Percutaneous biopsy in lung cancer

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Abstract

This paper presents current indications, contraindications, technical aspects, complications and yield of diagnosis of percutaneous lung biopsy in the setting of lung cancer. Percutaneous lung biopsy should be performed each time that the therapeutic strategy can be significantly influenced, when the procedure is technically feasible and to patients for which the benefits outweigh the risks, that are pneumothorax and pulmonary haemorrhage. Factors identified as potentially favouring post-biopsy pneumothorax are numerous whereas the use of a needle size larger than 18 gauge is the major risk factor of bleeding. Although a coaxial system is highly suitable in any case, two categories of needles can be used; those providing aspiration and those for core biopsies. Both offer similar yields for the diagnosis of malignancy, but core biopsies are more efficient for the specific diagnosis of benignity and lymphoma. Technical improvements of guidance, needle design and pathological techniques may contribute to lower the size limit of the nodule to be biopsied, to decrease the complication rate and their severity and to increase the yield of diagnosis.

Introduction

Percutaneous biopsy has emerged as an invasive procedure of choice for the diagnosis of lung cancer over the past three decades. The technique has been popularized by Nordenstrom [1] with the introduction of thin-walled needles with an outer diameter of 1 mm or less, quieting early concerns about the safety of biopsies using large cutting needles. Increased expertise of cytopathologists and operators and advances in imaging technique guidance have mainly contributed to the growing acceptance of the method. Nevertheless, many aspects of the topic have not been submitted to large control trials and remain controversial.

Section snippets

Indications

Biopsy during flexible bronchoscopy and percutaneous biopsy are the techniques most widely used for providing an accurate cytologic or histologic diagnosis of lung cancer. They should be considered as complementary procedures, although their position in the diagnostic algorithm remains a subject of debate. Percutaneous biopsy is mainly indicated when the histological diagnosis can influence the therapeutic strategy or modify the staging of the disease and when the diagnosis cannot be

Contraindications

Percutaneous biopsy should be limited to cases that are both truly indicated, technically feasible and for which the possible benefits outweigh the risks. Abnormal clotting function or thrombocytopenia should be recognized and corrected before the procedure. Suspected hydatid cyst or arterio-venous malformation should not be biopsied but can be identified or at least strongly suspected on CT. Mechanical ventilation which may lead to pneumothorax and favours air embolism, inability of a patient

Imaging modality

Fluoroscopic guidance has represented the traditional imaging modality for percutaneous biopsy [1]. The main advantages over CT guidance are the short procedure time, the real-time visualization of needle advancement and the low cost. Disadvantages include difficult access to central lesions and difficult avoidance of bullae and vascular structures in the needle pass [10].

CT has been used for 20 years and has become the standard in many institutions. CT permits planning a trajectory that avoids

Results

An overall sensitivity of 70ā€“100% has been reported for the diagnosis of malignancy, most reports being in the 85ā€“95% range [10]. In a large study involving almost 12ā€ˆ000 transthoracic needle aspiration specimen and more than 400 institutions, sensitivity was 89%, specificity 95%, positive predictive value 99% and negative predictive value 70% [27]. The most common causes of false-negative are sampling error and inaccurate needle placement [25]. Some investigators have stressed the importance

Complications

Common complications of percutaneous biopsy of the lung are pneumothorax and bleeding. Pneumothorax has been reported from 0 to 61%, 20% in most recent large series and the rate of pneumothoraces requiring treatment with chest tube varies from 1.6 to 17% [10]. Most pneumothoraces are detected within the first hour post-procedure, do not require drainage, and can be managed conservatively. Large, symptomatic and expanding pneumothoraces need a chest tube placement, usually of small bore type.

Conclusion

Percutaneous biopsy is today a well-established technique for the diagnosis of lung cancer. Technical improvements of guidance, needle design and pathological techniques may contribute to push back technical limitations, to decrease the rate of biopsies technically impracticable, the rate of complications and their severity and to increase the yield of specific diagnosis.

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