Percutaneous Computed Tomography-Guided Coaxial Core Biopsy for Small Pulmonary Lesions with Ground-Glass Attenuation Chia-Hung Lu, MD, FRCR, Cheng-Hsiang.

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Percutaneous Computed Tomography-Guided Coaxial Core Biopsy for Small Pulmonary Lesions with Ground-Glass Attenuation Chia-Hung Lu, MD, FRCR, Cheng-Hsiang Hsiao, MD, Yeun-Chung Chang, MD, PhD, Jang-Ming Lee, MD, PhD, Jin-Yuan Shih, MD, PhD, Li-An Wu, MD, Chong-Jen Yu, MD, PhD, Hon-Man Liu, MD, Tiffany Ting-Fang Shih, MD, Pan-Chyr Yang, MD, PhD Journal of Thoracic Oncology Volume 7, Issue 1, Pages 143-150 (January 2012) DOI: 10.1097/JTO.0b013e318233d7dd Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Flow diagram of patient management after receiving CT-guided coaxial TNB. TNB, transthoracic needle biopsy; VATS, video-assisted thoracoscopic surgery; LND, lymph node dissection; adenoca (inv), adenocarcinoma with stromal invasion; BAC, bronchiolar alveolar carcinoma; MALToma, mucosa-associated lymphoid tissue lymphoma; RFA, radiofrequency ablation of tumor; C/T, chemotherapy; F/U, follow-up. *Three false-negative results of CT-guided core TNB included two BAC and one MALToma. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 A 69-year-old woman was noted to have a pure GGO lesion in the right middle lobe during low-dose screening CT. CT-guided coaxial TNB was performed after a follow-up CT 2 months later showed a stationary size. A, Thin-section CT showed a localized pure ground glass nodule. B, Percutaneous CT-guided TNB was performed with a coaxial needle introduced to the edge of the lesion. C, Histopathologic specimen from the core biopsy (hematoxylin-eosin [HE] stain, ×400) showed cuboidal tumor cells lining the entrapped alveolar space without evident stromal invasion. D, Photomicrograph of the surgical specimen (HE stain, ×400) confirmed BAC with tumor cell proliferation along the alveolar space and lymphocyte infiltration in the interstitium. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 A 70-year-old woman who had a history of thyroid papillary carcinoma had a chest CT scan as follow-up, which showed a pure GGO nodule approximately 2.8 cm in diameter in the left upper lobe (A) and another smaller GGO nodule about 7 mm in diameter in the right upper lobe (not shown). B, Mild focal hemorrhage within the lesion was seen around the tip of the guiding needle during CT-guided coaxial TNB. C, Histopathologic specimen from the core biopsy (hematoxylin-eosin [HE] stain, ×400) showed cuboidal tumor cells lining the alveolar space without evident stromal invasion. D, Photomicrograph of the surgical specimen (HE stain, ×200) turned out to be adenocarcinoma with atypical glandular structures infiltrating the fibrotic stroma. In this case, stromal invasion was underestimated in the biopsy specimen obtained from CT-guided TNB. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 A 73-year-old woman receiving CT for a chronic cough. It showed a GGO-dominant nodule in the left upper lobe (A). CT-guided coaxial TNB biopsy was performed. A, Thin-section CT with 1.25-mm collimation showed a localized GGO-dominant nodule. B, Percutaneous CT-guided TNB was performed with a coaxial needle introduced into the middle of the lesion and to the edge of the solid part. C, Histopathologic specimen from the core biopsy (hematoxylin- eosin [HE] stain, ×200) showed cuboidal tumor cells lining the entrapped alveolar space without evident stromal invasion. D, Photomicrograph of the surgical specimen (HE stain, ×400) confirmed BAC with tumor cell proliferation along the alveolar space. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 5 A 64-year-old woman who had a history of thyroid papillary carcinoma underwent a positron emission tomography (PET) scan, which showed a hot spot in the left upper lobe. The lesion slightly increased in size on follow-up CT 5 months later. A, Thin-section CT with 3-mm collimation showed a 2.2-cm ground glass dominant nodule in the left upper lobe. B, Percutaneous CT-guided core biopsy was performed. C, Histopathologic specimen from the core biopsy (hematoxylin-eosin [HE] stain, ×400) showed cuboidal tumor cells lining the alveolar space as well as suspicious tumor invasion into the interstitium. D, Photomicrograph of the surgical specimen (HE stain, ×100) confirmed adenocarcinoma with evident stromal invasion. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 6 Comparison of the final histopathologic diagnoses between pure GGO and GGO-dominant lesions on CT in the 43 patients with VATS lobectomy. The chi-square test was used to analyze categorical proportions of BAC. A p value <0.05 was considered to be statistically significant. adenoca (inv), adenocarcinoma with stromal invasion; BAC, pure bronchioloalveolar carcinoma; MALToma, mucosa-associated lymphoid tissue lymphoma. Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 7 Logistic regression analysis was conducted based on the 42 patients with a surgical diagnosis of either BAC or adenocarcinoma. A conditional effect plot of GGO percentage of the pulmonary lesion on probability of stromal invasion in surgical pathology showed a significant negative correlation between the two parameters (p = 0.0028). Journal of Thoracic Oncology 2012 7, 143-150DOI: (10.1097/JTO.0b013e318233d7dd) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions