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    J Korean Soc Radiol. 2015 Oct;73(4):216-224. Korean.
    Published online Sep 25, 2015.
    https://doi.org/10.3348/jksr.2015.73.4.216
    Copyright © 2015 The Korean Society of Radiology
    Original Article

    Predicting Factors for Conversion from Fluoroscopy Guided Percutaneous Transthoracic Needle Biopsy to Cone-Beam CT Guided Percutaneous Transthoracic Needle Biopsy

    Kang Ji Lee, MD,1 Young Min Han, MD,1,2,3 Gong Yong Jin, MD,1,2 and Ji Soo Song, MD1
      • 1Department of Radiology, Chonbuk National University Hospital and Medical School, Jeonju, Korea.
      • 2Research Institute of Clinical Medicine, Chonbuk National University Hospital and Medical School, Jeonju, Korea.
      • 3Institute of Cardiovascular Research, Chonbuk National University Hospital and Medical School, Jeonju, Korea.
    • Corresponding author: Young Min Han, MD. Department of Diagnostic Radiology, Chonbuk National University Medical School and Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea. Tel. 82-63-250-1176, Fax. 82-63-272-0481, Email: ymhan@jbnu.ac.kr
    Received February 17, 2015; Revised August 04, 2015; Accepted August 07, 2015.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Purpose

    To evaluate the predicting factors for conversion from fluoroscopy guided percutaneous transthoracic needle biopsy (PTNB) to cone-beam CT guided PTNB.

    Materials and Methods

    From January 2011 to December 2012, we retrospectively identified 38 patients who underwent cone-beam CT guided PTNB with solid pulmonary lesions, and 76 patients who underwent fluoroscopy guided PTNB were matched to the patients who underwent cone-beam CT guided PTNB for age, sex, and lesion location. We evaluated predicting factors such as, long-axis diameter, short-axis diameter, anterior-posterior diameter, and CT attenuation value of the solid pulmonary lesion affecting conversion from fluoroscopy guided PTNB to cone-beam CT guided PTNB. Pearson χ2 test, Fisher exact test, and independent t test were used in statistical analyses; in addition, we also used receiver operating characteristics curve to find the proper cut-off values affecting the conversion to cone-beam CT guided PTNB.

    Results

    Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent fluoroscopy guided PTNB were 2.70 ± 1.57 cm, 3.40 ± 1.92 cm, 3.06 ± 1.81 cm, and 35.67 ± 15.70 Hounsfield unit (HU), respectively. Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent cone-beam CT guided PTNB were 1.60 ± 1.30 cm, 2.20 ± 1.45 cm, 1.91 ± 1.99 cm, and 18.32 ± 23.11 HU, respectively. Short-axis, long-axis, anterior-posterior diameter, and CT attenuation value showed a significantly different mean value between the 2 groups (p = 0.001, p < 0.001, p = 0.003, p < 0.001, respectively). Odd ratios of CT attenuation value and short-axis diameter of the solid pulmonary lesion were 0.952 and 0.618, respectively. Proper cut-off values affecting the conversion to cone-beam CT guided PTNB were 1.65 cm (sensitivity 68.4%, specificity 71.1%) in short-axis diameter and 29.50 HU (sensitivity 65.8%, specificity 65.8%) in CT attenuation value.

    Conclusion

    Low CT attenuation value and small short-axis diameter of the solid pulmonary lesion affect conversion from fluoroscopy guided PTNB to cone-beam CT guided PTNB.

    Keywords
    Percutaneous Transthoracic Needle Biopsy; Cone-Beam CT; Solid Pulmonary Lesion; Fluoroscopy; Predicting Factors

    Figures

    Fig. 1
    A small pulmonary nodule in the right upper lobe of a 47-year-old woman with history of breast cancer.
    A. About 1 cm-sized well-marginated, small, round nodule in RUL is noted on the lung setting axial image of the HRCT.

    B. CT mean attenuation value is measured using free-drawing ROI on the mediastinal setting of axial image.

    C. The nodule was not detected on fluoroscopy performed with the patient in supine position.

    D. The operator accordingly performed cone-beam CT guided PTNB with careful adjustment of the needle. The result of PTNB indicated a meta-static adenocarcinoma.

    HRCT = high-resolution CT, PTNB = percutaneous transthoracic needle biopsy, ROI = region of interest, RUL = right upper lobe

    Fig. 2
    A solitary pulmonary mass suspicious for malignancy in the right lower lobe of a 72-year-old man, which was well-marginated, irregular-shaped, and abutting the pleura.
    A. Antero-posterior diameter of the mass is measured to about 3.61 cm on the unenhanced axial image of the chest CT.

    B. CT mean attenuation value is subsequently measured using free-drawing ROI on the unenhanced axial image.

    C. Long-axis and short axis diameters are also measured on the coronal reconstructed image.

    D. Fluoroscopic image shows the mass with well-defined margin on the left side. The operator next performed fluoroscopy-guided PTNB with patient in prone position and careful adjustment of the needle; the result of PTNB indicated a squamous cell carcinoma.

    PTNB = percutaneous transthoracic needle biopsy, ROI = region of interest

    Fig. 3
    Box plots of predicting independent variables in conversion of fluoroscopy guided PTNB to cone-beam CT guided PTNB.
    A. Box plot comparing the short-axis diameter, long-axis diameter, and AP diameter of pulmonary lesion between the patients who underwent fluoroscopy-guided PTNB vs. cone-beam CT guided PTNB.

    B. Box plot showing CT attenuation value of pulmonary lesion of the above 2 groups.

    *, • = outlier.

    AP = anterior to posterior, PTNB = percutaneous transthoracic needle biopsy

    Fig. 4
    Receive operating characteristics curve (ROC curve). This graph showed statistically significant independent variables, short-axis diameter and CT attenuation value of the pulmonary lesion. AUC of these variables were 0.753 and 0.722, respectively. We set a cut-off value to 29.50 of CT attenuation that showed 65.8% of sensitivity and specificity, respectively; in addition, we set a cut-off value to 1.65 cm of short-axis diameter that showed 68.4% of sensitivity and 71.1% of specificity.
    AUC = area under the curve

    Tables

    Table 1
    Demographics and Image Characteristics between Patients Underwent Fluoroscopy Guided PTNB and Underwent Cone-Beam CT Guided PTNB

    Table 2
    Pathologic Results of the Percutaneous Transthoracic Needle Biopsies

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    MeSH Terms
    Biopsy, Needle*
    Cone-Beam Computed Tomography*
    Fluoroscopy*
    Humans
    Needles*
    ROC Curve
    Retrospective Studies
    Sensitivity and Specificity
    Metrics
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