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1
Department of Radiology, Albert Einstein College of Medicine and Montefiore
Medical Center, 111 E. 210th St., Bronx, NY 10467-2490.
2
Department of Radiology, New York Medical College and Westchester Medical
Center, Valhalla, NY 10595.
Received August 16, 1999;
accepted after revision November 15, 1999.
Address correspondence to A. M. Rozenblit.
Abstract
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SUBJECTS AND METHODS. CT-guided needle biopsy with the patient in an ipsilateral dependent position was performed in 23 patients with 17 lung lesions (15 posterior and two anterior) and six mediastinal lesions. Fine-needle aspiration was used in all patients, and core biopsy was also used in six patients. The technical difficulty of the procedure was classified into three grades compared with a routine transthoracic needle biopsy as follows: grade I, no more difficult; grade II, somewhat more difficult; and grade III, much more difficult.
RESULTS. Adequate samples were obtained in 22 (96%) of 23 patients. A small asymptomatic pneumothorax occurred in two patients (8.7%). Difficulty was rated grades I, II, and III in 18 (78%), two (9%), and three (13%) procedures, respectively. Four of the five grades II and III procedures were biopsies of anterior lesions. Traversing the pleura was avoided in three of six mediastinal masses.
CONCLUSION. Transthoracic needle biopsy of selected lung and mediastinal lesions using a ipsilateral dependent position is feasible, effective, and safe. The role of this technique for reducing the rate of pneumothorax as a result of the biopsy requires further investigation.
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In the first 12 months, only a 90° ipsilateral dependent position was used. This led to the exclusion of patients with lesions in the lateral two thirds of the dependent hemithorax. Of 49 transthoracic needle biopsies performed in this period, only seven (14%) were done in an ipsilateral dependent position. Later in the study, we modified the technique by using a variable obliquity, between 90° and 30°, of the ipsilateral dependent position. This variable obliquity expanded applicability for the method, allowing the biopsy of lesions located farther from the mediastinum while preserving the dependent position of the affected lung. Of 40 consecutive transthoracic needle biopsies performed in the second part of the study, the ipsilateral dependent position was feasible in 16 procedures (40%).
In a 24-month period between 1996 and 1998, CT-guided transthoracic needle biopsies in an ipsilateral dependent position were performed in 23 patients with 17 lung and six mediastinal lesions. The patients were 13 men and 10 women ranging in age from 34 to 82 years (mean, 60 years). Six patients had known primary tumors, and 17 patients had abnormal chest findings without a known diagnosis. Five patients (22%) had chronic obstructive pulmonary disease. Of 17 lung lesions, two were anterior and 15 posterior. Sixteen lesions were located in the medial half of the hemithorax, and one was in the posterolateral region. Of six mediastinal masses, the anterior mediastinal and aorticopulmonary window locations were found in four and two patients, respectively. For central mediastinal lesions, the predominantly involved side was categorized as the affected side and was selected for biopsy. All mediastinal lesions selected for the study would have required a transgression of the lung if a transthoracic needle biopsy were done with the patient in a supine position.
The lesions ranged in size from 0.8 to 7.0 cm (mean, 2.9 cm); 10 lesions (eight lung and two mediastinal) were smaller than 3 cm (Tables 1 and 2). The distance between the lesion and the pleural surface, or depth, varied from 0 to 5 cm (mean, 1.5 cm) as measured in the ipsilateral dependent position. For the extrapleural puncture of mediastinal lesions, the depth was considered 0 cm. Three lung lesions were pleura-based with a depth of 0 cm without apparent involvement of the chest wall as judged on CT. In four patients with lung lesions, the depth was also measured with the affected lung in a nondependent position to compare with that in the ipsilateral dependent position.
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CT scans were performed on a 9800 Advantage scanner (General Electric Medical Systems, Milwaukee, WI). We used 10-mm collimation for lesions larger than 15 mm, and 5-mm collimation for smaller lesions.
Biopsies were performed using a 90° ipsilateral dependent position in seven patients; in the remaining patients, the degree of obliquity from the table was less than 90° but greater than 30°. To stabilize patients in the ipsilateral dependent position, hips and knees were flexed. In addition, a fixation belt and supporting cushions were routinely used. The dependent arm was placed in front of the face. The nondependent arm was positioned along the body for the anterior approach or in front of the chest for the posterior approach. Patient comfort during the procedure was verified by questioning. All procedures were performed by three radiologists experienced with CT-guided biopsy. Technical difficulty of the procedure was assessed by the operators in comparison with a routine transthoracic needle biopsy as follows: grade I, no more difficult; grade II, somewhat more difficult; and grade III, much more difficult.
Biopsy was performed in suspended mid inspiration with the use of a routine sterile technique and local anesthesia. All patients had a fine-needle aspiration with a 20- or 22-gauge Westcott needle (Becton Dickinson, Rutherford, NJ). A single-needle technique was used in 20 patients and coaxial technique in three patients. The material was sent for cytologic analysis and a cell block for all patients and for microbiologic examination in four patients. In addition to a fine-needle aspiration, six patients had a cutting needle biopsy at the same sitting using an 18-gauge TEMNO needle (Bauer Medical, Clearwater, FL) and coaxial technique. A fine-needle aspiration specimen was initially examined by a cytologist present in the CT suite; when a specimen was judged to be sufficient for diagnosis, the procedure was terminated. If up to three fine-needle passes yielded indeterminate material, a cutting needle biopsy was performed. The number of biopsy specimens and needle passes with and without transgressing the pleura were recorded for each procedure (Table 3). For the coaxial technique, introducing a guiding cannula was considered a single pass transgressing the pleura. The final pathologic diagnosis was made 24-48 hr after the procedure.
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Patients were monitored during and after the procedure with a pulse oximeter and EKG and blood pressure measurements. Care after the procedure followed the standard protocol for our institution. Patients remained recumbent in the observation area for a variable period. The presence of a pneumothorax was initially determined on CT after the biopsy, followed by expiratory upright chest radiography. The latter was performed at 1 hr in patients without a pneumothorax, and at 2 and 4 hr in patients who had a pneumothorax on CT. Patients with normal findings on chest radiography and asymptomatic patients with a small and nonenlarging pneumothorax were discharged at 1 hr and 4 hr, respectively. Patients with a pneumothorax were instructed to return in 24 hr for chest radiography or earlier should they become symptomatic. The following morning, all outpatients and the referring physicians of the inpatients were contacted by telephone to verify their status.
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In all five cases of grades II and III difficulty, access to the lesion was hampered by a reduced lung volume and crowding of the ribs associated with the ipsilateral dependent position. The most problematic part of the procedure in these cases was the advancement of the needle through the chest wall to the pleural surface on the dependent side. Further positioning of the needle into the lesion and retrieval of the specimen did not differ from a routine biopsy. The three patients with grade III difficulty had mediastinal masses requiring an anterior approach. All were women with a large body habitus and prominent breast tissue, presenting an additional technical problem. This problem was remedied by using posterior obliquity in all difficult anterior biopsies.
The maximum number of needle passes was five (mean, 2.4). The number of needle passes transgressing the pleura was zero for three mediastinal lesions; the number ranged from one to four (mean, 1.9) for the remaining lesions (Table 3). The maximum number of obtained specimens was five (mean, 2.4).
Final analysis of the fine-needle specimens allowed a specific diagnosis in 19 (83%) of 23 patients. Eighteen (95%) of 19 malignant lesions were diagnosed on fine-needle aspiration. The lesions were 13 primary lung carcinomas and six metastatic tumors. A nondiagnostic specimen was obtained in one patient who developed an immediate onset of self-limited hemoptysis after a single fine-needle pass. On subsequent surgery this patient was found to have metastatic thyroid cancer. Of four benign lesions, a fine-needle aspiration was diagnostic in only one patient, who had cytomegalovirus pneumonia; in the remaining three patients no specific diagnosis was made. Core biopsy, which was prompted by indeterminate cytologic findings during the initial interpretation, confirmed the final cytologic diagnosis of malignancy in three patients; it showed no evidence of malignancy in the other three patients with a nondiagnostic fine-needle aspiration. Pathologic diagnoses in the latter group included fibrosis in one patient and nonspecific inflammatory tissue in two patients. In these three patients, no additional biopsy was performed. The lesions were presumed benign because follow-up CT showed that one lesion (fibrosis) was stable at 24 months, and two lesions decreased in size at 30 and 14 months. Of four specimens sent for microbiology, only one (cytomegalovirus) was positive. Overall, the biopsy results were accurate in 22 (96%) of 23 patients, including all mediastinal lesions, and in 16 (94%) of 17 lung lesions.
Of four patients who had CT with the affected lung in both dependent and nondependent positions, the lesion depth in the ipsilateral dependent position decreased from 2 to 1 cm in one patient and from 3 to 1 cm in another patient (Fig. 1A,1B), and did not change in two patients, one of whom had a subpleural lesion. In three of six patients with mediastinal lesions, the ipsilateral dependent position allowed an extrapleural needle passage because of the mediastinal shift (Fig. 2A,2B).
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No complications requiring treatment occurred in this series. A small apical postbiopsy pneumothorax was noted in two patients (8.7%) with metastatic lung lesions measuring 8 and 10 mm. Neither patient had chronic obstructive pulmonary disease. A single fine-needle pass and posterior approach were used in both cases. The patients remained asymptomatic, showing no evidence of enlargement of the pneumothorax on 2- and 4-hr upright chest radiography. They were discharged after 4 hr of observation. Complete resolution of the pneumothorax in these patients was documented on chest radiography at 24 hr in one and 48 hr in the other patient. Self-limited hemoptysis occurred in one patient who was discharged after 4 hr of observation.
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In addition, with an overall hypoinflation and reduced volume of the dependent lung with the patient in the ipsilateral dependent position, the distance between a lung lesion and the chest wall is expected to diminish for all but subpleural lesions. Yankelevitz et al. [9] found that the depth of a lung lesion varies considerably on prone and supine CT, with up to 4 cm less in depth for some lesions with the patient in the dependent position. In our series, a decrease in lesion depth in the dependent lung was found in two of the four lung lesions that were imaged in both dependent and nondependent positions. Theoretically, decreased lesion depth achieved by an ipsilateral dependent position may reduce the risk of a pneumothorax. Although in one recent study [10] the direct correlation between the lesion depth and the risk of pneumothorax was not established, other investigators have reported a higher pneumothorax rate with deeper lesions [1, 11].
Regardless of possible theoretic advantages of an ipsilateral dependent position, a lesion in the dependent lung may be difficult to sample because of crowding of the ribs and the proximity of the entry site to the CT table. A procedure that is difficult to perform often becomes impractical. Therefore, we tried to rate efforts associated with ipsilateral dependent position vis-à-vis biopsies in standard positions by subjective comparison of technical difficulties. Increased technical difficulty often translates in the prolongation of the procedure. Unfortunately, we did not time our studies. We believe that cases that we considered difficult certainly prolonged the procedure, possibly by 50% or more. The longer time resulted mainly from the necessity to reposition the patient, typically to less than 90° of obliquity, to achieve the optimal approach to the lesion, with subsequent rescanning and remarking of the entry point. We experienced a learning curve, but we learned to take into account both the lesion location relative to overlying bones and the patient body habitus for optimal positioning, thus keeping the procedure time standard.
Our results show that a biopsy in an ipsilateral dependent position is feasible in many cases. Most lesions in our patients were located in the medial half of the hemithorax. In most cases (78%), transthoracic needle biopsy in an ipsilateral dependent position was thought to be no more technically difficult than a routine chest biopsy. It appears that biopsy of posterior chest lesions can easily be performed in most cases using this position. The specific location of the lesion may require modification of a 90° ipsilateral dependent position to either anterior or posterior oblique to improve access to the lesion. We speculate that this technique may be especially useful for lesions in the inferior, most mobile portion of the lung.
Using an ipsilateral dependent position, biopsy was technically difficult in five patients in whom crowding of the dependent ribs presented a temporary obstacle for the advancement of the needle. Four of the five difficult lesions required an anterior approach. In addition, this approach was hampered by large body habitus with prominent soft tissues of the anterior chest wall, expecially breast tissue in women. Some degree of posterior obliquity was necessary to overcome the problem. Nevertheless, biopsy of anterior lesions was more difficult in an ipsilateral dependent position vis-à-vis a routine supine position in 50% of cases. Lesions located near the lateral and anterolateral chest wall are not accessible for biopsy using an ipsilateral dependent position. Additionally, we did not attempt to biopsy lesions located in the middle lobe and lingula because crowded lower anterior ribs in an ipsilateral dependent position were expected to significantly increase the difficulty of the procedure.
Biopsy of a mediastinal mass or paramediastinal lung lesion via an extrapleural pathway eliminates the risk of pneumothorax. Such a pathway may be formed by the instillation of a saline or a saline-lidocaine mixture [12, 13] along the planned needle pass. An extrapleural window can also be created by the mediastinal shift because of a positional change [14]. Using an ipsilateral dependent position, an extrapleural passage caused by the mediastinal shift became possible in three of the six patients with mediastinal lesions; thus, we avoided traversing the pleura and the risk of a pneumothorax. In three other patients a pleural transgression was not avoided with an ipsilateral dependent position, but the technique was probably helpful because the needle passed through a hypoinflated lung.
In this series, cytologic or histologic diagnosis was established in 96% of cases. Fine-needle aspiration was diagnostic in 95% of malignant lesions but in only 25% of benign lesions. These percentages are in concordance with some other, much larger published series reporting that fine-needle aspiration is reliable for diagnosis of malignancy, whereas histologic samples are more accurate for diagnosis of benign lesions [4, 15]. Thus, in our study, an ipsilateral dependent position for biopsy did not adversely affect the diagnostic yield of the procedure as compared with reported results of biopsies that were performed in standard positions.
A pneumothorax rate of 8.7% in this small series is lower than the rate typically reported for CT-guided transthoracic needle biopsy. It is also lower than our own pneumothorax rate of 15-18% encountered with standard techniques for the last 4 years, although a statistically significant difference cannot be proven because of the small sample size. We believe that a lower pneumothorax rate in an ipsilateral dependent position is related to limited motion and hypoinflation of the lung and improved extrapleural window for mediastinal lesions. However, because of a strong association of a pneumothorax with lesion size [10], relatively large lesions in our patients could contribute to a lower pneumothorax rate. We observed minimal pneumothorax after biopsy of the two smallest lesions in the series. We did not encounter any other significant complications. Mild hemoptysis occurred in one patient, limiting the procedure to a single nondiagnostic pass.
We conclude that biopsy of selected lung and mediastinal lesions with the patient in an ipsilateral dependent position is a feasible, effective, and safe procedure. The ipsilateral dependent position is associated with decreased motion and hypoinflation of the dependent lung. It is applicable to patients with lesions accessible in this position, in the absence of exclusion criteria. The technique may be especially useful for sampling central and lower lung lesions using a posterior approach. Additionally, the technique facilitates an extrapleural puncture of mediastinal masses. The ipsilateral dependent position cannot be used for lateral and anterolateral lesions because of the lack of access. The technique has limited application for some anterior lesions because of a difficult intercostal pathway and large body habitus, particularly in women. Although we did not encounter any significant complications, statistical analysis was not possible because of the small number of cases in the series. Further experience is necessary to determine the role of this technique for the prevention of a pneumothorax.
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