Barbara D. Florentine, Richard J. Helton, Michael M. Mitchell, Kara E. Schmidt, David B. Kozlov. Accuracy and Adequacy of Computed Tomography–Guided Lung Biopsies: Experience From a Community Hospital. J Am Osteopath Assoc 2015;115(10):592–603. doi: 10.7556/jaoa.2015.120.
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Context: Small tissue biopsies obtained through minimally invasive methods have become the primary diagnostic tools for the pathologic characterization and testing of lung masses. In view of recent advances in targeted therapy for non–small cell lung carcinoma, and lung adenocarcinoma in particular, pathologists are now expected to thoroughly characterize lung lesions microscopically while making certain that enough tissue remains for potential molecular analysis if indicated.
Objective: To report our experience with computed tomography (CT)–guided lung needle biopsies with particular concentration on diagnostic yield, diagnostic accuracy, and adequacy of tissue for molecular testing if indicated.
Methods: A retrospective observational study analyzed 224 biopsies in 222 patients undergoing CT-guided lung needle biopsies. Accuracy of diagnosis and adequacy of tissue for molecular testing, if applicable, was evaluated. A standardized protocol for specimen evaluation, triage, and processing was used. This protocol included intraprocedural real-time microscopic specimen evaluation and triage by a pathologist and use of a histologic protocol specifically designed to conserve tissue for ancillary testing. The initial biopsy was considered successful if the specimen was malignant, had specific benign features, or had nonspecific benign features with follow-up supporting benign lesion. Initial biopsy failure cases were those with inadequate tissue or a nonspecific result with highly suspicious imaging or clinical findings.
Results: Of the 224 biopsies, 8 cases with benign but nonspecific findings lacked follow-up and were excluded from the study. The biopsy was diagnostically successful in 189 of 216 (88%) cases. Of these 189 cases, 154 (81%) were malignant, and 35 (19%) were benign. There were 28 diagnostic failures. Subsequent tissue sampling of 13 of 28 diagnostic failures found 9 (69%) to be malignant. Molecular studies were requested on 25 cases: 24 had sufficient material for some of the requested tests, and 20 had enough tissue for all requested testing.
Conclusion: A standardized protocol and team approach for CT-guided lung needle biopsy optimizes the ability to achieve a high accurate diagnostic yield with adequate tissue for molecular testing.
a Out of 27 benign nonspecific cases, 8 were excluded from the study because of lack of follow-up, which left a total of 19 evaluable cases.
b Miscellaneous benign specific includes 5 patients with hamartoma/chondroma and 1 patient with neurofibroma.
c Metastatic malignant tumor includes the numbers of patients with the following cancers: breast, 3; gastrointestinal, 2; melanoma, 3; hepatocellular, 1; prostate, 1; female genital tract, 1; renal cell, 2; sarcoma, 2; and uncertain primary origin, 1.
d Miscellaneous cancers include 1 patient with malignant tumor not otherwise specified and 1 patient with lymphoma.
e Well differentiated neuroendocrine carcinomas are categorized separately from the NSCLC group.
f Nondiagnostic cases include 8 patients with normal lung, 7 patients with radiological features highly suspicious for malignant tumor or for a benign specific process, 5 patients with necrotic tissue, and 3 patients with insufficient tissue for diagnosis.
Abbreviations: CT, computed tomography; NSCLC, nonsmall cell lung cancer.
a The benign nonspecific group included cases in which the initial CT-guided biopsy results showed nonspecific tissue changes, such as chronic inflammation, fibrosis, or acute pneumonia, and the clinical presentation or radiological images at the time of the procedure were non-contributory.
b Although the imaging for case 222 was reported highly suspicious for malignancy, follow-up confirmed that this represented an overcall by radiology, and the case was therefore classified with the benign nonspecific group.
Abbreviation: CT, computed tomography.
a Although the initial CT biopsy was suspicious for lymphoma, this case was classified in the nondiagnostic category because the tissue was insufficient for definitive diagnosis.
Abbreviations: NA, not applicable; CT, computed tomography; NSCLC, nonsmall cell lung cancer.
a Diagnostic accuracy for malignant lesions was calculated as the number of true-negative malignant cases plus the number of true-positive malignant cases divided by the sum of the number of true-negative malignant cases plus the number of true-positive malignant cases plus the number of false-negative cases and the number of false-positive cases.
b Negative predictive value for malignancy was calculated as the number of true malignant cases divided by sum of the number of true-negative malignant cases and the number of false-negative malignant cases.
c Sensitivity for diagnosis of malignancy is calculated as the number of cases diagnosed as malignant on first biopsy divided by the number of true malignant lesions.
Abbreviations: ALK, anaplastic lymphoma kinase; BRAF, B-Raf proto-oncogene, serine/threonine kinase; c-MET, mesenchymal-epidermal transition; EGFR, epidermal growth factor receptor; ERCC1, excision repair cross-complementation group 1; FGFR1, fibroblast growth factor receptor 1; HER-2, human epidermal growth factor receptor 2; KRAS, Kirsten rat sarcoma viral oncogene homolog; PBK, PDZ binding kinase; RET, rearranged during transfection; ROS1, ROS proto-oncogene 1, receptor tyrosine kinase; RRM1, ribonucleotide reductase M1; Ts, thymidylate synthase.
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