Inconclusive Result from CT Guided Transthoracic Needle Aspiration and Biopsy: Affecting Factors and Final Outcome

Yeon Joo Lee; Yong Il Hwang; Tae Jeong Kim; Ho Il Yoon; Kyung Won Lee; Choon-Taek Lee; Jae-Ho Lee

doi:10.6058/jlc.2011.10.2.94

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Lee, Hwang, Kim, Yoon, Lee, Lee, and Lee: Inconclusive Result from CT Guided Transthoracic Needle Aspiration and Biopsy: Affecting Factors and Final Outcome

Original Article

J Lung Cancer 2011;10(2):94-101.

Published online: 11 January 2011

DOI: https://doi.org/10.6058/jlc.2011.10.2.94

Inconclusive Result from CT Guided Transthoracic Needle Aspiration and Biopsy: Affecting Factors and Final Outcome

Yeon Joo Lee, M.D.¹, Yong Il Hwang, M.D.², Tae Jeong Kim, M.D.³, Ho Il Yoon, M.D.⁴, Kyung Won Lee, M.D.³, Choon-Taek Lee, M.D.⁴, Jae-Ho Lee, M.D.⁴

¹Department of Internal Medicine, Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea

²Department of Internal Medicine and Lung Institute of Medical Research Center, Hallym University Sacred Heart Hospital, Anyang, Korea

³Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea

⁴Department of Internal Medicine, Lung Institute of Medical Research Center, Seoul National University Bundang Hospital, Seongnam, Korea

Address for correspondence Jae-Ho Lee, M.D. Department of Internal Medicine, Lung Institute of Medical Research Center Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang- gu, Seongnam 463-707, Korea Tel: 82-31-787-7011 Fax: 82-31-787-4052 E-mail: jhlee7@snubh.org

Revised 9 May 201117 October 2011 Accepted 6 November 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

Inconclusive results from computed tomography (CT)-guided transthoracic needle aspiration and biopsy (TNAB) performed for lung lesions presents a clinical dilemma. The purpose of this study was to determine the factors affecting an inconclusive result from a CT guided TNAB, and to evaluate the final outcomes of these inconclusive results. Materials and Methods: The medical records and radiologic features of 331 patients with lung lesion who received CT guided TNAB were analyzed retrospectively. The results of the TNAB were classified as conclusive (malignancy or specific benign diagnosis) or inconclusive (nonspecific benign or nondiagnostic).

Results:

Of the 331 cases, 269 (81.3%) were diagnosed as a malignancy (210) or a specific benign lesion (59) after the first TNAB. The remaining 62 (18.7%) were inconclusive. Benign disease, a lesion size ≤15 mm, and morphology of the consolidation type were features significantly correlated with inconclusive results. Of these 62 inconclusive cases a second TNAB was performed in 23, and conclusive diagnoses were obtained in 19 (82.6%). Surgery or radiographic follow up was done in other cases. Finally, among the 62 inconclusive results on the first CT guided TNAB, 16 lesions were diagnosed as malignant, 26 were classified as specific benign disease, and the remaining 20 were defined as nonspecific inflammation. Age over 50 and morphology of a nodule or a mass type were significantly correlated with a malignancy in these 62 cases with inconclusive results on the first TNAB.

Conclusion:

A final diagnosis of benign disease was significantly higher after the CT guided TNAB was inconclusive for lesions ≤15 mm that had consolidation type morphology. Despite the application of core biopsy procedures, there continue to be appreciable numbers of inconclusive results after the first CT guided TNAB. A repeat CT guided TNAB had a high diagnostic yield in these cases and therefore should be considered for cases with inconclusive results.

Keywords: Computed tomography, Transthoracic needle biopsy, Inconclusive result

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Fig. 1.

Diagnostic algorithm of 331 patients with pulmonary lesions after a first trial of transthoracic needle aspiration and biopsy. ∗In-cluding one false positive case of adenocarcinoma which proved to be tuberculosis after surgery, ^† Paragonimiasis, actinomycosis, non-tuberculous mycobacterium in-cluded.

Fig. 2.

Diagnostic algorithm of lung lesions with an inconclusive first CT guided TNAB result. TB: tuberculosis, BOOP: bronchiolitis obliterans with organizing pneumonia.

Table 1.

The Final Diagnosis in the Study Population

Final diagnosis	Number (%)
Malignancy	225 (68.0)
Pulmonary tuberculosis	43 (13.0)
Pneumonia	25 (7.6)
Nonspecific inflammation	20 (6.0)
Other infection∗	11 (3.3)
Hamartoma	4 (1.2)
Leiomyoma	1 (0.3)
BOOP	1 (0.3)
Sclerosing hemangioma	1 (0.3)

^∗ Paragonimiasis, actinomycosis, Nontuberculous mycobacteri-al disease. BOOP: bronchiolitis obliterans with organizing pneumonia.

Table 2.

Comparison of the Characteristics of the 331 Lung Lesions according to Whether the Correct Specific Diagnosis Was Made at the First CT Guided TNAB

Parameters	Number	Correct specific diagnosis
Parameters	Number	Success	Fail	p-value
Gender, M/F	331	184/85	37/25	0.189
Mean Age, yr		62.8±12.5	60.4±12.3	0.182
Age ＞50 yr	278	229	49	0.238
Final diagnosis				0.0001
Malignancy	225	209/225 (92.9)	16/225 (7.1)
Benign	106	59/106 (55.7)	47/106 (44.3)
Lesion morphology				0.0001
Nodule	124	90 (72.6)	34 (27.4)
Mass	132	122 (92.4)	10 (7.6)
Consolidation	32	20 (62.5)	12 (37.5)
Cavitary lesion	24	21 (87.5)	3 (12.5)
Ground glass opacity	19	15 (78.9)	4 (21.1)
Lesion size, mean	331	30.7±15.3	23.5±13.5	0.001
Size over 15 mm	263	226 (85.9)	37 (14.1)	0.0001
Range of lesion size, mm				0.006
＜10	12	6	6
10∼19	81	59	22
20∼29	85	70	15
30∼39	76	67	9
40∼49	38	32	6
≥50	39	34	5
Total	331	268	63

Values are presented as number (%) unless otherwise indicated. CT: computed tomography, TNAB: transthoracic needle aspiration and biopsy.

Table 3.

Comparison of Characteristics of the 62 Cases Where Malignancy or Benign Disease was Finally Diagnosed after an Inconclusive First TNAB

Parameters	Number	Malignancy	Benign	p-value
Patients, n	62	16	46
Male	39	11 (68.8)	27 (58.7)	0.425
Mean ages, yr	62	62.1±7.7	58.6±13.2	0.066
Age ＞50 yr	50	16 (100)	34 (73.9)	0.026
Smoking				0.390
Current or ex smoker	37	11 (68.8)	26 (56.5)
Nonsmoker	25	5 (31.3)	20 (43.5)
Lesion morphology				0.037
Nodule	33	9 (56.3)	24 (52.2)
Mass	10	6 (37.5)	4 (8.7)
Consolidation	12	1 (6.3)	11 (23.9)
Cavitary lesion	3	0	3 (6.5)
GGO	4	0	4 (8.7)
Lesion size (mean), mm	62	29.3±14.6	21.5±12.6	0.046
Lesion size ＞15 mm	37	13 (81.3)	24 (52.2)	0.074

Values are presented as number (%) unless otherwise indicated. TNAB: transthoracic needle aspiration and biopsy, GGO: ground glass opacity.

Table 4.

Characteristics of the Subjects Who Were Diagnosed with Non-specific Inflammation

Patient number	Age	Sex	Size (mm)	Underlying disease	Morphology	Smoking (py)	F/U duration (mo)	F/U results
1	63	F	5	Melanoma	Nodule	0	31	Nc
2	70	M	9		Nodule	40	27	Nc
3	45	M	5		Nodule	0	22	Decreased
4	65	F	8		GGO	0	21	Decreased
5	70	M	7	Lung cancer	GGO	90	14	Disappeared
6	74	F	10	Melanoma	Nodule	0	24	Nc
7	68	F	15		Nodule	0	3	Disappeared
8	62	F	10		Nodule	0	27	Nc
9	78	F	15		Nodule	0	22	Nc
10	62	F	15		Nodule	0	14	Disappeared
11	70	F	11	Lung cancer	Nodule	5	13	Decreased
12	48	M	13		Nodule	45	22	Decreased
13	49	M	10		Nodule	40	25	Nc
14	69	M	13		Nodule	120	31	Nc
15	60	M	10	Lung cancer	Nodule	120	31	Nc
16	35	F	27		GGO	10	25	Nc
17	67	F	32		Mass	0	24	Nc
18	62	F	35		Consolidation	0	36	Nc
19	60	M	30	Rectal cancer	Cavitary Lesion	40	33	Nc
20	55	M	33		GGO	30	26	Nc

Nc: no change, GGO: ground glass opacity, py: pack year.

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