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Year : 2019  |  Volume : 15  |  Issue : 7  |  Page : 1427-1429

Computed tomography-guided percutaneous core-needle biopsy after thermal ablation for lung ground-glass opacities: Is the method sound?

1 Minimally Invasive Tumor Therapies Center, Beijing Hospital; National Geriatric Medical Center, Beijing, China
2 Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China

Date of Submission30-Oct-2019
Date of Decision19-Nov-2019
Date of Web Publication13-Jan-2020

Correspondence Address:
Dr. Xin Ye
Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, Shandong Province 250021
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_926_19

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How to cite this article:
Li X, Ye X. Computed tomography-guided percutaneous core-needle biopsy after thermal ablation for lung ground-glass opacities: Is the method sound?. J Can Res Ther 2019;15:1427-9

How to cite this URL:
Li X, Ye X. Computed tomography-guided percutaneous core-needle biopsy after thermal ablation for lung ground-glass opacities: Is the method sound?. J Can Res Ther [serial online] 2019 [cited 2022 Jan 29];15:1427-9. Available from: https://www.cancerjournal.net/text.asp?2019/15/7/1427/275569

The implementation of lung cancer screening using low-dose computed tomography has demonstrated a trend toward a significant reduction in lung cancer mortality and overall mortality. This is due to the fact that the detection rate of pulmonary ground-glass opacities (GGOs) is increasing, and lung cancers manifesting as GGOs are usually indolent in biological behavior and generally do not metastasize to the lymph nodes or other organs.[1],[2] When properly managed, the 5-year cancer-specific survival rate for a GGO-dominant lung cancer can reach 100%.

However, not all GGOs are malignant or need to be surgically resected.[3] Many benign conditions such as focal interstitial fibrosis, aspergillosis, eosinophilic pneumonia, bronchiolitis obliterans and organizing pneumonia, endometriosis, and Wegener granulomatosis may manifest as GGOs. In general, persistent findings of GGOs on computed tomography (CT) may be suggestive of a neoplastic condition with a higher probability of malignancy when a solid component is present. A growing solid lesion within a GGO could be an indicator of malignancy, while a lesion which disappears after antibiotic or steroid therapy has a high probability of being benign.

Recent guidelines for the management of GGOs have been published by different societies, including the Fleischner Society, British Thoracic Society, and Japan Clinical Oncology Group. According to the size and components of the GGOs, different follow-up and management strategies may be adopted. In general, a biopsy or surgical resection should be considered for lesions with GGOs measuring 15 mm or a solid component measuring ≥5 mm.[3],[4]

Although most surgeons recommend biopsy before resection, others prefer direct surgical resection. They support this practice based on the high correlation between CT and histopathological findings and the simplicity and low invasiveness of video-assisted thoracoscopic surgery in removing GGOs. Nevertheless, it appears appropriate to perform histology before surgery to plan the best treatment for the patient. A preoperative CT-guided fine-needle aspiration biopsy can significantly reduce the resection of nonmalignant lung nodules.[5]

A CT-guided biopsy is an established technique that has high diagnostic yield and is used mainly for solid lung lesions. A meta-analysis investigating the overall diagnostic role of CT-guided percutaneous transthoracic needle biopsy (PTNB) for the differential diagnosis of GGO lesions reported that CT-guided PTNB for GGO lesions can yield high diagnostic accuracy with high specificity (0.94; 95% confidence interval [CI], 0.84–0.98) and sensitivity (0.92; 95% CI, 0.88–0.95).[6],[7],[8] However, a large-scale multicenter study by Lee et al.[9] indicated that PTNB demonstrated a relatively higher rate of diagnostic failures for small or subsolid lesions and that nonevaluable results were usually due to fine-needle aspiration or insufficient specimen quality. Hence, PTNB for GGO remains a significant clinical challenge.

In recent years, increasing experience has been gained with minimally invasive percutaneous therapies, such as radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation, and laser ablation, in in-operable early stage lung cancers with promising oncological results and safety profile. For GGO-dominant lung cancers, image-guided thermal ablation has achieved preliminary results comparable with surgical resection in terms of 5-year overall survival rate.[10],[11]

However, the lack of pathological information is a serious weakness for thermal ablation compared with surgical resection. Pathological diagnosis is also very important for patients undergoing thermal ablation in determining the follow-up period or need for adjuvant therapy. To compensate for this limitation and to avoid unnecessary treatment, a pathological confirmation of malignancy using bronchoscopic or transthoracic needle biopsy is recommended before the thermal ablation. However, a preprocedural biopsy carries a risk for complications. Moreover, patients who choose to undergo thermal ablation usually exhibit high-risk factors such as low respiratory function or severe comorbid diseases; therefore, performing biopsy separately from thermal ablation may sometimes be problematic. Biopsy performed in a separate session can potentially induce pneumothorax, hemorrhage, and gas embolism (which may lead to death) and increase patient discomfort.[12],[13]

To overcome this problem, some physicians choose to perform biopsy and ablation of lung tumors in the same session, especially for high-risk patients. Currently, there are two modes of this simultaneous diagnostic and therapeutic approach: one is to perform CT-guided biopsy first, followed immediately by thermal ablation and the other is to perform ablation first, followed by core-needle biopsy. Both modes are feasible and relatively safe.[14],[15]

A lung biopsy performed immediately before ablation carries the risk for potential difficulties in tumor targeting due to the postbiopsy hemorrhage, which can blur the tumor and alter the accuracy of positioning the thermal ablation applicator (electrode, antenna, or probe); moreover, a biopsy-induced pneumothorax will make the puncture more difficult. This problem is compounded in ablating GGO lesions.

Several studies have demonstrated that the diagnosis of malignancy and characterization of tumor morphology were feasible on postablation pathological examinations for lung tumors.[16],[17],[18] Analysis for epidermal growth factor receptor (EGFR) and KRAS genetic mutations can be performed for lung tumor specimens obtained immediately after RFA.[19] With this approach of ablation first, followed by immediate postablation biopsy, one can simultaneously accomplish the goal of diagnosis and precise treatment for highly suspected malignant lung nodules, thereby avoiding the risk and discomfort of a biopsy in a separate session and the potential difficulty in ablation when performing a biopsy immediately before ablation.

It is challenging to obtain sufficient specimens and improve the diagnostic yield of PTNB for lung GGOs. To obtain sufficient specimens for pathological analysis and possible molecular and genomic profiling of nonsmall cell lung cancers, obtaining more than one piece of specimen by core needle biopsy but fine-needle aspiration is essential, which are difficult and sometimes dangerous for lung GGOs. Therefore, there is a dilemma in performing PTNB of a lung GGO, both in terms of safety and efficiency. Biopsy immediately postthermal ablation provides a feasible avenue for achieving such a goal.

There have been only a few case reports describing post-RFA or postcryoablation biopsy results for lung GGO that demonstrated the feasibility and safety of such an approach. To our knowledge, the article by Wang et al.[20] is the first report of a large-scale case series that explored the diagnostic ability of PTNB immediately after MWA for lung GGOs. In that study, 74 patients with 74 lung GGOs were enrolled and treated with MWA, in which a percutaneous core needle biopsy was performed pre- and immediately post-MWA. All biopsy specimens were histologically examined using hematoxylin and eosin staining and immunostaining. The results revealed no significant difference in the positive diagnosis rate between the pre- and immediately post-MWA groups (P = 0.10). Noteworthy, the positive diagnosis rate of the combined diagnosis of pre- and immediately post-MWA was significantly higher than that of the pre-MWA biopsy (P < 0.05). Moreover, four patients with a diagnosis of normal lung tissue according to the pre-MWA biopsy were ultimately diagnosed with minimally invasive adenocarcinoma (n = 2) or invasive adenocarcinoma (n = 2) according to the immediate post-MWA biopsy. This suggested that post-MWA biopsy can play an important supplementary role in the final pathological diagnosis of GGO. This is understandable, given that after ablation, one can biopsy the GGO lesion confidently and obtain more samples without fear of hemorrhage. The main complications of this technique were also acceptable.

With the increasing detection of lung GGOs and accumulation of more evidence supporting the efficacy and safety of thermal ablation, we believe that an increasing number of GGOs highly suspicious for malignancy will be managed using thermal ablation. Furthermore, the technique of simultaneous ablation and immediate postablationbiopsy will help solve the dilemma of diagnosis and treatment of lung GGOs. Performing CT-guided PTNB after thermal ablation for lung GGOs is a sound method.

 > References Top

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