CT-guided lung biopsy keeps children from surgery

CT-guided transthoracic needle biopsy - a well-established diagnostic procedure in adults with lung tumors - can also help children avoid open surgical or thoracoscopic biopsy, according to a study in the September issue of the Journal of Vascular and Interventional Radiology.

Thoracotomy is still the standard for lung biopsies in children. But it is costly and riddled with complications. Minimally invasive procedures such as thoracoscopy continue to grow in popularity, but they have not been appropriately adjusted to the pediatric population. Many physicians question their cost, technical difficulty, safety, and long-term benefits (Ann Surg Oncol 2004;11[3]:340-343).

Dr. Anne Marie Cahill of the radiology department at Children's Hospital, Saint Peter's University Hospital, in New Brunswick, NJ, and colleagues enrolled from 1992 to 2002 64 consecutive pediatric patients presenting with suspicious nodes or masses on diagnostic chest CT.

Physicians performed 75 percutaneous transthoracic biopsies under CT guidance with local or general anesthesia when required. The researchers found percutaneous CT-guided biopsy was safe and accurate in children and helped obviate the costs, risks, and complications from open surgical biopsy.

Interventionalists performed biopsies using intravenous sedation with local anesthesia in 61 cases and general anesthesia in 14. They used the coaxial core technique in 56 patients, fine-needle aspiration in 15, and both techniques in four. The mean lesion diameters were 2.5 cm and 1 cm, respectively, for coaxial core and fine-needle aspiration.

Biopsy provided a diagnostic yield of 91% in 64 children. Samples confirmed infection in 29 cases, malignancy in 14, inflammation in 13, post-transplantation lymphoproliferative disorder (PTLD) in five, and fibrosis in four. One patient had both inflammation and infection.

Only one major complication (tension pneumothorax) occurred in a lung transplant patient who underwent successful treatment with a chest tube drainage.

Interventionalists generally abided by a set of guidelines to select the appropriate biopsy technique and equipment:

• smaller needle diameters for high-risk patients or those with lesions accessible only through aerated lung (18-gauge or smaller for fine-needle and 20-gauge needle or smaller through a 19-gauge or smaller coaxial system)

• needle throws limited to 1 to 2 cm in lesions 3 cm and smaller in diameter

• needle throws of 2 cm for lesions 3 to 5 cm in diameter

• large-diameter needles (15-, 16-gauge) for all other lesions

• aspirations performed only in cases of possible infection without the oversight of a pediatric cytopathologist

Compared with current methods, image-guided percutaneous lung biopsy techniques offer substantial advantages. Image guidance with CT, ultrasound, or fluoroscopy is widely available, allows for precise lesion localization, and boosts diagnosis.

Percutaneous techniques are less invasive, faster, safer, and cheaper than surgical alternatives. They may facilitate performance of other procedures simultaneously and can be performed on an outpatient basis, according to researchers.

Though rare, complications may occur. Patients should be monitored carefully for respiratory compromise from pneumothorax, hemothorax, or hypovolemic shock from hemorrhage.

Investigators concluded that percutaneous techniques should be considered the initial procedure for tissue diagnosis of lung pathology in this population.

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