 with mediastinal lesions and 3 each with hilar and pleural lesions. Conclusive cytodiagnosis was possible in 29 out of 34 patients (diagnostic accuracy 85.3%). Four cases (11.8%) developed pneumothorax and pulmonary hemorrhage, which did not require any treatment. The sensitivity and specificity for a diagnosis of malignancy was 92.6 & 100% respectively. Conclusion : CT-guided FNAC using a 20-gauge spinal needle is a highly sensitive and specific technique with a good diagnostic accuracy and can be used safely as an outdoor procedure in the diagnosis of thoracic masses that are not approachable by ultrasound.

How to cite this article:
Singh J P, Garg L, Setia V. Computed tomography (Ct) guided transthoracic needle aspiration cytology in difficult thoracic mass lesions-not approachable by USG. Indian J Radiol Imaging 2004;14:395-400

How to cite this URL:
Singh J P, Garg L, Setia V. Computed tomography (Ct) guided transthoracic needle aspiration cytology in difficult thoracic mass lesions-not approachable by USG. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Sep 20];14:395-400. Available from: http://www.ijri.org/text.asp?2004/14/4/395/28680

   Introduction Top


Percutaneous transthoracic needle biopsy (TNAB) of lung is a well-established method in the cytologic diagnosis of pulmonary nodules. Haaga and Alfidi reported computed tomography (CT)-guided biopsy in 1976, and numerous reports since that time have shown TNAB procedures to be both effective and accurate. The diagnostic accuracy has been reported as greater than 80% for benign disease and greater than 90% for malignant disease [1]. CT guidance permits biopsy of nearly all lesions that are visible on CT scans, regardless of size or position. Needle placement in small pulmonary lesions or deep mediastinal nodes can be accurately determined with CT, and vascular and cardiac structures are well demonstrated and safely avoided [2]. Pneumothorax is, by far, the most frequent complication of the procedure: Reported rates range widely, from 5% to 61% [3],[4]. Most of these data pertain to flouroscopic guided TNAB. The reported rate of pneumothorax with CT-guided biopsy may be slightly higher because CT is more sensitive for detection of pneumothorax. The authors of several investigations [3] have reported a 22%-45% risk of pneumothorax for CT-guided TNAB.

The relative contraindications to TNAB are severe chronic obstructive pulmonary disease, a bleeding disorder (including drug-induced bleeding tendency), a contralateral pneumonectomy and pulmonary arterial hypertension [5]. An uncooperative patient who is unable to suspend respiration on request is considered by some to be an absolute contraindication [6].

In the attempt to determine the nature of pulmonary nodule (benign versus malignant), clinical data alone do not allow a definite diagnosis. Therefore, radiological (morphological) evaluation with CT plays an important role in diagnostic algorithm. Characteristics such as lesion size, location, contour and edge, and density (including the presence or absence of calcifications or fat) should be evaluated. Unfortunately none of these features alone helps in establishing benignity or malignancy, and significant overlap exists among various lesions. However, specific combinations of features are more likely to be associated with either malignant or benign disease [7].

The purpose of this study was to evaluate the diagnostic accuracy and complications of CT guided aspiration cytology in thoracic masses and to know the pathological spectrum of thoracic masses along with the correlation of CT findings with cytopathological reports.


   Material and methods Top


The study was carried out in our Hospital in the Department of Radiodiagnosis from July 2002 till Dec 2003. Thirty-four patients (18 Males and 16 Females) with thoracic mass lesion on chest skiagram and CT were included in the study. The criteria for patient selection were as follows:

  1. Patient was cooperative and was able to hold breath for a short while.
  2. Patient had no bleeding tendency or coagulopathy.
  3. The mass was not approachable by ultrasound i.e. either it was not abutting the chest wall or was located behind the thoracic bones [Figure - 1].


Relevant investigations including BT, CT, INR etc were done. Plain and contrast CT of chest was made available prior to CT guided aspiration cytology. FNAC was done as an outpatient procedure after explaining the risks and benefits and obtaining informed consent.

First, an axial scan of area of interest only was done to locate the lesion; the best approach (Supine or prone) was judged and the skin puncture site was marked with a radio opaque marker. After cleaning and draping, local anaesthetic (2% Xylocaine) was infiltrated at the site of puncture. The 20-gauge spinal needle was then inserted during suspended respiration, directing the tip of needle towards the lesion. With the tip of the needle located in the outer edge of the lesion, a repeat slice of the area of interest was taken to check the exact position of its tip.

The stylet was then withdrawn 2-3 cm and the needle was advanced into the mass with a rotating motion during suspended respiration, so that its tip lied within the target lesion. 20-ml syringe was attached to the needle's hub and the plunger was pulled back, and during continued hard suction, the needle was jiggled to free material from the lesion to the needle's lumen. The aspirate was smeared on slides and fixed in 95% alcohol for cytological evaluation, whereas large fragment were placed in a formalin solution for histopathologic examination.

A repeat slice in the area of interest was taken to rule out pneumothorax. If any amount of pneumothorax developed, patient was kept under observation for 24 hours and a chest X-ray PA view was done after 24 hr to rule out any subsequent development of pneumothorax. In case no complication arose, patient was discharged.

The final diagnosis of each lesion was determined by using a decision matrix [8] from examination of surgical specimen, biopsy from other sites using tru-cut needle or by bronchoscope, therapeutic response, same diagnosis made elsewhere in the body, and from clinical follow-up for 18 months. A comparison was done between cytological diagnosis and the final diagnosis in 33 patients where a final diagnosis was obtained. Statistical analysis was done to see the sensitivity, specificity, positive and negative predictive values.


   Results Top


34 patients with thoracic mass lesions on chest skiagram and CT were included in the study. There were 18 Males (52%) and 16 Females (48%) in the age group 35-75 years (Mean age 56.4 years). The location of the lesions was as follows: Pulmonary in 22 (64.7%) cases, mediastinal [Figure - 2] in 6 (17.7%) cases, hilar in 3 (8.8%) cases and pleural in 3 (8.8%) cases. The mean lesion diameter was 2.4cm (range, 1.2-5.6cm).

In 29 out of 34 patients aspiration yielded adequate material for evaluation of conclusive cytodiagnosis. The overall diagnostic accuracy of the procedure was 85.3%. The final diagnosis was available in 33 patients. In one case where the patient was lost in follow-up no final diagnosis could be reached.

Of the 33 patients where a final diagnosis was available 27 patients had a malignant disease and 6 had a benign disease (Prevalence of malignancy, 81.8%). The spectrum of final diagnosis available in 33 patients is given in [Table - 1]. The statistical analysis of aspiration cytology in 33 definitely diagnosed lung masses for malignancy and benignity was made according to the final diagnosis. The sensitivity and specificity for a diagnosis of malignancy was 92.6% & 100% and for benignity was 50% and 100% respectively. The positive and negative predictive value for a diagnosis of malignancy is 100% and 75% respectively and for a diagnosis of benignity are 100% & 89.3% respectively.

Pain at the puncture site, pneumothorax, pulmonary hemorrhage and hemoptysis was the main complications observed. Pneumothorax [Figure - 3] & [Figure - 4] was seen in 11.8% of cases and was mild to moderate in amount; requiring no chest tube drainage. Small amount of pulmonary hemorrhage was seen around the lesion or along the needle track; this required no treatment. In cases where pulmonary hemorrhage surrounded

the lesion [Figure - 5][Figure - 6] no final diagnosis could be reached because hemorrhage into the lesion obscured the main lesion. The rate of pneumothorax and hemorrhage increased with the increase in the distance of the lesion from the pleura and decrease in the lesion size. Correlation of complication rate with distance from pleura and lesion size is given in [Table - 2].

The time needed to perform CT-guided aspiration wasvariable. Factors that prolonged cytology sessions weredifficult deep or small lesions, development ofpneumothorax and repeat cytology after an unsatisfactoryaspirate.


   Discussion Top


Computed tomography (CT) allows the performance offine needle aspiration biopsies in situations in which USGor conventional radiograph does not correctly visualizethe lesion or the needle track. Transthoracic fine needleaspiration cytology (FNAC) of thoracic lesion using CTguidanceis a relatively safe and accurate means ofdiagnosing benign and malignant lesions of the chestwith negligible mortality and limited mortality. The reportedaccuracy in the literature ranged from 64% to 97% [9]. In the present study, 34 cases of thoracic masses of sizes 1.2-5.6cm were taken and subjected to CT-guided FNAC. Conclusive cytodiagnosis was made in 29 patients resulting in a diagnostic accuracy of 85.3%.

All the patients tolerated the procedure well. The most common complaint was pain at the puncture site, which lasted for a few hours (4-8 hours) and subsided without medication. Pneumothorax and pulmonary hemorrhage occurred in 4 (11.8%) cases and haemoptysis in only one (2.9%) case. In all 4 cases, the pneumothorax was noted within 10 minutes of the procedure and it was mild to moderate in amount. These patients were kept under strict observation for any deterioration. A chest radiograph was done after 8 hours and it was observed the amount of pneumothorax was mild to moderate (< 1/3rd of chest) in all the case. None of these patients required chest tube insertion. The hemorrhage noted in 4 cases was small in amount and required no treatment. The complication rate depended on distance of the lesion from the pleura and the lesion size. The more the amount of the lung tissue traversed by the lesion the more was the complication rate and the smaller the lesion the more was the complication rate. This was same as studied by Cox et al [10] and Laurent et al [11].

The results of the diagnostic accuracy and complication of CT-guide aspiration cytology are comparable to other published studies [Table - 3]. The sensitivity and specificity for a diagnosis of malignancy were comparable with the already reported series as given in [Table - 4].

The thoracic lesions were studied on the basis of various CT characteristics as already mentioned. On an average the benign lesions were smaller in size than the malignant ones. Necrosis within the lesion was seen in all cases of Squamous cell carcinoma of lung and also in metastatic deposits of Squamous cell carcinoma cervix. Lobulation of the nodule contour was a feature predominantly associated with malignancy, both primary and metastatic. Smooth contour in malignancy was seen in 2 cases i.e. malignant fibrous histiocytoma and squamous cell carcinoma lung. An irregular margin was seen in 3 of the 6 cases of benign lesions, two of these were tubercular lesions and the third was pneumonia. Calcification was seen more commonly (16.7%) in benign lesions than in malignant lesions (3.7%). The average density of malignant lesions was lower than the benign lesions. Rib erosion and mediastinal invasion was seen to be highly specific for malignant lesions.


   Conclusions Top


We conclude that transthoracic aspiration of small pulmonary or pleural lesions allow their early diagnosis; this affords improved opportunity for either cure or expeditious treatment. The use of CT-guided aspiration in hilar and mediastinal lesions may avoid unnecessary exploratory surgery for staging by letting the diagnosis to be made with lesser trauma and at lower cost. CT-guided transthoracic needle aspiration cytology using a 20-gauge spinal needle is a highly sensitive and specific technique with a good diagnostic accuracy and can be used safely as an outdoor procedure in the diagnosis of thoracic masses that are not approachable by ultrasound. Needle aspiration can routinely be done in lesions as small as 1.2 cm [Figure - 7], irrespective of their location.


   Acknowledgement Top


The authors thank Dr. R. Shrimali MD, FICR for his suggestions and continuous encouragement during the study.[16]

 
   References Top

1.Geragthy PR, Kee ST, McFatlane G, Razavi MK, Sze DY, Dake MD. CT-guided Transthoracic needle aspiration biopsy of pulmonary nodules: Needle size and Pneumothorax rate. Radiology 2003; 229 (2): 475-482.  Back to cited text no. 1    
2.VanSonnenberg E, Casola G, Ho M, et al. Difficult Thoracic Lesions: CT-guided biopsy Experience in 150 cases. Radiology 1988; 167: 457-461.  Back to cited text no. 2    
3.Herman PG, Hessel SJ. The diagnostic accuracy and complications of closed lung biopsies. Radiology 1977; 125:11-14.  Back to cited text no. 3  [PUBMED]  
4.Poe RH, Kallay MC, Wicks CM, Odorof CL. predicting risk of pneumothorax in needle biopsy of the lung. Chest 1984; 85:232-235.  Back to cited text no. 4    
5.Hansell DM: Interventional techniques. In Armstrong P, Wilson AG, Dee P, et al (eds): Imaging of diseases of the chest, ed 2. St. louis, Mosby, 1995, pp 894-912.   Back to cited text no. 5    
6.Weisbrod GL: Transthoracic percutaneous lung biopsy. Radiol Clin North Am 1990; 28: 647-655.  Back to cited text no. 6    
7.Shaham D, Guralnik L. The Solitary Pulmonary Nodule: Radiological Considerations. Seminars in Ultrasound, CT and MRI 2000; 21(2): 97-115.  Back to cited text no. 7    
8.Dorith S. Semi-invasive and invasive procedures for the diagnosis and staging of lung cancer. Radiologic clin N diagnosis and staging of lung cancer. Radiologic clin N Am 2000; 38: 525-34.  Back to cited text no. 8    
9.Mohammad GM. CT guided fine needle aspiration cytology in the diagnosis of thoracic lesions. JIMA 2001; 99(10): 1-5.  Back to cited text no. 9    
10.Cox JE, Chiles C, McManus CM, Aquino SC, Choplin RH. Transthoracic needle aspiration biopsy with variables that affect risk of pneumothorax. Radiology 1999; 212:165-168.  Back to cited text no. 10    
11.Laurent F, Michel P, Latrabe V, Lara MTD, Marthan R. pneumothoraces and Chest tube placement after CT-guided transthoracic lung biopsy using a coaxial technique: Incidence and risk factors. AJR April 1999; 172: 1049-1053.  Back to cited text no. 11    
12.Stanley JH, Fish GD, Andriole JG, et al. Lung lesions: cytological diagnosis by fine needle biopsy. Radiology 1987; 162:389-91.  Back to cited text no. 12  [PUBMED]  
13.Haramati LB. CT-guided automated needle biopsy of the chest. AJR 1995; 165: 53- 55.  Back to cited text no. 13  [PUBMED]  
14.Santambrogio L, Nosotti M, Bellaviti N, Pavoni G, Radice F, Caputo V. CT guided fine needle aspiration cytology of solitary pulmonary nodules: a prospective, randomized study of immediate cytologic evaluation. Chest 1997; 112: 423-5.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Gouliamos AD, Giannopoulos DH, Panagi GM, Fletoridis NK, Deligeorgi-Politi HA, Vlahos LJ. Computed tomography-guided fine needle aspiration of peripheral lung opacities: An initial diagnostic procedure? Acta cytologica 2000; 44 (3): 344-348.  Back to cited text no. 15    
16.Gupta S, Michael JW, Frank AM, Kamran A, Marshall EH. CT guided percutaneous needle biopsy of intrathoracic lesions by using the transternal approach: experience in 37 patients. Radiology 2002; 222: 57-62.  Back to cited text no. 16    

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Correspondence Address:
J P Singh
82, New Mehar Singh Colony, Tripari, Patiala, (Punjab)
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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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    Abstract
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    Material and methods
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    Discussion
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