| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Letters to the Editor |
Departments of Diagnostic Imaging
Thoracic Medicine, Northern General Hospital NHS Trust, Herries Road, Sheffield S5 7AU, United Kingdom
Editor:
Three excellent reports (1–3) on the subject of needle lung biopsy have recently been published in Radiology. However, the authors of these articles failed to address the question of whether the technique is necessary in every patient with a focal lung opacity. Percutaneous needle biopsy, which is widely used, has a high accuracy in diagnosing lung malignancy (1–4). The technique, however, is limited in diagnosing nonmalignant lesions and has a reported accuracy of about 50% (2). Accurate specific diagnosis of benign lesions is attained in less than 50% of cases in most series (2,4). In the recent article by Dr Lucidarme and colleagues (1), the accuracy of the technique in diagnosing benign lesions improved to 70% with the use of an 18-gauge coaxial cutting needle. Nevertheless, it remains that a negative result for malignancy without a specific diagnosis of a benign lesion does not exclude the possibility that the lesion is malignant, even with this novel technique (1,4). In addition, the frequency of complications is higher with the use of cutting needles than with fine-needle aspiration. In Dr Lucidarme and colleagues' series, the incidence of hemoptysis was 10% and the incidence of pneumothorax was 34%. In 3% of cases, placement of a chest tube was necessary (1).
The majority of lesions in patients referred for fine-needle aspiration are indeed malignant, with an incidence of 80%–85% in most reports (1,2,4,5) we know of. In addition, all needle biopsy techniques are plagued by the inability to exclude malignancy and a low yield in identifying benign lesions (2). Consideration of these factors raises the question, is needle biopsy of a focal lung opacity of undetermined nature necessary in patients at high risk of lung malignancy (those older than 50 years or with a history of smoking)? The answer would be "yes" if a negative result for malignancy would prevent unnecessary thoracotomy for a benign lesion. The high prevalence of malignancy often promotes surgical resection of the lesion, even in the presence of a negative needle biopsy result (3).
Early resection of a malignant focal lung opacity offers the best prognosis for patients with peripheral lung cancer (6). The inability to use needle biopsy to exclude the diagnosis of lung malignancy within the clinical context of suspected lung cancer indicates that the technique is of limited value in these patients. The technique also does not have high accuracy in the cell typing of lung malignancy and should not be relied on to identify small-cell lung cancer (4,7), which does not commonly manifest as a peripheral focal lung opacity (6). The effect of needle biopsy on the clinical management of focal lung opacity has not been adequately investigated. Findings of the only study (8) of which we are aware that addresses this issue showed that needle biopsy is of little value when there is high clinical probability that the lesion is malignant and resectable. In such situations, patients should be referred directly for surgery to remove the opacity provided there is no contraindication to the surgical procedure. Needle biopsy may be of value when there is a contraindication to surgery and histologic proof is required.
In conclusion, the very few cases of benign lesions that are difficult to identify by using needle biopsy do not justify its routine use in every patient with a focal lung opacity. The technique is not without complications and morbidity. Assessment of the operability of the lesion should be the primary concern in the treatment of patients with a focal lung opacity who are at high risk of malignancy. Patients with operable lesions should be referred for surgery if there is no contraindication. The inoperable lesion could be considered for needle biopsy to confirm the presence of malignancy. Cell typing of the lesion should not be considered an indication for needle biopsy because the accuracy of the technique is limited (4,7).
Finally, to our knowledge, there is no clear proof in the literature that the use of needle biopsy has greatly influenced clinical management and consistently prevented unnecessary thoracotomy for benign lesions. In our view, the best approach to the management of a focal lung opacity remains "when in doubt, take it out!"
References
Department of Radiology, Hôpital de la Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
We thank Drs Morcos and Anderson for their excellent remarks on our article (1). The purpose of our study was to present a new computed tomographically guided lung biopsy technique. We discussed the positive aspects of the technique, which were aimed at improving the diagnostic accuracy of lung biopsy, particularly when no cytopathologist is available.
We did not discuss the indications for needle biopsy, as this is another subject. Goldberg-Kahn et al (2), using a decision-analytic model, showed that the best initial procedure for a solitary lung lesion in a patient who is a surgical candidate is the open biopsy. Open biopsy had the lowest cost per correct diagnosis before imaging-directed fine-needle aspiration and bronchoscopic examination.
We agree with Drs Morcos and Anderson that assessment of the operability of the lesion must be the primary concern in the treatment of patients with a focal lung lesion. We perform a needle biopsy only when we consider the lesion to be probably benign, there is a contraindication to the surgery, the patient refuses the surgery (to obtain potentially "persuasive" information), or we suspect that a lesion is treatable by using chemotherapy, in cases of lymphoma or small cell carcinoma. In such cases, we choose to use the technique that provides the best result, particularly with specific benign lesions or lymphoma, and an acceptable rate of complications.
References
Department of Radiology, FND 216, Massachusetts General Hospital, PO Box 9657, Boston, MA 02114-2698
I certainly agree with Drs Morcos and Anderson that in many individuals in whom there is a high clinical probability that a solitary nodule is malignant, a needle-aspiration biopsy is of little value if the lesion is considered to be resectable. In such instances, the pretest probability of lung cancer is high, and it is reasonable for such patients to proceed directly to thoracotomy.
However, there are patients who have a presumptive diagnosis of lung cancer and in whom the management may be influenced by the result of a needle-aspiration biopsy. These include patients with unresectable (stage IIIB or IV) disease or those who may require adjuvant chemotherapy or radiation therapy prior to resection (stage IIIA). In such instances, the diagnosis must be established prior to treatment. Patients who have a history of extrathoracic malignancy and either a solitary or multiple lung nodules that are not amenable to surgical therapy require a definitive diagnosis. Finally, there are patients with peripheral focal lesions in the lung in which active infection is suspected. This group often includes patients who are immunocompromised. Percutaneous needle-aspiration biopsy in such instances may yield a definitive diagnosis and a specific organism in over 70% of cases.
My colleagues and I recently reviewed our experience with 226 patients who underwent percutaneous thoracic needle biopsy over 12 months at our institution (1). The purpose of this review was to determine the role of needle biopsy in patient care decisions. We found that transthoracic needle biopsy results altered patient treatment in 54% of cases. Surgery was avoided in 74% of these cases. The cost of transthoracic needle biopsy was compared with the costs of surgical methods used to obtain a tissue diagnosis, such as video-assisted thoracoscopic surgery and thoracotomy. Video-assisted thoracoscopic surgery was 6.3 times and thoracotomy was 10.9 times more costly than transthoracic needle biopsy. In our series, the transthoracic needle biopsy results did not alter or influence management in only 22% of patients. All of these patients had resectable lung cancer. This experience may reflect the complex group of patients who are referred for needle biopsy at our institution, but it does not support the contention that the majority of patients do not benefit from needle-aspiration biopsy.
References
This article has been cited by other articles:
|
|
 |
|
  R. Thiessen, J. M. Seely, F. R. K. Matzinger, P. Agarwal, K. L. Burns, C. J. Dennie, and R. Peterson Necrotizing Granuloma of the Lung: Imaging Characteristics and Imaging-Guided Diagnosis Am. J. Roentgenol., December 1, 2007; 189(6): 1397 - 1401. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
