- Email: [email protected]
Fine needle aspiration of solitary pulmonary lesions
European Journal of Radiology 37 (2001) 200– 203 www.elsevier.nl/locate/ejrad
Fine needle aspiration of solitary pulmonary lesions Saleh Al-Damegh * Radiology Department no. 40, King Khalid Uni6ersity Hospital, P.O. Box 7805, Riyadh 11461, Saudi Arabia Received 25 May 1999; received in revised form 11 August 2000; accepted 14 August 2000
Abstract A 2-year experience using 25G sized needles for transthoracic fine needle aspiration (FNA) for solitary lung lesions under computed tomography (CT) guidance is documented with the main objective of reducing the postoperative complications through the use of a needle smaller than that previously routinely used. This study, in the hospital experience, demonstrated that FNAs became complication-free with the use of a smaller needle; whilst the sensitivity of the procedure was not much compromised. The duration of the hospitalization for the patients was reduced to under 24 h. The mandatory postoperative chest radiography can therefore be eliminated, provided no adverse clinical signs and symptoms are noted during the postoperative period. This is one of the first documented reports using 25G needles for FNAs. Further studies are needed on a wider scale to confirm the findings. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Fine needle aspiration; 25G needle; Lung
1. Introduction Percutaneous needle biopsy of the lung using fine needle aspiration (FNA) has over the years become a simple, quick, safe and highly accurate and routine procedure in the preoperative diagnosis of pulmonary lesions especially solitary ones [1 – 9]. Furthermore, when FNA is combined with immediate cytological assessment, the adequacy of the FNA specimens and their cytological evaluation improves diagnostic accuracy [4,10 –12]. FNA is usually computed tomography (CT), or fluoroscopically guided [4,13,14]. Sometimes FNA is done under oesophageal endoscopic ultrasound guidance for mediastinal lymph nodes [14] or via bronchoscopy [13]. Hitherto, different types of needles have been used; e.g. Chiba, Franseen, Temno, Westcott, Rotex II, with a gauge of 18–22 and a length of 10 – 22 cm [1,4,7 –11]. The procedure is as described by other workers [10] with the lesions biopsied, using an orthogonal approach, from the nearest point in chest wall. The need for subsequent passes was usually decided on the gross visual appearance of the first material as adjudged by the cytologist [3]. * Tel.: +966-1-4671155; fax: + 966-1-4671746. E-mail address: [email protected] (S. Al-Damegh).
Lately, smaller needles, a 23G needle, via an endoscope was used successfully with a high accuracy and minimal complications in the diagnosis and staging of bronchogenic carcinoma by Silvestri et al. [14]. The most common complications being pneumothorax and bleeding, have been related to the needle size as well as the number of passes; with the complications increasing with the bigger needles and the increased number of passes [1,3,4,10]. In order to minimize these complications a smaller size of needle may be the answer. Only one report of using an ultra thin needle (25G) has been found in the literature [15]. Hence the evaluation of FNA with 25G needles in this report.
2. Patients and methods The cumulative records of 97 patients who had undergone chest FNA performed by a single radiologist under CT guidance for solitary lesions using a spinal needle 25G (25G× 3.5 in.: Terumo, Tokyo, Japan), between 1997 and 1998 were analyzed against the recorded parameters and indices viz: age, sex, location of lesion number of passes, any associated procedural complications and pathological diagnosis. The 25G needle was used first and in all cases; and if an adequate
0720-048X/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 2 0 - 0 4 8 X ( 0 0 ) 0 0 2 7 6 - X
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203 Table 1 Size of needle versus number of cases Size of needle
25
No. passes
1 2 3 4
Total 22 20 18 Total
No. cases
Percentage out of 97 cases
7 9 3 2
58.8 9.3 3.1 2.1
71 5 15 6
73.2 5.1 15.5 6.2
97
201
was obtained post-operatively, though the vital signs for all patients were monitored every 15 min for 6 h post-operatively. Patients were hospitalized overnight.
3. Results
100
specimen was not obtained (as adjudged by the cytopathologist) then another pass was made for a maximum of four passes. If the specimen is still inadequate, then a bigger size needle was substituted in increasing order of sizes for two passes only until an adequate sample was obtained. All FNAs were performed by CT guidance using 10 mm slices and under local anaesthesia. The FNAs were collected with negative pressure or using capillary technique with the same cytologist being present on each occasion. The samples were smeared on glass slides; with some sent for microbiological investigation including culture and sensitivity for organisms including mycobacteria. After smearing, specimens were sent to the laboratory with special staining cell blocks performed. If lymphoma was suspected, flow cytometric studies were done. Each specimen was adjudged adequate by its cellularity after two or three smears. The indications complied with American Thoracic Society (ATS) guidelines [14]; and the contraindications included absence of patient consent, but prothrombin index, suspected vascular lesion or hydatidosis, severe pulmonary hypertension and chronic obstructive airway disease with bullae; and in the presence of the histopathologist; the same histopathologist being present in all studies. In addition, puncture-site-down position for 3 h after the procedure was mandatory. No chest radiograph
There was a total of 97 cases (59 males and 38 females) with ages ranging from 14 to 92 years with a mean of 50 years. Table 1 shows that in 71 cases (73.2% of cases) size 25G needle was successful, whilst in 26 cases (26.8% of total cases), FNA was unsuccessful with needle size 25G. A larger size of needle was therefore used especially size 20G in 26 cases (Table 2). In 71 cases in which the use of size 25G needle was successful only one pass was used in 57 cases. In 14 other cases (19.7%), more than one pass was made. The location of lesions within the chest, and the relation to the various needle sizes used is depicted on Table 2; 61.9% of lesions being within the lung and 17.5% within the mediastinum both together making 79.4% of the lesions. A total of 20.6% of cases were in the lateral third or pleura of the chest. The depth of lesion did not affect the success rate of puncture; rather and surprisingly increased depth favoured it. Table 3 shows the frequency of the pathologies where lesions comprised 42.3% of cases whilst benign tumours were 8.2%. A total of 10.3% of cases were normal or inconclusive; and nine out of these ten cases were biopsied only with 25G needle. Table 4 shows the frequency of tumours seen. No clinical complication whatsoever was recorded in this study. No patient spent over 24 h in hospital for this procedure.
4. Discussion The most common complication in FNA is of pneumothorax; ranging from 9.3 to 24% [1,3,4,10]. And in the study of Ariza et al. [3], the rate increased from 13.2 to 26.8% when 6-h post operative radiography was done and this was severe in some cases as to require
Table 2 Location of lesions in relation to various needle size Needle size
No. needle 25
Total
Percentage of successful cases with 25G needle
Percentage of total cases
22
20
18
Mediastinum/hilar 13 Lung (inner) 46 Lung (outer) including pleura 12
2 1 2
2 9 4
– 4 2
17 60 20
82.9 76.6 60.0
17.5 6109 20.6
Total
5
15
6
97
73.2
100
71
202
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203
Table 3 Frequency of pathological diagnosis in relation to needle size Lesions
Needle size
Total
Percent (of total)
25
22
20
18
Malignant lesions Benign lesions Tuberculosis Thyroid colloid nodule Non-tuberculous inflammation Abscess Normal or inconclusive
30 6 4 1 18 3 9
2 – 1 – 2 – 1
5 1 – – 6 2 –
4 1 – – 1 – –
41 8 5 1 27 5 10
42.3 8.2 5.1 1.0 27.8 5.1 10.3
Total
71
6
14
6
97
99.8 ( = 100%)
chest tube insertion. In a study, using a 19G introducer needle followed by a 22G aspirating needle, with a mean of three passes (range 1 – 7), a pneumothorax was present in 18% of cases [4]. Recently a 25% pneumothorax complication was obtained with a 22G needle in 38 elderly people over 70 years of age [11]. In this study, only two cases complicated with pneumothorax required pleural drains, one being discharged the following day. A total of 65% of the patients were discharged within 24 h of FNAs. Haemoptysis was not a problem in this study. In another study, the rate of pneumothorax was reduced from 23 to 13% when the number of aspirates was reduced from three to one [1]. In all of these, chest radiograph was used to assess the pneumothorax. Other procedural complications reported were pulmonary haemorrhage, the most serious and life threatening as well as chest pain or discomfort [4,11,15]. None of these occurred in this study and during follow-up. The patients, as a matter of policy and in accordance with radiation reducing measures of the institution did not have post operative chest radiographs although they were clinically monitored critically for the first 6 h post-operatively. It has been shown that the rate of complications increased significantly with the increasing size of the needle, the increased number of passes [1,3,4] and the absence of the on-site pathologist [17] and in patients with a reduced forced expiratory volume in 1 s [FEVI] [11]. No FEVI studies were done in this study. In this study, the mean number of passes was 1.3 with a range of 1– 6 passes. Size 25G needles were always used first and after a maximum of four passes, bigger sized needles were used. The mean number of passes favourably compares with other studies [10]. Within this period, the total number of passes for each case, and the need to used bigger sized needles has decreased with experience. It is therefore pertinent to conclude that the small needle size in the study was partly if not wholly responsible for the significant absence of post procedural complications.
Other factors which might have contributed to the complication-free procedure of FNA in this study are compliance with the ATS guidelines and the exclusion of contraindicated cases, the constant use of the same and experienced radiologist, and the post operative procedure of lying the patient puncture-site-down for 3 h after the FNA. In all the above quoted studies unlike in this study, pneumothorax was assessed by radiography; and not all of them were severe though a sizeable percentage of pneumothorax as well as bleeding mandated surgical treatment such as underwater drainage [1,3,4,10,15]. Previous experiences have also shown that in the presence of the on-site cytopathologist, the adequacy of the specimen or the diagnostic accuracy of FNA are significantly improved [1,10,18]. It has been shown that the availability of immediate cytology assessment ensures that the number of unsatisfactory and false negative lung FNA are reduced [1]. Ten out of 97 (10.3%) Table 4 Frequency of tumours Benign
Malignant
Type
No
Type
Carcinoid Benign spindle cell tumour Fibroma Lipoma Aspergilloma
2 2
Squamous cell carcinoma Adenocarcinoma
8 7
2 1 1
Spindle cell carcinoma Small cell carcinoma Large cell carcinoma Poorly differentiated carcinoma Recurrent cell carcinoma Malignant lymphoma Malignant mesothelioma Thymic carcinoma Posterior mediastinal malignancy Lymphoma
2 1 7 3
Total
8
Total
No
1 2 1 5 1 3 41
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203
were either normal or inconclusive despite the presence of on-site pathologist. This 89.7% sensitivity compares favourably with other studies which range from 72 to 97% [19,20]. The choice of which needle to use after a 25G needle was arbitrary. The 20G size was chosen as it was clearly the second largest to 25G. One tried to avoid 22G as it was quite close to the 25G size. The spectrum of diseases shown are as shown by other authors; but the percentage of tumours 42.3% is still less than when compared with other studies [4,13]. In conclusion the use of size 25G needles in FNA has produced very satisfactory results and without any clinical complications whatsoever in the hospital setting; thus reducing patient hospitalization to less than 24 h. The preferential use of this size of needle is therefore advocated. Furthermore, the use of routine postoperative chest radiography can be safely discarded in the absence of relevant clinical signs of pneumothorax or haemorrhage provided the ATS guidelines are complied with. However, further studies are needed to confirm these findings on a wider scale.
5. Furthr reading [16]
References [1] Stewart CJR, Stewart IS. Immediate assessment of fine needle aspiration cytology lung. J Clin Pathol 1996;49:839–43. [2] Padhani AR, Scott W, Cheema M, Erozan YS. The value of immediate cytological evaluation for needle aspiration biopsy. Clin Radiol 1995;50:350–1. [3] De Gregoria Ariza MA, Alfonso Aguiran ER, Villavieja Atance JL, et al. Transthoracic aspiration of biopsy of pulmonary and mediastinal lesions. Eur J Radiol 1991;12:98–103. [4] Boiselle PM, Shepard JO, Mark EJ, et al. Routine addition of an automated biopsy device to give needle aspiration of the lung: a
.
203
prospective assessment. Am J Radiol 1997;169:661– 5. [5] Wescott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137:31– 5. [6] Stanley JH, Fish GD, Andriole JG, et al. Lung lesions: cytologic diagnosis by fine needle biopsy. Radiology 1987;162:389–91. [7] Stewart FW. The diagnosis of tumours by aspiration. Am J Pathol 1933;9:801– 3. [8] Nordenstrom B. A new technique for transthoracic biopsy of lung changes. Br J Radiol 1965;38:550– 3. [9] Zornoza J, Snow J, Lukenan JM, Libshitz HI. Aspiration biopsy of discrete pulmonary lesions using a new thin needle. Radiology 1977;123:519– 20. [10] Santambrogrio L, Nosotti M, Bellaviti N, et al. CT guided fine needle aspiration cytology of solitary pulmonary nodules. Chest 1997;122:423– 5. [11] Brown TS, Kanthanpillai K. Transthoracic needle biopsy for suspected thoracic malignancy in elderly patients using CT guidance. Clin Radiol 1995;53:116– 9. [12] Padhani AR, Scott WW, Cheema M, Kearney D, Erozan YS. The value of immediate cytological evaluation for needle apsiration lung biopsy. Invest Radiol 1997;32:453– 8. [13] Rio FG, Lobato SD, Pino JM, et al. Value of CT-guided fine needle aspiration in solitary pulmonary nodules with negative fiberoptic bronchoscopy. Acta Radiol 1994;35:478– 80. [14] Silvestri G, Hoffman BJ, Bhutani MS. Endoscopic ultrasound with fine needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg 1996;61:1441– 6. [15] Man A, Schwarz Y, Greif J. Case report: cardiac tampernade following fine needle aspiration (FNA) of a mediastinal mass. Clin Radiol 1998;53:151– 2. [16] Sokoilowski JW, Jr, Burker L, Jones FLJr, Patterson JR, Selecky PA. Guidelines for percutaneous transthoracic needle biopsy. Am Rev Respir Dis 1989;140:255. [17] Klein JS, Solomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20G. Automated cutting needle: results in 122 patients. Radiology 1996;198:715– 20. [18] Austin JHM, Chohen B. Value of having a cytopathologist present during percutaneous fine needle aspiration biopsy of the lung: report of 55 cancer patients and meta analysis of the literature. Am J Radiol 1993;160:175– 7. [19] Lauby VW, Burnett WE, Rosemond GP, Tysoin RR. Value and risk of biopsy of pulmonary leisons by needle aspiration: twenty one years experience. J Thorac Cardiovasc Surg 1965;49:159–72. [20] Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137:31– 5.
Fine needle aspiration of solitary pulmonary lesions Saleh Al-Damegh * Radiology Department no. 40, King Khalid Uni6ersity Hospital, P.O. Box 7805, Riyadh 11461, Saudi Arabia Received 25 May 1999; received in revised form 11 August 2000; accepted 14 August 2000
Abstract A 2-year experience using 25G sized needles for transthoracic fine needle aspiration (FNA) for solitary lung lesions under computed tomography (CT) guidance is documented with the main objective of reducing the postoperative complications through the use of a needle smaller than that previously routinely used. This study, in the hospital experience, demonstrated that FNAs became complication-free with the use of a smaller needle; whilst the sensitivity of the procedure was not much compromised. The duration of the hospitalization for the patients was reduced to under 24 h. The mandatory postoperative chest radiography can therefore be eliminated, provided no adverse clinical signs and symptoms are noted during the postoperative period. This is one of the first documented reports using 25G needles for FNAs. Further studies are needed on a wider scale to confirm the findings. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Fine needle aspiration; 25G needle; Lung
1. Introduction Percutaneous needle biopsy of the lung using fine needle aspiration (FNA) has over the years become a simple, quick, safe and highly accurate and routine procedure in the preoperative diagnosis of pulmonary lesions especially solitary ones [1 – 9]. Furthermore, when FNA is combined with immediate cytological assessment, the adequacy of the FNA specimens and their cytological evaluation improves diagnostic accuracy [4,10 –12]. FNA is usually computed tomography (CT), or fluoroscopically guided [4,13,14]. Sometimes FNA is done under oesophageal endoscopic ultrasound guidance for mediastinal lymph nodes [14] or via bronchoscopy [13]. Hitherto, different types of needles have been used; e.g. Chiba, Franseen, Temno, Westcott, Rotex II, with a gauge of 18–22 and a length of 10 – 22 cm [1,4,7 –11]. The procedure is as described by other workers [10] with the lesions biopsied, using an orthogonal approach, from the nearest point in chest wall. The need for subsequent passes was usually decided on the gross visual appearance of the first material as adjudged by the cytologist [3]. * Tel.: +966-1-4671155; fax: + 966-1-4671746. E-mail address: [email protected] (S. Al-Damegh).
Lately, smaller needles, a 23G needle, via an endoscope was used successfully with a high accuracy and minimal complications in the diagnosis and staging of bronchogenic carcinoma by Silvestri et al. [14]. The most common complications being pneumothorax and bleeding, have been related to the needle size as well as the number of passes; with the complications increasing with the bigger needles and the increased number of passes [1,3,4,10]. In order to minimize these complications a smaller size of needle may be the answer. Only one report of using an ultra thin needle (25G) has been found in the literature [15]. Hence the evaluation of FNA with 25G needles in this report.
2. Patients and methods The cumulative records of 97 patients who had undergone chest FNA performed by a single radiologist under CT guidance for solitary lesions using a spinal needle 25G (25G× 3.5 in.: Terumo, Tokyo, Japan), between 1997 and 1998 were analyzed against the recorded parameters and indices viz: age, sex, location of lesion number of passes, any associated procedural complications and pathological diagnosis. The 25G needle was used first and in all cases; and if an adequate
0720-048X/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 2 0 - 0 4 8 X ( 0 0 ) 0 0 2 7 6 - X
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203 Table 1 Size of needle versus number of cases Size of needle
25
No. passes
1 2 3 4
Total 22 20 18 Total
No. cases
Percentage out of 97 cases
7 9 3 2
58.8 9.3 3.1 2.1
71 5 15 6
73.2 5.1 15.5 6.2
97
201
was obtained post-operatively, though the vital signs for all patients were monitored every 15 min for 6 h post-operatively. Patients were hospitalized overnight.
3. Results
100
specimen was not obtained (as adjudged by the cytopathologist) then another pass was made for a maximum of four passes. If the specimen is still inadequate, then a bigger size needle was substituted in increasing order of sizes for two passes only until an adequate sample was obtained. All FNAs were performed by CT guidance using 10 mm slices and under local anaesthesia. The FNAs were collected with negative pressure or using capillary technique with the same cytologist being present on each occasion. The samples were smeared on glass slides; with some sent for microbiological investigation including culture and sensitivity for organisms including mycobacteria. After smearing, specimens were sent to the laboratory with special staining cell blocks performed. If lymphoma was suspected, flow cytometric studies were done. Each specimen was adjudged adequate by its cellularity after two or three smears. The indications complied with American Thoracic Society (ATS) guidelines [14]; and the contraindications included absence of patient consent, but prothrombin index, suspected vascular lesion or hydatidosis, severe pulmonary hypertension and chronic obstructive airway disease with bullae; and in the presence of the histopathologist; the same histopathologist being present in all studies. In addition, puncture-site-down position for 3 h after the procedure was mandatory. No chest radiograph
There was a total of 97 cases (59 males and 38 females) with ages ranging from 14 to 92 years with a mean of 50 years. Table 1 shows that in 71 cases (73.2% of cases) size 25G needle was successful, whilst in 26 cases (26.8% of total cases), FNA was unsuccessful with needle size 25G. A larger size of needle was therefore used especially size 20G in 26 cases (Table 2). In 71 cases in which the use of size 25G needle was successful only one pass was used in 57 cases. In 14 other cases (19.7%), more than one pass was made. The location of lesions within the chest, and the relation to the various needle sizes used is depicted on Table 2; 61.9% of lesions being within the lung and 17.5% within the mediastinum both together making 79.4% of the lesions. A total of 20.6% of cases were in the lateral third or pleura of the chest. The depth of lesion did not affect the success rate of puncture; rather and surprisingly increased depth favoured it. Table 3 shows the frequency of the pathologies where lesions comprised 42.3% of cases whilst benign tumours were 8.2%. A total of 10.3% of cases were normal or inconclusive; and nine out of these ten cases were biopsied only with 25G needle. Table 4 shows the frequency of tumours seen. No clinical complication whatsoever was recorded in this study. No patient spent over 24 h in hospital for this procedure.
4. Discussion The most common complication in FNA is of pneumothorax; ranging from 9.3 to 24% [1,3,4,10]. And in the study of Ariza et al. [3], the rate increased from 13.2 to 26.8% when 6-h post operative radiography was done and this was severe in some cases as to require
Table 2 Location of lesions in relation to various needle size Needle size
No. needle 25
Total
Percentage of successful cases with 25G needle
Percentage of total cases
22
20
18
Mediastinum/hilar 13 Lung (inner) 46 Lung (outer) including pleura 12
2 1 2
2 9 4
– 4 2
17 60 20
82.9 76.6 60.0
17.5 6109 20.6
Total
5
15
6
97
73.2
100
71
202
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203
Table 3 Frequency of pathological diagnosis in relation to needle size Lesions
Needle size
Total
Percent (of total)
25
22
20
18
Malignant lesions Benign lesions Tuberculosis Thyroid colloid nodule Non-tuberculous inflammation Abscess Normal or inconclusive
30 6 4 1 18 3 9
2 – 1 – 2 – 1
5 1 – – 6 2 –
4 1 – – 1 – –
41 8 5 1 27 5 10
42.3 8.2 5.1 1.0 27.8 5.1 10.3
Total
71
6
14
6
97
99.8 ( = 100%)
chest tube insertion. In a study, using a 19G introducer needle followed by a 22G aspirating needle, with a mean of three passes (range 1 – 7), a pneumothorax was present in 18% of cases [4]. Recently a 25% pneumothorax complication was obtained with a 22G needle in 38 elderly people over 70 years of age [11]. In this study, only two cases complicated with pneumothorax required pleural drains, one being discharged the following day. A total of 65% of the patients were discharged within 24 h of FNAs. Haemoptysis was not a problem in this study. In another study, the rate of pneumothorax was reduced from 23 to 13% when the number of aspirates was reduced from three to one [1]. In all of these, chest radiograph was used to assess the pneumothorax. Other procedural complications reported were pulmonary haemorrhage, the most serious and life threatening as well as chest pain or discomfort [4,11,15]. None of these occurred in this study and during follow-up. The patients, as a matter of policy and in accordance with radiation reducing measures of the institution did not have post operative chest radiographs although they were clinically monitored critically for the first 6 h post-operatively. It has been shown that the rate of complications increased significantly with the increasing size of the needle, the increased number of passes [1,3,4] and the absence of the on-site pathologist [17] and in patients with a reduced forced expiratory volume in 1 s [FEVI] [11]. No FEVI studies were done in this study. In this study, the mean number of passes was 1.3 with a range of 1– 6 passes. Size 25G needles were always used first and after a maximum of four passes, bigger sized needles were used. The mean number of passes favourably compares with other studies [10]. Within this period, the total number of passes for each case, and the need to used bigger sized needles has decreased with experience. It is therefore pertinent to conclude that the small needle size in the study was partly if not wholly responsible for the significant absence of post procedural complications.
Other factors which might have contributed to the complication-free procedure of FNA in this study are compliance with the ATS guidelines and the exclusion of contraindicated cases, the constant use of the same and experienced radiologist, and the post operative procedure of lying the patient puncture-site-down for 3 h after the FNA. In all the above quoted studies unlike in this study, pneumothorax was assessed by radiography; and not all of them were severe though a sizeable percentage of pneumothorax as well as bleeding mandated surgical treatment such as underwater drainage [1,3,4,10,15]. Previous experiences have also shown that in the presence of the on-site cytopathologist, the adequacy of the specimen or the diagnostic accuracy of FNA are significantly improved [1,10,18]. It has been shown that the availability of immediate cytology assessment ensures that the number of unsatisfactory and false negative lung FNA are reduced [1]. Ten out of 97 (10.3%) Table 4 Frequency of tumours Benign
Malignant
Type
No
Type
Carcinoid Benign spindle cell tumour Fibroma Lipoma Aspergilloma
2 2
Squamous cell carcinoma Adenocarcinoma
8 7
2 1 1
Spindle cell carcinoma Small cell carcinoma Large cell carcinoma Poorly differentiated carcinoma Recurrent cell carcinoma Malignant lymphoma Malignant mesothelioma Thymic carcinoma Posterior mediastinal malignancy Lymphoma
2 1 7 3
Total
8
Total
No
1 2 1 5 1 3 41
S. Al-Damegh / European Journal of Radiology 37 (2001) 200–203
were either normal or inconclusive despite the presence of on-site pathologist. This 89.7% sensitivity compares favourably with other studies which range from 72 to 97% [19,20]. The choice of which needle to use after a 25G needle was arbitrary. The 20G size was chosen as it was clearly the second largest to 25G. One tried to avoid 22G as it was quite close to the 25G size. The spectrum of diseases shown are as shown by other authors; but the percentage of tumours 42.3% is still less than when compared with other studies [4,13]. In conclusion the use of size 25G needles in FNA has produced very satisfactory results and without any clinical complications whatsoever in the hospital setting; thus reducing patient hospitalization to less than 24 h. The preferential use of this size of needle is therefore advocated. Furthermore, the use of routine postoperative chest radiography can be safely discarded in the absence of relevant clinical signs of pneumothorax or haemorrhage provided the ATS guidelines are complied with. However, further studies are needed to confirm these findings on a wider scale.
5. Furthr reading [16]
References [1] Stewart CJR, Stewart IS. Immediate assessment of fine needle aspiration cytology lung. J Clin Pathol 1996;49:839–43. [2] Padhani AR, Scott W, Cheema M, Erozan YS. The value of immediate cytological evaluation for needle aspiration biopsy. Clin Radiol 1995;50:350–1. [3] De Gregoria Ariza MA, Alfonso Aguiran ER, Villavieja Atance JL, et al. Transthoracic aspiration of biopsy of pulmonary and mediastinal lesions. Eur J Radiol 1991;12:98–103. [4] Boiselle PM, Shepard JO, Mark EJ, et al. Routine addition of an automated biopsy device to give needle aspiration of the lung: a
.
203
prospective assessment. Am J Radiol 1997;169:661– 5. [5] Wescott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137:31– 5. [6] Stanley JH, Fish GD, Andriole JG, et al. Lung lesions: cytologic diagnosis by fine needle biopsy. Radiology 1987;162:389–91. [7] Stewart FW. The diagnosis of tumours by aspiration. Am J Pathol 1933;9:801– 3. [8] Nordenstrom B. A new technique for transthoracic biopsy of lung changes. Br J Radiol 1965;38:550– 3. [9] Zornoza J, Snow J, Lukenan JM, Libshitz HI. Aspiration biopsy of discrete pulmonary lesions using a new thin needle. Radiology 1977;123:519– 20. [10] Santambrogrio L, Nosotti M, Bellaviti N, et al. CT guided fine needle aspiration cytology of solitary pulmonary nodules. Chest 1997;122:423– 5. [11] Brown TS, Kanthanpillai K. Transthoracic needle biopsy for suspected thoracic malignancy in elderly patients using CT guidance. Clin Radiol 1995;53:116– 9. [12] Padhani AR, Scott WW, Cheema M, Kearney D, Erozan YS. The value of immediate cytological evaluation for needle apsiration lung biopsy. Invest Radiol 1997;32:453– 8. [13] Rio FG, Lobato SD, Pino JM, et al. Value of CT-guided fine needle aspiration in solitary pulmonary nodules with negative fiberoptic bronchoscopy. Acta Radiol 1994;35:478– 80. [14] Silvestri G, Hoffman BJ, Bhutani MS. Endoscopic ultrasound with fine needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg 1996;61:1441– 6. [15] Man A, Schwarz Y, Greif J. Case report: cardiac tampernade following fine needle aspiration (FNA) of a mediastinal mass. Clin Radiol 1998;53:151– 2. [16] Sokoilowski JW, Jr, Burker L, Jones FLJr, Patterson JR, Selecky PA. Guidelines for percutaneous transthoracic needle biopsy. Am Rev Respir Dis 1989;140:255. [17] Klein JS, Solomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20G. Automated cutting needle: results in 122 patients. Radiology 1996;198:715– 20. [18] Austin JHM, Chohen B. Value of having a cytopathologist present during percutaneous fine needle aspiration biopsy of the lung: report of 55 cancer patients and meta analysis of the literature. Am J Radiol 1993;160:175– 7. [19] Lauby VW, Burnett WE, Rosemond GP, Tysoin RR. Value and risk of biopsy of pulmonary leisons by needle aspiration: twenty one years experience. J Thorac Cardiovasc Surg 1965;49:159–72. [20] Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137:31– 5.