Percutaneous transthoracic needle biopsy of pulmonary nodules under XperGuide cone-beam CT guidance

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1 Clinical applications Percutaneous transthoracic needle biopsy of pulmonary nodules under XperGuide cone-beam CT guidance G. Carrafiello F. Fontana M. Mangini F. Piacentino A. Cani C. Pellegrino C. Fugazzola Department of Radiology, Insubria University, Varese, Italy. E Image-guided percutaneous transthoracic needle biopsy is a consolidated, safe and accurate diagnostic technique. 12 MEDICAMUNDI 54/ Image-guided percutaneous transthoracic needle biopsy is a consolidated, safe and accurate diagnostic technique for the evaluation of benignity or malignancy of pulmonary nodules [1,2]. However, it is very much dependent on the imaging technique employed. Traditional computed tomography (CT) guidance has several limitations: there is exposure to ionizing radiation for both patient and operator, the view is limited to the plane of the needle insertion, and there is no real-time visualization [3]. Computed Tomography fluoroscopy was developed to solve the lack of real-time visualization, but some disadvantages still remain: there is significant operator exposure and there are limitations in real time 3D image reconstruction [4]. Recently, Cone-Beam CT (CBCT) imaging was developed to offer more flexibility than traditional CT in the orientation of the detector system around the patient. Cone-Beam CT is available in C-arm systems with a flat-panel detector integrated with a cone beam X-ray tube, such as the Philips Allura Xper FD20, linking the advantage of real-time fluoroscopy with three-dimensional (3D) CT-like imaging. XperGuide, available with Philips C-arm systems, overlays live fluoroscopy on the acquired CBCT images, providing information on the needle path and target. The aim of this study is to evaluate the feasibility of percutaneous transthoracic needle biopsy of pulmonary nodules under XperGuide CBCT guidance. Materials and methods Between June 2009 and June 2010, 30 percutaneous transthoracic needle biopsies of pulmonary nodules with XperGuide CBCT guidance were performed in 30 patients (22 males, 8 females, mean age 63.5 years, range years). Written informed consent was obtained from all patients. The skin was prepared with an antiseptic solution and all procedures were performed with local anesthesia (subcutaneous injection of 10 ml of carbocaine 2%). Ten biopsies were performed in the left upper lobe, eight in the right upper lobe, three in the left lower lobe, three in the right lower lobe, two in the lingula and four in the right middle lobe. The mean size of the lesions was 5.5 cm (range 1-11 cm). During the procedure, heart rate, ECG, oxygen saturation and respiratory rate were continuously monitored, while blood pressure was determined every 4 minutes. An 18 G bioptic needle (Biopsy Bell, Medical Devices, Modena, Italy) was used in all cases (all data are summarized in Table 1).

2 Age Sex Lesion site Lesion diam. Needle Histopathologic findings Complications 77 M left 21 mm 18 Adenocarcinoma // 41 F right 120 mm 18 MTS - Leiomyosarcoma // 65 M right 15 mm 18 Bronchopneumonia // 57 M right 40 mm 18 Adenocarcinoma Pneumothorax 64 M left 73 mm 18 Spinocellular // 47 M left 60 mm 18 Bronchiolitis Pneumothorax 72 M right 25 mm 18 MTS Myeloma Pneumothorax 64 M left 35 mm 18 Normal Tissue // 64 M left 35 mm 18 Adenocarcinoma // 73 F right 110 mm 18 Adenocarcinoma // 77 F left 40 mm 18 Adenocarcinoma // 86 M right 20 mm 18 Adenocarcinoma Pneumothorax 66 M left 35 mm 18 Spinocellular Pneumothorax 43 F right 65 mm 18 Adenocarcinoma // 71 M right 30 mm 18 Anthracosis // 66 M left 60 mm 18 Spinocellular // 66 F right 48 mm 18 Neuroendocrine ca. // 85 M right 42 mm 18 Large-cell ca. // 45 M left 50 mm 18 Bronchopneumonia // 44 M right 25 mm 18 TB // 77 M left 30 mm 18 Adenocarcinoma // 69 F left 18 mm 18 Large-cell ca. // 54 F left 10 mm 18 Normal tissue // 58 M left 86 mm 18 Adenocarcinoma // 77 M right 90 mm 18 Adenocarcinoma // 52 F right 50 mm 18 Spinocellular // 57 M right 52 mm 18 Adenocarcinoma // 62 F right 15 mm 18 Adenocarcinoma // 74 M right 25 mm 18 Hamartoma // 57 M right 30 mm 18 Adenocarcinoma // Image acquisition Images were acquired using a Philips Allura Xper FD20 system. This has a flat panel detector mounted on a C-arm, which can be rotated around the patient for CBCT (XperCT) soft tissue imaging. In our study we used a 5 s acquisition time for a rotation of 240, which generates 310 images with a 512 x 512 image matrix and a total reconstruction time of 25 s. Depending on the image matrix and field of view, the highest spatial resolution is 0.4 mm while contrast resolution for the soft tissue is equivalent to 5 HU at a slice thickness of 10 mm. The reconstructed isotropic soft-tissue volume is displayed automatically on the monitor in the examination room; manipulation and viewing of the image volume can be done directly at the tableside as well as in the control room. G Table 1. Study population. Demographic data, lesion size and location, histopathologic findings and complications. MEDICAMUNDI 54/

3 1a 1b 1c 1d 1e G Figure 1. Needle biopsy of a nodule in the right lung with XperGuide. Figure 1a. Cone Beam CT (CBCT) axial image performed before the procedure showing a round nodule in the right lung. Figures 1b 1d. Needle positioning in the nodule with XperGuide: CBCT axial (b), volume rendering (c) and sagittal images (d). Figure 1e. CBCT axial image: control after biopsy, with no evidence of complications. 14 MEDICAMUNDI 54/ The resulting XperCT images are used in the XperGuide to plan a virtual needle path, choosing the skin entrance site and the destination target site. XperGuide XperGuide supports percutaneous needle procedures in the interventional suite by superimposing live fluoroscopy on the acquired CBCT images, providing information on the needle path and target. Live 3D image guidance and feedback on any deviations from the desired path gives the operator full control and confidence in guiding the needle along the correct path. XperGuide indicates the skin to target distance from site to site, and the planned virtual needle path can be viewed on the XperCT slices, to verify its feasibility. Based on the predefined point-to-point path, the system determines the optimal projection for visualizing the needle advancement, and automatically rotates the C-arm to the needle insertion position ( entry point view ).

4 2a 2b 2c 2d 2e G Figure 2. Needle biopsy of a left lung para-mediastinal nodule with XperGuide. Figure 2a. Cone Beam CT (CBCT) axial image performed before the procedure showing an oval nodule in the left lung near the mediastinal pleura. Figure 2b - 2d) Needle positioning in the nodule with XperGuide: CBCT sagittal (b), axial (c) and MIP images (d). Figure 2e. CBCT axial image: control after the biopsy showing a slight pleural effusion near the nodule. The needle inserted under fluoroscopic guidance must be angled until the circles given by XperGuide are superimposed on each other and then fixed using a needle holder. The C-arm then rotates to a perpendicular view ( progression view ), superimposing the fluoroscopy image on the XperCT image. The user-defined needle trajectory is shown in real time on the image as the needle advances, allowing any deviation from the projected path to be corrected immediately. XperGuide adapts in real time to changes in the angulation or rotation of the C-arm, as well to changes in the field of view; moreover XperGuide software compensates for any parallax distortion in the visualization of the needle path. Results Technical success was defined as correct deployment of the needle into the lesion. The final diagnosis of benign or malignant nodule was assessed on the basis of biopsy findings, and MEDICAMUNDI 54/

E CBCT with XperGuide could be considered a good alternative to CT fluoroscopy for pulmonary nodule biopsies. E In 2011, we expect XperGuide will be used for 40% of all lung biopsies.

5 E CBCT with XperGuide could be considered a good alternative to CT fluoroscopy for pulmonary nodule biopsies. E In 2011, we expect XperGuide will be used for 40% of all lung biopsies. the diagnostic accuracy, sensitivity and specificity of percutaneous needle biopsy were defined. A nodule was defined as benign when the histological report showed a definitive diagnosis of benignity or when it was reduced in size at the imaging follow up. Complications were classified into minor and major complications according to SIR classification [5]. The evaluation of complications was performed with CBCT imaging at the end of the procedure; a standard chest X-ray was performed three hours later when a pneumothorax was found at CBCT. Technical success was achieved in all lesions (100%). Pulmonary biopsies had the following histological results: 24 neoplasms (21 primary tumors, 2 metastases), 2 bronchopneumonia, 1 bronchiolitis, 1 anthracosis, 1 tuberculosis granuloma and 1 normal lung tissue. Diagnostic accuracy, sensitivity and specificity of percutaneous needle biopsy were all 100%. At the end of the procedure five minor complications (16.6%), all of which consisted of a small pneumothorax, were recorded (three in the right lung and two in the left lung); in all cases no specific therapy or chest drain was necessary. Discussion Computed Tomography (CT) guided biopsy of the lung is a widely used diagnostic tool in the management of patients with suspected lung cancer. Computed Tomography fluoroscopy is a computed system for real-time reconstruction of CT images, combining the high spatial resolution of a CT scan with the high temporal resolution of fluoroscopy. Compared with conventional CT, CT fluoroscopy allows real-time needle guidance with fewer needle passes than standard CT-guided procedures [6]. CT fluoroscopy represents the gold standard technique for performing pulmonary nodule biopsies, thanks to the possibility of precise scan selection that allows correct needle deployment. Various studies in the literature [7,8] assessed the efficacy of CT fluoroscopy for interventional procedures in different anatomical sites and stated that CT fluoroscopy is necessary when it is the only imaging technique able to identify and reach the biopsy target. The rapid identification of the suspected lesion and the simultaneous visualization of the needle tip is the most important advantage of CT fluoroscopy, allowing continuous and accurate monitoring of the needle progression to the target site. For this reason CT fluoroscopy is considered to be a fast, efficient and safe procedure, with a high technical success rate. Diagnostic accuracy, sensitivity and specificity reported for CT fluoroscopy are 96%, 95%, 100% respectively, compared to 95%, 93% and 100% for traditional CT guidance. However, CBCT with XperGuide could be considered a good alternative to CT fluoroscopy for pulmonary nodule biopsies, in order to reduce the CT schedule, thanks to its high diagnostic accuracy, sensitivity and specificity. As reported in the literature, CBCT is feasible and safe for percutaneous abdominal and transthoracic needle biopsies with diagnostic accuracy, sensitivity, specificity and incidence of complications of 98.4%, 97%, 100% and 38% respectively [9-10]. This study describes our preliminary experience with percutaneous transthoracic needle biopsies of pulmonary nodules using XperGuide CBCT. As our familiarity with the technique is continuously improving, procedure time is decreasing and we now select smaller lesions for biopsy with the XperGuide system. In 2011, we expect that XperGuide will be used for approximately 40% of all lung biopsies. The most common complication of a lung biopsy is surely pneumothorax. The pneumothorax rate reported in the literature for the last ten years is 8-45%, but most studies report rates lower than 20% [11]. In our experience the pneumothorax rate was 16.6%. This relatively low rate is probably due to the lesions being relatively large and close to the surface: the mean lesion size was 5.5 cm, while 35% of the lesions were close to the pleura, making it unnecessary to pass through areated lung tissue. Deep and small lesions have a much stronger correlation with pneumothorax formation [12]. In conclusion, XperGuide could be useful in Radiology Departments where CT is less available. This would allow CT to be mainly used for diagnostic examinations, with an optimization of resources. In addition, the possibility of performing needle interventions in the angiography room using XperGuide is advantageous, because dedicated staff ensures an optimal compliance and low complications during the procedure L 16 MEDICAMUNDI 54/3 2010

6 References [1] Ohno Y, Hatabu H, Takenaka D, et al. CT-Guided Transthoracic Needle Aspiration Biopsy of Small (<= 20mm) Solitary Pulmonary Nodules. AJR. 2003; 180: [2] Gupta S, Krishnamurty S, Broemeling LD, et al. Small (<= 2cm) Subleural Pulmonary Lesions: Short-Versus Long Needle Path CT Guided Biopsy Comparison of Diagnostic Yields and Complications. Radiology. 2005; 234: [3] Frank K, Wacker BM. CT- and MR-Guided Interventions in Radiology. In: Wacker FK, Meer B (eds) Interventions using C-Arm Computed Tomography. Springer, Heidelberg, (2009) [4] Carlson SK, Felmlee JP, Bender CE, et al. CT Fluoroscopy-Guided Biopsy of the Lung or Upper Abdomen with a Breath-Hold Monitoring and Feedback System: A Prospective Randomized Controlled Clinical Trial. Radiology. (2005) 237: [5] Cardella JF, Kundu S, Miller DL, Millward SF, Sacks D. Society of Interventional Radiology. Society of Interventional Radiology Clinical Practice Guidelines. J Vasc Interv Radiol. 2009; 20(7 Suppl): S [6] Daly B, Templeton PA. Realtime CT Fluoroscopy: Evolution of an Interventional Tool. Radiology 1999; 211: [7] Bissoli E, Bison L, Gioulis E, et al. Multislice CT Fluoroscopy: Technical Principles, Clinical Applications and Dosimetry. Radiol Med. 2003; 106(3): [8] Laganà D, Carrafiello G, Mangini M, et al. Hepatic Radiofrequency under CT-fluoroscopy Guidance. Radiol Med : [9] Spelle L, Ruijters D, Babic D, et al. First Clinical Experience in Applying XperGuide in Embolization of Jugular Paragangliomas by Direct Intratumoral Puncture. Int J Comput Assist Radiol Surg. 2009; 4(6): [10] Jin KN, Park CM, Goo JM, et al. Initial Experience of Percutaneous Transthoracic Needle Biopsy of Lung Nodules using C-Arm Cone-Beam CT Systems. Eur Radiol. 2010; 20(9): [11] Lucidarme O, Howarth N, Finet JF, Grenier PA. Intrapulmonary Lesions: Percutaneous Automated Biopsy with a Detachable, 18 Gauge, Coaxial Cutting Needle. Radiology. 1998; 207: [12] Kazerooni EA, Lim FT, Mikahil A, Martinez FJ. Risk of Pneumothorax in CT-Guided Transthoracic Needle Aspiration Biopsy of the Lung. Radiology. 1996; 198: MEDICAMUNDI 54/

Disclosures. Role of the Pulmonologist in a Multidisciplinary Thoracic Program. Introduction. Access. None. Access

Disclosures. Role of the Pulmonologist in a Multidisciplinary Thoracic Program. Introduction. Access. None. Access Role of the Pulmonologist in a Multidisciplinary Thoracic Program Disclosures None Ken Y. Yoneda, M.D. Professor of Medicine Division of Pulmonary and Critical Care University of California, Davis VA Northern