Diagnostic value and complication rate of ultrasound-guided transthoracic core needle biopsy in mediastinal lesions

Abstract

Background: Ultrasound-guided transthoracic core needle biopsy (US-TCNB) is a promising method for establishing the correct diagnosis of mediastinal masses. However, the existing studies in this area are scant and with small samples.

Purpose: To evaluate the diagnostic value and the complication rate of US-TCNB, particularly large bore cutting biopsy in patients with mediastinal lesions.

Material and methods: This retrospective study includes 566 patients with mediastinal lesions suspicious of malignancy evaluated between March 2004 and December 2018. Inclusion criteria: 1. Patients with mediastinal lesions detected on thoracic CT scan; 2. Lesions more than 15 mm; 3. Negative histological diagnosis after bronchoscopic biopsy; 4. Normal coagulation status; 5. Cooperative patient; 6. Written informed consent. US visualization of the mediastinal lesions was successful in 308 (54.4%). In all of them, US-TCNB was performed. All patients with mediastinal lesions unsuitable for US visualization were evaluated for a CT-guided transthoracic needle biopsy (CT-TTNB), which was done if the presence of a safe trajectory was available (n = 41, 7.2%). All patients inappropriate for image-guided TTNB were referred to primary surgical diagnostic procedures (n = 217, 38.3%).

Results: The US-TCNB is a highly effective (accuracy 96%, sensitivity 95%) and safe tool (2.6% complications) in the diagnosis of all subgroups mediastinal lesions. It is non-inferior to CT-TTNB (90%) and comes close to the effectiveness of surgical biopsy techniques (98.4%), but is less invasive and with a lower complication rate.

Conclusion: US-TCNB of mediastinal lesions is highly effective and safe tool which is particularly helpful in critically ill patients.

Fig 1. The decision tree illustrating the diagnostic approaches to the patients included in the study.

Abbreviations: ML: mediastinal lesions; MLy: malignant lymphoma; CT: computed tomography; US: ultrasound; US-TCNB: US-guided transthoracic needle biopsy; CT-TTNB: CT guided transthoracic needle biopsy; SP: surgical procedures.

Fig 2

A. Color Dopler US imaging: a “twinkling sign” with visualization of the biopsy needle during its manual movement (arrow). B. Color Dopler US-imaging supraclavicular approach, convex probe 3.5 MHz: Enlarged upper paratracheal lymph nodes (R2). US-TCNB (18G): The biopsy needle placed into the target mediastinal lesion (arrow).

Fig 3

A. CT scan: Large mediastinal lesion in the anterior-superior compartment. B. Real-time Virtual Sonography (RVS) fusion imaging technology CT/ US Color Doppler (CD) imaging, left site parasternal approach (transversal section), with a convex probe 2.5–5.0 MHz: Visualization of a. thoracica int. sin. (yellow arrow), the biopsy needle (18G) placed across the thoracic wall. C. Biopsy needle into the tumor mass (blue arrow marks the apex). D. Twinkling sign (CD phenomenon) marks the needle.

Fig 4. Distribution of the patients according to the localization of mediastinal lesions.

Surgical division of the mediastinum into compartments: A-S—anterior-superior mediastinal compartment; M—Middle mediastinal compartment; P—posterior mediastinal compartment.