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* From the Division of Pulmonary and Critical Care Medicine (Drs. Garpestad, Herth, and Ernst, and Mr. Garland), Division of Thoracic Surgery (Drs. LoCicero and Thurer), and Department of Radiology (Dr. Goldberg), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Beth Israel Deaconess Medical Center, West Campus, One Deaconess Rd, Boston, MA 02115; e-mail: aernst{at}caregroup.harvard.edu
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
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Design: Prospective, observational.
Setting: A tertiary-care, university-affiliated medical center.
Methods: From December 1998 to April 2000, 35 patients underwent CT fluoroscopy-guided TBNA. Patients with subcarinal and precarinal lymph nodes were only included if a previous attempt was nondiagnostic, as the initial yield in this setting with conventional TBNA is high. TBNA was performed using standard technique in a CT-scan suite. Needle location was confirmed with fluoroscopy without IV contrast being used. Specimens were evaluated on-site for adequacy.
Results: The procedure had to be aborted in three patients before TBNA could be performed. Samples were obtained in 32 patients. Samples were nondiagnostic in four patients. Adequate tissue was obtained in 28 of 32 patients (87.5%). Twenty-two patients had a specific benign or malignant diagnosis made, and 6 patients had lymphocytes only on the specimen. In follow-up, only one of these six patients proved to have a malignancy. All procedures were performed within a regular interventional CT time slot of 1 h. No TBNA side effects were noted.
Conclusion: TBNA under CT fluoroscopic guidance is easy to perform. The yield in all accessible lymph node stations is high.
Key Words: bronchoscopy • CT fluoroscopy • mediastinal lymphadenopathy • transbronchial needle aspiration
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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In contrast to ultrasound-guided GI needle biopsy, TBNA is a fairly "blind" procedure, with guidance generally limited to few endobronchial landmarks and mental reconstruction of a preprocedure CT of the chest. This precludes immediate control over the needle placement and does not allow for real-time feedback during the learning period.
A previous study has shown that the yield of conventional CT scan-guided biopsies may be increased over regular attempts. In the study by Rong and Cui,4 a very low baseline diagnostic yield of TBNA of 20% prompted the use of conventional CT guidance during all subsequent procedures. The yield was improved with that technique, but unfortunately was still low at 60%. Additionally, this study required the use of IV contrast material, and a significant amount of radiation may have been associated with the sizable number of CT slices needed before and after needle puncture.
With the introduction of CT fluoroscopy, real-time imaging during the procedure is possible and has been reported to be feasible in a case report.5 In a pilot study of 12 patients,6 we have previously described the technical aspects of CT fluoroscopy-guided TBNA. We postulated that real-time imaging with CT fluoroscopy could increase the yield of the procedure, as the placement of the needle can be confirmed or adjusted. Also, CT fluoroscopy is less cumbersome than conventional CT guidance, as it is driven via a foot pedal similar to regular fluoroscopy and the screen can be mounted next to the endoscopy unit. No IV contrast material is required. In this article, we describe our experience in a larger group of patients, which resembles everyday clinical practice.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Patient Population
Patients were considered eligible for CT fluoroscopy-guided
procedure if they had lymph node (LN) enlargement accessible by TBNA.
As subcarinal or precarinal locations promise a high yield with regular
TBNA, only patients with previously nondiagnostic attempts on LNs in
these locations were selected for the procedure (n = 8). In all other
LN stations, CT guided-TBNA was considered as the primary diagnostic
procedure (n = 27). From December 1998 to April 2000, 35 patients
underwent bronchoscopy with TBNA under CT fluoroscopy.
Procedure
Technical details of the procedure have previously been
described in detail.6
Briefly, patients were placed in a
CT fluoroscopic unit (Siemens Somatom Plus 4; Siemens; Erlangen,
Germany). Preliminary axial, noncontrast-enhanced CT scans were
obtained throughout the regions of interest to confirm exact biopsy
location, and skin markers were applied to facilitate CT-image
alignment.
All patients received conscious sedation with midazolam, 1 to 4 mg IV, and fentanyl, 25 to 200 µg IV, with close monitoring of all vital signs. Topical anesthesia was achieved with 4% lidocaine solution for the vocal cords and 1% lidocaine solution in the airways. Bronchoscopy was then performed in a standard fashion via transnasal or transoral approaches.
Transbronchial needles (MW122 and MW319; Mill Rose Laboratories; Mentor, OH), both for cytology and histology as indicated, were then inserted with the "jabbing technique," as previously described.7 An image was obtained to confirm the needle position. If adequate, a specimen was obtained. If the needle was not in the appropriate location, it was withdrawn and redirected with radiologic confirmation (Fig 1 ).
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Four procedures were nondiagnostic (no lymphocytes and no malignant cells). Of these, one patient refused further workup and was lost to follow-up and three patients were followed by surgical evaluation. Diagnosis on surgical evaluation were squamous cell cancer and adenocarcinoma of the lung and metastatic melanoma.
In 28 of 32 patients, adequate tissue could be obtained (87.5%). Six patients had a "normal" biopsy result (lymphocytes, but no specific benign or malignant diagnosis). Three of those patients underwent follow-up mediastinoscopy, which confirmed nonspecific enlargement in two patients but showed adenocarcinoma in one patient. One patient was followed up with a positron emission tomography scan, which was normal; two patients were followed up clinically without evidence of malignancy for > 1 year in one patient and 6 months in the other patient.
Twenty-two patients did have a specific benign or malignant diagnosis. Table 1 lists the final pathologic diagnosis or outcomes in all patients. None of the patients who underwent TBNA suffered from any complications. All procedures were accomplished in a regular interventional CT time slot of 1 h. The average (± SD) fluoroscopy time was 20.5 ± 12.7 s, as tracked in the first 12 patients.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Conventional CT guidance can increase the yield of the procedure, as shown by Rong and Cui,4 but criticism of that study included the low yield at baseline and the still-suboptimal yield with radiologic imaging.
In our institution, TBNA is routinely performed. For this study, we excluded patients with first subcarinal or precarinal aspirations, as the yield with conventional technique is very high. In our study, we show that CT fluoroscopy-guided TBNA is very successful and effective in patients with previously nondiagnostic biopsies and in LN stations that are less-easily accessible. Biopsies of small nodes and hilar nodes can be performed reliably.
Six of our patients had normal biopsy findings with only lymphocytes on the specimen. Only one of these patients had false-negative findings. We are planning to focus on this patient cohort in the future, trying to establish a protocol of who needs to be followed up with surgical exploration.
Interestingly, imaging guidance also allows some insight into the reasons for nondiagnostic biopsy attempts, as outlined in our pilot study. A small but significant number of passes do not penetrate the tracheobronchial tree, and some passes access the large vessels.6 As previously described in the literature, no significant side effects stem from vascular penetration.
CT fluoroscopy is easy to perform; once mastered, it does not necessarily require a radiologist to be present. The procedure duration conforms to a fairly standard interventional CT time slot, and radiation time can be limited with increasing experience to a few seconds. No IV contrast is necessary. It will be interesting to compare the impact of real-time imaging techniques such as CT fluoroscopy to other technologies in development, such as endobronchial ultrasound.
It must be emphasized that CT imaging does not provide a substitute for good TBNA technique, but we believe it may be useful to serve as an adjunct to improve yield for small and less well-accessible LN biopsies. Real-time imaging may also prove helpful for the novice in the technique of TBNA, as it affords immediate feedback.
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Footnotes |
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Received for publication January 5, 2000. Accepted for publication August 8, 2000.
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References |
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