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Cutting Needle Biopsies
monary lesions, and perhaps that the core needle should be used by him only in those cases where a diagnosis by less dangerous methods has failed to yield a diagnosis and where the risk of open thoracotomy is considered to be prohibitive. I would still stand by the opinion, however, that the use of a cutting or a coring needle for percutaneous biopsy of the lung should be abandoned. There certainly seems to be increasing support for this view in the literature. Timothy Takaro, M.D. Chief, Surgical Seroice Veterans Administration Hospital Asheville, NC
pleura and chest wall when the aspiration biopsy is inconclusive. (We have utilized the cutting needle in two cases in the past year in which the cutting biopsy provided a definitive diagnosis of malignant mesothelioma when an aspiration biopsy revealed only "malignant cells.") John V. Forrest, M.D., and Stuart S. Sagel, M.D. Associate Professors, School of Medicine Washinf.,rton University, St. Louis REFERENCES
1 Sinner WN; Transthoracic needle biopsy of small peripheral malignant lung lesions. Invest Radiol 8:305-314, 1973 2 Zelch IV, Lalli AF, McCormack LJ, et al; Aspiration biopsy in diagnosis of pulmonary nodule. Chest 63: 149152, 1973
To the Editor:
In reply to Dr. Feist's comments, we would like to emphasize that our results with needle aspiration biopsy in over 450 cases of malignant disease (89 percent positive with a single aspiration; greater than 96 percent positive when the procedure was repeated) are approximately the same as his with cutting needle biopsy, except for the differentiation of cell type. The accuracy of this technique is undoubtedly influenced by the expertise of the cytopathologist. But the lack of good cytologic services in a hospital is certainly no insurmountable problem, as techniques are available for cell preservation prior to transportation to consultative laboratories. Similar success rates with aspiration biopsy have been reported by others.P Our mortality has been zero. Our cytologist can distinguish oat cell carcinoma, malignant melanoma, and a few other rare types of malignant lesions, but in most cases the pathologic report simply reads "malignant cells seen." In the overwhelming number of cases, the lack of a specific cell type is usually not of therapeutic significance. The difference in our experience with cutting needle biopsy compared to Dr. Feist's could be explained simply by statistical variation. Virtually all of our cutting biopsies were also performed utilizing the Tru-Cut biopsy instrument and a technique similar to that described by Dr. Feist. We might parenthetically add that in our institution there has been only one death from a limited diagnostic thoracotomy in the past five years. We would not be willing to accept even the three deaths in the 200 cases of Dr. Feist, preferring to use needle aspiration biopsy for localized pulmonary lesions and either transbronchoscopic forceps biopsy or limited thoracotomy for diffuse pulmonary disease. We restrict the use of cutting needle biopsy to those extremely rare large lesions (greater than 3 cm) abutting upon the CHEST, 69: 2, FEBRUARY, 1976
left Atrioventricular Valvular Insufficiency Surgical Treatment in Corrected Transposition with Cardiac Dextrorotation To the Editor:
Severe insufficiency of the left-sided atrioventricular valve commonly is a complication of corrected transposition of the great vessels. In addition, the valve may be stenotic or the seat of Ebstein's anomaly. This communication emphasizes that when the left atrium is large and anteriorly placed in corrected transposition with cardiac dextrorotation, the technical difficulties encountered in replacement of the left atrioventricular valve are much simplified. CASE REPORT
A 34-year-old man was admitted on Jan 14, 1975 to the Hospital Italiano, Buenos Aires, with symptoms of severe cardiac decompensation. He had been treated for mild congestive heart failure for several years. When the patient was four years old, the cardiac right-sided position had been diagnosed, and auscultation had revealed a cardiac murmur. The electrocardiogram on admission showed atrial fibrillation, the electrical axis at +100, frequent ventricular extrasystoles, slow intraventricular conduction, and hypertrophy of the leftsided ventricle. The abdominal viscera were in their normal position (situs solitus). Auscultation revealed a pansystolic regurgitant murmur with maximal localization on the right side of the chest. The patient's condition was worse on Jan 26. Cardiac catheterization studies were performed on Jan 28, 1975; the results of the pressure measurements were as follows: pulmonary artery, 65/20 mm Hg (mean, 30 mm Hg ): right ventricle, 65/4-12 mm Hg, right atrium, mean of 11 mm Hg, aorta, 85/60 mm Hg (mean, 75 mm Hg); left ventricle, 85/15-20 mm Hg (postventriculographic value, 90/24-28 mrn Hg); and pulmonary arterial wedge, mean of .30 mm Hg
COMMUNICATIONS TO THE EDITOR 245
pleura and chest wall when the aspiration biopsy is inconclusive. (We have utilized the cutting needle in two cases in the past year in which the cutting biopsy provided a definitive diagnosis of malignant mesothelioma when an aspiration biopsy revealed only "malignant cells.") John V. Forrest, M.D., and Stuart S. Sagel, M.D. Associate Professors, School of Medicine Washinf.,rton University, St. Louis REFERENCES
1 Sinner WN; Transthoracic needle biopsy of small peripheral malignant lung lesions. Invest Radiol 8:305-314, 1973 2 Zelch IV, Lalli AF, McCormack LJ, et al; Aspiration biopsy in diagnosis of pulmonary nodule. Chest 63: 149152, 1973
To the Editor:
In reply to Dr. Feist's comments, we would like to emphasize that our results with needle aspiration biopsy in over 450 cases of malignant disease (89 percent positive with a single aspiration; greater than 96 percent positive when the procedure was repeated) are approximately the same as his with cutting needle biopsy, except for the differentiation of cell type. The accuracy of this technique is undoubtedly influenced by the expertise of the cytopathologist. But the lack of good cytologic services in a hospital is certainly no insurmountable problem, as techniques are available for cell preservation prior to transportation to consultative laboratories. Similar success rates with aspiration biopsy have been reported by others.P Our mortality has been zero. Our cytologist can distinguish oat cell carcinoma, malignant melanoma, and a few other rare types of malignant lesions, but in most cases the pathologic report simply reads "malignant cells seen." In the overwhelming number of cases, the lack of a specific cell type is usually not of therapeutic significance. The difference in our experience with cutting needle biopsy compared to Dr. Feist's could be explained simply by statistical variation. Virtually all of our cutting biopsies were also performed utilizing the Tru-Cut biopsy instrument and a technique similar to that described by Dr. Feist. We might parenthetically add that in our institution there has been only one death from a limited diagnostic thoracotomy in the past five years. We would not be willing to accept even the three deaths in the 200 cases of Dr. Feist, preferring to use needle aspiration biopsy for localized pulmonary lesions and either transbronchoscopic forceps biopsy or limited thoracotomy for diffuse pulmonary disease. We restrict the use of cutting needle biopsy to those extremely rare large lesions (greater than 3 cm) abutting upon the CHEST, 69: 2, FEBRUARY, 1976
left Atrioventricular Valvular Insufficiency Surgical Treatment in Corrected Transposition with Cardiac Dextrorotation To the Editor:
Severe insufficiency of the left-sided atrioventricular valve commonly is a complication of corrected transposition of the great vessels. In addition, the valve may be stenotic or the seat of Ebstein's anomaly. This communication emphasizes that when the left atrium is large and anteriorly placed in corrected transposition with cardiac dextrorotation, the technical difficulties encountered in replacement of the left atrioventricular valve are much simplified. CASE REPORT
A 34-year-old man was admitted on Jan 14, 1975 to the Hospital Italiano, Buenos Aires, with symptoms of severe cardiac decompensation. He had been treated for mild congestive heart failure for several years. When the patient was four years old, the cardiac right-sided position had been diagnosed, and auscultation had revealed a cardiac murmur. The electrocardiogram on admission showed atrial fibrillation, the electrical axis at +100, frequent ventricular extrasystoles, slow intraventricular conduction, and hypertrophy of the leftsided ventricle. The abdominal viscera were in their normal position (situs solitus). Auscultation revealed a pansystolic regurgitant murmur with maximal localization on the right side of the chest. The patient's condition was worse on Jan 26. Cardiac catheterization studies were performed on Jan 28, 1975; the results of the pressure measurements were as follows: pulmonary artery, 65/20 mm Hg (mean, 30 mm Hg ): right ventricle, 65/4-12 mm Hg, right atrium, mean of 11 mm Hg, aorta, 85/60 mm Hg (mean, 75 mm Hg); left ventricle, 85/15-20 mm Hg (postventriculographic value, 90/24-28 mrn Hg); and pulmonary arterial wedge, mean of .30 mm Hg
COMMUNICATIONS TO THE EDITOR 245