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Ultrasonically Guided Percutaneous Biopsy of Peripheral Pulmonary Masses
Ultrasonically Guided Percutaneous Biopsy of Peripheral Pulmonary Masses* Arcot ]. Chandrasekhar, M.D., F.C.C.P.;•• Carlos]. Reynes, M.D.;t and Robert]. Churchill, M.D.t
UltrasooicaDy guided percutaneous biopsy aud aspiration of sofid aud cystic structures In the abdomen, neck, aud pericardial space are common practice. The technique may be utiHzed for biopsy of periphenl pulmonary masses iu contact with the chest wall, iu order to assure accurate placement of the needle lu the center of the
mass, reduce the risk of pneumothorax, aud eliminate the exposure to radiation that occurs with fluoroscopic guidauce. Four patients had successful biopsies In this man• ner, without complications. Histologic studies revealed maUguaut neoplasm in three aud Upoid pneumonia In one.
percutaneous biopsy of the lung is used as a diagnostic tool in evaluating diffuse pulmonary disease, coin lesions, and masses situated close to the chest wall. Fluoroscopic guidance is not used for biopsy in diffuse parenchymal disease but is required to guide the needle in percutaneous biopsy of deep pulmonary lesions. Biopsies of masses close to the chest wall may be obtained blindly if there are clinical signs of chest-wall extension, such as tendemes~ or swelling, or with Huoroscopic localization. Ultrasound is employed for localization of masses, both cystic and solid, in various organs and is utilized for biopsy or aspiration of loculated pleural Huid, 1 pericardia! effusion, 2 thyroid cysts, 3 liver, 4 pancreas, 5 renal cysts, 6 and amniotic Huid. 7 This report describes percutaneous needle biopsy of pulmonary masses in contact with the chest wall, using ultrasonic guidance.
chest were obtained over the area of the mass. Sonic transmission into the mass occurred at the point of attachment to the chest wall, and a B-scan representation of the mass was recorded on the CRT screen. The size of the lesion was measured by means of calibrated markers on the screen or hard-copy printout with A or B modes. Permanent photographic records could also be obtained. Finally, the skin overlying the lesion was appropriately marked. The skin was prepared and then infiltrated with a local anesthetic agent. Sterile mineral oil was applied, and the mass was localized again with a sterile biopsy transducer.s Distances from the skin to the anterior and posterior surfaces of the mass were again measured through the overlying rib interspace using the A-mode scan. We used a disposable biopsy needle (Vim). It consisted of an outer sheath and an inner needle that extends 2.8 em beyond the end of the sheath in the open position. The distance from the edge of the lesion in contact with the chest wall to the skin surface was measured and added to the height of the biopsy transducer ( 2 em ) . This distance was measured with a sterile ruler on the needle, and a mark was placed on the outer sheath. A needle stop was put on the sheath 2.8 em above this mark. To obtain the biopsy of the lesion, the open needle was passed through the central canal of the biopsy transducer to the level of the first mark and could be simultaneously observed on the A-mode scan in homogeneous lesions. The outer cutting sheath was then advanced over the needle to the needle stop ( 2.8 em ) , and then the whole unit was withdrawn. Measurements should be appropriately adjusted for smaller lesions to ensure that the needle does not pass completely through them. Achest x-ray film was routinely taken after the biopsy.
MATERIALS AND METIIODS
Four patients with masses judged to be close to the chest wall on conventional chest x-ray films were selected for biopsy. A tissue diagnosis was essential for proper management. A commercial ultrasonic unit with A-mode, B-mode, and M-mode capabilities utilizing a 2.25-MHz transducer was employed. Bistable scans were obtained prior to the development of gray-scale equipment. After application of a coupling agent ( mineral oil ) , longitudinal and transverse scans of the °From the Departments of Medicine and Radiology, Loyola University, Stritch School of Medicine and Foster G. McGaw Hospital, Maywood Ill. •• Associate Professor of Medlcine and Chief, Division of Pulmonary Medicine. tAssociate Professor of Radiology and Director, Division of Ultrasound. ":j:Fellow in Ultrasound. Manuscript received April 6; revision accepted May 24. Reprint requests: Dr. Reynes, Loyola University Hospital, 2160 South First, Maywood, Illinois 60153
CHEST, 70: 5, NOVEMBER, 1976
RESULTS
Four patients had successful biopsies using ultrasonic guidance. Multiple specimens were obtained in each patient. Each specimen was approximately 2 em long and 0.2 em in diameter. None of the patients developed hemoptysis or pneumothorax following the procedure. The diagnosis of a malignant ULTRASONICALLY GUIDED PERCUTANEOUS BIOPSY 627
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neoplasm was established in three patients. In one patient the tissue obtained did not reveal malignant cells.
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CASE! A 54-year-old man with a 70 pack-year smoking history complained of left scapular pain for six months. A chest x-ray film revealed a mass in the apical posterior segment of the left upper lobe. The initial needle biopsy was performed without the assistance of Huoroscopic or ultrasonic guidance at the area of point tenderness of the chest wall. Evidently the needle was not placed in the mass of the tumor because the specimen consisted of fibroadipose tissue. A second biopsy was obtained with ultrasonic guidance (Fig 1) and revealed adenocarcinoma. CASE2 A 54-year-old woman with a 30 pack-year smoking history who had had a stage-3 carcinoma of the cervix two years previously and had received radiation therapy now had pain in the left shoulder of two months' duration. Acavitating mass in the left apex was seen on the chest x-ray film. A biopsy of the mass was obtained with ultrasonic guidance, without complications. The specimen revealed nonkeratinizing squamous cell carcinoma (probably primary) in the lung.
FiGURE 1. Longitudinal (A, top) and transverse ( B, bottom) scans showing mass ( m) and electronic measuring device advanced to distal wall of mass (arrow). Areas of lack of sound penetration represent lung (case 1 ) .
CASE3
A 71-year-old man had had weakness in the left arm foc three weeks. Physical examination revealed
FIGURE 2. Posteroanterior (A, left) and lateral ( B, right) chest x-ray films reveal mass in posterior segment of right lower lobe (case 3).
821 CHAJIDRASEKHAR, REYNES, CHURCHILL
CHEST, 70: 5, NOVEMBER, 1976
3A. B-scan ultrasonogram showing mass ( M) and normal lung ( 1). Note reverberation echoes behind posterior border of mass created by posterior border-lung interface (case3). FIGURE
paresis of the left arm and a positive Hoffmann's sign. Pathologic toe signs were present on the left as well, and a computer assisted, tomographic scan r~ vealed multiple lesions in the brain compatible with metastasis. The chest x-ray film disclosed a mass in the right lower lobe (Fig 2). Biopsy was performed with ultrasonic guidance (Fig 3) and revealed anaplastic small cell carcinoma.
CASE4 A 69-year-old man with a 50 pack-year smoking history and previous exposure to silica and asbestos had had weight loss and fatigability for two months. Clubbing was noted on physical examination. A chest x-ray film disclosed a mass in the right middle lobe, pleural thickening, and calcification of the parietal pleura. Percutaneous biopsy with ultrasonic guidance was attempted first, since it was believed that this was a simpler procedure and would be better tolerated by the patient than bronchoscopic examination; however, the specimen revealed lipoid pneumonia. Bronchoscopic examination was then performed. and obstruction of the middle lobe bronchus was observed. Class-4 cells were obtained with bronchial brushing. It was believed that the lipoid pneumonia occurred distal to an obstructing lesion. Anaplastic squamous cell carcinoma and asbestosis were found at surgery. DiscuSSION
Ultrasonically guided percutaneous needle biopsy of pulmonary masses in contact with the chest wall is a safe, simple procedure in our experience and offers distinct advantages over biopsy performed CHEST, 70: 5, NOVEMBER, 1976,
FIGURE 3B. A-mode ultrasonogram of mass performed with biopsy transducer prior to insertion of needle. Echo-free space towards left part of scan represents mass at point chosen for biopsy. 3C. A-mode scan taken at time of biopsy demonstrates echo produced by tip af needle ( N ) within mass (case 3) .
blindly or with fluoroscopic guidance. Ideally, the biopsy needle should pass through the chest wall directly into the mass without passing through interposed aerated lung, as this reduces the risk of pneumothorax. It is also advantageous to simultaneously visualize the anterior and posterior walls of the mass and the .needle tip during the procedure to ensure proper placement of the needle within the mass. Ultrasound fulfills these criteria without exposure to radiation and, in addition, offers the advantage of working in a well-lighted setting with the patient and physician in comfortable positions. The mass must be in contact with the chest wall at some point to be defined with ultrasound. since the interface between the pleura and the lung is an acoustical barrier. Biopsy was occasionally performed blindly in the past if there were clinical signs of involvement of the chest wall. In many instances, neoplastic tissue w~ ULTRASONICALLY GUIDED PERCUTANEOUS BIOPSY 629
obtained; however, one was never sure if the mass was entered or how far to advance the needle. Fluoroscopic observation may not permit an unobstructed view of the mass in two planes to assure precise placement of the needle. There is also a chance of passing the needle through interposed aerated lung with fluoroscopic guidance, since the .exact point of contact between the mass and the chest wall is difficult to ascertain. In addition to the exposure to radiation, it is often technically difficult to manipulate the needle with the fluoroscopic unit ~position.
In most cases, we do not recommend localizing the mass in the ultrasound department and sending the patient to the floor for biopsy. This may result in negative findings on the biopsy, especially if the mass is apically located, since a change in the position of the shoulder can move the skin so that the mark does not overlie the lesion; however, this is less likely to occur with lesions located in the lower portion of the lung. Since the mass and the needle are visualized throughout the procedure with ultrasonic guidance, we recommend that the biopsy be performed in the ultrasound department. One biopsy specimen did not reveal neoplasm
(case 4) . We do not consider this to be a failure of the procedure, since a biopsy of the mass was obtained. The mass that was in contact with the chest wall was verified as an area of lipoid pneumonia that had developed distal to an obstructing bronchogenic carcinoma.
1 Sandweiss DA, Hanson JC, Gosink BB : Untrasound tn diagnosis, localization, and treatment of loculated pleural empyema. Ann Intern Med 82:50-53, 1975 2 Goldberg BB, Pollack HM : Ultrasonically guided pericardiocentesis. Am J Cardiol31 :490, 1973 3 Miskin M, Rosen IB, Walflsh PC: Ultrasonography of the thyroid gland. Radiol Clin North Am 13:479-492, 1975 4 Rasmussen SN, Holm HH, Kristensen JK, et al: Ultrasonically guided liver biopsy. Br Med J 2:500, 1972 5 Smith EH, Bartrum RJ, Chang YC: Ultrasonically guided percutaneous aspiration biopsy of the pancreas. Radiology 112:737-738, 1974 6 Doust BD, Maklad NF: Control of renal cyst puncture by transverse ultrasonic B scanning. Radiology 109:679-681, 1973 7 Rampone JF, Sanders RC, Niebyl JR: Ultrasonic aspiration transducer for management of Rh incompatibility. Obstet Gynecol43 :780, 1974 8 Goldberg BB, Pollack HM: Ultrasonic aspiration transducer. Radiology 102:187-189, 1972
Long-Distance Travelers Champion among migrant birds is the Arctic tern. Every year this delicate relative of the gulls flies in autumn from its nesting grounds within the arctic circle to spend the southern winter on the shores of the Antarctic Ocean, at the opposite end of the globe. When the Antarctic ice begins to melt in spring, the terns wing their way back to the distant north to breed. This amazing journey, from one pole to another and back
630 CHANDRASEKHAR, REYNES, CHURCHILL
again, is over 22,000 miles long. The Arctic tern sees the sun for a longer time each year than any other animal on earth-it spends about eight months of the year in constant daylight, and sees more daylight than darkness in the remaining four months. Jarman C: Atlas of Animal Migration, New York, John Day, 1972
CHEST, 70: 5, NOVEMBER, 1976
UltrasooicaDy guided percutaneous biopsy aud aspiration of sofid aud cystic structures In the abdomen, neck, aud pericardial space are common practice. The technique may be utiHzed for biopsy of periphenl pulmonary masses iu contact with the chest wall, iu order to assure accurate placement of the needle lu the center of the
mass, reduce the risk of pneumothorax, aud eliminate the exposure to radiation that occurs with fluoroscopic guidauce. Four patients had successful biopsies In this man• ner, without complications. Histologic studies revealed maUguaut neoplasm in three aud Upoid pneumonia In one.
percutaneous biopsy of the lung is used as a diagnostic tool in evaluating diffuse pulmonary disease, coin lesions, and masses situated close to the chest wall. Fluoroscopic guidance is not used for biopsy in diffuse parenchymal disease but is required to guide the needle in percutaneous biopsy of deep pulmonary lesions. Biopsies of masses close to the chest wall may be obtained blindly if there are clinical signs of chest-wall extension, such as tendemes~ or swelling, or with Huoroscopic localization. Ultrasound is employed for localization of masses, both cystic and solid, in various organs and is utilized for biopsy or aspiration of loculated pleural Huid, 1 pericardia! effusion, 2 thyroid cysts, 3 liver, 4 pancreas, 5 renal cysts, 6 and amniotic Huid. 7 This report describes percutaneous needle biopsy of pulmonary masses in contact with the chest wall, using ultrasonic guidance.
chest were obtained over the area of the mass. Sonic transmission into the mass occurred at the point of attachment to the chest wall, and a B-scan representation of the mass was recorded on the CRT screen. The size of the lesion was measured by means of calibrated markers on the screen or hard-copy printout with A or B modes. Permanent photographic records could also be obtained. Finally, the skin overlying the lesion was appropriately marked. The skin was prepared and then infiltrated with a local anesthetic agent. Sterile mineral oil was applied, and the mass was localized again with a sterile biopsy transducer.s Distances from the skin to the anterior and posterior surfaces of the mass were again measured through the overlying rib interspace using the A-mode scan. We used a disposable biopsy needle (Vim). It consisted of an outer sheath and an inner needle that extends 2.8 em beyond the end of the sheath in the open position. The distance from the edge of the lesion in contact with the chest wall to the skin surface was measured and added to the height of the biopsy transducer ( 2 em ) . This distance was measured with a sterile ruler on the needle, and a mark was placed on the outer sheath. A needle stop was put on the sheath 2.8 em above this mark. To obtain the biopsy of the lesion, the open needle was passed through the central canal of the biopsy transducer to the level of the first mark and could be simultaneously observed on the A-mode scan in homogeneous lesions. The outer cutting sheath was then advanced over the needle to the needle stop ( 2.8 em ) , and then the whole unit was withdrawn. Measurements should be appropriately adjusted for smaller lesions to ensure that the needle does not pass completely through them. Achest x-ray film was routinely taken after the biopsy.
MATERIALS AND METIIODS
Four patients with masses judged to be close to the chest wall on conventional chest x-ray films were selected for biopsy. A tissue diagnosis was essential for proper management. A commercial ultrasonic unit with A-mode, B-mode, and M-mode capabilities utilizing a 2.25-MHz transducer was employed. Bistable scans were obtained prior to the development of gray-scale equipment. After application of a coupling agent ( mineral oil ) , longitudinal and transverse scans of the °From the Departments of Medicine and Radiology, Loyola University, Stritch School of Medicine and Foster G. McGaw Hospital, Maywood Ill. •• Associate Professor of Medlcine and Chief, Division of Pulmonary Medicine. tAssociate Professor of Radiology and Director, Division of Ultrasound. ":j:Fellow in Ultrasound. Manuscript received April 6; revision accepted May 24. Reprint requests: Dr. Reynes, Loyola University Hospital, 2160 South First, Maywood, Illinois 60153
CHEST, 70: 5, NOVEMBER, 1976
RESULTS
Four patients had successful biopsies using ultrasonic guidance. Multiple specimens were obtained in each patient. Each specimen was approximately 2 em long and 0.2 em in diameter. None of the patients developed hemoptysis or pneumothorax following the procedure. The diagnosis of a malignant ULTRASONICALLY GUIDED PERCUTANEOUS BIOPSY 627
l
...
~,. ~., · .
,....;...
..:..
~~ ;::>~
~ ~-....
neoplasm was established in three patients. In one patient the tissue obtained did not reveal malignant cells.
..
..
·A
CASE! A 54-year-old man with a 70 pack-year smoking history complained of left scapular pain for six months. A chest x-ray film revealed a mass in the apical posterior segment of the left upper lobe. The initial needle biopsy was performed without the assistance of Huoroscopic or ultrasonic guidance at the area of point tenderness of the chest wall. Evidently the needle was not placed in the mass of the tumor because the specimen consisted of fibroadipose tissue. A second biopsy was obtained with ultrasonic guidance (Fig 1) and revealed adenocarcinoma. CASE2 A 54-year-old woman with a 30 pack-year smoking history who had had a stage-3 carcinoma of the cervix two years previously and had received radiation therapy now had pain in the left shoulder of two months' duration. Acavitating mass in the left apex was seen on the chest x-ray film. A biopsy of the mass was obtained with ultrasonic guidance, without complications. The specimen revealed nonkeratinizing squamous cell carcinoma (probably primary) in the lung.
FiGURE 1. Longitudinal (A, top) and transverse ( B, bottom) scans showing mass ( m) and electronic measuring device advanced to distal wall of mass (arrow). Areas of lack of sound penetration represent lung (case 1 ) .
CASE3
A 71-year-old man had had weakness in the left arm foc three weeks. Physical examination revealed
FIGURE 2. Posteroanterior (A, left) and lateral ( B, right) chest x-ray films reveal mass in posterior segment of right lower lobe (case 3).
821 CHAJIDRASEKHAR, REYNES, CHURCHILL
CHEST, 70: 5, NOVEMBER, 1976
3A. B-scan ultrasonogram showing mass ( M) and normal lung ( 1). Note reverberation echoes behind posterior border of mass created by posterior border-lung interface (case3). FIGURE
paresis of the left arm and a positive Hoffmann's sign. Pathologic toe signs were present on the left as well, and a computer assisted, tomographic scan r~ vealed multiple lesions in the brain compatible with metastasis. The chest x-ray film disclosed a mass in the right lower lobe (Fig 2). Biopsy was performed with ultrasonic guidance (Fig 3) and revealed anaplastic small cell carcinoma.
CASE4 A 69-year-old man with a 50 pack-year smoking history and previous exposure to silica and asbestos had had weight loss and fatigability for two months. Clubbing was noted on physical examination. A chest x-ray film disclosed a mass in the right middle lobe, pleural thickening, and calcification of the parietal pleura. Percutaneous biopsy with ultrasonic guidance was attempted first, since it was believed that this was a simpler procedure and would be better tolerated by the patient than bronchoscopic examination; however, the specimen revealed lipoid pneumonia. Bronchoscopic examination was then performed. and obstruction of the middle lobe bronchus was observed. Class-4 cells were obtained with bronchial brushing. It was believed that the lipoid pneumonia occurred distal to an obstructing lesion. Anaplastic squamous cell carcinoma and asbestosis were found at surgery. DiscuSSION
Ultrasonically guided percutaneous needle biopsy of pulmonary masses in contact with the chest wall is a safe, simple procedure in our experience and offers distinct advantages over biopsy performed CHEST, 70: 5, NOVEMBER, 1976,
FIGURE 3B. A-mode ultrasonogram of mass performed with biopsy transducer prior to insertion of needle. Echo-free space towards left part of scan represents mass at point chosen for biopsy. 3C. A-mode scan taken at time of biopsy demonstrates echo produced by tip af needle ( N ) within mass (case 3) .
blindly or with fluoroscopic guidance. Ideally, the biopsy needle should pass through the chest wall directly into the mass without passing through interposed aerated lung, as this reduces the risk of pneumothorax. It is also advantageous to simultaneously visualize the anterior and posterior walls of the mass and the .needle tip during the procedure to ensure proper placement of the needle within the mass. Ultrasound fulfills these criteria without exposure to radiation and, in addition, offers the advantage of working in a well-lighted setting with the patient and physician in comfortable positions. The mass must be in contact with the chest wall at some point to be defined with ultrasound. since the interface between the pleura and the lung is an acoustical barrier. Biopsy was occasionally performed blindly in the past if there were clinical signs of involvement of the chest wall. In many instances, neoplastic tissue w~ ULTRASONICALLY GUIDED PERCUTANEOUS BIOPSY 629
obtained; however, one was never sure if the mass was entered or how far to advance the needle. Fluoroscopic observation may not permit an unobstructed view of the mass in two planes to assure precise placement of the needle. There is also a chance of passing the needle through interposed aerated lung with fluoroscopic guidance, since the .exact point of contact between the mass and the chest wall is difficult to ascertain. In addition to the exposure to radiation, it is often technically difficult to manipulate the needle with the fluoroscopic unit ~position.
In most cases, we do not recommend localizing the mass in the ultrasound department and sending the patient to the floor for biopsy. This may result in negative findings on the biopsy, especially if the mass is apically located, since a change in the position of the shoulder can move the skin so that the mark does not overlie the lesion; however, this is less likely to occur with lesions located in the lower portion of the lung. Since the mass and the needle are visualized throughout the procedure with ultrasonic guidance, we recommend that the biopsy be performed in the ultrasound department. One biopsy specimen did not reveal neoplasm
(case 4) . We do not consider this to be a failure of the procedure, since a biopsy of the mass was obtained. The mass that was in contact with the chest wall was verified as an area of lipoid pneumonia that had developed distal to an obstructing bronchogenic carcinoma.
1 Sandweiss DA, Hanson JC, Gosink BB : Untrasound tn diagnosis, localization, and treatment of loculated pleural empyema. Ann Intern Med 82:50-53, 1975 2 Goldberg BB, Pollack HM : Ultrasonically guided pericardiocentesis. Am J Cardiol31 :490, 1973 3 Miskin M, Rosen IB, Walflsh PC: Ultrasonography of the thyroid gland. Radiol Clin North Am 13:479-492, 1975 4 Rasmussen SN, Holm HH, Kristensen JK, et al: Ultrasonically guided liver biopsy. Br Med J 2:500, 1972 5 Smith EH, Bartrum RJ, Chang YC: Ultrasonically guided percutaneous aspiration biopsy of the pancreas. Radiology 112:737-738, 1974 6 Doust BD, Maklad NF: Control of renal cyst puncture by transverse ultrasonic B scanning. Radiology 109:679-681, 1973 7 Rampone JF, Sanders RC, Niebyl JR: Ultrasonic aspiration transducer for management of Rh incompatibility. Obstet Gynecol43 :780, 1974 8 Goldberg BB, Pollack HM: Ultrasonic aspiration transducer. Radiology 102:187-189, 1972
Long-Distance Travelers Champion among migrant birds is the Arctic tern. Every year this delicate relative of the gulls flies in autumn from its nesting grounds within the arctic circle to spend the southern winter on the shores of the Antarctic Ocean, at the opposite end of the globe. When the Antarctic ice begins to melt in spring, the terns wing their way back to the distant north to breed. This amazing journey, from one pole to another and back
630 CHANDRASEKHAR, REYNES, CHURCHILL
again, is over 22,000 miles long. The Arctic tern sees the sun for a longer time each year than any other animal on earth-it spends about eight months of the year in constant daylight, and sees more daylight than darkness in the remaining four months. Jarman C: Atlas of Animal Migration, New York, John Day, 1972
CHEST, 70: 5, NOVEMBER, 1976