Thorax 1992;47:457-460 457 Ultrasound guided percutaneous cutting biopsy

for the diagnosis of pulmonary consolidations of Thorax: first published as 10.1136/thx.47.6.457 on 1 June 1992. Downloaded from unknown aetiology

Pan-Chyr Yang, Dun-Bing Chang, Chong-Jen Yu, Yung-Chie Lee, Sow-Hsong Kuo, Kwen-Tay Luh

Abstract tion, serological tests, and fibreoptic broncho- Background Ultrasound has been used scopy with biopsy are rational diagnostic to guide percutaneous aspiration biopsy approaches. If these procedures fail, the of thoracic tumours with high diagnostic patient may require a more invasive yield. This study assessed the diagnostic procedure, such as percutaneous needle value of ultrasound guided percutaneous aspiration or biopsy, to determine the cutting biopsy for pulmonary consolida- diagnosis. Most percutaneous aspirations for tion of unknown aetiology. pulmonary consolidation have been carried Methods Thirty patients with undiag- out through a fine needle2' and the material nosed lobar or segmental consolidation aspirated is often too small to allow detailed underwent ultrasound guided percutan- microbiological or histological study. Al- eous needle aspiration and large bore though diagnostic yields of 31-77% have been cutting biopsy. The needle aspirates and reported for infections, the procedure is not biopsy specimens were sent for cyto- sensitive for non-infectious lesions' and logical, microbiological, and histo- some patients will require a thoracotomy for a pathological examination. definite diagnosis. Results Percutaneous needle aspira- Ultrasound has been used recently to guide tion provided a diagnosis in nine of 30 percutaneous aspiration biopsy of thoracic patients (30%), whereas cutting biopsy lesions.7 The high quality of image resolu- tion and the precise guiding system have made obtained a satisfactory specimen for http://thorax.bmj.com/ histological diagnosis in 28 patients the percutaneous puncture a safe procedure (93%) and provided a definite aetiological with a high diagnostic yield.8 01' diagnosis in 17 patients (57%). The com- In this study we have assessed whether bination of needle aspiration with ultrasound guided percutaneous cutting Trucut biopsy provided a diagnostic rate biopsy can be used to obtain a diagnosis in of 63%. The underlying diagnoses were patients with pulmonary consolidation not fungal (five patients), tuber- diagnosed by conventional methods, such as culosis (five), (one), fibreoptic bronchoscopy with biopsy. We com- bronchioloalveolar carcinoma (three), pare the diagnostic yield of large bore cutting on September 23, 2021 by guest. Protected copyright. lymphoma (two), adenocarcinoma (one), biopsy with that obtained by fine needle vasculitis (one), acute pneumonia of aspiration, and discuss the technical aspects unknown aetiology (one), and chronic and complications of the procedure. non-specific pneumonia (nine). Two patients, who had necrotic tissue only in the biopsy specimen, were found at Methods thoracotomy to have an adenocarcinoma Thirty patients with undiagnosed lobar or and aspergillosis. Two patients had com- segmental consolidations underwent trans- plications from the technique, a small thoracic fine needle aspiration and large bore Department of in one and a small cutting biopsy under ultrasound guidance from Internal Medicine haemoptysis in another. January 1986 to December 1990. The criteria P-C Yang Conclusions for were: D-B Chang Ultrasound guided per- selecting patients (1) radiographic C-J Yu cutaneous cutting biopsy is a valuable evidence of lobar or segmental consolidations Department of method for diagnosing pulmonary con- that extended to the visceral pleura; (2) treat- Surgery solidation of unknown aetiology. The ment with antibiotics for at least a week without Y-C Lee diagnostic yield is high and the pro- improvement; (3) failure to make a diagnosis Department of cedure appears to be relatively safe. by conventional methods, including sputum Clinical Pathology with S-H Kuo examination and fibreoptic bronchoscopy K-T Luh biopsy. Thirty patients were included in the National Taiwan Pulmonary consolidation has many causes.1 study, 23 men and seven women aged 20-69 University Hospital, Although pneumonia is the most common, (mean 56) years. Six had underlying malig- 1 Chang-Te Street, non-infectious diseases such as lymphoma, nancy (two leukaemia, one lymphoma, and Taipei, Taiwan 10016, Republic of China infarction, bronchioloalveolar carcinoma and three a solid tumour) treated previously with vasculitis may also present as pulmonary con- Four had diabetes and Reprint requests to: chemotherapy. patients Dr P-C Yang solidation. For patients with consolidation three had a collagen disease (two systemic Accepted 9 January 1992 unresponsive to antibiotics sputum examina- lupus erythematosus and one mixed connective 458 Yang, Chang, Yu, Lee, Kuo, Luh

tissue disease); one had rheumatic heart dis- needle (Top Surgical, Tokyo). The technique ease. The other 16 patients had no known of ultrasound guided percutaneous needle underlying disease. Twenty six patients had aspiration and cutting biopsy is described else-

respiratory symptoms of cough, fever, and where.8-' After the consolidated lesons had Thorax: first published as 10.1136/thx.47.6.457 on 1 June 1992. Downloaded from sputum production. Two patients had been been assessed by ultrasound the skin was given amphotericin B in addition to antibiotics. prepared and a local anaesthetic agent applied. Consolidation occurred in the right upper lobe A sterile puncture transducer (Aloka UST-507 in 15 patients, the middle lobe in two, the right BP) with a preset puncture area and a guiding lower lobe in four, the left upper lobe in four, channel was used to localise the lesion. The and the left lower lobe in one; four had more aspiration needle or Trucut needle was inserted than one affected lobe. through a guiding channel and advanced to the Patients were screened for coagulation consolidated lung parenchyma under real time abnormalities before the biopsy and excluded if image monitoring and aspiration or biopsy was they had thrombocytopenia platelets ( <1 0 x conducted. The biopsy route was chosen to 1010/1) or prolonged prothrombin time avoid penetrating areated lung, major bronchi, (prolonged by over three seconds). All patients or vessels. Patients were asked to hold their were examined with real time, linear array, breath during the biopsy procedure, which convex, and sector ultrasonic units with a 3 5, usually took 10 seconds. 3-75 and 5 0 MHz transducer (Aloka SSD 630, Patients usually received two or more needle Toshiba IOOA, Tokyo). The sector ultrasonic aspirations followed by a cutting biopsy. The units were also integrated with a Doppler aspirated materials were sent for cytological ultrasound to identify vascular structures. The examination and microbiological cultures. The patients were scanned in the supine posture by tissue specimens obtained by cutting biopsy an intercostal approach. The sonographic were divided and sent for histopathology and images were recorded on Polaroid films microbiological cultures. Gram staining, acid (Polaroid, Cambridge, Massachusetts) and the fast staining, and bacterial and fungal cultures area of consolidation, the pleural line, and the were included routinely. After the aspiration air andfluid bronchograms were identified. The biopsy the patient was observed for one hour echogenicities of liver and gall bladder were and a routine chest radiograph was taken the used as reference echoes for solid and liquid next day to assess any potential complications. lesions. After the ultrasound assessment the patients underwent percutaneous needle Results aspiration with a 22 gauge needle and a large Twenty four patients had two percutaneous bore cutting biopsy with a 16 gauge Trucut needle aspirations and six patients had three http://thorax.bmj.com/

Results of ultrasoundguided needle aspiration and cutting biopsy in 30 patients with pulmonary consolidation Patient no Age (y) Sex Location oflesion Needle aspiration Cutting biopsy 1 40 F RLL Necrotic tissue Aspergillosis 2 27 F RUL Necrotic tissue Aspergillosis 3 63 F RUL Aspergillosis Aspergillosis 4 64 M RUL Negative Candidiasis on September 23, 2021 by guest. Protected copyright. 5 69 M LUL Negative Pseudodallescheria boydii 6 65 M RML Actinobacillus Acute pneumonia actinomycetemcomitans 7 20 M RML Negative Acute pneumonia 8 38 M RUL Negative Tuberculosis 9 78 M RUL Tuberculosis Tuberculosis 10 74 M RUL Negative Tuberculosis 11 64 M RUL Tuberculosis Tuberculosis 12 66 F RUL Tuberculosis Tuberculosis 13 39 M LUL Negative Chronic inflammation 14 66 M RUL Negative Chronic inflammation 15 61 M RLL Negative Chronic inflammation 16 71 M RUL Negative Chronic inflammation 17 47 M RUL Suspicious Chronic inflammation 18 30 M RUL Negative Chronic inflammation 19 66 M RUL Negative Chronic inflammation with fibrosis 20 67 M RLL Negative Chronic inflammation with fibrosis 21 67 M RUL Negative Chronic inflammation with fibrosis 22 27 M RML + LUL Negative Vasculitis 23 63 M RUL Lymphoma Lymphoma 24 51 M RML + LLL Lymphoid hyperplasia Lymphoma 25 67 M RML + RUL Negative Bronchioloalveolar ca 26 38 M LLL Bronchioloalveolar ca Bronchioloalveolar ca 27 60 M RLL Bronchioloalveolar ca Bronchioloalveolar ca 28 55 F RML + LUL Negative Adenocarcinoma 29 66 M LUL Adenocarcinoma Necrosis* 30 65 F LUL Negative Necrosist *Thoracotomy showed adenocarcinoma. tThoracotomy showed aspergillosis. R-right; L-left; LL-lower lobe; UL-upper lobe; ML-middle lobe; ca-carcinoma. Ultrasoundguidedpercutaneous cutting biopsyfor the diagnosis ofpulmonary consolidations of unknown aetiology 459

A-Chest radiograph (A) of a 66 year old woman showing a consolidation of the anterior segment of the

right upper lobe. The Thorax: first published as 10.1136/thx.47.6.457 on 1 June 1992. Downloaded from transbronchial lung biopsy showed chronic inflammation. B-Wedge shaped isoechoic lesion, indicating the consolidated segment, shown on the chest ultrasound scan (convex scanner). Ultrasound guided percutaneous cutting biopsy showed tuberculosis. Arrowheads indicate the air bronchogram. H- heart; L-consolidated lung.

aspirations. Twenty one patients had one cut- biopsy, and even open lung biopsy, may ting biopsy specimen taken and nine patients sometimes be necessary. Although flexible two specimens because of an inadequate first fibreoptic bronchoscopy with biopsy is a safe specimen. The patients' characteristics and the and useful procedure, the diagnostic yield is results of the two biopsies are shown in the often low.'2 13 table. The figure illustrates a typical ultrasound Percutaneous needle aspiration provides an image. alternative diagnostic method for such In nine of the 30 patients (30%) a definite patients. The procedure is conducted under diagnosis was made from the percutaneous fluoroscopic guidance. Many studies have needle aspiration. Five patients had an infec- reported its value and low complication tion: Aspergillus fumigatus in one, Actino- rate14; a diagnostic yield of 31-64% has been bacillus actinomycetemcomitans in one, and reported.2"6 The method is restricted by the Mycobacterium tuberculosis, grown in culture, size of the needle that can used, so that http://thorax.bmj.com/ in three. aspirated material is suitable only for cyto- A satisfactory specimen for histological diag- logical or microbiological examination. A large nosis was obtained from 28 ofthe 30 patients by bore cutting biopsy needle provides a better Trucut cutting biopsy (93%). A definite tissue sample for histopathological exam- aetiological diagnosis was made or confirmed in ination and diagnostic yields of more than 70% 17 patients (57%). In 10 patients an infective have been reported with this method.'5 The cause was identified. Six patients had consolida- complication rate exceeds that of transbron-

tion due to malignancy and one due to vas- chial lung biopsy or open lung biopsy, how- on September 23, 2021 by guest. Protected copyright. culitis. Two patients had the histological ever, and for this reason percutaneous cutting picture of acute pneumonia in the cutting biopsy has been abandoned by some inves- biopsy specimens but no definite pathogens tigators.'6 The major factor contributing to the were identified (in one case Actinobacillus high complication rate of this method may be actinomycetemcomitans was cultured from the the image guiding system rather than the needle aspirate). Histologically, 11 patients had needle itself. Differentiation of vascular struc- chronic inflammatory changes with fibrosis and tures and major bronchi located in consolidated had a diagnosis of chronic non-specific lung parenchyma may be difficult with fluoro- pneumonia. In the two remaining patients scopic guidance, and penetration of such necrotic tissue only was obtained. Thoraco- vessels and bronchi is presumed to be the tomy in these two patients showed an adeno- principal cause of complications. carcinoma in one patient and aspergillosis Recently we have shown that chest in the other. Cytological examination of the ultrasound is useful in the assessment of pul- needle aspirate from the former showed adeno- monary consolidation.9 The major bronchi and carcinoma. vessels can be identified by high resolution Two patients developed complications. One ultrasound in conjunction with Doppler had a small pneumothorax and one a small ultrasound, and the biopsy route can then be haemoptysis. Both complications resolved selected to avoid injury to the structures. This spontaneously. allows percutaneous biopsy to be conducted safely under the guidance of real time ultrasound images. In the present study per- Discussion cutaneous cutting biopsy was carried out safely Obtaining a definite aetiological diagnosis in with a high specific diagnostic yield. cases of pulmonary consolidation may be dif- We conclude that for patients with pulmon- ficult. Invasive procedures, such as fibreoptic ary consolidation of unknown aetiology bronchoscopy, percutaneous needle aspiration ultrasound guided percutaneous cutting biopsy 460 Yang, Chang, Yu, Lee, Kuo, Luh

is a good method for providing a definite 7 Izumi S, Tamaki S, Natori H, Kira S. Ultrasonically guided aspiration needle biopsy in disease ofchest. Am Rev Respir diagnosis and more invasive procedures such as Dis 1982;125:460-4. open lung biopsy can be avoided. This tech- 8 Yang PC, Luh KT, Sheu JC, Kuo SH, Yang SP. Peripheral nique may be particularly useful for immuno- pulmonary lesions: ultrasonography and ultrasonically guided aspiration biopsy. Radiology 1985;155:451-6. Thorax: first published as 10.1136/thx.47.6.457 on 1 June 1992. Downloaded from compromised patients with pulmonary 9 Yang PC, Luh KT, Wu HD, Chang DB, Lee LN, Kuo SH, consolidation who have failed to be diagnosed et al. Lung tumors associated with obstructive pneumon- itis: US studies. Radiology 1990;174:717-20. by conventional approaches. 10 Yang PC, Lee LN, Luh KT, Kuo SH, Yang SP. Ultra- sonography of Pancoast tumor. Chest 1988;94:124-8. 11 Yu CJ, Yang PC, Chang DB, Wu HD, Lee LN, Lee YC, et 1 Lillington GA. Lobar and segmental consolidation. In: al. Evaluation ofultrasonically guided biopsies ofmedias- Collins N, ed. A diagnostic approach to chest diseases. tinal masses. Chest 1991;100:399-405. Baltimore: Williams and Wilkins, 1987:173-87. 12 Poe RH, Utell MJ, Israel RH, Hall WJ, Eshleman JD. 2 Palmer DL, Davidson M, Lusk R. Needle aspiration of the Sensitivityandspecificityofthenonspecifictransbronchial lung in complex . Chest 1980;78:16-21. lung biopsy. Am Rev Respir Dis 1979;119:25-31. 3 Gherman C, Simon H. Pneumonia complicating severe 13 Cunningham JH, Zavala DC, Corry RJ, Keim LW. Tre- underlying disease: a current appraisal of transthoracic phine air drill, bronchial brush and fiberoptic transbron- lung puncture. Dis Chest 1965;18:297-304. chial lung biopsies in immuno-suppressed patients. Am 4 Greenman R, Goodall P, King D. Lung biopsy in immuno- Rev Respir Dis 1977;115:213-20. compromised hosts. Am J Med 1975;59:488-96. 14 Stevens G, Weigen J, Lillington G. Needle aspiration biopsy 5 Chaudhary S, Hughes WT, Feldman S, Sanyal SK, Coburn oflocalized pulmonary lesions with amplified fluoroscopic T, Ossi M, et al. Percutaneous transthoracic needle guidance. Am J Roentgenol Rad Ther Nucl Med 1968; aspiration of the lung. Diagnosing Pneumocystis carinii 103:561-71. . Am J Dis Child 1977;131:902-7. 15 Bandt P, Blank N, Castellino R. Needle diagnosis of 6 Torres A, Jimenez P, de la Bellacasa JP, Celis R, Gonzalez J, pneumonitis: value in high risk patients. JAMA 1972; Gea J. Diagnostic value of nonfluoroscopic percutaneous 220:1578-80. lung needle aspiration in patients with pneumonia. Chest 16 Stover DE. Diagnosis ofpulmonary disease in the immuno- 1990;98:840-4. compromized host. Semin Respir Med 1989;10:89-100.

appeal to those with interests in tuberculosis and its control, but may not find its way on to departmental BOOK NOTICES shelves.-LPO

Recent Advances in Respiratory Medicine 5. D M Mitchell. (Pp 312; £32.95.) Edinburgh: Churchill A Century of Tuberculosis-South African Pers- Livingstone, 1991. ISBN 0-433-04467-8. pectives. HM Coovadia and SR Benatar. (Pp 319;

£17.50.) Cape Town: Oxford University Press, 1991. Despite regular reading ofthe journals it is quite difficult http://thorax.bmj.com/ ISBN 0 19 570583 1. for the practising physician to obtain a balanced view of the changes and developments occurring in all aspects of This South African perspective of tuberculosis over the respiratory medicine over a period of time. Recent last 100 years divides into four main sections. "History Advances in Respiratory Medicine thus has an important and epidemiology" covers the history of tuberculosis role. Five years seems a long time since the last volume from early times into the prechemotherapy era, followed in this series was produced, so volume 5 is very by the epidemiology of tuberculosis in South Africa welcome. The aim, as always, is to provide up to date documenting control efforts and the detailed epi- reviews of the growing areas in respiratory medicine, demiology in various ethnic groups. "Clinical aspects" written by leaders in each subject, for consumption by covers tuberculosis in children and adults in general, doctors in training as well as the practising physician. In on September 23, 2021 by guest. Protected copyright. with specific chapters on pericardial, skin, neurological, volume 5, as in previous volumes, this is undoubtedly and bone and joint forms, which are commonly seen in achieved. Of the 17 chapters in the book, two are South Africa. Next the relationships between occupa- devoted to and four to aspects oflung transplan- tion and tuberculosis, particularly between mining and tation, the latter being of special value for those who do , are fully examined. The final section covers not have the privilege ofworking in a transplant centre. various aspects of diagnosis, treatment, and immuno- Each oftheother 1 1 chapters covers different and specific logy, including the spectrum of radiographic changes; a areas of respiratory medicine, ranging from cystic review ofthe immune response to Mycobacterium tuber- fibrosis to chronic . The culosis; and diagnostic considerations in management emphasis is mainly on clinical topics but the basic and epidemiology. The evolution of antituberculosis sciences are not neglected, with sections of the chapters chemotherapy is charted for both developed and on the adult respiratory distress syndrome, asthma, developing countries, and it was pleasing to see the , and occupational lung disease dedicated British Thoracic Society treatment guidelines listed in to these. Most chapters are concisely presented and the milestones of tuberculosis treatment. The final extensively referenced, allowing readers to delve even section deals with the role of voluntary organisations further into a particular subject if they wish. It is and other aspects of tuberculosis control in South impossible to be impressed with every aspect of any Africa. It is disappointing to see relatively little on the book. I would like to have seen more detail on the risk of tuberculosis-HIV interaction, even though this will treatment in the chapter on venous thromboembolism. clearly be a major problem for this part of Africa. The chapter on interstitial lung diseases might have Although HIV infection is mentioned in various sec- been better if it had been more selective in its content tions, there are no figures for the prevalence of HIV- rather than giving an overview of all aspects, especially tuberculosis cases in South Africa, and nothing about when separate chapters on and occupational local clinical experience in treatment. The book's lung disease cover some of the same ground. The price strength is in the non-clinical sections, which clearly at £32-95 seems a lot for a small volume but given the show the interaction of social, economical, and political amount of information crammed into the 312 pages this factors in tuberculosis, the importance ofwhich tends to is perhaps unfair. These are but minor quibbles about be neglected in the developed world. In particular, the what is an otherwise excellent volume. It should be on pernicious and detrimental effects of the apartheid and the bookshelf of any practising respiratory physician homeland systems on the incidence and control of and should be read by all those in training in respiratory tuberculosis are graphically brought out. The book will medicine.-MW