J Korean Soc Radiol.  2015 Oct;73(4):216-224. 10.3348/jksr.2015.73.4.216.

Predicting Factors for Conversion from Fluoroscopy Guided Percutaneous Transthoracic Needle Biopsy to Cone-Beam CT Guided Percutaneous Transthoracic Needle Biopsy

• Lee KJ
• Han YM
• Jin GY
• Song JS

• KMID: 2068711
• DOI: http://doi.org/10.3348/jksr.2015.73.4.216

Abstract

PURPOSE
To evaluate the predicting factors for conversion from fluoroscopy guided percutaneous transthoracic needle biopsy (PTNB) to cone-beam CT guided PTNB.
MATERIALS AND METHODS
From January 2011 to December 2012, we retrospectively identified 38 patients who underwent cone-beam CT guided PTNB with solid pulmonary lesions, and 76 patients who underwent fluoroscopy guided PTNB were matched to the patients who underwent cone-beam CT guided PTNB for age, sex, and lesion location. We evaluated predicting factors such as, long-axis diameter, short-axis diameter, anterior-posterior diameter, and CT attenuation value of the solid pulmonary lesion affecting conversion from fluoroscopy guided PTNB to cone-beam CT guided PTNB. Pearson chi2 test, Fisher exact test, and independent t test were used in statistical analyses; in addition, we also used receiver operating characteristics curve to find the proper cut-off values affecting the conversion to cone-beam CT guided PTNB.
RESULTS
Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent fluoroscopy guided PTNB were 2.70 +/- 1.57 cm, 3.40 +/- 1.92 cm, 3.06 +/- 1.81 cm, and 35.67 +/- 15.70 Hounsfield unit (HU), respectively. Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent cone-beam CT guided PTNB were 1.60 +/- 1.30 cm, 2.20 +/- 1.45 cm, 1.91 +/- 1.99 cm, and 18.32 +/- 23.11 HU, respectively. Short-axis, long-axis, anterior-posterior diameter, and CT attenuation value showed a significantly different mean value between the 2 groups (p = 0.001, p < 0.001, p = 0.003, p < 0.001, respectively). Odd ratios of CT attenuation value and short-axis diameter of the solid pulmonary lesion were 0.952 and 0.618, respectively. Proper cut-off values affecting the conversion to cone-beam CT guided PTNB were 1.65 cm (sensitivity 68.4%, specificity 71.1%) in short-axis diameter and 29.50 HU (sensitivity 65.8%, specificity 65.8%) in CT attenuation value.
CONCLUSION
Low CT attenuation value and small short-axis diameter of the solid pulmonary lesion affect conversion from fluoroscopy guided PTNB to cone-beam CT guided PTNB.

MeSH Terms

Biopsy, Needle*
Cone-Beam Computed Tomography*
Fluoroscopy*
Humans
Needles*
Retrospective Studies
ROC Curve
Sensitivity and Specificity

Figure

• 

  Fig. 1 A small pulmonary nodule in the right upper lobe of a 47-year-old woman with history of breast cancer. A. About 1 cm-sized well-marginated, small, round nodule in RUL is noted on the lung setting axial image of the HRCT. B. CT mean attenuation value is measured using free-drawing ROI on the mediastinal setting of axial image. C. The nodule was not detected on fluoroscopy performed with the patient in supine position. D. The operator accordingly performed cone-beam CT guided PTNB with careful adjustment of the needle. The result of PTNB indicated a meta-static adenocarcinoma. HRCT = high-resolution CT, PTNB = percutaneous transthoracic needle biopsy, ROI = region of interest, RUL = right upper lobe

• 

  Fig. 2 A solitary pulmonary mass suspicious for malignancy in the right lower lobe of a 72-year-old man, which was well-marginated, irregular-shaped, and abutting the pleura. A. Antero-posterior diameter of the mass is measured to about 3.61 cm on the unenhanced axial image of the chest CT. B. CT mean attenuation value is subsequently measured using free-drawing ROI on the unenhanced axial image. C. Long-axis and short axis diameters are also measured on the coronal reconstructed image. D. Fluoroscopic image shows the mass with well-defined margin on the left side. The operator next performed fluoroscopy-guided PTNB with patient in prone position and careful adjustment of the needle; the result of PTNB indicated a squamous cell carcinoma. PTNB = percutaneous transthoracic needle biopsy, ROI = region of interest

• 

  Fig. 3 Box plots of predicting independent variables in conversion of fluoroscopy guided PTNB to cone-beam CT guided PTNB. A. Box plot comparing the short-axis diameter, long-axis diameter, and AP diameter of pulmonary lesion between the patients who underwent fluoroscopy-guided PTNB vs. cone-beam CT guided PTNB. B. Box plot showing CT attenuation value of pulmonary lesion of the above 2 groups. *, • = outlier. AP = anterior to posterior, PTNB = percutaneous transthoracic needle biopsy

• 

  Fig. 4 Receive operating characteristics curve (ROC curve). This graph showed statistically significant independent variables, short-axis diameter and CT attenuation value of the pulmonary lesion. AUC of these variables were 0.753 and 0.722, respectively. We set a cut-off value to 29.50 of CT attenuation that showed 65.8% of sensitivity and specificity, respectively; in addition, we set a cut-off value to 1.65 cm of short-axis diameter that showed 68.4% of sensitivity and 71.1% of specificity. AUC = area under the curve

Reference

1. Hwang HS, Chung MJ, Lee JW, Shin SW, Lee KS. C-arm cone-beam CT-guided percutaneous transthoracic lung biopsy: usefulness in evaluation of small pulmonary nodules. AJR Am J Roentgenol. 2010; 195:W400–W407.

2. Laurent F, Latrabe V, Vergier B, Montaudon M, Vernejoux JM, Dubrez J. CT-guided transthoracic needle biopsy of pulmonary nodules smaller than 20 mm: results with an automated 20-gauge coaxial cutting needle. Clin Radiol. 2000; 55:281–287.

3. Westcott JL. Percutaneous transthoracic needle biopsy. Radiology. 1988; 169:593–601.

4. Hur J, Lee HJ, Nam JE, Kim YJ, Kim TH, Choe KO, et al. Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2009; 192:629–634.

5. Froelich JJ, Ishaque N, Regn J, Saar B, Walthers EM, Klose KJ. Guidance of percutaneous pulmonary biopsies with real-time CT fluoroscopy. Eur J Radiol. 2002; 42:74–79.

6. Daly B, Templeton PA. Real-time CT fluoroscopy: evolution of an interventional tool. Radiology. 1999; 211:309–315.

7. Kim GR, Hur J, Lee SM, Lee HJ, Hong YJ, Nam JE, et al. CT fluoroscopy-guided lung biopsy versus conventional CT-guided lung biopsy: a prospective controlled study to assess radiation doses and diagnostic performance. Eur Radiol. 2011; 21:232–239.

8. Choi JW, Park CM, Goo JM, Park YK, Sung W, Lee HJ, et al. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of small (≤ 20 mm) lung nodules: diagnostic accuracy and complications in 161 patients. AJR Am J Roentgenol. 2012; 199:W322–W330.

9. Choo JY, Park CM, Lee NK, Lee SM, Lee HJ, Goo JM. Percutaneous transthoracic needle biopsy of small (≤ 1 cm) lung nodules under C-arm cone-beam CT virtual navigation guidance. Eur Radiol. 2013; 23:712–719.

10. 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. 2012; 85:e217–e222.

11. Jin KN, Park CM, Goo JM, Lee HJ, Lee Y, Kim JI, et al. Initial experience of percutaneous transthoracic needle biopsy of lung nodules using C-arm cone-beam CT systems. Eur Radiol. 2010; 20:2108–2115.

12. Ohno Y, Hatabu H, Takenaka D, Higashino T, Watanabe H, Ohbayashi C, et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) solitary pulmonary nodules. AJR Am J Roentgenol. 2003; 180:1665–1166.

13. Geraghty PR, Kee ST, McFarlane G, Razavi MK, Sze DY, Dake MD. CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate. Radiology. 2003; 229:475–481.

14. 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. 2011; 37:209–216.

15. Lee SM, Park CM, Lee KH, Bahn YE, Kim JI, Goo JM. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of lung nodules: clinical experience in 1108 patients. Radiology. 2014; 271:291–300.