| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Vascular and Interventional Radiology |
1 From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305–5105. Received April 29, 2002; revision requested June 29; final revision received February 24, 2003; accepted March 7. Address correspondence to S.T.K. (e-mail: skee@stanford.edu).
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
MATERIALS AND METHODS: Retrospective review of 846 consecutive CT-guided TNAB procedures was performed. A coaxial approach was implemented in all patients by using an 18- or 19-gauge outer stabilizing needle through which a smaller aspiration needle or automated biopsy gun was inserted for tissue sampling. Univariate and multivariate regression analyses were used to analyze coaxial needle size, age, sex, smoking history, lesion size, use of an automated core biopsy gun, number of needle passes, and frequency of chest tube placement. Sensitivity, specificity, and diagnostic accuracy were calculated for 676 patients with at least 18 months of clinical follow-up.
RESULTS: Pneumothorax occurred in 226 of 846 patients. Coaxial needle size and patient age had a significant effect on pneumothorax rate. Pneumothorax occurred in 124 (38%) of 324 patients who underwent procedures with 18-gauge needles and in 121 (23%) of 522 patients who underwent procedures with 19-gauge needles (P < .001). The overall diagnostic accuracy was 96% for procedures performed with 18-gauge needles and 92% for procedures performed with 19-gauge needles, with a sensitivity of 95% and 89% and a specificity of 100% and 99%, respectively. Pneumothorax occurred in 153 patients older than 60 years, in 99 patients 60 years and younger (P < .02), in 90 patients older than 70 years, and in 162 patients younger than 70 years (P < .01). The relationship between pneumothorax rate and age as a continuous distribution was not significant (P < .07), nor were the 50- or 75-year age cutoffs (P < .06 and P < .9, respectively).
CONCLUSION: Use of a smaller coaxial stabilizing needle produces a substantially decreased risk of pneumothorax with comparable diagnostic accuracy, sensitivity, and specificity for histopathologic diagnosis of pulmonary nodules.
© RSNA, 2003
Index terms: Computed tomography (CT), guidance 60.1211 • Interventional procedures, complications, 60.1263, 66.732 • Lung, biopsy, 68.1263 • Lung, nodule • Pneumothorax, 60.734
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
CT-guided TNAB is generally regarded as a safe procedure with limited morbidity and extremely rare mortality (2–10). Pneumothorax remains the most frequent complication of TNAB, and a tube thoracostomy is occasionally required for treatment (10–14). The reported frequency of pneumothorax for CT-guided procedures varies from 8% to 64% (2–15). Fatal complications due to systemic air embolism, hemorrhage, or pericardial tamponade have been reported (9,16,17), but these are rare. Coaxial biopsy systemsdiminish the number of passes through the visceral pleura and theoretically reduce the likelihood of pneumothorax, although to our knowledge this has not been statistically proved (6,8,11–13,18). During the past 2 decades, there has been a trend toward the use of smaller needles (19 gauge or smaller) (2,4–6,10,11,19–22). This change was driven by reports of clinically important bleeding associated with large cutting needles, not by unacceptable rates of pneumothorax (2,9,16,23). Reports indicate that the incremental use of fine (19 gauge or smaller) needles has reduced bleeding complications and allowed easier access to lesions that were previously deemed too small for sampling without an associated loss of diagnostic accuracy (2,4–6,11,16,19–22). The purpose of our study was to evaluate the effect of coaxial needle size on pneumothorax rate and the diagnostic accuracy of CT-guided TNAB of pulmonary nodules.
|
MATERIALS AND METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
to 87 years (mean, 59.1 years; median, 62.0 years). A smoking history for use of cigarettes, cigars, or both was obtained by the research nurse (G.M.) prior to each procedure. Of the 846 patients, 338 admitted a smoking history and 508 denied one. A lung neoplasm was diagnosed previously in 54 (6%) patients, and a remote primary malignancy had been established in 456 (54%) patients. All patients underwent a diagnostic CT examination of the chest prior to biopsy. At the time of biopsy, selected images were obtained in the area of interest with 3–10-mm-thick contiguous transverse computed tomographic sections, depending on the size of the lesion. The mean lesion diameter was 3.02 cm (range, 0.4–15.0 cm). Biopsies were planned to avoid visible bullae and to cross the least number of pleural surfaces. All biopsies were performed either by a staff interventional radiologist (S.T.K, M.K.R., D.Y.S., or MD.D.) or by radiologists in training with staff supervision, in accordance with the protocol of the Interventional Radiology Section at our institution. The procedure was performed with the patient in a prone, supine, or lateral decubitus position, depending on the location of the lesion. Conscious sedation was induced in anxious patients, and a subcutaneous injection of 1% lidocaine was used for local anesthesia. To reduce the number of transpleural punctures, all biopsies were performed by using the coaxial method with either an 18- or 19-gauge outer stabilizing needle. The initial 324 patients underwent the procedure with an 18-gauge needle, which was the standard at that time; however, the next 522 patients underwent the procedure with a 19-gauge needle. A smaller 20- or 21-gauge inner aspiration needle or an automated core biopsy gun was then used to acquire specimens. Imaging was performed immediately before needle aspiration or core biopsy to document the position of the stabilizing needle within the lesion.
A cytotechnologist was present during all procedures, and specimens were immediately processed and stained to determine if there was sufficient cellularity to make a diagnosis. When specimens were insufficient for diagnosis, additional aspirates were obtained. If no malignant material was evident and infection was suspected, Gram stain and cultures were performed. A cytopathologist performed the final examination and made the diagnosis in all specimens. The results of the biopsies were classified as malignant on the basis of the presence or absence of malignant cells in the TNAB samples. A biopsy sample was regarded as benign if a specific benign disease (ie, granuloma, abscess, hamartoma) was demonstrated in the sample. A biopsy sample was given the pathologic diagnosis 
negative for malignancy
if there were no malignant cells but the lesion had nonspecific changes (ie, nonspecific inflammatory or fibrous tissue). Lesions without a clear-cut malignant process but with some abnormal features were classified as atypical or suspicious for malignancy. If there was inadequate tissue for diagnosis, the sample was labeled as nonrepresentative. In malignant lesions, either a specific diagnosis was made or the lesion was described as malignant if the type of abnormality could not be differentiated.
Postprocedure Imaging and Care
After the procedure, CT images were obtained to help verify the appearance of the lung and to check for immediate pneumothorax. The patients were monitored in a holding unit, and a posteroanterior erect expiratory chest radiograph was obtained 3 hours after they underwent biopsy. If a small, asymptomatic pneumothorax developed, the patient was treated conservatively with monitoring of vital signs, administration of supplemental oxygen, and follow-up chest radiography 1 hour later to evaluate the stability of the pneumothorax. If the patient presented with symptoms of pneumothorax such as dyspnea or respiratory distress, aspiration of the pneumothorax was attempted. If aspiration was inadequate or if a large or rapidly enlarging pneumothorax was found, a tube was placed in the patient’s chest. The tubes used were various types of locking loop pigtail catheters (usually 8 or 10 F) and were placed by an interventional radiologist (S.T.K., M.K.R., D.Y.S., or M.D.D.) with fluoroscopic guidance in the angiography suite. All patients who underwent chest tube placement were admitted to a surveillance unit where the tube was connected for at least 24 hours to a closed pleural drainage and collection system set to deliver 20 cm of water pressure with moderate continuous wall suction. The following morning, suction was discontinued, the tube was placed to the water seal, and chest radiography was repeated. If the pneumothorax resolved, the chest tube was removed and the patient was discharged. If the pneumothorax persisted, the chest tube was kept in place for another day and the process was repeated.
Data Analysis
The type and frequency of all complications, including pneumothorax, associated with the 846 TNAB procedures were recorded. Variables analyzed with regard to the occurrence of pneumothorax included patient age, sex, smoking history, lesion size, size of the outer stabilizing needle, whether a core biopsy needle and automated gun system were used, and the number of needle passes. These data were obtained by chart review performed by two authors (P.R.G. and S.T.K.). The multiple logistic regression model was built in a stepwise approach. Independent variables that were significant in univariate analysis at P 
.10 or that were known to be associated with pneumothorax from other studies were retained for stepwise inclusion in the model. Variables with the strongest association in univariate analysis were fit first in the model. Only predictor variables that were independently associated with pneumothorax at P .05 were retained for inclusion in the final model. All independent variables were tested for interactions with each other. No significant interaction variables were found, and thus none were included in the final model.
A P value of less than .05 was considered to indicate a statistically significant difference. The treatment required for resolution of pneumothorax (none, aspiration, or chest tube) and the length of hospitalization required for this treatment were also correlated with the coaxial needle size used.
The sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were also calculated for all 676 patients with subsequent follow-up data on the basis of clinical and imaging follow-up and review of medical records for at least 18 months after the biopsy was performed. These data were collected by one author (P.R.G.). The patients were separated by the accuracy of their diagnosis into four groups (true-positive, true-negative, false-positive, and false-negative). The patients in the true-positive group included those who received a definitive malignant diagnosis at biopsy and either underwent a second procedure (subsequent biopsy or surgery) that helped confirm the diagnosis or had a malignant course during follow-up of at least 1 year. The patients in the true-negative group included those with either no malignant cells at biopsy; a definitive diagnosis of a benign entity, such as pneumonia, granuloma, abscess, sarcoidosis, hamartoma, or carcinoid tumor; or a nonspecific biopsy result that was either atypical, suspicious for malignancy, or negative for malignancy, and both a nonmalignant clinical course observed during follow-up of more than 1 year and a stable or decreased lesion size on a chest radiograph or CT scan. Patients in the false-negative group included those with a benign or nonspecific diagnosis at biopsy who either underwent a subsequent procedure that revealed a malignancy or were followed up for more than 1 year and in whom a malignant clinical course, increased lesion size, or both were established. Patients in the false-positive group were those in whom the TNAB resulted in a malignant diagnosis, but subsequent histopathologic evaluation of resected tissue or clinical follow-up of more than 1 year indicated benign disease.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
|
|
|
|
|
|
There was a borderline statistically significant relationship between age and pneumothorax rate when patient age was analyzed as a continuous distribution (P < .07). When the age distribution was divided into quartiles (Table 2), a significant difference was found in the relative pneumothorax rates of each group (P < .008). To identify the age above which pneumothorax rate sharply increased, pneumothorax rates were individually calculated and compared for different age groups (Table 3). A significant increase in the rate of pneumothorax was seen in patients older than 60 years (P < .02) and older than 70 years (P < .01) compared with their younger counterparts. There was no significant difference in the rate of pneumothorax for age comparisons in patients 50 years or younger and those older than 75 years.
Further examination of the relationship between pneumothorax rate and size of the stabilizing needle was performed by using multivariate regression analysis. When adjusted for sex, age, lesion size, and use of a core gun or needle, there was still a significant increase in the rate of pneumothorax with the 18-gauge introducer needle compared with the 19-gauge needle (Table 4). Multivariate regression analysis also revealed a significantly higher rate of pneumothorax with 18-gauge compared with 19-gauge needles within the nonsmoking group, yet the same analysis of patients with a smoking history showed no significant difference in the rate of pneumothorax between the two sizes of needle cannula used.
Complications occurred in 252 (30%) of 846 patients, including 226 with pneumothorax, 17 with hemoptysis (none of whom required transfusion), three with vasovagal response, one with subcutaneous emphysema, one with hemothorax, one with a subcutaneous hematoma, one with supraventricular tachycardia that required cardioversion, one with cardiopulmonary arrest, and one who died. The patient who died was a 35-year-old man with a lung mass who was an inpatient and recently underwent renal transplantation. After returning to the unit after TNAB, he collapsed and went into cardiopulmonary arrest. Despite best efforts, including sternotomy and cardiac massage, the patient could not be resuscitated.
The various treatment strategies employed in the 226 patients whose procedures were complicated by pneumothorax are described in Table 5. When patients with pneumothorax were analyzed according to the size of the needle used, no significant difference was found in the rates of pneumothorax in patients who required treatment or the type of therapy required (P < .14). The length of hospital stay required for resolution of pneumothorax was also unrelated to use of an 18- versus a 19-gauge stabilizing needle (P < .5 and P < .23, respectively).
The histopathologic findings for the 846 TNAB samples are listed in Table 6. To evaluate the accuracy of these biopsy results, patient follow-up data from at least 18 months after biopsy were reviewed to either confirm or revise the initial diagnosis. All 676 patients with follow-up data were divided into those with a true-positive diagnosis, those with a true-negative diagnosis, those with a false-negative diagnosis, and those with a false-positive diagnosis (Table 7). Overall sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value were calculated (Table 7). These calculations were also performed separately for 211 patients with follow-up data who underwent TNAB procedures with 18-gauge needles and for 465 patients with follow-up data who underwent TNAB procedures with 19-gauge needles (Table 7).
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
Our report demonstrates a dramatic decrease, with an almost 50% reduction in pneumothorax rate associated with coaxial procedures performed with the smaller 19-gauge stabilizing needles versus the older 18-gauge needles. This relationship between needle size and pneumothorax was consistent, regardless of patient age, sex, lesion size, or use of a core gun to acquire tissue samples. On the basis of these results, this study demonstrates the effect of smaller needles on reducing the rate of pneumothorax after TNAB performed with a coaxial technique.
Age also had a significant effect on the incidence of pneumothorax. Although analysis of pneumothorax rate with patient age as a continuous distribution was not quite significant (P < .07), this is explained by the fact that more than half of our patients were older than 60 years; therefore, the age series did not fit a normal distribution curve. When the patient age distribution was divided into quartiles and age groups, however, a significant difference was found in the relative pneumothorax rates. Specifically, patients older than 60 and 70 years showed a significant increase in pneumothorax in comparison with their younger counterparts (P < .02 and .01, respectively). This finding may be useful for guiding TNAB recommendations and discussion of complications with patients, and it suggests that practitioners discuss the greater risks of pneumothorax with patients over 60 years of age. There was no significant difference in the pneumothorax rate for similar comparisons of the 50- or 75-year age cutoffs, which is likely explained by the fact that our patient population was heavily weighted with patients older than 60 years, with only 32 patients older than 75 years who underwent TNAB during the study period.
We were unable to find a relationship between patients with a smoking history and rate of pneumothorax. Although Kazerooni et al (10) and Anderson et al (24) found no significant increase in pneumothorax for patients with abnormal pulmonary function tests, there are reports in the literature that demonstrate higher pneumothorax rates with obstructive lung disease (10,11,25–27). The high likelihood of underlying obstructive lung disease in patients who smoked led us to anticipate finding a higher pneumothorax rate in patients who reported a smoking history, but we did not collect pulmonary function test data or clinical data regarding the presence of emphysema for our patient sample. When findings from patients who smoked and findings from patients who did not smoke were analyzed separately for the effect of stabilizing needle size on the rate of pneumothorax, the group that did not smoke showed a significantly higher rate of pneumothorax when 18-gauge as compared with 19-gauge needles were used. For patients who smoked, however, there was no significant difference in the rate of pneumothorax between the two sizes of needle cannula evaluated. It is possible that our patient population is skewed because only 338 (40%) admitted a smoking history.
Use of a coaxial system requires placement of an outer stabilizing needle with a single pleural pass, through which multiple tissue acquisitions are made with a smaller aspiration needle or gun. The major benefit of this technique is the reduction in number of visceral pleural punctures required. Although it is reassuring that the coaxial technique makes a single pleural pass possible, some studies have failed to show a relationship between the number of pleural passes and the rate of pneumothorax with this system (10,11,14,25,27).
To our knowledge, no study has proved that a coaxial system has a statistically lower risk of causing pneumothorax compared with other biopsy techniques. We did not find a significant relationship between the pneumothorax rate and the number of passes made with an aspiration needle or core biopsy gun through the stabilizing needle because more than 700 patients required only one pass to obtain a diagnostic sample and because there were not enough patients who required multiple needle passes to make a statistically significant comparison of pneumothorax rates between these groups. Prior studies found comparable pneumothorax rates between 9% and 54% when investigators evaluated automated core biopsy guns versus the aspiration biopsy technique (8,13,15,21,28). Similarly, we did not find a significant difference in pneumothorax associated with use of an automated core biopsy gun to retrieve tissue versus use of an aspiration needle.
Previous studies have found a strong correlation between lesion size and pneumothorax rate (3,6,10–12,25); however, our data did not support these findings. Lesions were separated into groups of smaller than 1 cm and larger than 1 cm and of smaller than 2 cm and larger than 2 cm. Analyses at each threshold failed to demonstrate a significant difference in the rates of pneumothorax between smaller and larger lesion groups. To our knowledge, only two other studies (6,29) failed to find a significant difference in the rate of pneumothorax between patients with small nodules and those with large nodules. When multivariate analysis was performed to compare lesion size, needle size, and pneumothorax rate, there was no significant difference in the rate of pneumothorax for small versus large lesions.
We found that 83 (37%) of 226 patients with pneumothorax recovered without any therapy. Direct catheter aspiration was used to treat 69 (31%) patients with pneumothorax, and a chest tube was used to treat the remaining 74 (33%) patients. No significant difference was found between the size of the stabilizing needle used and the percentage of patients who required a chest tube, direct catheter aspiration, or no therapy (P < .14). Some investigators reported the feasibility of treating patients with simple pneumothorax by using catheter aspiration alone (30,31). They achieved success in 70%–75% of patients and advanced the hypothesis that small pleural injuries may seal more quickly (30,31).
The overall diagnostic accuracy, sensitivity, and specificity of CT-guided biopsy in our patients (Table 6) are similar to those obtained in previous studies (2–8,10,22). Of the 676 lesions sampled that had at least 18 months follow-up data available, 202 had an inconclusive histopathologic diagnosis, including negative for malignancy, suspicious for malignancy, or atypical. Careful review of the clinical and imaging follow-up data of these patients revealed that many patients (n = 43) with biopsy specimens read as atypical and suspicious did in fact have malignancies, yielding a high false-negative rate and a low negative predictive value of 81%. The overall positive predictive value was greater than 99%.
When the sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value were calculated individually for the groups of patients whose biopsies were performed with an 18-gauge versus a 19-gauge stabilizing needle, the results were comparable. This study clearly demonstrates that use of a smaller coaxial stabilizing needle results in a substantially decreased risk of pneumothorax, with comparable diagnostic accuracy, sensitivity, and specificity for histopathologic diagnosis of pulmonary nodules. We therefore recommend uniform use of 19-gauge stabilizing needles for TNAB procedures that use coaxial systems.
Further reduction in the size of the outer stabilizing needle, through which samples are obtained with a coaxial method, is currently limited. In addition, core biopsy needle systems smaller than 20 gauge are not readily obtainable; thus, it seems unlikely that a coaxial system smaller than that investigated in this study will be available in the near future.
In conclusion, factors in this study that independently alter the risk of pneumothorax after lung biopsy are the size of the stabilization needle and age of the patient. The pneumothorax rate was not significantly influenced by sex, smoking history, lesion size, or whether coaxial passes were performed with a core gun or aspiration needle. In those patients with pneumothorax, the use of an 18- or 19-gauge stabilizing needle had no effect either on the rates of chest tube placement or simple catheter aspiration for treatment of pneumothorax or on the length of treatment required.
|
ACKNOWLEDGMENTS |
|---|
|
FOOTNOTES |
|---|
Author contributions: Guarantor of integrity of entire study, S.T.K.; study concepts and design, S.T.K., P.R.G.; literature research, P.R.G., D.Y.S., M.K.R.; clinical studies, S.T.K., P.R.G., D.Y.S., M.K.R., MD.D.; data acquisition, G.M., S.T.K., P.R.G.; data analysis/interpretation, S.T.K., P.R.G.; manuscript preparation, S.T.K., P.R.G., MD.D.; manuscript definition of intellectual content, S.T.K., MD.D.; manuscript editing, S.T.K., D.Y.S., M.K.R., MD.D.; manuscript revision/review and final version approval, S.T.K.
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
|---|
This article has been cited by other articles:
|
|
 |
|
  N. A. Durick, P. F. Laeseke, L. S. Broderick, F. T. Lee Jr, L. A. Sampson, T. M. Frey, T. F. Warner, J. P. Fine, D. W. van der Weide, and C. L. Brace Microwave Ablation with Triaxial Antennas Tuned for Lung: Results in an in Vivo Porcine Model Radiology, April 1, 2008; 247(1): 80 - 87. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. G. Welch, S. Woloshin, L. M. Schwartz, L. Gordis, P. C. Gotzsche, R. Harris, B. S. Kramer, and D. F. Ransohoff Overstating the Evidence for Lung Cancer Screening: The International Early Lung Cancer Action Program (I-ELCAP) Study Arch Intern Med, November 26, 2007; 167(21): 2289 - 2295. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Veronesi, M. Bellomi, U. Veronesi, G. Paganelli, P. Maisonneuve, P. Scanagatta, F. Leo, G. Pelosi, L. Travaini, C. Rampinelli, et al. Role of Positron Emission Tomography Scanning in the Management of Lung Nodules Detected at Baseline Computed Tomography Screening Ann. Thorac. Surg., September 1, 2007; 84(3): 959 - 966. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Anantham, D. Feller-Kopman, L. N. Shanmugham, S. M. Berman, M. M. DeCamp, S. P. Gangadharan, R. Eberhardt, F. Herth, and A. Ernst Electromagnetic Navigation Bronchoscopy-Guided Fiducial Placement for Robotic Stereotactic Radiosurgery of Lung Tumors: A Feasibility Study Chest, September 1, 2007; 132(3): 930 - 935. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. P. Rivera and A. C. Mehta Initial Diagnosis of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) Chest, September 1, 2007; 132(3_suppl): 131S - 148S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Eberhardt, D. Anantham, A. Ernst, D. Feller-Kopman, and F. Herth Multimodality Bronchoscopic Diagnosis of Peripheral Lung Lesions: A Randomized Controlled Trial Am. J. Respir. Crit. Care Med., July 1, 2007; 176(1): 36 - 41. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Makris, A. Scherpereel, S. Leroy, B. Bouchindhomme, J-B. Faivre, J. Remy, P. Ramon, and C-H. Marquette Electromagnetic navigation diagnostic bronchoscopy for small peripheral lung lesions Eur. Respir. J., June 1, 2007; 29(6): 1187 - 1192. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Eberhardt, D. Anantham, F. Herth, D. Feller-Kopman, and A. Ernst Electromagnetic Navigation Diagnostic Bronchoscopy in Peripheral Lung Lesions Chest, June 1, 2007; 131(6): 1800 - 1805. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. H. Diacon, M. M. Schuurmans, J. Theron, K. Brundyn, M. Louw, C. A. Wright, and C. T. Bolliger Transbronchial needle aspirates: how many passes per target site? Eur. Respir. J., January 1, 2007; 29(1): 112 - 116. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. R. Gildea, P. J. Mazzone, D. Karnak, M. Meziane, and A. C. Mehta Electromagnetic Navigation Diagnostic Bronchoscopy: A Prospective Study Am. J. Respir. Crit. Care Med., November 1, 2006; 174(9): 982 - 989. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Kinoshita, T. Kato, K. Sugiura, M. Nishimura, T. Kinoshita, M. Hashimoto, T. Kaminoh, and T. Ogawa CT-Guided Transthoracic Needle Biopsy Using a Puncture Site-Down Positioning Technique Am. J. Roentgenol., October 1, 2006; 187(4): 926 - 932. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Loubeyre, M. Copercini, and P.-Y. Dietrich Percutaneous CT-Guided Multisampling Core Needle Biopsy of Thoracic Lesions Am. J. Roentgenol., November 1, 2005; 185(5): 1294 - 1298. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W-Y. Liao, J-S. Jerng, K-Y. Chen, Y-L. Chang, P-C. Yang, and S-H. Kuo Value of imprint cytology for ultrasound-guided transthoracic core biopsy Eur. Respir. J., December 1, 2004; 24(6): 905 - 909. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. C. Borczuk, L. Shah, G. D. N. Pearson, K. L. Walter, L. Wang, J. H. M. Austin, R. A. Friedman, and C. A. Powell Molecular Signatures in Biopsy Specimens of Lung Cancer Am. J. Respir. Crit. Care Med., July 15, 2004; 170(2): 167 - 174. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. C. van Rijn and P. M. Bossuyt Needle Size in CT-guided Transthoracic Needle Aspiration Biopsy: Complications and Accuracy [letter] * The statistical consultant responds: Radiology, July 1, 2004; 232(1): 305 - 306. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
2 Analysis for Age Quartiles and Pneumothorax Rate