136 percutaneous lung biopsy in the molecular profiling ...€¦ · introduction image-guided...
TRANSCRIPT
PHILLIP GUICHET, B.A. 1, FEREIDOUN ABTIN, M.D. 2, CHRISTOPHER LEE, M.D. 1
1 K E C K S C H O O L O F M E D I C I N E O F U S C , D E P T O F R A D I O L O G Y
2 D A V I D G E F F E N S C H O O L O F M E D I C I N E A T U C L A , D E P T O F R A D I O L O G Y
Percutaneous Lung Biopsy in the Molecular Profiling Era:
A Survey of Current Practices
Disclosures
No Financial Disclosures
Introduction
Image-guided percutaneous lung biopsy is the invasive procedure of choice for the assessment of suspicious or indeterminate lung lesions Safe, inexpensive, reliable High diagnostic accuracy, sensitivity, and specificity in
the detection of malignancy
Klein et al. Radiol Clin North Am 2003;38:235-66
Radiologists play an important role in management of pulmonary nodules Expected to accelerate with implementation of USPSTF
and CMS guidelines for lung cancer screening with low-dose CT
Image-guided percutaneous lung biopsy is increasingly an essential piece of the diagnostic algorithm
Sharpe et al. JACR 2013;10:770-3
Introduction
Nearly any lung lesion is accessible to the skilled radiologist with special consideration of options in technique, equipment, and image guidance Imaging technology Patient positioning Needle design Biopsy technique
Introduction
In the current molecular profiling era, increasing importance is placed on safely obtaining greater amounts of tissue to identify actionable mutations for personalized therapy Core needle biopsy (CNB) vs fine needle aspiration (FNA)
CNB provides more tissue than FNA for molecular and genomic testing
Number of needle passes through target lesionsMore needle passes = greater tissue retrieval
Introduction
Prior studies have described techniques to maximize lung biopsy diagnostic yield, tissue retrieval, and patient safety Use of CT or CT fluoroscopy for image guidance Use of CNB for maximal tissue retrieval Minimum of 3 needle passes Autologous blood patch for pneumothorax risk reduction
Laurent et al. Cardiovasc Intervent Radiol 2000;23:266-72Gong et al. Am J Clin Pathol 2006;125:438-44Cheung et al. Lung Cancer 2010;67:166-9Malone et al. AJR 2013;200:1238-43
Introduction
The last broad survey of radiologist practice patterns for percutaneous lung biopsy was published by Aviram et al in 2005
Practices have evolved in the past decade influenced by advancements in technique, technology, and molecular/genomic science
Introduction
Aviram et al. Clin Radiol 2005;60:370-74
Objectives
To assess the current techniques and practice patterns of radiologists performing percutaneous lung biopsies
To identify areas that may necessitate further education
Methods
This cross-sectional study used a web-based survey sent to the Society of Thoracic Radiology (STR) membership from August-October 2015
Responses were collected anonymously, and results were tallied
Results
244 STR members responded to the survey 137 (58%) reported regularly performing
percutaneous lung biopsies
102 (74%)
19 (14%)
14 (10%)
2 (2%)
Primary Practice Setting
Academic teachinghospitalPrivate or grouppracticeMixed private andacademic practiceGroup model HMO
Results – Image Guidance
130 (95%) respondents most commonly utilize CT or CT fluoroscopy for image guidance
82 (60%)
48 (35%)
6 (4%) 1 (1%)
Preferred Modality of Image Guidance
CTCT FluoroscopyFluoroscopyUltrasound
Results – Biopsy Technique
116 (85%) respondents perform CNB alone or in conjunction with FNA for a routine lung biopsy
20 (15%) respondents perform FNA alone
59 (43%)
57 (42%)
20 (15%)
Preferred Biopsy Technique
CNB + FNA
Core Needle Biopsy(CNB)Fine NeedleAspiration (FNA)
Results – Biopsy Technique Needle gauge
Fine needle aspiration
22 gauge most common
Core needle biopsy
20 gauge most common
Use of coaxial technique
85 (74%) respondents for FNA
126 (96%) respondents for CNB
19 gauge outer needle most common
1%13% 18%
60%
8%0
50
100
16 17 18 19 20
Outer needle gauge
No. of Radiologists
2%
29%14%
49%
6%0
20
40
60
19 20 21 22 >22
FNA needle gauge
4%23% 14%
58%
1%0
20406080
17 18 19 20 >20
CNB needle gauge
Results – Biopsy Technique
Number of needle passes 66 (59%) respondents perform 3+ needle passes for FNA
85 (66%) respondents perform 3+ needle passes for CNB
41% 34%
49%
50%
6%
12%
4% 4%
0
10
20
30
40
50
60
70
FNA CNB
No. of radiologists
1-2 passes 3-4 passes 5-6 passes >6 passes
Results – Biopsy Analysis
Among the 99 respondents who reported access to such services, on-site cytology was regularly requested by 70 (71%)
In cases of suspected lung cancer, 79 (60%) respondents estimated sending tissue for molecular analysis at least 25% of the time
Results – Patient Safety
53 (40%) respondents routinely use intravenous conscious sedation during biopsy
43 (32%) respondents routinely use intraproceduraltechniques for pneumothorax risk reduction
91 (68%)
27 (20%)
6 (5%)10 (7%)
Method of Pneumothorax Risk Reduction
None
Yes, Autologous bloodpatchYes, Hydrogel Plug
Yes, Other
Results – Patient Safety
115 (86%) respondents routinely keep the patient under observation between 1 to 4 hours
Post-biopsy CXR 72 (54%) respondents routinely
obtain 1 CXR
47 (35%) respondents routinely obtain 2 CXRs
35 (27%)
24 (18%)39 (30%)
33 (25%)
Time to First Chest Radiograph Post-Biopsy
Within 30 minutes
30 minutes to 1 hour
1-2 hours
2-3 hours
9 (7%)
32 (24%)
37 (28%)
46 (34%)
9 (7%)
Duration of Observation Post-Biopsy
Less than 1 hour
1-2 hours
2-3 hours
3-4 hours
Greater than 4 hours
Discussion
Among surveyed radiologists who perform percutaneous lung biopsies, most utilize CT guidance either with CNB alone or in conjunction with FNA
Multiple prior studies support the use of CNB for Diagnosis of nonepithelial malignancies and benign
lesions Molecular/genomic profiling of NSCLC
Discussion
Since 2005, significant changes in percutaneous lung biopsy practice were observed in: Use of CT/CT fluoroscopy for image guidance
70% of surveyed radiologists in 2005, 95% in 2015 Use of CNB, either with or without FNA
27% in 2005, 85% in 2015 Use of intravenous conscious sedation
19% in 2005, 40% in 2015
Aviram et al. Clin Radiol 2005;60:370-74
Discussion
Since 2005, practices are stable in: FNA, CNB, and coaxial needle gauge
22 gauge needle most common for FNA20 gauge needle most common for CNB19 gauge outer coaxial needle most common
Percentage of radiologists that requests on-site cytology73% of surveyed radiologists in 2005, 71% in 2015
Aviram et al. Clin Radiol 2005;60:370-74
Discussion
Just over half of surveyed radiologists regularly sends biopsy material of lung cancer for molecular analysis In this era of personalized therapy, further
education of radiologists and referring physicians needed so that this is performed in most cases
Preventive measures for pneumothorax are not yet in widespread use
Limitations
This survey of practice patterns was sent only to the STR membership Most respondents are subspecialists in academic setting
Practice patterns amongst subspecialty and academic radiologists often differ from those of community radiologists A survey with a greater proportion of community
radiologists would more closely resemble overall radiologist practice
There is often a lag in broad adoption of best practices
Conclusions
The majority of academic thoracic radiologists performing percutaneous lung biopsies practices in accordance with published recommendations in technique, especially with regard to obtaining sufficient tissue for molecular/genomic analysis
A small minority routinely performs FNA alone which may negatively impact diagnostic accuracy and provide insufficient tissue for molecular profiling
Conclusions
Radiologists performing biopsies of suspected lung cancer should be proactive in sending tissue for molecular analysis
There is room for growth in the adoption of intra-procedural preventive measures for pneumothorax risk reduction
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Gong Y, Sneige N, Guo M, Hicks ME, Moran CA. Transthoracic fine-needle aspiration vs concurrent core needle biopsy in diagnosis of intrathoracic lesions: a retrospective comparison of diagnostic accuracy. Am J Clin Pathol. 2006;125:438-444.
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