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CT-guided Percutaneous Cutting Needle Biopsy of Thymic Epithelial Tumors

Posted May 31, 2010 Updated Apr 7, 2023
By Masahiro Yanagawa MD PhD , Noriyuki Tomiyama MD PhD , Osamu Honda MD PhD , Ayano Kikuyama MD , Hiromitsu Sumikawa MD PhD , Mitsuhiro Koyama MD PhD , Atsuo Inoue MD PhD , Takeshi Johkoh MD PhD , Meinoshin Okumura MD PhD , Eiichi Morii MD PhD
12 min read

Rationale and Objectives

The aims of this study were to compare diagnostic accuracy between computed tomography (CT)–guided percutaneous cutting needle biopsy (PCNB) and surgery or open biopsy for thymic epithelial tumors in accordance with the World Health Organization (WHO) classification and to evaluate computed tomographic diagnosis additionally.

Materials and Methods

Subjects were 20 patients (11 men, 9 women) in whom CT, CT-guided PCNB, and surgery had been performed for anterior mediastinal tumors. All diagnoses of both CT-guided PCNB and surgery or open biopsy were made in accordance with the WHO classification. Computed tomographic diagnoses were performed by two radiologists on the basis of radiologic characteristics previously reported according to the simplified WHO classification (types A and AB, type B1, types B2 and B3, and thymic carcinoma). The concordance of the WHO classification or the simplified WHO classification between the diagnosis on either CT or CT-guided PCNB and that on surgery was evaluated using the weighted κ statistic.

Results

The histologic classifications on the basis of surgical resection specimens were as follows: type A, n = 3; type AB, n = 5; type B1, n = 3; type B2, n = 4; type B3, n = 4; and thymic carcinoma, n = 1. The overall concordance with the diagnosis according to the WHO classification established using CT-guided PCNB specimens (weighted κ = 0.757) was higher than that using computed tomographic diagnosis (weighted κ = 0.437).

Conclusion

CT-guided PCNB is a technique with good concordance of the WHO classification of thymic epithelial tumors between the diagnoses of surgery or open biopsy.

In 1999, the World Health Organization (WHO) proposed a consensus classification of thymic epithelial tumors , which was revised in 2004 . It stratifies thymic epithelial tumors into six categories (types A, AB, B1, B2, and B3 and thymic carcinoma) on the basis of epithelial cell morphology and the lymphocyte/epithelial cell ratio. The WHO histologic classification reflects the clinical features of thymic epithelial tumors, and this system may contribute to the clinical assessment and treatment of patients with thymoma . Computed tomography (CT) is commonly used in biopsies to assist with precision guidance of the instruments necessary to perform the biopsies in the appropriate areas of the body. CT-guided biopsy is often preferred because most mediastinal tumors are located adjacent to major vessels and other important structures . Percutaneous cutting needle biopsy (PCNB) has become safer and more accurate by using larger, 18-gauge to 20-gauge needles , which allow sufficient tissue to be obtained for histologic examination and diagnosis of thymic epithelial tumor . However, to our knowledge, only a few studies have assessed the reliability of both CT and CT-guided PCNB for the diagnosis of thymic epithelial tumors according to the WHO classification. The aims of the present study were to compare diagnostic accuracy between CT-guided PCNB and surgery or open biopsy and also to evaluate computed tomographic image diagnosis by radiologists on the basis of previously reported computed tomographic features of thymic epithelial tumors in accordance with the WHO classification.

Materials and Methods

Patients

Subjects were 20 patients (11 men, 9 women; age range, 35–74 years; mean age, 61 years), in whom CT-guided PCNB had been performed for anterior mediastinal tumors between May 2000 and November 2006 and for whom definitive diagnoses of thymic epithelial tumors were established by surgical resection or open surgical biopsy. CT was performed in all patients prior to CT-guided PCNB. Computed tomographic images were obtained before and after contrast medium administration using 8-detector (LightSpeed Ultra; GE Healthcare, Milwaukee, WI; n = 14) and 64-detector (LightSpeed VCT; GE Healthcare; n = 6) computed tomographic scanners. The ethics review boards of the institutions that contributed cases to this study did not require patients’ approval or informed consent for the retrospective review of patient records and images.

CT-guided PCNB

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Evaluation of the Diagnostic Accuracy of CT-guided PCNB for Thymic Epithelial Tumors

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Diagnosis According to Computed Tomographic Findings of Thymic Epithelial Tumors

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Table 1

Referential Diagnostic Criteria on the Basis of Previously Reported Computed Tomographic Features for Thymic Epithelial Tumors in Accordance with the World Health Organization Classification

Probability CT Feature High Low Smooth contour Type A Others Lobulated contour Type B2, type B3, carcinoma Others Calcification Type B1, type B2, type B3 Others Inhomogeneous enhancement Type B2, type B3, carcinoma Others Invasion Type B2, type B3, carcinoma Others Lymphadenopathy Carcinoma Others

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Statistical Analysis

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wij=1−(i−j)2/(I−1), w

i

j

=

1

−

(

i

−

j

)

2

/

(

I

−

1

)

,

where i and j are indices of the categories being used, and I is the number of categories. Interobserver agreement was classified as poor (κ = 0.00–0.20), fair (κ = 0.21–0.40), moderate (κ = 0.41–0.60), good (κ = 0.61–0.80), or excellent (κ = 0.81–1.00).

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Results

CT-guided PCNB

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Table 2

Gauges of Cutting Needles and Frequency of Puncture

Needle Gauge Number of Cases Frequency of Puncture CT-guided PCNB Diagnosis Surgical Resection Specimen Diagnosis 14, 16 1 2 AB (1) AB (1) 16 2 2 Carcinoma (1) Carcinoma (1) 3 B1 (1) B1 (1) 18 17 1 A (1) A (1) B3 (1) B3 (1) 2 A (2) A (1) AB (1) AB (3) A (1) AB (2) B1 (7) AB (1) B1 (2) B2 (3) B3 (1) B2 (1) B2 (1) B3 (2) B3 (2)

CT, computed tomography; PCNB, percutaneous cutting needle biopsy.

Values in parentheses are numbers of cases.

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Diagnoses of CT, CT-guided PCNB Specimens, and Surgical Resection Specimens

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Table 3

Computed Tomographic Findings of Thymic Epithelial Tumors in This Study and Diagnoses of CT-guided PCNB Specimens and Surgical Resection Specimens

Specimen ∗ Case Size, Long Axis × Short Axis (cm) Contours/Shape LDA Calcification Enhancement LN Invasion Diagnosis by CT CT-guided PCNB Surgical Resection 1 5.0 × 4.8 Lobular/oval − + Inhomogeneous − + 3 1 (A) 1 (A) 2 5.0 × 3.8 Smooth/oval + − Homogeneous − − 1 1 (A) 1 (A) 3 8.0 × 7.2 Smooth/oval + − Homogeneous − − 1 1 (A) 1 (AB) 4 7.0 × 4.7 Lobular/oval − − Homogeneous − − 1 1 (AB) 1 (A) 5 5.1 × 4.5 Lobular/oval + + Inhomogeneous − − 2 1 (AB) 1 (AB) 6 9.0 × 8.2 Lobular/oval + + Inhomogeneous − − 3 1 (AB) 1 (AB) 7 4.8 × 3.3 Lobular/oval − − Homogeneous − − 1 1 (AB) 1 (AB) 8 7.3 × 4.2 Lobular/oval − − Homogeneous − + 3 2 (B1) 3 (B2) 9 5.3 × 3.3 Smooth/oval − − Homogeneous − − 1 2 (B1) 1 (AB) 10 5.0 × 3.6 Lobular/oval − + Homogeneous − + 2 2 (B1) 3 (B2) 11 5.9 × 4.0 Lobular/oval − − Inhomogeneous − − 2 2 (B1) 3 (B2) 12 5.4 × 5.3 Lobular/oval + + Inhomogeneous − + 3 2 (B1) 3 (B3) 13 6.4 × 3.8 Lobular/oval − + Inhomogeneous − + 3 2 (B1) 2 (B1) 14 6.5 × 3.9 Smooth/oval − − Homogeneous − − 1 2 (B1) 2 (B1) 15 7.2 × 3.5 Lobular/oval − + Inhomogeneous − + 3 2 (B1) 2 (B1) 16 5.3 × 3.8 Lobular/oval − − Homogeneous − + 3 3 (B2) 3 (B2) 17 6.7 × 4.7 Smooth/oval − − Inhomogeneous − − 1 3 (B3) 3 (B3) 18 5.7 × 3.5 Lobular/oval + + Inhomogeneous − − 3 3 (B3) 3 (B3) 19 6.2 × 4.1 Lobular/oval + − Inhomogeneous − − 3 3 (B3) 3 (B3) 20 4.2 × 2.6 Lobular/oval + − Inhomogeneous + + 4 4 (carcinoma) 4 (carcinoma)

CT, computed tomography; LDA, low-density area (necrosis or cystic degeneration); LN, lymphadenopathy; PCNB, percutaneous cutting needle biopsy.

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Table 4

Concordance Between the Diagnoses of CT-guided PCNB Specimen and Those of Surgical Resection Specimens Classified According to the World Health Organization Classification

Diagnosis of the Surgical Resection Specimen CT-guided PCNB Diagnosis A AB B1 B2 B3 Carcinoma Total A 2 1 0 0 0 0 3 AB 1 3 0 0 0 0 4 B1 0 1 3 3 1 0 8 B2 0 0 0 1 0 0 1 B3 0 0 0 0 3 0 3 Carcinoma 0 0 0 0 0 1 1 Total 3 5 3 4 4 1 20

CT, computed tomography; PCNB, percutaneous cutting needle biopsy.

The overall concordance between the diagnosis according to the World Health Organization classification established by PCNB specimen and that by surgical specimen was 65% (weighted κ = 0.757).

Table 5

Concordance Between the Diagnoses of CT and Those of Surgical Resection Specimens Classified According to the Simplified World Health Organization Classification

Diagnosis of the Surgical Resection Specimen Diagnosis on CT A and AB B1 B2 and B3 Carcinoma Total A and AB 5 1 1 0 7 B1 1 0 2 0 3 B2 and B3 2 2 5 0 9 Carcinoma 0 0 0 1 1 Total 8 3 8 1 20

CT, computed tomography.

The overall concordance between the diagnosis according to the World Health Organization classification established by CT and that by the surgical specimen was 55% (weighted κ = 0.437).

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Cases with Complete Concordance Between Diagnoses of the CT-guided PCNB Specimens and Those of the Surgical Resection Specimens

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Figure 1, A 49-year-old man with complete concordance between diagnosis of the computed tomography (CT)–guided percutaneous cutting needle biopsy (PCNB) specimen and that of the surgical resection specimen ( Table 4 , case 1). Unenhanced and enhanced transaxial computed tomographic images ( a,b ) showed an inhomogeneous, enhanced lobular mass (diameter, 5 cm) with coarse calcifications in contact with the aorta and displacing the superior vena cava leftward (arrow). A photomicrograph of the CT-guided PCNB specimen ( c ) demonstrated the proliferation of spindle cells with no nuclear atypia, arranged in a storiform pattern. Note the small number of lymphocytes. The mass was confirmed histopathologically as type A thymoma (hematoxylin and eosin). A photomicrograph of the surgical resection specimen ( d ) showed features similar to the CT-guided PCNB specimen. The mass was confirmed histopathologically as type A thymoma (hematoxylin and eosin).

Figure 2, A 71-year-old man with complete concordance between diagnosis of the computed tomography (CT)–guided percutaneous cutting needle biopsy (PCNB) specimen and that of the surgical resection specimen ( Table 2 , case 17). Unenhanced and enhanced transaxial computed tomographic images ( a,b ) showed an inhomogeneous, enhanced smooth mass (diameter, 6.7 cm) with no calcifications that did not contact adjacent structures. A photomicrograph of the CT-guided PCNB specimen ( c ) demonstrated numerous tumor epithelial cells and very few lymphocytes. The mass was confirmed histopathologically as type B3 thymoma (hematoxylin and eosin). A photomicrograph of the surgical resection specimen ( d ) showed features similar to the CT-guided PCNB specimen. The mass was confirmed histopathologically as type B3 thymoma (hematoxylin and eosin).

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Cases with Discrepancies Between Diagnoses of the CT-guided PCNB Specimens and Those of the Surgical Resection Specimen

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Figure 3, A 71-year-old man with discrepancy between diagnosis of the computed tomography (CT)–guided percutaneous cutting needle biopsy (PCNB) specimen and that of the surgical resection specimen ( Table 4 , case 12). Unenhanced and enhanced transaxial computed tomographic images ( a,b ) showed an inhomogeneous, enhanced partly lobular mass (diameter, 5.4 cm) with tiny calcification and necrosis in contact with the right atrium. A photomicrograph of the CT-guided PCNB specimen ( c ) demonstrated the predominance of lymphocytes and a few inconspicuous epithelial cells (lymphocyte-rich type). The mass was confirmed histopathologically as type B1 thymoma (hematoxylin and eosin). A photomicrograph of the surgical resection specimen ( d ) demonstrated polygonal epithelial cells with atypia and lymphocytes, partially resulting in a sheetlike growth of epithelial cells. The mass was confirmed histopathologically as type B3 thymoma (hematoxylin and eosin).

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Discussion

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Academic Radiology, Volume 17, Issue 6
Journals General Radiology
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