Rationale and Objectives
The role of transthoracic needle biopsy (TTNB) in patients with hematologic malignancies, particularly in discriminating between malignant and benign etiologies, has not been well studied. Hence, the diagnostic efficacy and safety of computed tomography–guided TTNB were retrospectively evaluated in this population.
Materials and Methods
The records of 53 patients with hematologic malignancies who underwent TTNB from August 1, 1999, to July 31, 2007, were reviewed. Potential factors for increased diagnostic yield and risk for complications were collected and analyzed, including the status of neutropenia, thrombocytopenia, chemotherapy, and transplant as well as lesion size and location. Both cytopathologic and microbiologic results were assessed.
Results
The most common underlying hematologic malignancy was non-Hodgkin lymphoma, in 20 patients (37.7%). Lesions were most frequently located in the left upper lobe (16 [30.2%]); 33 lesions were pleural based (63.5%), and nine had cavitation (17.0%). TTNB established specific diagnoses in 22 patients (41.5%): malignancies was found in 12 (22.6%) and infections in 10 (18.9%). Sensitivity for detecting malignancy was 50.0%, and sensitivity for the detection of a specific infection was 40.0%. There were no false-positive results. Complications occurred in nine patients (17.0%): self-limited small-volume hemoptysis in one patient (1.9%) and pneumothorax in eight patients (15.1%), one requiring chest tube placement. The results of TTNB led to changes in antimicrobial therapy for eight of the 22 patients with specific diagnoses (36.4%).
Conclusions
TTNB is a safe diagnostic procedure in patients with hematologic malignancies and has the potential of making specific diagnoses with minimal morbidity.
Pulmonary syndromes are relatively common in patients with hematologic malignancies . Although infections are a major concern, the differential diagnosis includes infectious (viral, bacterial, fungal, parasitic) and noninfectious (malignancy, drug toxicity, inflammatory disorders) etiologies . Concurrent pulmonary pathologic processes are common . Routine chest radiography and sputum samples usually fail to diagnose concomitant pathologies , especially in patients with chemotherapy-induced neutropenia and empirical therapy .
Establishing a diagnosis is difficult in this population; early diagnosis and prompt initiation of effective therapy are crucial for successful clinical outcomes and subsequent management . Additionally, an aggressive approach to diagnosis limits unnecessary drug toxicity and exposure to potentially inadequate therapy .
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Materials and methods
Patient Cohort
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Data
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TTNB Procedure
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Cytopathologic Review
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Definitions
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Statistical Analysis
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Results
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Table 1
Patient Characteristics
Characteristic Value Patients 53 Sex Female 24 (45.3%) Male 29 (54.7%) Age at time of TTNB (y) 57 (43 to 68, 20 to 83) Underlying hematologic disease NHL 20 (37.7%) AML 10 (18.9%) MDS 5 (9.4%) HD 5 (9.4%) CLL 5 (9.4%) CML 3 (5.7%) Other ∗ 5 (9.4%) HSCT None 40 (75.5%) Allogeneic 8 (15.1%) Autologous 5 (9.4%) Time between HSCT and TTNB (mo) ( n = 13) 4.9 (3.4 to 22.7, 0.9 to 42.5) Time between last cycle of chemotherapy and TTNB (mo) ( n = 47) 1.9 (0.63 to 5.9, 0 to 125.5) Patients with neutropenia Not within 1 month before TTNB nor at TTNB 25 (47.2%) Within 1 month before TTNB, not at TTNB 15 (28.3%) At TTNB ( n = 43) † 13 (24.5%) Platelet count at TTNB (×10 3 /μL) ( n = 43) † 95 (67 to 194, 9 to 461) Patients with thrombocytopenia at TTNB (%) 23 (44.2%) Patients who received platelets before TTNB 22 (41.5%) Platelet count at TTNB (×10 3 /μL) 67 (56 to 77, 9 to 101) Platelet increase after transfusion (×10 3 /μL) 24 (9 to 38, −14 to 77)
AML, acute myelogenous leukemia; CLL, chronic lymphocytic leukemia; CML, chronic myelogenous leukemia; HD, Hodgkin’s disease; HSCT, hematopoietic stem cell transplantation; MDS, myelodysplastic syndrome; NHL, non-Hodgkin lymphoma; TTNB, transthoracic needle biopsy.
Data are expressed as number (percentage) or as median (interquartile range, range).
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Imaging Characteristics
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Table 2
Imaging Characteristics of Lesions That Underwent TTNB and Relationship to Specific Diagnoses
Characteristic Number of Cases (% of Total) Cases Providing Specific Diagnoses ( n = 22) Cases Providing No Specific Diagnosis ( n = 31)P Cavitation 9 (17.0%) 5 (22.7%) 4 (12.9%) .46 Pleural based ∗ 33 (62.3%) 11 (50.0%) 22 (71.0%) .16 Lesion size (cm 2 ) 8.9 (1.7–57.0) 7.8 (2.3–41.8) 10.5 (1.7–57.0) .88 Lesion location .73 LUL 16 (30.2%) 9 (31.8%) 7 (22.6%) LLL 10 (18.9%) 3 (13.6%) 7 (22.6%) RUL 9 (17.0%) 5 (22.7%) 4 (12.9%) RLL 8 (15.1%) 3 (13.6%) 5 (16.1%) RML 5 (9.4%) 1 (4.6%) 4 (12.9%) Other thoracic locations † 5 (9.4%) 3 (13.6%) 2 (6.5%)
LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; TTNB, transthoracic needle biopsy.
Data are expressed as number (percentage) or as median (interquartile range).
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Procedure
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Table 3
Complications of TTNB and Relationships to Thrombocytopenia, Lesion Location, and Number of Needle Passes
Risk Factor Total Number TTNB with Complication ( n = 9) TTNB without Complication ( n = 44)P Thrombocytopenia (%) 23 (44.2%) 3 (13%) 20 (87%) .69 Location of lesion .07 Pleural 33 (62.3%) 3 (9.1%) 30 (90.9%) Nonpleural 20 (37.7%) 6 (30%) 14 (70%) Number of passes 2 (1–5) 1 (1–3) 2 (1–5) .07
TTNB, transthoracic needle biopsy.
Data are expressed as number (percentage) or as median (range).
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Diagnostic Efficacy
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Table 4
Specific Diagnoses Provided by TTNB (Diagnostic Efficacy) and Final Specific Diagnoses Established After TTNB
Diagnosis Diagnosis Provided by TTNB Final Diagnosis Established Malignancy 12 24 Lung cancer 5 ∗ 7 Recurrent lymphoma 7 16 Presumed lymphoma 0 1 † Infection 10 25Aspergillus 4 6Nocardia 2 2Candida 1 1 Zygomycetes 1 1 Bacterial infection 1 1Actinomyces odontolyticus 1 2Alternaria , disseminated 0 1 Presumed 0 11 ‡ No diagnosis § 31 — ‖
TTNB, transthoracic needle biopsy.
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Table 5
Changes in Antimicrobial Therapy as a Result of Specific Diagnoses Provided by TTNB
Patient Date of FNA Indication for TTNB ∗ Antimicrobial Treatment Before TTNB Specific Diagnosis Provided by TTNB Antimicrobial Treatment After TTNB A December 1999 Infection None_Nocardia asteroides_ Imipenem, trimethoprim-sulfamethoxazole B January 2003 Infection/malignancy L-AMB_Aspergillus_ sp Voriconazole C November 2003 Infection Fluconazole, caspofungin_Aspergillus_ sp Voriconazole D April 2004 Infection L-AMB_Aspergillus_ sp Voriconazole and caspofungin added E October 2005 Infection Fluconazole_Aspergillus_ sp Voriconazole F April 2006 Infection Voriconazole_Actinomyces odontolyticus_ Penicillin G March 2007 Infection/malignancy None Zygomycetes Posaconazole H Jul 2007 Infection L-AMB_Candida albicans_ Fluconazole
FNA, fine-needle aspiration; L-AMB, liposomal amphotericin B; TTNB, transthoracic needle biopsy.
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Table 6
Relationship of a Specific Diagnosis of Infection Established with TTNB to Clinical Risk Factors for Infection
Clinical Risk Factor Total Number Cases Providing Specific Diagnoses of Infection ( n = 10) Cases Providing No Diagnosis of Infection ( n = 43)P Neutropenic patients .02 Not within 1 mo before or at TTNB 25 (47.2%) 1 (10%) 24 (55.8%) Within 1 mo before, not at, TTNB 15 (28.3%) 5 (50%) 10 (23.3%) At TTNB only 13 (24.5%) 4 (40%) 9 (20.9%) HSCT 1.00 Yes 13 (24.5%) 2 (20%) 11 (26.6%) No 40 (75.5%) 8 (80%) 32 (74.4%) Time between last cycle of chemotherapy and TTNB (mo) ( n = 47) 1.9 (0–125.5) 1.5 (0–125.5) ∗ 2.2 (0–81.5) † .74
HSCT, hematopoietic stem cell transplantation; TTNB, transthoracic needle biopsy.
Data are expressed as number (percentage) or as median (range).
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Outcomes
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Discussion
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Conclusion
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References
1. White D.A., Wong P.W., Downey R.: The utility of open lung biopsy in patients with Hematologic malignancies. Am J Respir Crit Care Med 2000; 161: pp. 723-729.
2. Fishman JA. Approach to the immunocompromised patient with fever and pulmonary infiltrates. Available at: http://www.uptodate.com . Accessed November 14, 2008.
3. Wong P.W., Stefanec T., Brown K., et. al.: Role of fine-needle aspirates of focal lung lesions in patients with hematologic malignancies. Chest 2002; 121: pp. 527-532.
4. Salonen J.H.: Successful management of cerebral and pulmonary mucormycosis with liposomal amphotericin B in a 28-year-old woman with acute lymphoblastic leukemia. Acta Biomed 2006; 77: pp. 28-31.
5. Kuhlman J.E., Fishman E.K., Burch P.A., et. al.: Invasive pulmonary aspergillosis in acute leukemia. The contribution of CT to early diagnosis and aggressive management. Chest 1987; 92: pp. 95-99.
6. Rubin R.H.: Clinical approach to infection in the compromised host.4th ed2002.SpringerNew York
7. Chung T.: Fine needle aspiration of the solitary pulmonary nodule. Semin Thorac Cardiovasc Surg 2002; 14: pp. 275-280.
8. Cahill A.M., Baskin K.M., Kaye R.B., et. al.: CT-guided percutaneous lung biopsy in children. J Vasc Interv Radiol 2004; 15: pp. 955-960.
9. Lacasse Y., Wong E., Guyatt G.H., et. al.: Transthoracic needle aspiration biopsy for the diagnosis of localised pulmonary lesions: a meta-analysis. Thorax 1999; 54: pp. 884-893.
10. Hehn S.T., Grogan T.M., Miller T.P.: Utility of fine-needle aspiration as a diagnostic technique in lymphoma. J Clin Oncol 2004; 22: pp. 3046-3052.
11. Arslan S., Yilmaz A., Bayramgürler B., et. al.: CT-guided transthoracic fine needle aspiration of pulmonary lesions: accuracy and complications in 294 patients. Med Sci Monit 2004; 8: pp. CR493-CR497.
12. Zihlif M., Khanchandani G., Ahmed H.P., et. al.: Surgical lung biopsy in patients with hematological malignancy or hematopoietic stem cell transplantation and unexplained pulmonary infiltrates: improved outcome with specific diagnosis. Am J Hematol 2005; 78: pp. 94-99.
13. Nosari A., Anghilieri M., Carrafiello G., et. al.: Utility of percutaneous lung biopsy for diagnosing filamentous fungal infections in hematologic malignancies. Haematologica 2003; 88: pp. 1405-1409.
14. Carrafiello G., Lagana D., Nosari A.M., et. al.: Utility of computed tomography (CT) and of fine needle aspiration biopsy (FNAB) in early diagnosis of fungal pulmonary infections. Study of infections from filamentous fungi in haematologically immunodeficient patients. Radiol Med 2006; 111: pp. 33-41.
15. Choi C.-M., Um S.-W., Yoo C.-G., et. al.: Incidence and risk factors of delayed pneumothorax after transthoracic needle biopsy of the lung. Chest 2004; 126: pp. 1516-1521.