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Background CT-guided transthoracic core needle biopsy ( TCNB) is a minimally invasive diagnostic procedure and a useful radiological method for diagnosing pleural lesions smaller than 10 mm in the presence of loculated pleural effusion. The purpose of this study was to retrospectively assess the diagnostic accuracy of CT-guided TCNB of small pleural lesions and determine the incidence of complications. Methods This retrospective study included a total of 56 patients (45 men and 11 women; mean [± SD] age, 71.84 ± 10.11 years) with small costal pleural lesions (thickness of < 10 mm) who underwent TCNB performed at the Department of Radiology from January 2015 to July 2021. One of the inclusion criteria for this study was a loculated pleural effusion greater than 20 mm, with a nondiagnostic cytological analysis. Sensitivity, specificity and positive as well as negative predictive values (PPV, NPV ) were calculated. Results The sensitivity of CT-guided TCNB for the diagnosis of small pleural lesions in this study was 84.6% (33 of 39), specificity 100% (17 of 17), PPV 100% (33 of 33), and NPV 73.9% (17 of 23), while diagnostic accuracy was 89.3% (50 of 56). The overall diagnostic contribution of TCNB in our study is comparable with the results of other recent reports. Loculated pleural effusion was considered a protective factor since no complications were noted. Conclusion CT-guided transthoracic core needle biopsy ( TCNB) is an accurate diagnostic method for small suspected pleural lesions with a near-zero complication rate in the presence of loculated pleural effusion. Keywords CT, Transthoracic core needle biopsy, Pleura, Pleural lesions Background Pleural diseases are common, affecting more than 0.3% of the population yearly. They originate from a wide range of pathologies; therefore, a systematic approach to diag- nosis and treatment is required . Most common solid pleural lesions can be divided into benign (such as fibrous pleural thickening, solitary fibrous tumour, and lipoma) *Correspondence: and malignant plaques (such as metastases, malignant Eduard Oštarijaš mesothelioma, lymphoma, and Askin tumour) [2, 3]. The email@example.com Department of Radiology, Rijeka Clinical Hospital Centre, University of vast majority of pleural neoplasms invade the pleura sec- Rijeka, Rijeka, Croatia ondarily, while primary pleural neoplasms are less com- Doctoral School of Pharmacological and Pharmaceutical Sciences, mon . Malignant pleural mesothelioma is an aggressive University of Pécs Medical School, Pécs, Hungary © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kukuljan et al. Cancer Imaging (2023) 23:48 Page 2 of 6 primary pleural tumour and is most associated with pre- a total number of patients, 80.4% (45 of 56) were male vious asbestos exposure . Treatment and prognosis (age 72.93 ± 8.63 years), and 19.6% (11 of 56) were female vary considerably, so a definite histopathological diagno - (age 67.36 ± 14.39 years). The mean patient age was sis is required for planning a treatment strategy. 71.84 ± 10.11 years (range 43–86). Pleural effusion is the most common, clinically impor - During the period of 6 years, a total of 158 CT-guided tant secondary finding caused by pleural lesions. His - transthoracic biopsies of pleural lesions were performed tologically, effusion can be divided into transudate and at our institution. The total number of patients excluded exudate. The latter is frequently caused by infection, from the study was 102 for the following reasons: pleural infarction, or malignancy . Usually, a pleural cytologic lesions with thickness measuring 10 mm or more (n = 58), examination is an initial step in the diagnostic work-up. patients who do not have loculated pleural effusion The diagnostic yield of cytologic analysis of thoraco - greater than 20 mm (n = 33), and less than 12 months of centesis-obtained pleural effusion is 40–60%, while the follow-up after the procedure (n = 11). sensitivity of pleural fluid cytology is 60%, which is rel - Inclusive criteria for this study were small lesions atively low . Also, there is a considerable variation in (lamellar or spindle-shaped plaque) of costal pleura the sensitivity of cytological assessment of pleural effu - with thickness up to 10 mm, and the presence of locu- sion, with significantly lower sensitivity for mesothelioma lated, gravity independent, pleural effusion, greater than and haematological malignancies than for adenocarci- 20 mm, localised immediately adjacent to the target noma [7–9]. The diagnostic yield of the above mentioned lesion. Due to pleural effusion, the needle did not pen - examination can be improved by repeated thoracocente- etrate the visceral sheet of the pleura nor did it enter sis, especially when combined with a percutaneous pleu- the lung parenchyma, thus avoiding the most common ral biopsy . complications such as pneumothorax and needle tract An image-guided transthoracic biopsy is a widely used, bleeding. An additional inclusive criterion was a non- safe, and accurate diagnostic procedure for the diagnosis diagnostic cytological analysis of pleural effusion. of pleural lesions. It can be performed under the guid- We collected patient data (age and sex) consecutively ance of CT or ultrasound (US). The advantages of US are from the hospital information system (Ibis), while TCNB real-time multiplanar monitoring and the absence of ion- data (lesion size, needle size, number of tissue sampling) ising radiation. US-guided transthoracic biopsy of pleural were collected from the picture archiving and communi- lesions is an effective radiological diagnostic method with cation system (PACS). excellent diagnostic accuracy for pleural lesions smaller than 20 mm, ranging from 66.7 to 97.1% . Others  Biopsy procedure have suggested that US guidance should be considered The multidisciplinary team (radiologist, pulmonologist, for biopsy of peripheral lung and pleural lesions larger thoracic surgeon, pathologist, and oncologist) indicated than 10 mm. this diagnostic procedure for suspected pleural malig- CT is a guidance modality of choice for transthoracic nancy. The interventional radiologist estimated if the biopsy of small pleural lesions as a minimally invasive pleural lesion was suitable for the biopsy based on a pre- diagnostic procedure with high diagnostic contribution viously performed diagnostic contrast-enhanced chest and an acceptably low complication rate . The pur - CT. On the day of the intervention, every patient was pose of this study was to assess the previously mentioned admitted to day rehabilitative and curative care at the statements for CT-guided TCNB of small pleural lesions Department of Pulmonology. with the presence of loculated pleural effusion as the pro - Criteria for the biopsy procedure included the patient’s tective factor for complications. ability to cooperate adequately and tolerate the supine position. Also, a valid coagulation test (prothrombin time Methods (PT), international normalised ratio (INR), and partial The ethics committee of the Rijeka University Clinical thromboplastin time (PTT)) was required as well as a Hospital Centre approved the conduct of this retrospec- signed informed consent. tive study. Written informed consent from patients was All interventions included in this study were performed not required since this study was considered a review of by two interventional thoracic radiologists, one (KM) clinical practice. with 20 years of experience and the other with three years of experience in TCNB. Study cohort Patient’s position (pronation, supination, or lat- This retrospective study included 56 patients who eral decubitus) was determined based on the lesion underwent CT-guided transthoracic pleural biopsy at localisation. the Department of Radiology, Rijeka University Clinical The procedure begins with a CT scanogram on which Hospital Centre, from January 2015 to July 2021. Out of a scanning field was determined that encompasses only Kukuljan et al. Cancer Imaging (2023) 23:48 Page 3 of 6 Fig. 1 Axial scan of a chest CT obtained during CT-guided transthoracic biopsy (histopathological diagnosis: epithelioid mesothelioma) 1a: radiopaque marker immediately next to a 5 mm thick solid pleural lesion (arrowhead) 1b: biopsy needle (arrow) Fig. 2 Axial scan of a chest CT obtained during CT-guided transthoracic biopsy (histopathological diagnosis: epithelioid mesothelioma) 2a: radiopaque marker immediately next to a 4 mm thick solid pleural lesion (arrowhead) 2b: biopsy needle (arrow) that part of the thorax in which the target lesion was two samples. Since at our institution it is not possible located. Due to radiation protection, the narrowest pos- to organise the presence of a cytopathologist during the sible field was chosen. All biopsies were performed with - biopsy, we evaluated the quality of the sample based on out contrast agents, under the guidance of CT Siemens the morphology, whether the sample was disintegrated, Somatom Definition AS (128), with a layer thickness of and whether it dissolved in formalin. Two biopsy passes 2 mm. were performed in 47 (83.9%) of patients, while one pleu- The puncture site was labelled with a radiopaque ral puncture was performed in only 9 (16.1%) of patients. marker, followed by preprocedural cleansing of the The obtained tissue cylinders were sent for pathologi - biopsy site with an antiseptic agent and a subsequent cal analysis. After the procedure, a control non-contrast subcutaneous injection of local anaesthetic (2 mL of 2% CT scan was performed to detect possible complications lidocaine). (Figs. 1, 2). After the skin incision, the pleural biopsy was per- formed with a single needle technique, 16-gauge semi- Statistical analysis automated non-coaxial core biopsy needle (Original Histopathological results were evaluated and divided into TEMNO™ Biopsy Device). The lesion was accessed along two diagnostic categories. The first diagnostic category the upper margin of the lower rib to avoid damage to the included the diagnosis of a malignant pleural tumour vascular and nerve structures. A biopsy needle was led confirmed by lesion regression after undergoing onco - step-by-step to the pleural lesion; after each step, a CT logical therapy or lesion progression despite received scan was performed to check the needle position. Each therapy. Patients with the above mentioned findings were needle manipulation and CT scan were performed only included in the group of patients with true-positive (TP) during suspended respiration. The number of punctures results. depended on the specimen quality, resulting in one or Kukuljan et al. Cancer Imaging (2023) 23:48 Page 4 of 6 Table 1 Histopathological diagnosis for 56 biopsies Table 2 Measures of diagnostic accuracy Histopathological diagnosis N of patients % Diagnostic contribution N / % Primary malignancy 19 33.9 True positive 33 / 58.9 Mesothelioma 19 33.9 False positive 0 / 0 Secondary malignancy 14 25 True negative 17 / 30.4 Lung adenocarcinoma 8 14.3 False negative 6 / 10.7 Breast adenocarcinoma 2 3.6 Sensitivity 84.6 Colon adenocarcinoma 1 1.8 Specificity 100 Melanoma 1 1.8 Positive predictive value 100 Non-Hodgkin lymphoma 1 1.8 Negative predictive value 73.9 Adenoid cystic carcinoma 1 1.8 Diagnostic accuracy 89.3 Benign lesions 17 30.4 Chronic fibrinous pleuritis 6 10.7 patients, 7.1%) and biphasic (2 patients, 3.6%) mesotheli- Chronic inflammatory infiltrate 5 8.9 oma. The second most frequent diagnosis was metastasis Asbestosis 4 7.1 of primary tumours, diagnosed in 14 patients (25%). Fibrous pleural plaque 2 3.6 Among all, the malignant disease was identified in 33 False-inconclusive findings 6 10.7 patients (58.9%) included in the group with true-positive results. The final benign diagnosis was confirmed in 17 The second diagnostic category included patients with patients (30.4%), so they were counted as true-negative negative histopathological findings or those who have results. A total of 6 (10.7%) inconclusive findings of nega - been definitively diagnosed with a benign lesion. All tive or non-representative samples were categorised as patients included in this category were clinically moni- false-negative results since TCNB did not determine the tored and controlled using non-invasive radiological diagnosis. In these six patients, the CT morphology of methods for 6–12 months. In the observed period, if the the pleural lesions was highly suspected to be a malig- lesion size regressed or remained the same, they were nant tumour, which was later confirmed by VATS biopsy included in the group of patients with true-negative (TN) or open surgery. The final diagnoses of all six false-nega - results. Patients with negative histopathological findings, tive biopsies were epithelioid mesothelioma. whose clinical course and following CT findings referred Based on the obtained data, the diagnostic contribu- to the malignant aetiology of pleural disease, were tion of CT-guided TCNB of pleural lesions in this study included in the group of patients with false-negative (FN) was: sensitivity 84.6% (33 of 39), specificity 100% (17 of results. The definitive diagnosis of patients in the FN cat - 17), PPV 100% (33 of 33), and NPV 73.9% (17 of 23), and egory was determined by video-assisted thoracoscopic diagnostic accuracy 89.3% (50 of 56) (Table 2). (VATS) biopsy or open surgical biopsy. Positive histopathological diagnoses after surgery in the Discussion case of an operable pleural tumour, regression of lesion This retrospective study included transthoracic core size after undergoing oncological therapy, or progression needle biopsies (TCNB) of 56 small pleural lesions with of findings despite therapy were taken as confirmation of thickness up to 10 mm in patients with loculated pleu- diagnosis. ral effusion, which was considered a protective factor for The diagnostic contribution of this method was deter - complications. Major complications of TCNB of pleural mined by tests of overall diagnostic accuracy, sensitivity, lesions include pneumothorax, haemorrhage or needle specificity, and positive and negative predictive values. tract bleeding, and haemothorax. In this study, no com- plications occurred. Results Maskell et al.  and Adams et al.  also reported In this study, no complications were noted among all 56 a zero-complication rate of CT-guided TCNB of pleural patients who underwent CT-guided TCNB. The smallest lesions in the presence of pleural effusion. In the study biopsied pleural plaque was 4 mm thick, while the mean of 33 TCNB, Welch et al.  also reported no compli- thickness of the pleural lesions was 6.2 mm. cations, nor did they mention the presence of pleural The histopathological diagnoses of tissue samples effusion. obtained from biopsy procedures are shown in Table 1. Benamore et al.  reported that 4.7% of CT-guided The most common malignant diagnosis among patients pleural biopsies were associated with pneumothorax and in this study was malignant pleural mesothelioma, diag- 7.5% with significant bleeding up the trocar needle. They nosed in 19 patients (33.9%). Division of mesothelioma also mentioned that none of the patients with pneumo- by cell type shows that the epithelioid was the most com- thorax had pleural effusion. mon (13 patients, 23.2%), followed by sarcomatoid (4 Kukuljan et al. Cancer Imaging (2023) 23:48 Page 5 of 6 The complication rates in the Cao et al. study [ 18] were It should be noted that we obtained our results by 6.5% for pneumothorax, 8.7% for haemorrhage, and 1.1% analysing lesions smaller than 10 mm and compared for haemothorax. They also reported that 25% of cases them with studies that included differently sized pleural had pleural effusion but did not state whether it had any plaques because we did not find studies showing exclu - impact on the rate of complications. They both stated sively biopsy results of small pleural lesions in recent that the observed pneumothoraces may have resulted publications. from the introduction of air by the biopsy or drain rather The limitation of our study may be due to a retrospec - than direct communication with the airway. tive design with a possible risk of selection bias. Also, In the Niu et al. study , pneumothorax was all procedures were performed by two radiologists with observed in 16% of patients and chest pain in 2% of significant experience in performing CT-guided pleural patients, while haemothorax was detected in one patient biopsies. (1%). The same authors reported a lesion size/pleural thickening as a significant risk factor; pleural effusion, Conclusions present in 40.9% of patients, was noted as a significant The results from our study, which include zero complica - protective factor for pneumothorax. tion rate and significant diagnostic contribution, indicate As already mentioned, the mandatory criterion for that CT-guided transthoracic core needle biopsy (TCNB) this study was the presence of loculated pleural effu - is a useful method for diagnosing suspected small pleural sion, greater than 20 mm, localised immediately adja- lesions in the presence of loculated pleural effusion as a cent to the pleural lesion. Consequently, the needle did protective factor for complications. not penetrate the visceral pleural sheet nor enter the lung Abbreviations parenchyma, avoiding the most common complications CT Computed tomography (pneumothorax and needle tract bleeding). TCNB Transthoracic core needle biopsy PPV Positive predictive value In the recent publications, to our knowledge, only NPV Negative predictive value Adams et al.  reported minor haemoptysis (1%) as a PACS Picture archiving and communication system complication of CT-guided TCNB of the pleura.PT Prothrombin time INR International normalised ratio In our study, the sensitivity of CT-guided transtho- PTT Partial thromboplastin time racic biopsy was 84.6%, specificity 100%, PPV 100%, and TP True positive NPV 73.9%, while diagnostic accuracy was 89.3%. The FP False positive TN True negative overall diagnostic contribution of TCNB in our study is FN False negative comparable with the results of other reports. In the avail- VATS Video–assisted thoracoscopic biopsy able literature, all authors [14, 15, 17–21] stated the same N Number (of patients) specificity and PPV of 100%, while sensitivity [ 14, 16–19, Acknowledgements 21] ranged from 75 to 90.9%, NPV from different stud - Not applicable. ies [14, 15, 17–19, 21] varied from 58.3 to 88.1%, while Authors’ contributions overall diagnostic accuracy [15, 18, 21] ranged from 89.2 MK designed the study, defined the variables for collection, supervised to 94.6%. the study and described the clinical interpretation of the collected data. In the most recent study, Park et al.  reported a EM defined the variables for collection, collected the data and performed the preliminary statistical analysis. EO helped set the proper methodology similar diagnostic yield of US-guided TCNB of pleural and performed the definite statistical analysis. All authors participated in lesions smaller than 20 mm; accuracy, sensitivity, speci- the writing and preparation of the manuscript equally and they approved ficity, PPV, and NPV were 85.4%, 84.8%, 100.0%, 100%, the submitted version. All authors have agreed to be accountable for their contributions. All authors read and approved the final manuscript. and 21.1%, respectively. The only complication in the pre - viously mentioned study was pneumothorax, which was Funding found in 3.9% of patients. Not applicable / none to declare. Open access funding provided by University of Pécs. Khosla et al.  compared US-guided biopsy with CT- guided biopsy of pleural-based lung lesions. They showed Data Availability that the US guidance method has an equivalent diag- The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. nostic yield, with fewer complications and significantly reduced procedure time. It is important to emphasise Declarations that the study included larger lesions, with a mean lesion size of 4.9 and 5.6 cm for CT and US guidance, respec- Ethics approval and consent to participate tively. Furthermore, Lee et al.  concluded that US The ethics committee of the Rijeka University Clinical Hospital Center approved the conduct of this retrospective study. Written informed consent guidance should be considered for biopsy of peripheral from patients was not required since this study was considered a review of lung and pleural lesions larger than 10 mm. clinical practice. Kukuljan et al. Cancer Imaging (2023) 23:48 Page 6 of 6 Consent for publication of CT and ultrasound characteristics. AJR Am J Roentgenol. 2021;217(3):699– Not applicable. 706. https://doi.org/10.2214/AJR.20.24120. Epub 20201007. 12. Lee MH, Lubner MG, Hinshaw JL, Pickhardt PJ. 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Cancer Imaging – Springer Journals
Published: May 22, 2023
Keywords: CT; Transthoracic core needle biopsy; Pleura; Pleural lesions
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