Percutaneous Lung Biopsy in the Molecular Profiling Era: A Survey of Current Practices PHILLIP GUICHET, B.A. 1, FEREIDOUN ABTIN, M.D. 2, CHRISTOPHER LEE, M.D. 1 1 KECK SCHOOL OF MEDICINE OF USC, DEPT OF RADIOLOGY 2 DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA, DEPT OF RADIOLOGY
Disclosures No Financial Disclosures
Introduction Image-guided percutaneous lung biopsy is the invasive procedure of choice for the assessment of suspicious or indeterminate lung lesions Safe, inexpensive, reliable High diagnostic accuracy, sensitivity, and specificity in the detection of malignancy Klein et al. Radiol Clin North Am 2003;38:235-66
Introduction Radiologists play an important role in management of pulmonary nodules Expected to accelerate with implementation of USPSTF and CMS guidelines for lung cancer screening with lowdose CT Image-guided percutaneous lung biopsy is increasingly an essential piece of the diagnostic algorithm Sharpe et al. JACR 2013;10:770-3
Introduction Nearly any lung lesion is accessible to the skilled radiologist with special consideration of options in technique, equipment, and image guidance Imaging technology Patient positioning Needle design Biopsy technique
Introduction In the current molecular profiling era, increasing importance is placed on safely obtaining greater amounts of tissue to identify actionable mutations for personalized therapy Core needle biopsy (CNB) vs fine needle aspiration (FNA) CNB provides more tissue than FNA for molecular and genomic testing Number of needle passes through target lesions More needle passes = greater tissue retrieval
Introduction Prior studies have described techniques to maximize lung biopsy diagnostic yield, tissue retrieval, and patient safety Use of CT or CT fluoroscopy for image guidance Use of CNB for maximal tissue retrieval Minimum of 3 needle passes Autologous blood patch for pneumothorax risk reduction Laurent et al. Cardiovasc Intervent Radiol 2000;23:266-72 Gong et al. Am J Clin Pathol 2006;125:438-44 Cheung et al. Lung Cancer 2010;67:166-9 Malone et al. AJR 2013;200:1238-43
Introduction The last broad survey of radiologist practice patterns for percutaneous lung biopsy was published by Aviram et al in 2005 Practices have evolved in the past decade influenced by advancements in technique, technology, and molecular/genomic science Aviram et al. Clin Radiol 2005;60:370-74
Objectives To assess the current techniques and practice patterns of radiologists performing percutaneous lung biopsies To identify areas that may necessitate further education
Methods This cross-sectional study used a web-based survey sent to the Society of Thoracic Radiology (STR) membership from August-October 2015 Responses were collected anonymously, and results were tallied
Results 244 STR members responded to the survey 137 (58%) reported regularly performing percutaneous lung biopsies Primary Practice Setting 2 (2%) 19 (14%) 14 (10%) 102 (74%) Academic teaching hospital Private or group practice Mixed private and academic practice Group model HMO
Results Image Guidance 130 (95%) respondents most commonly utilize CT or CT fluoroscopy for image guidance Preferred Modality of Image Guidance 6 (4%) 1 (1%) 48 (35%) 82 (60%) CT CT Fluoroscopy Fluoroscopy Ultrasound
Results Biopsy Technique 116 (85%) respondents perform CNB alone or in conjunction with FNA for a routine lung biopsy 20 (15%) respondents perform FNA alone Preferred Biopsy Technique 20 (15%) 57 (42%) 59 (43%) CNB + FNA Core Needle Biopsy (CNB) Fine Needle Aspiration (FNA)
Results Biopsy Technique Needle gauge Fine needle aspiration 22 gauge most common Core needle biopsy 20 gauge most common Use of coaxial technique 85 (74%) respondents for FNA 126 (96%) respondents for CNB 19 gauge outer needle most common 60 40 20 0 80 60 40 20 0 100 50 0 49% 29% 14% 2% 6% 19 20 21 22 >22 FNA needle gauge 58% 23% 14% 4% 1% 17 18 19 20 >20 CNB needle gauge No. of Radiologists 60% 13% 18% 1% 8% 16 17 18 19 20 Outer needle gauge
Results Biopsy Technique Number of needle passes 66 (59%) respondents perform 3+ needle passes for FNA 85 (66%) respondents perform 3+ needle passes for CNB 70 60 50 1-2 passes 3-4 passes 5-6 passes >6 passes 50% 49% 41% 34% No. of radiologists 40 30 20 10 0 FNA 6% 12% 4% 4% CNB
Results Biopsy Analysis Among the 99 respondents who reported access to such services, on-site cytology was regularly requested by 70 (71%) In cases of suspected lung cancer, 79 (60%) respondents estimated sending tissue for molecular analysis at least 25% of the time
Results Patient Safety 53 (40%) respondents routinely use intravenous conscious sedation during biopsy 43 (32%) respondents routinely use intraprocedural techniques for pneumothorax risk reduction 6 (5%) Method of Pneumothorax Risk Reduction 10 (7%) None 27 (20%) 91 (68%) Yes, Autologous blood patch Yes, Hydrogel Plug Yes, Other
Results Patient Safety 115 (86%) respondents routinely keep the patient under observation between 1 to 4 hours Post-biopsy CXR 72 (54%) respondents routinely obtain 1 CXR 47 (35%) respondents routinely obtain 2 CXRs Duration of Observation Post- Biopsy 9 (7%) 9 (7%) 46 (34%) Time to First Chest Radiograph Post-Biopsy 33 (25%) 39 (30%) 32 (24%) 37 (28%) 35 (27%) 24 (18%) Less than 1 hour 1-2 hours 2-3 hours 3-4 hours Greater than 4 hours Within 30 minutes 30 minutes to 1 hour 1-2 hours 2-3 hours
Discussion Among surveyed radiologists who perform percutaneous lung biopsies, most utilize CT guidance either with CNB alone or in conjunction with FNA Multiple prior studies support the use of CNB for Diagnosis of nonepithelial malignancies and benign lesions Molecular/genomic profiling of NSCLC
Discussion Since 2005, significant changes in percutaneous lung biopsy practice were observed in: Use of CT/CT fluoroscopy for image guidance 70% of surveyed radiologists in 2005, 95% in 2015 Use of CNB, either with or without FNA 27% in 2005, 85% in 2015 Use of intravenous conscious sedation 19% in 2005, 40% in 2015 Aviram et al. Clin Radiol 2005;60:370-74
Discussion Since 2005, practices are stable in: FNA, CNB, and coaxial needle gauge 22 gauge needle most common for FNA 20 gauge needle most common for CNB 19 gauge outer coaxial needle most common Percentage of radiologists that requests on-site cytology 73% of surveyed radiologists in 2005, 71% in 2015 Aviram et al. Clin Radiol 2005;60:370-74
Discussion Just over half of surveyed radiologists regularly sends biopsy material of lung cancer for molecular analysis In this era of personalized therapy, further education of radiologists and referring physicians needed so that this is performed in most cases Preventive measures for pneumothorax are not yet in widespread use
Limitations This survey of practice patterns was sent only to the STR membership Most respondents are subspecialists in academic setting Practice patterns amongst subspecialty and academic radiologists often differ from those of community radiologists A survey with a greater proportion of community radiologists would more closely resemble overall radiologist practice There is often a lag in broad adoption of best practices
Conclusions The majority of academic thoracic radiologists performing percutaneous lung biopsies practices in accordance with published recommendations in technique, especially with regard to obtaining sufficient tissue for molecular/genomic analysis A small minority routinely performs FNA alone which may negatively impact diagnostic accuracy and provide insufficient tissue for molecular profiling
Conclusions Radiologists performing biopsies of suspected lung cancer should be proactive in sending tissue for molecular analysis There is room for growth in the adoption of intraprocedural preventive measures for pneumothorax risk reduction
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Contact Information Phillip Guichet, B.A. Email: phillipguichet@gmail.com Twitter: @pguichet