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Percutaneous aspiration biopsy of malignant lung lesions using the Chiba needle. An initial experience
Clin. Radiol. (1978) 29, 617-619 PERCUTANEOUS ASPIRATION BIOPSY OF MALIGNANT LUNG LESIONS USING THE CHIBA NEEDLE. AN INITIAL EXPERIENCE WAH SENG CHIN and IVY SNG TSUN YEE
From the Departments o f Diagnostic Radiology and Pathology, Singapore General Hospital, Outram Road, Singapore 3 The fine gauge Chiba needle was evaluated in percutaneous aspiration biopsy in 20 patients with suspected malignant lung neoplasm. Adequate aspirate can be obtained with one biopsy. A confident cytological diagnosis of malignancy was made in 19 out of 20 patients. Most of the patients were elderly. Nine patients developed pneumothoraces which were small and asymptomatic. The needle is easy to handle and very acceptable to patients. This needle therefore appears to be very suitable for percutaneous aspiration biopsy of lung neoplasms and possibly other non-neoplastic lesions too. It promises to supersede the larger aspiration needles currently in use.
INTRODUCTION Percutaneous needle biopsy of lung lesions is an accepted diagnostic procedure. But it has not become an accepted routine procedure partly because of a natural reluctance to cut, drill or aspirate lung tissue with relatively large needles. Needle sizes of 16F to 20F gauge are presently used for aspiration biopsy (Stevens et al., 1968; Sargent et al., 1974). It was felt that a simple fine gauge needle would be much more attractive to radiologists and referring clinicians if it gave as good or better diagnostic yield and was safer than the current larger aspiration needles. We wish to report our initial experience in using the fine Chiba beedle (Okuda et al., 1974) for cytological diagnosis of suspected malignant lung neoplasm. PATIENTS The need to confirm malignancy in a pulmonary lesion is a very frequent problem and particularly important in high surgical risk patients. For the purpose of evaluation of the Chiba needle, all patients suspected of having a malignant lung lesion were biopsied in the period June to October 1977. There was no selection and all patients referred were accepted. There were 20 patients: 15 males and 5 females, with ages ranging from 43 to 77 years; 14 were above 50 years and 9 above 60 years. The lesions varied in size. Of the solitary tumours, seven were 2 - 4 cm in diameter, seven were 4 - 6 cm and two were 6 - 8 cm. Three presented as innumerable small discrete opacities. There was one right upper lobe collapse-consolidation; biopsy of the occluded bronchus was performed.
Regarding the location of tile lesions biopsied, two were apical (right and left), four right upper zone, four right mid zone, three right lower zone, two left upper zone, two left mid zone, one left lower zone, one right hilum and one right superior paramediastinum. METHOD The Chiba needle is a simple thin-walled flexible 23F gauge needle of stainless steel, with an outer diameter of 0.7 mm, inner diameter of 0.5 mm and a bevel angle of 30 °. The 20 cm needle was used in preference to the 15 cm model. The lesion is localised by radiography and single plane fluoroscopy. A direct vertical approach is used in the supine or prone position. The lateral position was used once for a peripheral right mid zone lesion. Apical cap lesions are biopsied in the prone position to avoid brachial plexus injury. A point is marked on the skin directly over the lesion after fluoroscopic localisation. Following local anaesthetic infiltration of the skin and chest wall, a small stab wound is made to facilitate entry of the needle. During suspended respiration, the needle is advanced vertically down in a smooth swift manner. Intermittent fluoroscopy may be utilised to aid straight passage of the needle. Respiration is suspended whenever the needle is advanced or withdrawn. The depth is estimated from radiography or tomography and contact with the lesion confirmed by a change in resistance and by utilising the principle of parallax. The stylet is removed and a 20 ml plastic syringe is attached to the needle. Strong manual suction is applied as the needle is moved back and forth v~ith rotation four to five times over a distance of 1 - 3 cm
618
CLINICAL
RADIOLOGY
depending on the size of the lesion. Suction is then released and the needle removed. For innumerable small lesions, the needle is advanced into-the most concentrated area. The aspirate obtained is quickly smeared on glass slides and fixed in 95% ethyl alcohol. The direct smears were stained with Papanicolaou stains and were cytologically screened for malignant cells. On a few occasions, the aspirate appeared chunky enough for cell blocks but this was not attempted. Erect frontal view of the chest was taken immediately after biopsy, at 4 h and finally at 24 h before discharge from hospital.
The aspirate was adequate and a confident cytologic diagnosis of malignancy was made in 19 out of 20 patients (Table 1). Attempts at turnout typing where primary lung carcinoma was suspected were made (Kreyberg, 1967). Figs 1 and 2 show specimens from two patients. The sample usually showed an abundance of malignant cells. Although the recognition of malignant cells was relatively simple, the typing of the tumour was not always easily possible. Well differentiated squamous cell carcinoma was readily recognisable as was the small cell anaplastic carcinoma (oat cell type). Large cell anaplastic carcinoma was only definitely identified when single cancer cells were found with some keratinising features (Koss, 1968). Otherwise the tumour could not morphologically be distinguished from a poorly differentiated adenocarcinoma. In the one case with negative result there were features of an inflammatory reaction. The majority (15 patients) had only one biopsy and only one patient required three biopsies to produce a presentable aspirate. One patient had the procedure terminated prematurely because of persistent coughing when the needle entered her lung but the biopsy was uneventful a week later. Some of the large tumours gave slight pressure sensation associated with a tendency to cough during the actual biopsy. The procedure was almost painless and very acceptable by all. Table 1 - Aspiration biopsy results according to tumour type
Cases
Squamous cell carcinoma Large cell anaplastic carcinoma Small cell anaplastic carcinoma Undifferentiated carcinoma Total
%
lk
Fig. 1 - Undifferentiated carcinoma showing clumps of malignant cells. Pulmonary metastases from a nasopharyngeal carcinoma (X 200).
RESULTS
Histological type
m
19
Fig. 2 - Keratinising malignant squamous cells. Well differentiated squamous cell carcinoma (X 200). Nine patients developed a pneumothorax. All the pneumothoraces were asymptomatic. They were very small and apical except two which were of moderate size. One patient suffered temporary hypotension from a vaso-vagal reaction. No other complication was encountered. DISCUSSION
The thin 23 gauge Chiba needle now widely used in percutaneous transhepatic cholangiography has also been used in aspiration biopsy of retroperitoneal lymph nodes (Zornoza et aL, 1977a, c) and abdominal masses (Goldstein et al., 1977; Zornoza et al., 1977c). Being so slender it might appear difficult to control and the aspirate insufficient for a confident cytological diagnosis. However the fine gauge should be less traumatic, and fewer complications should be expected. Selection of patients can then be less restricted and more than one attempt at biopsy permitted. Our initial experience shows that control of the needle is not difficult. The aspirate was adequate and
PERCUTANEOUS ASPIRATION BIOPSY USING THE CHIBA NEEDLE a cytologic diagnosis of malignancy was made in 19 out of 20 cases. The pneumothorax occurrence was 9 out of 20 (comparable with that in the literature) but all were asymptomatic and none required treatment. No other complication was encountered. The procedure was very well tolerated b y all patients. This experience supports strongly the work of Zornoza et al., (1977b) who published the first and only report on percutaneous lung biopsy using the Chiba needle. Of 100 cases with discrete lung lesions, they reported a diagnostic accuracy (histological and bacteriological) o f 87% and a pneumothorax rate of 14%. Our smaller series restricted to confirming the suspicion of malignant lung lesions by cytology was very successful. We are therefore very encouraged to continue the use o f this needle and to include other pulmonary lesions for investigation. CONCLUSION Percutaneous aspiration biopsy of lung malignancy using the Chiba needle is simple and effective. A diagnostic accuracy of 19 out of 20 patients was obtained. The fine gauge of the needle appears to prevent s y m p t o m a t i c pneumothoraces. The needle is recommended for wider usage in investigating malignant lung lesions.
619
REFERENCES Goldstein, H. M., Zornoza, J., Wallace, S., Anderson, J. H., Bree, R, L., Samuels, B. I. & Lukeman, J. (1977). Percutaneous fine needle aspiration biopsy of pancreatic and other abdominal masses. Radiology, 123, 319-322. Koss, L. (1968). Diagnostic Cytology and its Histopathologic Bases. J. B. Lippincott. Kreyberg, L. (1967). Histological typing of lung tumours. International Histological Classification of Tumours No. 1, World Health Organisation, Geneva. Okuda, K. et al. (1974). Non-surgical, percutaneous transhepatic cholangiography - diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 26. Sargent, E. N., Turner, A. F., Gordonson, J., Schwinn, C. P. & Pashky, O. (1974). Percutaneous pulmonary needle biopsy. Report of 350 patients. American Journal of Roentgenology, 122, 758-768. Stevens, G. M., Weigen, J. F. & Lillington, G. A. (1968). Needle aspiration biopsy of localised pulmonary lesions with amplified fluoroscopic guidance. American Journal ofRonetgenology, 103, 561-571. Zornoza, J., Wallace, S., Goldstein, H. M., Lukeman, J. M. & Bao-Shan Jing (1977a). Transperitoneal percutaneous retroperitoneat lymph node aspkation biopsy. Radiology, 122, 111-115. Zornoza, J., Snow, J., Lukeman, J. M. & Libshitz, H. I. (1977b). Aspiration needle biopsy of discrete pulmonary lesions using a new thin needle. Radiology, 123, 519-520. Zornoza, J., Jonsson, K., Wallace, S. & Lukeman, J. M. (1977c). Fine needle aspiration biopsy of retroperitoneal lymph nodes and abdominal masses: an updated report. Radiology, 125, 87-88.
From the Departments o f Diagnostic Radiology and Pathology, Singapore General Hospital, Outram Road, Singapore 3 The fine gauge Chiba needle was evaluated in percutaneous aspiration biopsy in 20 patients with suspected malignant lung neoplasm. Adequate aspirate can be obtained with one biopsy. A confident cytological diagnosis of malignancy was made in 19 out of 20 patients. Most of the patients were elderly. Nine patients developed pneumothoraces which were small and asymptomatic. The needle is easy to handle and very acceptable to patients. This needle therefore appears to be very suitable for percutaneous aspiration biopsy of lung neoplasms and possibly other non-neoplastic lesions too. It promises to supersede the larger aspiration needles currently in use.
INTRODUCTION Percutaneous needle biopsy of lung lesions is an accepted diagnostic procedure. But it has not become an accepted routine procedure partly because of a natural reluctance to cut, drill or aspirate lung tissue with relatively large needles. Needle sizes of 16F to 20F gauge are presently used for aspiration biopsy (Stevens et al., 1968; Sargent et al., 1974). It was felt that a simple fine gauge needle would be much more attractive to radiologists and referring clinicians if it gave as good or better diagnostic yield and was safer than the current larger aspiration needles. We wish to report our initial experience in using the fine Chiba beedle (Okuda et al., 1974) for cytological diagnosis of suspected malignant lung neoplasm. PATIENTS The need to confirm malignancy in a pulmonary lesion is a very frequent problem and particularly important in high surgical risk patients. For the purpose of evaluation of the Chiba needle, all patients suspected of having a malignant lung lesion were biopsied in the period June to October 1977. There was no selection and all patients referred were accepted. There were 20 patients: 15 males and 5 females, with ages ranging from 43 to 77 years; 14 were above 50 years and 9 above 60 years. The lesions varied in size. Of the solitary tumours, seven were 2 - 4 cm in diameter, seven were 4 - 6 cm and two were 6 - 8 cm. Three presented as innumerable small discrete opacities. There was one right upper lobe collapse-consolidation; biopsy of the occluded bronchus was performed.
Regarding the location of tile lesions biopsied, two were apical (right and left), four right upper zone, four right mid zone, three right lower zone, two left upper zone, two left mid zone, one left lower zone, one right hilum and one right superior paramediastinum. METHOD The Chiba needle is a simple thin-walled flexible 23F gauge needle of stainless steel, with an outer diameter of 0.7 mm, inner diameter of 0.5 mm and a bevel angle of 30 °. The 20 cm needle was used in preference to the 15 cm model. The lesion is localised by radiography and single plane fluoroscopy. A direct vertical approach is used in the supine or prone position. The lateral position was used once for a peripheral right mid zone lesion. Apical cap lesions are biopsied in the prone position to avoid brachial plexus injury. A point is marked on the skin directly over the lesion after fluoroscopic localisation. Following local anaesthetic infiltration of the skin and chest wall, a small stab wound is made to facilitate entry of the needle. During suspended respiration, the needle is advanced vertically down in a smooth swift manner. Intermittent fluoroscopy may be utilised to aid straight passage of the needle. Respiration is suspended whenever the needle is advanced or withdrawn. The depth is estimated from radiography or tomography and contact with the lesion confirmed by a change in resistance and by utilising the principle of parallax. The stylet is removed and a 20 ml plastic syringe is attached to the needle. Strong manual suction is applied as the needle is moved back and forth v~ith rotation four to five times over a distance of 1 - 3 cm
618
CLINICAL
RADIOLOGY
depending on the size of the lesion. Suction is then released and the needle removed. For innumerable small lesions, the needle is advanced into-the most concentrated area. The aspirate obtained is quickly smeared on glass slides and fixed in 95% ethyl alcohol. The direct smears were stained with Papanicolaou stains and were cytologically screened for malignant cells. On a few occasions, the aspirate appeared chunky enough for cell blocks but this was not attempted. Erect frontal view of the chest was taken immediately after biopsy, at 4 h and finally at 24 h before discharge from hospital.
The aspirate was adequate and a confident cytologic diagnosis of malignancy was made in 19 out of 20 patients (Table 1). Attempts at turnout typing where primary lung carcinoma was suspected were made (Kreyberg, 1967). Figs 1 and 2 show specimens from two patients. The sample usually showed an abundance of malignant cells. Although the recognition of malignant cells was relatively simple, the typing of the tumour was not always easily possible. Well differentiated squamous cell carcinoma was readily recognisable as was the small cell anaplastic carcinoma (oat cell type). Large cell anaplastic carcinoma was only definitely identified when single cancer cells were found with some keratinising features (Koss, 1968). Otherwise the tumour could not morphologically be distinguished from a poorly differentiated adenocarcinoma. In the one case with negative result there were features of an inflammatory reaction. The majority (15 patients) had only one biopsy and only one patient required three biopsies to produce a presentable aspirate. One patient had the procedure terminated prematurely because of persistent coughing when the needle entered her lung but the biopsy was uneventful a week later. Some of the large tumours gave slight pressure sensation associated with a tendency to cough during the actual biopsy. The procedure was almost painless and very acceptable by all. Table 1 - Aspiration biopsy results according to tumour type
Cases
Squamous cell carcinoma Large cell anaplastic carcinoma Small cell anaplastic carcinoma Undifferentiated carcinoma Total
%
lk
Fig. 1 - Undifferentiated carcinoma showing clumps of malignant cells. Pulmonary metastases from a nasopharyngeal carcinoma (X 200).
RESULTS
Histological type
m
19
Fig. 2 - Keratinising malignant squamous cells. Well differentiated squamous cell carcinoma (X 200). Nine patients developed a pneumothorax. All the pneumothoraces were asymptomatic. They were very small and apical except two which were of moderate size. One patient suffered temporary hypotension from a vaso-vagal reaction. No other complication was encountered. DISCUSSION
The thin 23 gauge Chiba needle now widely used in percutaneous transhepatic cholangiography has also been used in aspiration biopsy of retroperitoneal lymph nodes (Zornoza et aL, 1977a, c) and abdominal masses (Goldstein et al., 1977; Zornoza et al., 1977c). Being so slender it might appear difficult to control and the aspirate insufficient for a confident cytological diagnosis. However the fine gauge should be less traumatic, and fewer complications should be expected. Selection of patients can then be less restricted and more than one attempt at biopsy permitted. Our initial experience shows that control of the needle is not difficult. The aspirate was adequate and
PERCUTANEOUS ASPIRATION BIOPSY USING THE CHIBA NEEDLE a cytologic diagnosis of malignancy was made in 19 out of 20 cases. The pneumothorax occurrence was 9 out of 20 (comparable with that in the literature) but all were asymptomatic and none required treatment. No other complication was encountered. The procedure was very well tolerated b y all patients. This experience supports strongly the work of Zornoza et al., (1977b) who published the first and only report on percutaneous lung biopsy using the Chiba needle. Of 100 cases with discrete lung lesions, they reported a diagnostic accuracy (histological and bacteriological) o f 87% and a pneumothorax rate of 14%. Our smaller series restricted to confirming the suspicion of malignant lung lesions by cytology was very successful. We are therefore very encouraged to continue the use o f this needle and to include other pulmonary lesions for investigation. CONCLUSION Percutaneous aspiration biopsy of lung malignancy using the Chiba needle is simple and effective. A diagnostic accuracy of 19 out of 20 patients was obtained. The fine gauge of the needle appears to prevent s y m p t o m a t i c pneumothoraces. The needle is recommended for wider usage in investigating malignant lung lesions.
619
REFERENCES Goldstein, H. M., Zornoza, J., Wallace, S., Anderson, J. H., Bree, R, L., Samuels, B. I. & Lukeman, J. (1977). Percutaneous fine needle aspiration biopsy of pancreatic and other abdominal masses. Radiology, 123, 319-322. Koss, L. (1968). Diagnostic Cytology and its Histopathologic Bases. J. B. Lippincott. Kreyberg, L. (1967). Histological typing of lung tumours. International Histological Classification of Tumours No. 1, World Health Organisation, Geneva. Okuda, K. et al. (1974). Non-surgical, percutaneous transhepatic cholangiography - diagnostic significance in medical problems of the liver. American Journal of Digestive Diseases, 19, 21 26. Sargent, E. N., Turner, A. F., Gordonson, J., Schwinn, C. P. & Pashky, O. (1974). Percutaneous pulmonary needle biopsy. Report of 350 patients. American Journal of Roentgenology, 122, 758-768. Stevens, G. M., Weigen, J. F. & Lillington, G. A. (1968). Needle aspiration biopsy of localised pulmonary lesions with amplified fluoroscopic guidance. American Journal ofRonetgenology, 103, 561-571. Zornoza, J., Wallace, S., Goldstein, H. M., Lukeman, J. M. & Bao-Shan Jing (1977a). Transperitoneal percutaneous retroperitoneat lymph node aspkation biopsy. Radiology, 122, 111-115. Zornoza, J., Snow, J., Lukeman, J. M. & Libshitz, H. I. (1977b). Aspiration needle biopsy of discrete pulmonary lesions using a new thin needle. Radiology, 123, 519-520. Zornoza, J., Jonsson, K., Wallace, S. & Lukeman, J. M. (1977c). Fine needle aspiration biopsy of retroperitoneal lymph nodes and abdominal masses: an updated report. Radiology, 125, 87-88.