CT-guided fine needle aspiration cytology (FNAC) of pulmonary lesions: radiologic-hystologic correlation.

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1 CT-guided fine needle aspiration cytology (FNAC) of pulmonary lesions: radiologic-hystologic correlation. Poster No.: C-0881 Congress: ECR 2012 Type: Scientific Exhibit Authors: E. Canales Lachén, M. Fernandez-Velilla, V. Pérez Dueñas, P. López-Ferrer, R. Tur González, M. I. Torres; Madrid/ES Keywords: Lung, Interventional non-vascular, CT, Diagnostic procedure, Biopsy, Tissue characterisation DOI: /ecr2012/C-0881 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 19

2 Purpose To evaluate the role of CT-guided fine needle aspiration cytology (FNAC) as a diagnostic procedure for pulmonary lesions. To analyze its accuracy using histology as gold-standard, its advantages, and complications. Methods and Materials We included in the study 288 patients with pulmonary lesions consecutively referred to the Department of Radiology for CT guided percutaneous FNAC from June 2005 to July The indication for puncture-aspiration was to confirm the malignant or benign characteristics of lesions. Exclusion criteria were contraindications for this procedure. The only absolute contraindication was lack of patient collaboration, whereas relative contraindications were haemorrhages with INR >1.3 or < platelets, medication with anticoagulant effects (dicoumarine or acetylsalicylic acid) and difficulty in maintaining the position necessary for the procedure. All patients signed an informed consent form approved by the ethics committee of our centre. Images were obtained using spiral CT whit the minimum radiation dose that made it possible to assess the needle position in relation to the lesion (40 mas, standard 120 kv). Section with was determined based on the size of the lesions (standard 3 mm). No iodine contrast was given intravenously. The patients were placed in a supine position, prone or on their sides according to the location of the lesion, its size and the tolerance of the patient. The needles used were G and measured 9, 11 or 15 cm, according to the distance from the skin to the centre of the lesion. Page 2 of 19

3 A Chest Radiology Specialist or a Radiology Resident under their supervision carried out the planning of the punctures and needle placement. Aspirations were taken by a cytopathologist with wide experience who immediately stained the samples with Diff-QuikR to determine, using a microscope, if there was sufficient appropriate material for a cytological diagnosis. Part of the material was fixated in alcohol for subsequent Papanicolau staining and, if necessary, the use of additional techniques (immunocytochemistry and genetic studies). If the sample was insufficient, new aspirations were made up to a maximum of 3. Once the procedure was ended, a CT section was obtained on expiration to rule out pneumothorax, haemorrhage or other complications. Subsequently, the cytological diagnosis of benign or malignant was made with the corresponding type and subtype classifications. Non-specific lesions with absence of malignant cells were accepted as "benign" as long as the tip of the puncture needle had been within the lesion, samples had been taken from different areas of the lesion, there was a sufficient number of cells present and radiological follow-up of the lesion showed that this had not increased in size. Histological studies were carried out on the samples obtained by percutaneous or endoscopic biopsy, or surgical procedure. Histological diagnosis was considered the procedure of reference and, in those cases where there was no biopsy or surgical specimen, the diagnosis relied in the patient's clinical history during a 2 year follow-up after the FNAC. Images for this section: Page 3 of 19

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5 Fig. 1: FNAC of a right lower lobe nodule. The target lesion is located and the distance and angle between the skin and the lesion measured. The tip of the needle is whithin the lesion. The citology showed metastasis from a colonic adenocarcinoma. Page 5 of 19

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7 Fig. 2: FNAC of a left upper lobe nodule wiht spiculated margins. The target lesion is located and the distance and angle between the skin and the lesion measured. The tip of the needle is whithin the lesion. The diagnosis was lung adenocarcinoma. Page 7 of 19

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9 Fig. 3: FNAC of a right upper lobe cavitated mass. The target lesion is located and the distance and angle between the skin and the lesion measured. The tip of the needle is whithin the lesion s wall. The diagnosis was lung squamous cell carcinoma. Page 9 of 19

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11 Fig. 4: FNAC of a left upper lobe consolidation. The target lesion is located and the distance and angle between the skin and the lesion measured. The tip of the needle is whithin the lesion. The diagnosis was lung adenocarcinoma. Page 11 of 19

12 Results We studied 288 patients with pulmonary lesions, 205 men (71.2%) and 83 women (28.8%) with a mean age of 65 years (age range: years). Lesion were located in the right upper lobe (30.4%), middle lobe (8.8%), right lower lobe (19%), left upper lobe (25.6%) and left lower lobe (16.1%). The lesions diameter ranged from 0.8 to 13.9 cm. Its margins were speculated in 121 (44.6%), lobulated in 48 (17.7%), smooth edge in 85 (31.4%) and alveolar in 17 (6.3%). 13 sample could not be assessed cytologically. FNAC had a yield of 95.5%. Bening lesions were diagnosed by FNAC in 76 patients (26.4%) and malign lesions in 199 patients (69.1%). Of the 275 cases with cytological diagnosis, 74 histological samples were abailable. Correct cytologic typing was done in 64 cases (90.4%). Sensitivity for the detection of malignancy was 91.2%, specificity 61.5% and accuracy 86.5%. Primary tumors Adenocarcinoma % Squamous cell carcinoma % Large cell carcinoma % Ca.poorly differentiated 2 1% Ca. with elements sarcomatoid 1 0,5% Small cell carcinoma 5 2.6% Lymphoma 1 0.5% Neuroendocrine 8 4.2% Sarcoma 2 1% Hamartoma 4 2.1% Metastatic disease % There were 43 cases of post-puncture pneumothorax (14.9 %). Page 12 of 19

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15 Fig. 5: FNAC of a left upper lobe spiculated nodule. The target lesion is located and the distance and angle between the skin and the lesion measured. The tip of the needle is whithin the lesion. The CT obtained after the procedure showed minimum pneumothorax. Page 15 of 19

16 Conclusion CT-guided FNAC is a safe and minimally invasive procedure for the diagnosis of pulmonary lesions, with high sensitivity and accuracy for depicting malignancy. FNAC is an effective diagnostic technique, despite of large variety of pulmonary lesions Collaboration between radiologist and cytologists is crucial to get the highest diagnostic accuracy References Lee WJ, Chong S, Seo JS, Shim HJ. Transthoracic fine-needle aspiration biopsy of the lungs using a C-arm cone-beam CT system: diagnostic accuracy and post-procedural complications. Br J Radiol Oct 18. doi: /bjr/ Lima CD, Nunes RA, Saito EH, Higa C, Cardona ZJ, Santos DB. Results and complications of CT-guided transthoracic fine-needle aspiration biopsy of pulmonary lesions. J Bras Pneumol Apr;37: Minot DM, Jaben E, Aubry MC, et al. Evolution of transthoracic fine needle aspiration and core needle biopsy practice: A comparison of two time periods, and Diagn Cytopathol Mar 22. doi: /dc Priola AM, Priola SM, Cataldi A, et al. Diagnostic accuracy and complication rate of CTguided fine needle aspiration biopsy of lung lesions: a study based on the experience of the cytopathologist. Acta Radiol. 2010;51: Kothary N, Lock L, Sze DY, Hofmann LV. Computed tomography-guided percutaneous needle biopsy of pulmonary nodules: impact of nodule size on diagnostic accuracy.clin Lung Cancer. 2009;10: Laspas F, Roussakis A, Efthimiadou R, Papaioannou D, Papadopoulos S, Andreou J. Percutaneous CT-guided fine-needle aspiration of pulmonary lesions: Results and complications in 409 patients. J Med Imaging Radiat Oncol. 2008;52: Page 16 of 19

17 Ng YL, Patsios D, Roberts H, eta al. CT-guided percutaneous fine-needle aspiration biopsy of pulmonary nodules measuring 10 mm or less. Clin Radiol. 2008;63: Lourenço R, Camacho R, Barata MJ, Canário D, Gaspar A, Cyrne C. CT-guided percutaneous transthoracic biopsy in the evaluation of undetermined pulmonary lesions. Rev Port Pneumol. 2006;12: Shimizu K, Ikeda N, Tsuboi M, Hirano T, Kato H. Percutaneous CT-guided fine needle aspiration for lung cancer smaller than 2 cm and revealed by ground-glass opacity at CT. Lung Cancer. 2006;51: Aviram G, Schwartz DS, Meirsdorf S, Rosen G, Greif J, Graif M. Transthoracic needle biopsy of lung masses: a survey of techniques. Clin Radiol. 2005;60(3): Savage C, Walser EM, Schnadig V, Woodside KJ, Ustuner E,Zwischenberger JB. Transthoracic image-guided biopsy of lung nodules: when is benign really benign? J Vasc Interv Radiol. 2004;15: Anderson JM, Murchison J, Patel D. CT-guided lung biopsy: factors influencing diagnostic yield and complication rate. Clin Radiol. 2003;58: Wallace MJ, Krishnamurthy S, Broemeling LD, Gupta S, Ahrar K, Morello FA Jr, Hicks ME. CT-guided percutaneous fine-needle aspiration biopsy of small (< or =1-cm) pulmonary lesions. Radiology. 2002;225: Solli P, Cattelani L, Rusca M, Ganzetti A. Pneumothorax after fine-needle aspiration biopsy. Radiology. 1998;208: Padhani AR, Scott WW Jr, Cheema M, Kearney D, Erozan YS. The value of immediate cytologic evaluation for needle aspiration lung biopsy. Invest Radiol. 1997;32: Personal Information Dr. Elena Canales Lachen Department of Radiology. Hospital Universitario La Paz. Page 17 of 19

18 Madrid. Spain. Dr. María Fernández-Velilla Peña Department of Radiology. Hospital Universitario La Paz. Madrid. Spain. Virginia Pérez Dueñas Department of Radiology. Hospital Universitario La Paz. Madrid. Spain. Pilar López-Ferrer Department of Pathology. Hospital Universitario La Paz. Madrid. Spain. Raquel Tur Gonzalez Department of Pathology. Hospital Universitario La Paz. Madrid. Spain. Isabel Torres Sanchez Department of Radiology. Hospital Universitario La Paz. Madrid. Spain. Page 18 of 19

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