Korean J Radiol.  2018 Oct;19(5):872-879. 10.3348/kjr.2018.19.5.872.

Cone-Beam CT Virtual Navigation-Guided Percutaneous Needle Biopsy of Suspicious Pleural Metastasis: A Pilot Study

• Lim HJ
• Park CM
• Yoon SH
• Bae JS
• Goo JM

• KMID: 2418550
• DOI: http://doi.org/10.3348/kjr.2018.19.5.872

Abstract

OBJECTIVE
To evaluate the diagnostic performance of cone-beam computed tomography (CBCT) virtual navigation-guided percutaneous pleural biopsy for suspected malignant pleural disease.
MATERIALS AND METHODS
This study enrolled 59 patients (31 males and 28 females; mean age, 63.4 years) with suspected malignant pleural disease diagnosed with CBCT from December 2010 to December 2016. Sixty-three CBCT-guided biopsies were performed using a coaxial system with 18- or 20-gauge cutting needles. Procedural details, diagnostic performance, radiation exposure, and complication rates were investigated.
RESULTS
The mean diameter perpendicular to the pleura of 51 focal and 12 diffuse pleural lesions was 1.53 ± 0.76 cm. The mean distance from the skin to the target was 3.40 ± 1.51 cm. Mean numbers of CT acquisitions and biopsies were 3.21 ± 0.57 and 3.05 ± 1.54. Total procedure time and coaxial introducer indwelling time were 11.87 ± 5.59 min and 8.78 ± 4.95 min, respectively. The mean dose area product was 12013.61 ± 7969.59 mGym². There were 48 malignant, 10 benign, and 5 indeterminate lesions. Sensitivity, specificity, and diagnostic accuracy were 93.8% (45/48), 100% (10/10), and 94.8% (55/58), respectively. Positive and negative predictive values for malignancy were 100% (45/45) and 76.9% (10/13), respectively. Four patients (6.8%) with benign pathology during initial biopsy but still showing a high suspicion of malignancy underwent repeat biopsy and three of them were finally diagnosed with malignant pleural disease. There were three cases of minimal pneumothorax and no grave procedure-related complications.
CONCLUSION
Cone-beam computed tomography-guided biopsy is an accurate and safe diagnostic technique for suspected malignant pleural lesion with reasonable radiation exposure and procedure time.

Keyword

Cone-beam computed tomography; Virtual navigation guidance; Pleura; Biopsy; Metastasis

MeSH Terms

Biopsy
Biopsy, Needle*
Cone-Beam Computed Tomography*
Female
Humans
Male
Needles*
Neoplasm Metastasis*
Pathology
Pilot Projects*
Pleura
Pleural Diseases
Pneumothorax
Radiation Exposure
Sensitivity and Specificity
Skin

Figure

• 

  Fig. 1 44-year-old man diagnosed with AML: example of true positive case of CBCT virtual navigation-guided percutaneous pleural lesion biopsy. A. Contrast-enhanced diagnostic CT performed prior to procedure showed that possibility of pleural metastasis or AML cannot be excluded for right apical pleural thickening (arrow) in this patient. B. Pre-procedural CBCT image shows focal pleural thickening (arrow) in right apical hemithorax. C, D. Needle entry site, approach technique and needle advance length are determined in pre-procedural CBCT. E. Coaxial introducer needle is introduced into “bull's eye” view of fluoroscopic image, in which skin entry site (pink circle) is superimposed onto target (green circle). F. CBCT image shows precise location of tip of coaxial introducer needle within target lesion. Biopsy was performed twice and final pathological diagnosis was involvement of AML. AML = acute myeloid leukemia, CBCT = cone-beam CT

• 

  Fig. 2 81-year-old man with colon cancer and hepatic metastasis: true negative case of CBCT virtual navigation-guided percutaneous pleural lesion biopsy. A. Pre-procedural contrast-enhanced diagnostic CT shows possibility of pleural metastasis involving right lower pleural thickening (arrow) in this patient. B. PET CT performed prior to procedure revealed that this pleural lesion was associated with mild hypermetabolism (arrow). C. Pre-procedural CBCT image shows pleural nodular thickening (arrow). D. Needle entry site, approach technique and needle advance length are determined in pre-procedural CBCT. E. Coaxial introducer needle is introduced into “bull's eye” view of fluoroscopic image, in which skin entry site (pink point) is superimposed onto target (green circle). F. CBCT image shows coaxial introducer needle tip within target. Biopsy was repeated twice and final pathological diagnosis suggested chronic granulomatous inflammation with caseous necrosis (acid-fast bacilli-negative, tuberculosis polymerase chain reaction-positive).

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