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Vascular and Interventional Radiology |
1 From the Departments of Radiology (A.H.), Pathology (A.E.S.), and Oncology (Ø.P.S.), the Norwegian Radium Hospital, Ullernchausséen 70, N-0310 Oslo, Norway. Received October 6, 1997; revision requested December 16; revision received September 10, 1998; accepted December 11. Address reprint requests to A.H.
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: The authors reviewed the findings in 70 patients with a tentative diagnosis of MPM who underwent US-guided core-needle biopsy at our institution during the past 10 years.
RESULTS: Fifty-two of the 70 patients who underwent automatic high-speed core-needle biopsy at our institution had MPM; 18 had other disorders. The correct diagnosis was made in 56 patients. Twelve of 14 inadequate biopsy specimens were false-negative for MPM. There were no false-positive biopsy results. In the detection of MPM, US-guided core-needle biopsy had a sensitivity of 77%, specificity of 88%, accuracy of 80%, positive predictive value of 100%, and negative predictive value of 57%. There were no serious complications.
CONCLUSION: US-guided core-needle biopsy is highly effective in the diagnosis of MPM. Owing to its simplicity, low cost, and few side effects, it could be the biopsy method of choice for detection of this condition.
Index terms: Biopsies, technology • Mesothelioma, 66.3254 • Pleura, biopsy, 66.1263, 66.12985 • Pleura, neoplasms, 66.3254 • Ultrasound (US), guidance, 66.12985
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MPM is a highly lethal neoplasm; it is associated with a median survival of not more than 2 years after the diagnosis (2,3). Diagnosing MPM is often difficult, especially in the early stages of the disease. The symptoms may be vague and nonspecific for a long time. Chest radiography and computed tomography (CT) may help to reveal only pleural effusion. When a pleural thickening is present, biopsy is usually performed. At the end of the 1950s, clinicians started to blindly perform histologic biopsy of the pleura with Cope and Abrams needles. However, the small tissue samples yielded from these biopsies have been shown to have limited sensitivity in the diagnosis of MPM. Ruffie et al (4) in 1989 reported that percutaneous needle biopsy produced sufficient tissue to diagnose MPM in about one-third of their cases. Thus, very often it was necessary to perform open surgical biopsy. In the 1980s, these methods were increasingly replaced by thoracoscopically guided biopsy (5,6), which is used to a large extent today. However, surgical and thoracoscopic procedures are expensive and time-consuming and seem to cause either tumor seeding or direct tumor growth through the chest wall more often than does percutaneous pleural biopsy in patients with MPM (5).
To our knowledge, there are few reports in the literature on imaging-guided biopsy of MPM (7–10). Fluoroscopy does not provide good guidance for biopsy of the pleura. Although CT can accurately demonstrate the location of a solid pleural lesion, the biopsy procedure normally must be performed blindly. The newer CT-fluoroscopy imaging units, however, allow one to follow the needle while placing it. Ultrasonography (US) is an ideal imaging method for the detection of diseases in those parts of the pleura that are not hidden behind bone or aerated lung tissue, and it provides excellent guidance for needle biopsy. The purpose of this study was to determine the clinical use and safety of US-guided core-needle biopsy with a one-hand automatic sampling technique compared with that of other biopsy techniques in the diagnosis of MPM.
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The US-guided biopsy procedures were performed by using model RT 3000 equipment (GE Medical Systems, Milwaukee, Wis) with either a 3.5- or 5-MHz sector transducer combined with a needle guide or a 5-MHz linear-array transducer with a free-hand technique. The punctures were made after a local anesthetic had been injected along the needle route with continuous US guidance.
Automatic high-speed core biopsy equipment (Biopty instrument and Biopty-Cut needles; Bard Urological, Covington, Ga) was used. One to five punctures (average, 2.7) were made each time; a total of 218 punctures were made in 82 procedures. The three different needle-gun combinations used were as follows: an 18-gauge needle and 23-mm gun ("18-gauge, 23-mm" combination; 165 punctures in 63 procedures), an 18-gauge, 11.5-mm combination (five punctures in two procedures), and a 14-gauge, 23-mm combination (48 punctures in 17 procedures).
The specimens were stored in a Ringer solution with a temperature below 4°C and immediately transported to the pathologist (A.E.S.), who divided the material into samples to be used for light microscopic, ultrastructural, and immunohistochemical studies. No blood tests for hemorrhagic disorders were performed before biopsy.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In the 52 patients with mesothelioma, first-attempt biopsy of lesions in the costophrenic region was performed 21 times. The diagnosis was determined 17 times, and the result was false-negative four times. Eight of the 31 biopsies of lesions elsewhere in the pleura were false-negative. The diagnosis was determined with repeat biopsy at the same lateral location in one of six patients with mesothelioma who underwent repeat biopsy; however, the diagnosis was determined all three times in which biopsy was performed in a lesion in the costophrenic region.
There was no significant difference in the diagnostic accuracy between the different needle-gun combinations. Of the 63 procedures performed with the 18-gauge, 23-mm combination, 17 (27%) were inconclusive. Both of the procedures performed with the 18-gauge, 11.5-mm combination were conclusive. Of the 17 procedures performed with the 14-gauge, 23-mm combination, five (29%) were inconclusive.
Two minor complications were encountered. After the second procedure, one patient had a slight hemoptysis that did not necessitate treatment, and one patient had local chest pain for about 1 hour after a puncture in the supraclavicular region. Pneumothorax was never encountered.
The patient observation time varied from 1 month to about 10 years. The mean observation time was about 1
years. No skin metastases at the biopsy needle entry site were observed, but two cases of skin metastases after pleural fluid drainage were reported in the patients' journals.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The results of former reports in the literature (3–6) show biopsies performed with Abrams needles without imaging guidance to have low accuracy and surgical and thoracoscopic biopsies to have high accuracy. In the few reports (7–10) on imaging-guided biopsy of MPM, both CT- and US-guided biopsy with either Abrams or Biopty-Cut needles have been used. By using imaging guidance, the accuracy of biopsy has been remarkably increased. We used US guidance because we were familiar with this biopsy technique, it was readily available, and it is generally a quick and safe procedure with a high diagnostic yield (11,12). With US guidance, focal tumors as well as more diffuse pleural thickening that is not hidden behind bone or aerated lung tissue can be localized, regardless of the presence of pleural fluid, and biopsy can be performed.
With regard to needle size and the number of punctures made in each procedure, there was no substantial difference in accuracy in our study. It seems more important to look at the macroscopic appearance of the biopsy specimen, which could be either a solid, almost homogeneous core indicating viable tumor tissue, or a fragmented core indicating necrosis, fibrin, or inflammation.
Diffuse MPM often infiltrates the diaphragmatic and adjacent thoracic parietal pleura. In our experience, the best results are obtained when biopsy is performed in this region (Figure). This is very often possible, and the US-guided biopsy procedure is very simple owing to the presence of fluid in the pleural cavity.
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Surgically and thoracoscopically guided biopsies seem to have a higher accuracy in the diagnosis of MPM than does US-guided biopsy. We believe, however, that when radiologists and other physicians become more familiar with US of the chest and the biopsy technique in general, US-guided core-needle biopsy of possible MPM may become the method of choice owing to its high accuracy, ease of performance, safety, and low cost.
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Footnotes |
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Author contributions: Guarantor of integrity of entire study, A.H.; study concepts and design, A.H.; definition of intellectual content, A.H.; literature research, A.H.; clinical studies, A.H.; data acquisition and analysis, A.H., Ø.P.S.; manuscript preparation, A.H., Ø.P.S.; manuscript editing, A.H.; manuscript review, A.H., Ø.P.S., A.E.S.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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iksoy S, Kaya T, Ekici M, Erginel S, et al. CT-guided pleural needle biopsy in the diagnosis of malignant mesothelioma. J Comput Assist Tomogr 1995; 19:370-374.[Medline]
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