original article
Wien Klin Wochenschr (2011) 123: 79–82 DOI 10.1007/s00508-011-1538-y © Springer-Verlag 2011 Printed in Austria
Wiener klinische Wochenschrift The Central European Journal of Medicine
The results of computed tomography guided tru-cut transthoracic biopsy: complications and related risk factors Fahri Halit Beşir1, Remzi Altın2, Levent Kart3, Muhammed Akkoyunlu4, Hüseyin Özdemir5, Tacettin Örnek2, Sadi Gündoğdu6 1
Department of Radiology, School of Medicine, Duzce University, Duzce, Turkey Department of Chest Diseases, School of Medicine, Karaelmas University, Zonguldak, Turkey 3 Department of Chest Diseases, Bezm-i Alem Valide Sultan Vakıf Gureba Education and Research Hospital, Istanbul, Turkey 4 Department of Chest Diseases, Igdir State Hospital, Igdir, Turkey 5 Department of Radiology, Trakya University, School of Medicine, Edirne, Turkey 6 Department of Radiology, Ufuk University Rıdvan Ege Research Hospital, Ankara, Turkey 2
Received May 4, 2010, accepted after revision December 15, 2010, published online February 17, 2011
Ergebnisse von thransthorakalen CT-gezielten Tru-Cut Biopsien: Komplikationen und damit verbundene Risikofaktoren Zusammenfassung. Einleitung: Die transthorakale Biopsie (TTB) ist eine gut definierte und effiziente Methode zur Gewinnung von Gewebe für die histopathologische Diagnose pulmonaler Läsionen. Sie ist weniger invasiv als chirurgische Verfahren und hat eine bessere diagnostische Aussagekraft als Fein-Nadel-Biopsien (FNAB), vor allem bei der Beurteilung benigner Läsionen. In der vorliegenden Studie präsentieren wir unsere mit TTB erhobenen Ergebnisse, sowie die Komplikationen beziehungsweise die damit verbundenen Risikofaktoren. Material und Methoden: 102 Patienten, bei denen zwischen Jänner 2003 und Dezember 2007 pulmonale Läsionen mittels CT gezielter TTB evaluiert wurden, sind in die Studie aufgenommen. TTB assoziierte Komplikationen wurden festgehalten. Faktoren, wie die Tiefe und Größe der Läsion, sowie das Ausmaß eines um die Läsion bestehenden Emphysems wurden mit χ2-Test evaluiert. Ergebnisse: Von den gewonnenen Gewebeproben waren 51 % histopathologisch malign und 49 % benign. Bei 15,7 % der 102 Prozeduren entstand ein Pneumothorax. Das Risiko der Entwicklung eines Pneumothorax stieg signifikant mit dem Abstand der Läsion von der Pleura, mit der Größe der Läsion, sowie mit dem Ausmaß emphysematöser Veränderungen rund um die Läsion.
Correspondence: Dr. Fahri Halit Beşir, Department of Radiology, Medicine School, Duzce University, Duzce, Turkey, E-mail:
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Schlussfolgerung: Die Komplikationsrate der TTB ist mit der der FNAB vergleichbar. In Zentren, wo die zytologische Diagnostik von pulmonalen Läsionen insuffizient ist, empfehlen wir die routinemäßige Anwendung der CT-gezielten TTB, da diese ebenso verlässlich ist, wie die FNAB. Summary. Introduction: Transthoracic biopsy (TTB) is a well-defined and effective method used for pathologic sampling in the diagnosis of the pulmonary lesions. It is less invasive in comparison to surgical procedures. In addition, diagnostic rate of tru-cut biopsy is higher than that of fine needle aspiration biopsy (FNAB) especially for benign lesions. In this study, we presented tru-cut transthoracic biopsy (TTB) procedure results and the frequency of TTB complications with related risk factors. Material and methods: A total of 102 patients were evaluated by CT scan guided tru-cut TTB in the diagnosis of lung lesions between January 2003 and December 2007. The complications due to tru-cut TTB were recorded. The factors such as the lesion depth, the lesion size, and the emphysematous changes that accompany the lesion were evaluated through χ2 test. Results: Among the samples, 51% malignancy and 49% benign pathology were observed. Pneumothorax developed in 15.7% of the 102 procedures. It was found that the lesion’s distance from the pleura, the size of the lesion, and emphysematous changes around the lesion significantly increased the risk of pneumothorax. Discussion: The tru-cut biopsy complications are similar to those of FNAB. In the centers where cytologic examination is insufficient in the diagnosis of lung lesions, tru-cut biopsy should be routinely performed as it is a reliable biopsy technique compared to FNAB. Transthoracic tru-cut biopsy
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Key words: Pulmonary lesion, transthoracic biopsy, trucut, pneumothorax, hemoptysis.
Introduction Transthoracic biopsy (TTB) is a well-defined and effective method which is used for pathologic sampling in the diagnosis of the pulmonary lesions (especially peripheral location), and which is less invasive in comparison to surgical procedures [1,2]. The ratio of accurate diagnosis is more than 80% with benign lesions and more than 90% with malign lesions with TTB [2]. TTB is performed by two methods: fine needle aspiration biopsy (FNAB) and tru-cut biopsy [3]. There are many factors involved in pathologic diagnosis and development of complications during biopsy procedures. It has been stated that distance of the lesion to the pleura (the lesion depth), the lesion size, and the emphysematous changes that accompany the lesion, could affect the development of pneumothorax [2, 4, 5]. Recurrent biopsy may increase complication frequency [6]. The most frequent complication encountered during transthoracic procedures is pneumothorax which can present between 8 and 61% at different series. The rate of placing a chest-tube is between 10.4 and 17.4% [2, 4]. In this study, we presented tru-cut TTB procedure results and the frequency of TTB complications with related risk factors.
Material and methods We conducted our research by examining 102 patients retrospectively who were diagnosed with CT guided TTB due to pulmonary lesions in the radiology department of our hospital between January 2003 and December 2007. All CT guided TTBs were done as core biopsy due to insufficient cytologic examination experience in our center. Mediastinal lesions, lesions located in the chest wall, and those believed to have no pulmonary origin were excluded from the study. The factors which could affect the pneumothorax rates as the lesion depth, the lesion size, and emphysematous changes around the lesion were recorded. TTB procedure was done by two experienced radiologists (HO and FHB). The lesions were divided into three groups according to their depth. 0 cm (lesions were completely adjacent to the pleura), 0.5–3 cm, and >3 cm (lesions passed through the parenchyma). The sizes of lesions were also divided into three groups: 0–2 cm, 2.1–4 cm, and >4 cm. While determining the position of the patient for the TTB procedure, the most important considerations were the most comfortable position in which the procedure could be performed and in which the patient could lie, and the shortness of the aspirated lung’s parenchymal distance which had to be crossed with the needle trace. After an appropriate entrance location was determined through repetitive CT scans for the lesion on which TTB was going to be applied, this region was desensitized through local anesthesia. For TTB, 18-gauge (G) tru-cut biopsy gun was used. In order to check for the procedure-induced pneumothorax, a CT section was regularly taken at the end of the procedure. In cases in whom no early pneumothorax developed, posteroante-
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rior (PA) lung radiographies were taken for control after 2 hours [3]. In cases in whom pneumothorax was discovered in the CT section, patients were put in positions where the biopsy side would face down. They were given oxygen with masks and observed for 2 hours. If pneumothorax was minor and no development was detected in the PA lung radiography, the patient was discharged after necessary recommendations were made. The patients becoming rapidly symptomatic and whose pneumothorax worsened were evaluated for the placement of a chest-tube surgically. The materials obtained through TTB were sent to pathology laboratory in formaldehit solution. Statistical analysis was done by SPSS 11 program. The factors which were believed to affect pneumothorax were evaluated through Chi-square (χ2) test. A p value < 0.05 was considered statistically significant.
Results Of the 102 cases included in our study, 10 were females and 92 were males. The ages ranged between 17 and 83 years and the average age was 61.24 ± 13.56 years. The size of the pulmonary legions included in the study ranged from 1 to 9 cm. The average size was 3.57 ± 1.62 cm. The classification of the cases according to the lesions sizes of lesions were as follows: 20 cases between 0 and 2 cm; 51 cases between 2.1 and 4 cm; 31 cases at 4.1 cm or above (Table 2). According to pathologic evaluation, 50 of the lesions were benign, and 52 of them were malignant (Table 1). Benign lesions were anthracosis, inflammation, nonspecific changes, fibrosis, and inflammation pseudotumor. Malignant lesions included adenocarcinoma, non small cell carcinoma, squamous cell carcinoma, small cell carcinoma, large cell carcinoma, metastasis, lymphoma, and unclassified malignancy. After TTB, complications were observed in 18 cases (17.6%). Pneumothorax developed in 15.7% (n: 16) and hemoptysis was seen in 1.9% (n:2) of the cases. Massive hemoptysis did not develop. Tube thoracostomy was applied to 8.8% (n: 9) of the cases for the treatment of pneumothorax after the procedure. Patients with pneumothorax who were not applied chest tube did not show any worsening of clinical situation. Table 1. Classification of pulmonary lesions according to pathology results (%) Benign lesions
(n: 50) Anthracosis (n: 32) Inflammation (n: 11) Nonspecific changes (n: 3) Fibrosis (n: 3) Inflammation pseudotumor (n: 1)
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Malignant lesions
(n: 52) Adenocarcinoma (n: 19) Non small cell carcinoma (n: 13) Squamous cell carcinoma (n: 11) Small cell carcinoma (n: 3) Large cell carcinoma (n: 1) Metastasis (n: 1) Lymphoma (n: 2) Unclassified malignancy (n: 1)
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Table 2. Correlation of pneumothorax rate with risk factors with Chi-square test No PTX
PTX
Total
PTX rate %
p (Chisquare)
Lesion depth 0 0.5 – 3 cm 3.1 – ↑ cm
45 28 13
1 9 6
46 37 19
2.2 24.3 31.6
0.002
Lesion size 0 – 2 cm 2.1 – 4 cm 4.1 – ↑ cm
14 42 30
6 9 1
20 51 31
30 17.7 3.2
0.032
Emphysematous changes Absent Present
63 23
7 9
70 32
10 28.1
0.02
PTX, pneumothorax.
The factors which could lead to the development of pneumothorax were analyzed. The lesion depth from the pleura (p = 0.002), the lesion size (p = 0.032), and the emphysematous changes (p = 0.02) accompanying the lesions were found to be the factors significantly increased the risk of pneumothorax (Table 2).
Discussion In the pulmonary lesions, the benign–malign distinction and the pathologic diagnosis bear importance with regard the determination of the treatment to be applied [7, 8]. The bronchoscope is an important method of diagnosing lung cancer, but TTB is frequently used when bronchoscope is not sufficient for the diagnosis particularly peripheral pulmonary lesions [9]. TTB is performed widespread due to increased percentage in diagnosis, the ease of the procedure, and the little complications rate [10]. One of the disadvantages of FNAB is recurrent biopsies due to insufficient sampling. Recurrent biopsies may cause pleura and lung tear and may increase complication frequency. FNAB should be supported by other diagnostic methods due to high insufficient sampling frequency [6]. Diagnostic rate of tru-cut biopsy is higher than FNAB especially for benign lesions and diagnostic rate of malign lesions does not differ between FNAB and tru-cut biopsy. However, tru-cut biopsy supplies more adequate materials for immunohistochemical study in malignant lesions [3, 11]. In FNAB, recurrent biopsy is needed in 10–20% of patients due to insufficient sampling [12]. It is advised that during the FNAB procedure on site radiologist, clinician, and cytopatologist should be present for decreasing insufficient number of sampling and misdiagnosis [6]. That is why, we prefer performing tru-cut TTB in order to decrease recurrent biopsies (due to inadequate cytologic evaluation in FNAB) and to increase diagnostic rate of benign lung diseases which are highly frequent in our center. Of the 102 TTB procedures conducted in our study, malignity was diagnosed in 51% of the all cases whereas lesions with a benign nature were 49%. The most frequent complication which develops during TTB is pneumothorax and hemoptysis. In the case of FNAB, the pneumothorax rate reported over the last 10 wkw
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years was 8–45%, but most of the rates were above 20% [13]. In the literature, tru-cut biopsy caused pneumothorax rate is around 12.8%. Pneumothorax occurred in 12.5% and 13.3% of patients by 17-G and 19-G coaxial needles, respectively [14]. In patients with FNAB, the rate of placing a chest-tube is between 10.4 and 17.4% [2, 4]. On the other hand, it has been reported that the rate of pneumothorax requiring treatment with chest tube varies from 1.6% to 17% of the patients having tru-cut biopsy [15]. In a recent study done by Bozbas et al., pneumothorax developed in 59 patients; a drainage tube was needed in 22 of them (7.3% of total) [16]. It is seen in the literature that there is no difference between FNAB and tru-cut biopsy concerning pneumothorax complication and placement of chest tube. In our study, the rate of pneumothorax was 16.1% and chest tubes were placed in 8.9% of our cases. Our results are similar to those of the literature. The factors which could lead to the development of pneumothorax are the lesion depth from the pleura, the lesion size, and the emphysematous changes accompanying the lesions. In our study, the pneumothorax rate in pleurabased lesions was found to be 3.9% and the risk of pneumothorax was increased if the lesion was located in the parenchyma (Table 2). This result is concordant with the view accepted in the literature that the increase in the depth of needle entrance to the margin of the lesion from the pleural surface was correlated with a high rate of pneumothorax [17–22]. Also parallel with this, Khan et al., have found that factors which have an effect on the risk of pneumothorax after cutting-needle biopsy are length of intrapulmonal biopsy path and puncture time [23]. The strong correlation between the pneumothorax rate and lesion size is difficult to explain, and a possible explanation for this finding is that the up-and-down movement of the needle tip during biopsy results in more tearing of adjacent lung parenchyma when the lesion is relatively small. In our study, parallel with the conclusion of Cox et al., Heyer et al. and Charig et al. studies we found high rate of pneumothorax when the lesion size was small (Table 2) [2, 22, 24]. The presence of emphysema around the lesion can be assumed as an important risk factor for the development of pneumothorax. This factor has been evaluated in many studies [2, 17, 18, 21, 25–27]. It was pointed out that the pneumothorax risk had increased two to three fold in the cases with roentgenograms showing obstructive disease, however in the later studies, it was claimed that the chest roentgenograms were not reliable to determine the risk [18, 21]. There are some reports using visual scoring on CT slices for the evaluation of the emphysema [2, 25]. Instead, we used CT evaluation of emphysema presence or absence. In Cox et al. study, emphysema was present in 49.3% of total pneumothorax cases [2]. In our study, the rate of emphysematous changes in pneumothorax cases was 28.1% of total pneumothorax (Table 2). Hemoptysis is the second most frequent complication in TTB procedures. It is reported to be seen between 1.7 and 8.8% in the literature of patients having FNAB [28–31]. Whereas in Cheung et al. study, the rate of hemoptysis was Transthoracic tru-cut biopsy
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6.3% by 18-G core needle biopsy [14]. However, in Bozba sı et al. study, this rate is so small as 0.7% of total [16]. In our study, hemoptysis rate was 1.8%, and massive hemoptysis did not develop in any of the cases. Our result is similar with to that of the literature. However, in a recently published study Heyer et al. have reported that emphysema was related with higher incidence of hemorrhage rather than pneomothorax [22]. In the Khan et al. study, factors affecting hemorrhage are lesion size, and number of pleural needle passes. Length of intrapulmonal biopsy path (>4 cm) showed significantly higher numbers of perifocal hemorrhage as well as pneumothorax [23]. In conclusion, the pneumothorax is the most frequent complication encountered during TTB. Lesion depth, lesion size, and the emphysematous changes that accompany the lesion affect the risk of developing pneumothorax. In our study, the rates of most frequent complications are similar to both the tru-cut biopsy and FNAB complication rates reported in the literature. That is why, in the centers where cytologic examination is insufficient in the diagnosis of lung lesions, tru-cut biopsy should be routinely performed as it is a reliable biopsy technique compared to FNAB. Conflict of interest There is no conflict of interest.
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