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(Chest. 2004;126:744-747.)
© 2004 American College of Chest Physicians

Percutaneous Needle Biopsy for Small Lung Nodules Beneath the Rib Under CT Scan Fluoroscopic Guidance With Gantry Tilt*

Takuji Yamagami, MD, PhD; Takeharu Kato, MD; Shigeharu Iida, MD; Tatsuya Hirota, MD and Tsunehiko Nishimura, MD, PhD

* From the Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.

Correspondence to: Takuji Yamagami, MD, PhD, Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-chyo, Kawaramachi-Hirokoji, Kamigyo, Kyoto, 602-8566, Japan; e-mail yamagami{at}koto.kpu-m.ac.jp


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objectives: The present study was performed to evaluate the efficacy and safety of gantry tilting for the performance of lung biopsy of peripheral small lesions located beneath the rib.

Design: Interventional.

Materials and methods: Our study was based on 22 of 237 lesions for which percutaneous needle biopsies of the lung were performed under CT scan-fluoroscopic guidance at our institution between January 2000 and August 2002. For these 22 lesions, a biopsy was performed with gantry tilt because a rib blocked the biopsy route even after trials to change the relationship between the target and the rib. The characteristics of each lesion, the success rate for obtaining an adequate specimen, and the ability to determine whether the lesion was malignant or benign were investigated, specific cell types were characterized, and the complications that were encountered were identified.

Results: In all 22 lesions, adequate specimens for cytopathologic evaluation were obtained using fine-needle aspiration biopsy, tissue core biopsies, or both. In 21 lesions, whether the lesion was malignant or benign was precisely diagnosed, and in 19 lesions the specific cell type was determined. No serious complications occurred.

Conclusion: Percutaneous needle biopsy under CT scan-fluoroscopic guidance with gantry tilt is a useful and safe technique for the biopsy of small lung nodules located beneath the rib.

Key Words: biopsies • CT guidance • lung biopsy • technology


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The CT scan-guided needle biopsy of lung lesions is a well-established technique for diagnosing lung nodules.1 This biopsy procedure, with a preliminary CT scan performed just before biopsy for purposes of planning, usually requires the alignment of the biopsy needle in a ventral plane so that the entire needle pathway can be visualized in the scanning plane. However, because of overlying skeletal structures on the biopsy route it is sometimes difficult to maintain visualization of the entire needle during its advancement. The biopsy of small lung lesions located just beneath the rib is an example of such a difficult situation.

In 1993, Stern et al2 suggested the usefulness of CT gantry tilt in facilitating transthoracic biopsies with conventional CT scans in patients with lung lesions for which the approach would otherwise be more difficult and less safe. They reported technical success in all of the six procedures in which they used this technique. This led us to wonder whether the gantry-tilt technique might also be useful in CT fluoroscopy. We have consistently utilized this technique in performing needle biopsies of small lesions just beneath the rib. The present study evaluated the safety and efficacy of this technique for the purpose of a precise diagnosis in a larger number of subjects than previously has been studied.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Materials
Among all of the 237 lesions in which percutaneous needle biopsies of the lung were performed using real-time CT scan-fluoroscopic guidance at our institution between January 2000 and August 2002, the procedure was performed on 22 lesions with the gantry tilt technique (Fig 1 ). These lesions are the subjects of the present study. In applying the gantry tilt technique in biopsies of these 22 lesions, the following criteria were met: (1) small lung nodules (ie, < 2 cm in diameter) located adjacent to or very near (ie, within 2 cm) to the rib, as shown on a preliminary CT scan with the gantry in the vertical position; (2) the location of the rib was as an obstacle to advancing the biopsy needle so that the entire needle could be visualized on the CT image; and (3) the rib continued to block the biopsy route even after all attempts to change the relationship of the lung nodules to the rib had been made.



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  		Figure 1.. Diagram of gantry tilt. With the gantry of the CT scanner in the vertical position, the orbit of puncture needle advancement is blocked by the rib. After tilting the gantry, the rib is no longer in the route of the advancing needle.

 
Biopsy Procedures
The procedure was performed by one of three interventional radiologists experienced in CT-guided biopsy. Figure 2 shows CT scans (X Vigor Laudator; Toshiba Medical Systems; Tokyo, Japan) of the procedure. A CT fluoroscopic imaging system was used for all CT-guided biopsy procedures, details of which have been described elsewhere.3 Patients who could not hold their breath underwent the procedure with normal respiration. After confirming that the needle tip had reached the lesion, a specimen was obtained, and the needle was withdrawn. When the obtained specimen was insufficient, rebiopsy was performed.



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  		Figure 2.. A 55-year-old woman with a single, solid pulmonary nodule that was 8 mm in diameter undergoing needle biopsy of the lung under CT fluoroscopic guidance. Top: CT scan prior to the biopsy procedure without gantry tilt and with the patient in the prone position shows the nodular lesion (arrow) located near the rib (arrowhead). This image suggests that the overlying rib blocks the shortest direct path of the needle. Bottom: real-time CT fluoroscopic scan with a gantry tilt of 10° to the cranial site shows the tip of a 20-gauge biopsy needle penetrating the nodule in the shortest direct path without being blocked by the rib.

 
All biopsy procedures were performed under local anesthesia. After the biopsy procedure, axial CT scan images were obtained to evaluate for the presence of complications such as pneumothorax. While still on the scanner table, patients with a moderate or severe pneumothorax or with symptoms of pneumothorax underwent immediate manual aspiration of air from the pleural space using an IV catheter, according to methods reported by Yankelevitz et al,4 or chest tube placement, if necessary.

A 21-gauge needle (Sonopsy; Hakko; Nagano, Japan) was used for fine-needle aspirations, and a 20-gauge needle (Auto Surecut; Create Medics; Yokohama, Japan) or either an 18-gauge or 20-gauge needle (Monopty; Bard, Covington, GA) was used for tissue core biopsies. The specimens obtained were evaluated by experienced chest cytopathologists.

Investigated Parameters
We evaluated the following parameters: (1) characteristics of the 22 lesions in which CT scan-guided lung biopsies with gantry tilt was performed; (2) the success rates in obtaining adequate specimens for determining whether the lesion was malignant or benign and in characterizing specific cell types; and (3) complications.

The final diagnosis was confirmed by independent surgical pathology, independent culture results, or clinical follow-up. Clinical proof of a malignant lesion was accepted if the patient was treated for malignancy, provided that the subsequent clinical course and response to therapy were appropriate. Clinical proof of a benign lesion was accepted if any of following three conditions were satisfied: (1) spontaneous resolution; (2) resolution after treatment for conditions other than cancer, such as antibiotic treatment; and (3) no change in lesion size for > 12 months.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Information on all lung nodules in which a needle biopsy was performed under CT scan-fluoroscopic guidance with gantry tilt was as follows. The mean required time for biopsy procedures was 19 min (range, 10 to 33 min), which included the entire length of time that the patient was on the CT scanner table. Therefore, this period included time for emergent management of cases with biopsy-induced complications, such as immediate percutaneous manual aspiration for complicating pneumothorax. The average number of punctures by the biopsy needle was 2.5 (range, 1 to 4). The average size of the lesion was 13 mm (range, 7 to 20 mm). Thirteen lesions were adjacent to the rib, 7 were away from the rib but within 10 mm, and 2 were 11 to 20 mm from the rib. For eight lesions, a tissue core biopsy alone was performed, and for 14 lesions both fine-needle aspiration biopsy and tissue core biopsy were performed.

Specimens that were adequate for cytopathologic evaluations were obtained from all lesions by either fine-needle aspiration biopsy or tissue core biopsy, in 12 lesions they were obtained by fine-needle aspiration alone, and in 22 lesions they were obtained by core biopsy alone (12 overlapped—in 12 lesions, adequate samples were obtained by both fine-needle aspiration and core biopsy; in 10 lesions, samples were obtained by core biopsy alone). Two specimens obtained from fine-needle aspiration biopsy were deemed inadequate for evaluation because they contained only blood or normal lung cells.

Of the 22 specimens, 21 (95%) were precisely diagnosed by aspiration biopsy, tissue core biopsy, or both (true-positive result, 14 specimens; true- negative result, 7 specimens). The remaining specimen diagnosed as negative for malignancy on biopsy was finally proven to be lung adenocarcinoma.

In all of the 14 lesions diagnosed as malignant by CT scan-guided lung biopsy with gantry tilt, specific cell types were clarified from the analysis of specimens obtained with aspiration biopsy, tissue core biopsy, or both. Specific cell types determined for primary malignant lesions were adenocarcinoma (seven lesions), small cell carcinoma (one lesion), and squamous cell carcinoma (two lesions). Cell types were identified in four metastatic malignant lesions. The origins of the metastatic lesions were colon-rectum (two lesions), uterus (one lesion), and skin (malignant melanoma, one lesion). In five of the seven lesions diagnosed as benign by CT scan-guided lung biopsy, specific cell types were determined. The specific cell types clarified were chondromatous hamartoma (one lesion), tuberculoma (one lesion), organizing pneumonia (two lesions), and atelectasis (one lesion).

Regarding biopsy-induced complications, pneumothorax, which was the most frequent complication in the present study, appeared on CT images obtained immediately after biopsy in 7 of the 22 procedures (32%). Immediate manual aspiration was performed in three of these patients, and further treatment with chest tube insertion was necessary in one patient. In one case, hemoptysis occurred after the biopsy. None of the patients had serious complications.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The modalities that are commonly employed for imaging-guided percutaneous needle biopsy of lung nodules include fluoroscopy, 5 conventional CT scanning,16 and helical CT scanning,6 which has become more widely used. CT fluoroscopy, which was developed most recently, has simplified the process and decreased the time required for CT scan-guided needle biopsies.789

Most CT scan-guided lung biopsies in earlier reports were performed with fine-needle aspiration for cytology and were useful in differentiating malignant from benign lesions.1011 More recently, tissue core biopsy utilizing an automated cutting needle, which enables the histologic evaluation of the samples obtained,8121314 has been implemented, although it remains controversial whether cytology or histology is more useful in diagnosing lung nodules.8101112131415 In efforts to improve the diagnostic ability of the lung biopsy, the combined use of fine-needle aspiration and tissue core biopsy has been reported to be useful.71617

The most widely accepted advantage of CT fluoroscopy is in performing a lung biopsy in small lesions.9 According to our previous report7 evaluating 138 lung nodules that were diagnosed by the combination of fine-needle aspiration and tissue core biopsy under CT fluoroscopic guidance, precise diagnosis was achieved in 94% of lesions (30 of 32 lesions) ranging from 3 to 10 mm in diameter, 93% of lesions (42 of 45 lesions) ranging from 11 to 20 mm in diameter, 93% of lesions (43 of 46 lesions) ranging from 21 to 30 mm in diameter, and 100% of lesions (15 of 15 lesions) ranging from 31 to 100 mm in diameter. From these data, it is evident that true-positive rates plus true-negative rates were high even as lesion size decreased. In addition, these procedures could be performed easily in a relatively short time (average time, 25.6 min) even though two different biopsies were performed during a single biopsy procedure. In consideration of the excellent diagnostic ability and the ease of performing both fine-needle aspiration and tissue core biopsy under CT fluoroscopic guidance, in this current research we used both in 14 of the 22 lesions. Again, the required time for performing the procedures was short (average, 19 min).

One weak point in the use of CT fluoroscopy as a convenient imaging modality for needle biopsy that enables real-time monitoring of needle advancement is that in the case of some peripheral small lesions skeletal structures, such as a rib, overlie the biopsy route. Yankelevitz18 stated that such a geometrical relationship between lesions and the rib occasionally can be changed by having a patient change arm position (ie, putting the arm above the head or at the side) or by changing the depth of inspiration. For small peripheral lesions, in which the relationship with the rib cannot be changed by such means, it is necessary to advance the needle obliquely through intercostal spaces. For real-time monitoring of the entire needle in such situations, the CT gantry should be tilted, with the adjustment made at the angle of the puncturing needle.

The gantry-tilt technique, which is used to avoid penetrating interposed structures during needle biopsy, has been widely performed in biopsies of the intra-abdominal, peritoneal, and pelvic regions.1920 However, reports of an indication for thoracic regions have been scant.2 An excellent diagnostic ability (precise diagnosis, 95% [21 of 22 biopsies]; determination of specific cell types, 86% [19 of 22 biopsies]), as shown in the present study, and a rate of complications similar to those reported in many previous studies6781011121314151617 of CT-guided lung biopsy (eg, rate of pneumothorax: Laurent et al,6 18%; Boiselle et al,17 54%) demonstrate the usefulness and safety of the gantry tilt technique in performing percutaneous needle biopsy under CT fluoroscopic guidance in the lung, especially for small lung nodules located beneath the rib.

Received for publication November 10, 2003. Accepted for publication April 14, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Westcott, JL (1988) Percutaneous transthoracic needle biopsy. Radiology 169,593-601[Free Full Text]
  2. Stern, EJ, Webb, WR, Gamsu, G CT gantry tilt utility in transthoracic fine-needle aspiration biopsy. Radiology 1993;187,873-874[Abstract/Free Full Text]
  3. Katada, K, Kato, R, Anno, H, et al Guidance with real-time CT fluoroscopy: early clinical experience. Radiology 1996;200,851-856[Abstract/Free Full Text]
  4. Yankelevitz, DF, Davis, SD, Henschke, CI Aspiration of a large pneumothorax resulting from transthoracic needle biopsy. Radiology 1996;200,695-697[Abstract/Free Full Text]
  5. Westcott, JL Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137,31-35[Abstract/Free Full Text]
  6. Laurent, F, Latrabe, V, Vergier, B, et al Percutaneous CT-guided biopsy of the lung: comparison between aspiration and automated cutting needle using a coaxial technique. Cardiovasc Intervent Radiol 2000;23,266-272[CrossRef][ISI][Medline]
  7. Yamagami, T, Iida, S, Kato, T, et al Combining fine-needle aspiration and core biopsy under CT fluoroscopy guidance: a better way to treat patients with lung nodules? AJR Am J Roentgenol 2003;180,811-815[Abstract/Free Full Text]
  8. Yamagami, T, Iida, S, Kato, T, et al Usefulness of new automated cutting needle for tissue-core biopsy for lung nodules under CT fluoroscopic guidance. Chest 2003;124,147-154[Abstract/Free Full Text]
  9. Daly, B, Templeton, PA Real-time CT fluoroscopy: evolution of an interventional tool. Radiology 1999;211,309-315[Free Full Text]
  10. Austin, JH, Cohen, MB Value of having a cytopathologist present during percutaneous fine-needle aspiration biopsy of lung: report of 55 cancer patients and meta-analysis of the literature. AJR Am J Roentgenol 1993;160,175-177[Abstract/Free Full Text]
  11. Li, H, Boiselle, PM, Shepard, JO, et al Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules. AJR Am J Roentgenol 1996;167,105-109[Abstract/Free Full Text]
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  13. Lucidarme, O, Howarth, N, Finet, JF, et al Intrapulmonary lesions: percutaneous automated biopsy with a detachable, 18-gauge, coaxial cutting needle. Radiology 1998;207,759-765[Abstract/Free Full Text]
  14. Tsukada, H, Satou, T, Iwashima, A, et al Diagnostic accuracy of CT-guided automated needle biopsy of lung nodules. AJR Am J Roentgenol 2000;175,239-243[Abstract/Free Full Text]
  15. Hayashi, N, Sakai, T, Kitagawa, M, et al CT-guided biopsy of pulmonary nodules less than 3 cm: usefulness of the spring-operated core biopsy needle and frozen-section pathologic diagnosis. AJR Am J Roentgenol 1998;170,329-331[Abstract/Free Full Text]
  16. Klein, JS, Salomon, G, Stewart, EA Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients. Radiology 1996;198,715-720[Abstract/Free Full Text]
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  20. Levine, ML, Hall, FM Gantry angulation for CT-guided or aspiration [letter]. AJR Am J Roentgenol 1989;152,1345-1346[ISI][Medline]




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