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CT-Fluoroscopy Versus Conventional Helical CT Guidance for Lung Biopsies Performed by Clinical Fellows Without Prior Training

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CT-Fluoroscopy Versus Conventional Helical CT Guidance for Lung Biopsies Performed by Clinical Fellows Without Prior Training Research Article iMedPub Journals Journal of Imaging and Interventional Radiology 2020 www.imedpub.com Vol.3 No.1:2 DOI: 10.21767/2471-8564.3.1.2 CT-Fluoroscopy versus Conventional Helical CT Guidance for Lung Biopsies Performed By Clinical Fellows without Prior Training: Radiation Dose and Workflow Sonja Kandel* Department of Medical Imaging, University of Toronto, Toronto General Hospital, NCSB 1C547, 585 University Avenue, Toronto, Ontario, M5G 2N2, Canada *Corresponding author: Kandel S, Department of Medical Imaging, University of Toronto, Toronto General Hospital, NCSB 1C547, 585 University Avenue, Toronto, Ontario, M5G 2N2, Canada, Tel: 416 323 6400 4081; E-mail: [email protected] Received date: December 4, 2019; Accepted date: February 10, 2020; Published date: February 17, 2020 Citation: Kandel S (2020) CT-fluoroscopy versus conventional helical CT guidance for lung biopsies performed by clinical fellows without prior training: radiation dose and workflow. J Imaging Interv Radiol Vol 3 No.1:2. DOI: 10.21767/2471-8564.3.1.2 Copyright: © 2020 Kandel S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Abstract Computed tomography (CT) guided chest biopsies have been integrated into clinical practice as a standard procedure to Purpose: To analyse the impact of CT-fluoroscopy versus obtain samples from pulmonary nodules and mediastinal lesions conventional CT-guidance in lung biopsies, performed by for tissue diagnosis. The two most commonly used methods are radiologists (clinical fellows) without prior CT-fluoroscopy CT-fluoroscopy (CTF) and CT helical (CTH) mode guidance [1-3]. experience, on radiation dose and navigation time. CTF allows for real time monitoring of the needle during the Material and Methods: Ninety-one consecutive patients biopsy procedure and can be applied both continuously and referred for CT-guided chest biopsies within the first half of intermittently. CTF has been shown to decrease both the the academic year were retrospectively analysed. All procedure time and complication rate [4-6]. The literature biopsies were performed by three clinical fellows who had regarding the radiation dose to patients is controversial. Some pre-existing experience with conventional CT-guided authors report higher doses when compared to biopsies biopsies but were novices to CT-fluoroscopy guidance. performed under CT helical mode guidance [7,8]; others report a Needle navigation was guided by helical CT mode in 45 relative dose reduction [9,10]. However, the performing patients (Group I) and by CT fluoroscopy in 46 patients (Group II). Patient age, gender, lesion size, site of the lesion, radiologist ’ s exposure to radiation is higher in CTF as the depth (skin to lesion, pleura to lesion), complications, operator remains in the room at the time of CT scanning [11]. To navigation time and DLP were recorded and statistically the contrary, radiation exposure to the operator does not exist compared. with CT helical mode guidance when the operator leaves the room during helical data acquisition. Going in and out of the Results: Mean patient radiation dose (DLP, mGy*cm) was scan room may be tedious, leaves the patient alone on the table 76.12 (SD: 57.72) in Group I (~ 1.29 mSv) and 59.59 (SD: possibly with a needle on its way to the target, and can increase 36.28) in Group II (~1.01 mSv) (p=0.05). Navigation time of 21 min (SD: 14) in Group I was significantly longer than 12 the procedure time [12]. min in Group II (SD: 9) (p=0.0004). All other parameters did As in most interventional procedures the radiation dose and not show significant differences between the two groups. procedure time may, to a certain extent, depend on the experience of the performing operator [13]. The aim of our Conclusion: CT-fluoroscopy guidance in lung biopsies performed by fellows leads to shorter navigation time and study was to analyse the difference in radiation exposure and lower radiation dose to the patients. needle navigation time between CTF and CTH guidance of chest biopsies performed by fellows who are inexperienced in using CTF guidance. Keywords: Navigation time; Radiation dose; Fellows; Lung; Biopsy Materials and Methods This retrospective study was approved by our institutional Abbreviations ethics review board. During the first half of the academic year CTH: CT helical; CTF: CT-fluoroscopy; ROSE: Rapid on site (July-December) a total of 102 consecutive patients underwent a evaluation; EPR: Electronic patient record lung biopsy using CT guidance in our Department. All patients were referred for a CT guided lung biopsy as part of their clinical workup. All procedures were performed by three clinical fellows © Copyright iMedPub | This article is available from: https://interventional-radiology.imedpub.com/ 1 Journal of Imaging and Interventional Radiology 2020 Vol.3 No.1:2 who had undergone baseline hands-on training in CT guided acquired with a foot pedal while table position was controlled by biopsies as part of their residency programme, but were novices the radiologist using the table handle under sterile conditions in using CT-fluoroscopy techniques. All patients were booked by (floating table). a central booking office solely based on patient preference and If the conventional CT helical technique was chosen as the schedule availability from Monday through Friday. Biopsies were guidance method, several short 3 cm helical scans were acquired approved prior to booking by the attending staff radiologist over the area of the expected needle position during which the based on existing internal or outside prior CT images. All operator left the scanning room and observed the biopsies were performed by the clinical fellows under reconstruction on the CT console. CT helical parameters were: supervision by the attending staff radiologist assigned to the 30-50 mA, 120 kV, rotation time of 0.5 sec, reconstruction slice service on that day. The clinical schedule both for fellows and thickness of 3 mm. staff radiologists was made weeks in advance, this cases were not specifically assigned to any operator (fellow or supervising At the end of the biopsy procedure, a low dose CT (120 kV, 10 staff radiologist). mA) of the whole chest was performed to exclude possible complications. Chest radiographs in upright position were At the beginning of their fellowship, the fellows were obtained after 1 hour. Follow up chest radiographs after 2 hours instructed to become acquainted with both CT guidance were acquired if the patient was older than 70 years or the post techniques as part of their clinical training program, supported biopsy CT showed a pneumothorax. The decision to drain a by all six staff radiologists. The decision as to the CT guidance pneumothorax was made by the fellow and supervising staff. technique was exclusively left with the fellow who was assigned to biopsy service on a rotating schedule, and varied on a daily All radiologists who remained physically present in the basis. scanner room during CT fluoroscopy data acquisition mandatorily wore certified whole-body lead aprons and thyroid CT Protocol and technique protection, both with more than 95% absorption rate (0.5 mm lead equivalent in front, 0.3 mm lead equivalent in the back of All biopsies were performed on a Toshiba 64-slice scanner the apron), and were monitored with film dosimeters (worn (Toshiba Aquilion 64, Toshiba Medical Systems, Nasu/Otawara, under the apron) according to the regulatory framework. Finger Japan). The unit was measured by the institutional Radiation ring dosimetrs were not used. Protection Officer and approved for clinical use. Scatter exposure for an operator in 100 cm distance to the point of Biopsy technique entry was 0.001 mSv/s based on a 8 mm slice thickness, 32 cm water phantom, 120 kV and 50 mA, and 0.5 s rotation time. CT biopsies were performed using a 19-gauge co-axial introducer needle (Bard R Truguide) with a 22-gauge Chiba Patients were put in feet-first prone, supine, lateral or biopsy needle (COOK) for fine-needle aspiration (FNA). All FNA decubitus position on the CT table based on the assumed best samples were assessed for adequacy by a cytopathologist and approach and our standard of care process. The best approach cytotechnologist (Rapid On Site Evaluation, ROSE). Core samples was clinically defined as follows: shortest possible skin to lesion were obtained using a 20-gauge cutting needle (Care Fusion) distance, while avoiding visible bullae and crossing fissures if at when the FNA samples were deemed inconclusive by the onsite all possible. cytopathologist or in case of suspected lymphoma. When An initial scout and low dose helical CT (120 kV, 30 mA) performed, the core samples were fixed in 7.5% formalin without breath-holding for planning purposes were acquired for solution for histopathology analysis. every case. After localisation of the target lesion, the access path was measured on the corresponding CT-slice and the intended Data collection and statistical analysis entry point of the biopsy needle was marked on the patient’s skin accordingly using the integrated laser beam. Patient age, gender, lesion size, site of the lesion, depth (skin to lesion, pleura to lesion) and navigation time were obtained If CT-fluoroscopy was the chosen method for guidance, the using the PACS, RIS and electronic patient record (EPR) systems. scanner was exclusively operated in the intermittent mode in Navigation time was defined as the time between the first image which a single axial slice was being acquired and immediately showing the needle in the skin to the time when the coaxial reconstructed and displayed, initiated by the performing needle was in its desired position at the edge or within the operator in the room.
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