136 Percutaneous Lung Biopsy in the Molecular Profiling ...€¦ · Introduction Image-guided percutaneous lung biopsy is the invasive procedure of choice for the assessment of suspicious

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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thoracic biopsies are performed percutaneously. J Am Coll Radiol. 2013;10:770-773. Laurent F, Latrabe V, Vergier B, Michel P. Percutaneous CT-guided biopsy of the lung: comparison between

aspiration and automated cutting needles using a coaxial technique. Cardiovasc Intervent Radiol. 2000;23:266-272.

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.

Cheung YC, Chang JW, Hsieh JJ, Lin G, Tsai YH. Adequacy and complications of computed tomography-guided core needle biopsy on non-small cell lung cancers for epidermal growth factor receptor mutations demonstration: 18-gauge or 20-guage biopsy needle. Lung Cancer. 2010;67:166-169.

Malone LJ, Stanfill RM, Wang H, Fahey KM, Bertino RE. Effect of intraparenchymal blood patch on rates of pneumothorax and pneumothorax requiring chest tube placement after percutaneous lung biopsy. Am J Roentgenol. 2013;200:1238-1243.

Aviram G, Schwartz DS, Meirsdorf S, Rosen G, Greif J, Graif M. Transthoracic needle biopsy of lung masses: a survey of techniques. Clin Radiol. 2005;60:370-374.

Lorenz G. Updates in percutaneous lung biopsy: new indications, techniques and controversies. SeminIntervent Radiol. 2012;29:319-324.

Winokur RS, Pua BB, Sullivan BW, Madoff DC. Percutaneous lung biopsy: technique, efficacy, and complications. Semin Intervent Radiol. 2013;30:121-127.

Contact Information

Phillip Guichet, B.A.Email: [email protected]

Twitter: @pguichet