The Role of Percutaneous Transthoracic Core Needle Biopsy on

Diagnostic of Central and Peripheral Lung Nodule/Mass

using Chest CT Scan and Chest Ultrasound Guidance

Andhika Kesuma Putra

, Noni Novisari Soeroso

, Hendra Taufik

Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Sumatera Utara,

Universitas Sumatera Utara Hospital, Jl. Dr. Mansyur No. 5 Medan 20155, Sumatera Utara, Indonesia

Keywords: Core biopsy, Percutaneous, Transthoracic

Abstract: Percutaneous transthoracic core needle biopsy is a technique using a longer sized needle and hooks allowing

tissue for histopathological examination on certain indications (lesion size over 8 mm or transthoracic

needle aspiration (TTNA) is not representative). The aim of this study was to analyze the role of core biopsy

size 14G (the largest size available in Indonesia) with a co-axially needle on diagnostic of central and

peripheral lung nodule/mass with the use of chest CT scan and chest ultrasound guidance. This is a

retrospective study of 58 patients with peripheral lung nodule/mass from the year 2014 to 2019.

1 INTRODUCTION

Core needle biopsy has become the dominant method

in obtaining tissue samples from pulmonary lesions

to make a pathological diagnosis (Zhou et al., 2013).

The development of imaging methods especially

computed tomography (CT) has contributed to more

accurate localization of lung lesions. It has

contributed to making this procedure universally

well-known and performed on a large scale. The

procedure has actually become a viable alternative to

other diagnostic procedures such as sputum cytology,

bronchoscopy, and thoracotomy, with a high quality

of material sampling collected for analysis (Beckh,

Blcskei, and Lessnau, 2002; Junqueira et al., 1990).

The guided biopsy with computed tomography

has been widely accepted as an effective and safe

procedure for a specific diagnosis (Guimarães et al.,

2009; Yu et al., 2002).

Another imaging development for lung lesion is

an ultrasound (US). Sonogram has been described as

a useful tool in characterizing unspecified pleural or

subpleural pulmonary lesions, when there is no lung

aeration in between (Sartori et al., 2007). In addition,

US can be used as a safe and effective method to

guide the biopsy of masses in the chest wall

(Schubert et al., 2005). The main advantage of this

imaging modality is that the US allows real-time

monitoring of procedures and can be done at the

patient's bedside, without using radiation.

Transthoracic core needle biopsy is indicated to

determine nodules or pulmonary masses tissue. Core

biopsy is a technique similar to transthoracic needle

aspiration (TTNA) using a longer and bigger size

needle with a cutting needle so it can obtain tissue for

histopathology examination based on certain

indications (tumor size is more 8 mm or yield TTNA

is not representative).

While core biopsy size 14-18 G was used for the

first time in the early 1980s. It has been shown that

only 40-50% of small peripheral thoracic lesions are

malignant. Using percutaneous biopsy, surgery or

thoracoscopy can be avoided in 64% of patients

(Liao et al., 2000).

Core biopsy was performed with image guidance,

including chest CT and US. Some previously

published articles for CT guided biopsy have

described their role as modalities effective guidelines

for diagnosing intrathoracic lesions (Liang et al.,

2014).

In this study, our aim was to describe the sample

characteristics and the accuracy of transthoracic

biopsy cores using US or CT guidelines to diagnose

lung lesions.

2 METHODS

The researchers collected retrospectively cases of

biopsy procedures that had been conducted by

Putra, A., Soeroso, N. and Tauﬁk, H.

The Role of Percutaneous Transthoracic Core Needle Biopsy on Diagnostic of Central and Peripheral Lung Nodule/Mass using Chest CT Scan and Chest Ultrasound Guidance.

DOI: 10.5220/0009841100120014

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 12-14

ISBN: 978-989-758-469-5

researchers from 2014 to 2019 at Columbia Asia

Hospital Medan and Malahayati Islamic Hospital

Medan, Indonesia. A total of 58 patients consisted of

12 women and 46 men aged 19 to 79 years old was

enrolled.

By using chest radiographs or chest CT scan we

determined if there were nodules or masses in the

lung. All patients were then informed of which

procedures they should receive and all subjects

consented for the procedures to be performed.

Of the 58 core biopsy actions, two guides were

selected, imaging CT scan or US guide. Forty-three

patients were guided using chest CT scan and 15

patients used US guide. If the lesions were located

near the chest wall or peripherally and the size was

more than 2 cm, it will be guided with the US. But if

the lesion was less than 2 cm and located in the

deeper or center, it was done with the CT scan

guidance.

We marked the site of insertion of the core

biopsy needle. We infiltrated the local anesthesia

lidocaine from the skin through the parietal pleura

using a 26G needle syringe. Then we inserted the co-

axially needle as the core biopsy cutting needle

cannula catheter to obtain the tissues. Each specimen

was immediately put into a container containing 10%

formalin and sent to the pathology department for

further examination.

At the end of the procedure, all patients were

monitored for signs and symptoms of complications,

such as hemoptysis and pneumothorax.

3 RESULTS

During this period, a total of 58 core biopsy actions

were carried out. Of those, 43 were guided using CT

scan and 15 patients were guided with the US. Table

1 describes the baseline characteristics of patients.

Table 1: Characteristics of patients underwent core biopsy

randomized to US guidance or CT guidance.

Characteristics US-guided

(n=15)

CT-guided

(n=43)

Mean age

(years)

53,28 ± 14,63 years

Age (years)

16-35 3 (19.8.%) 9 (20.8%)

36-55 6 (39.9%) 17 (39.4%)

56-75 6 (40.0%) 17 (39.4%)

Sex

Male 12 (80.0%) 34 (79.0%)

Female 2 (13.3%) 10 (23.0%)

Histopathology diagnosis is described in table 2, and

the complications of the procedures are stated in

table 3. There were 3 pneumothorax complications

(6.9%) that occurred with an area of pneumothorax

<20% but there was no requirement to place

intercostal chest tube placement, and 1 (1.7%)

hemoptysis complication was reported.

Table 2: Final histopathology diagnosis.

Histopathology

Classification

US-guided

(n=15)

CT-guided

(n=43)

Adenocarcinoma 8 (53.0%) 10 (23.0%)

Squamous cell ca 4 (26.0%) 11 (25.0%)

Large cell ca 1 (6.6%) 2 (4.6%)

Adenosquamous 1 (6.6%) 0

Small cell lung

carcinoma

0 3 (6.9%)

Oat Cell 0 1 (2.3%)

Yolk sac 0 2 (4.6%)

Mature teratoma 0 1 (2.3%)

NHL 1 (6.6%) 0

Lung

fibrosarcoma

0 1 (2.3%)

Non specific

inflamatory

process

0 2 (4.6%)

Pulmonary TB 1 (6.6 %) 4 (9.3 %)

Pneumonia 0 1 (2.3%)

Fibrotic Mass 0 2 (4.6%)

Plasmacytoma 0 1 (2.3%)

Cryptococcus 0 1 (2.3%)

Loss Connective

Tissue

0 1 (2.3%)

Table 3: Complication core biopsy

Complication US-guided

(n=15)

CT-guided

(n=43)

Pneumothorax

<20%

0 3 (9.3%)

Hemoptysis 0 1 (2.3%)

4 DISCUSSION

Transthoracic core needle biopsy is an alternative

intervention when bronchoscopy is not available. A

percutaneous pulmonary biopsy is a safe and

accurate procedure for the diagnosis of focal

thoracic lesions. A study conducted by Liang et al.

(2014) showed that CT-guided biopsy cores with

cytology evaluation had a low and adequate atypical

level. Pulmonary core biopsy can provide a more

accurate tumor classification and specific diagnosis

for non-neoplastic lesions. Adequate networks are

often available for molecular studies.

The Role of Percutaneous Transthoracic Core Needle Biopsy on Diagnostic of Central and Peripheral Lung Nodule/Mass using Chest CT

Scan and Chest Ultrasound Guidance

The rate of complication of biopsy of

pneumothylactic core needles is compatible with

fine needle aspiration. Pneumothorax and mild

bleeding are the common complications of core

biopsy. Liang et al. (2014) reported pneumothorax

incidence at 31.4%. Beslic et al. (2012) compared

the rates of complications in percutaneous fine

needle aspiration biopsy guided by CT and core

needle biopsy and discovered that pneumothorax

was detected in 9.7% of patients with a fine needle

biopsy and 31.5% in patients with core biopsy.

However, other authors reported varying rates of

pneumothorax ranging from less than 10% to more

than 60% in fine needle aspiration and core biopsy

(Minot et al., 2012). In our institution, CT-scan and

US were immediately performed post-procedure in

all patients and broad criteria for the pneumothorax

was used from the Light study (Light, 1990).

The limitation of our study is that the authors

did not report the size of radiological lesions, TNM

grading, and pain score.

5 CONCLUSION

The percutaneous core needle biopsy procedure

guided by CT and US showed high accuracy of

results, 79.3% of the lesions obtained

histopathologically were malignant lesions.

In all cases studied, there was no report from the

pathologists of an inadequate sample or

unavailability of tissue. Although the needle used is

a large type of needle (size 14G) and it is the largest

needle available in Indonesia but the complications

of pneumothorax turned out to be low (6,9 %).

Pneumothorax is a common complication and has

been reported to occur in 50% of events. In our

report, there were no additional intervention

procedures like simple aspiration or chest tube

insertion needed.

Our study shows that CT biopsy with CT or US

guidelines is a safe procedure and is generally well

tolerated. Some patients may experience significant

and lasting pain and therefore must receive detailed

information regarding this procedure.

FUNDING

No grant support or funding from public institutions

or private enterprises was received for this research.

ACKNOWLEDGMENTS

The researcher would like to thank Columbia Asia

Hospital and Universitas Sumatera Utara Hospital

which have allowed the retrieval of medical history

data.

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