even to determine the primary sites fur secondary cancers on the basis of cytomorphologic features. With the experience and confidence gained in the past decades in the cytomorphologic interpretation of the aspiration biopsy, we realize that the microscopic evidence of malignancy found in the aspirate is not always so easily demonstrated in the submitted tissue sections which rely greatly on the gross findings of the surgical specimens. This situation is usually seen in a small cancer of which the consistency is similar to its surrounding tissue, (a small scar cancer in a larger area of scarring). We have had 3 such cases" in recent years which were initially considered as "false positive" and eventually proved to be false "false positive" after careful re-examination of the surgical specimen (serial sectioning of the entire lesion). Having examined thousands of cytologic samples of lung lesions, .we conclude that transthoracic fine-needle aspiration biopsy is an excellent diagnostic method with a high degree of accuracy in obtaining a pathologic diagnosis in experienced hands. It greatly enhances the diagnostic potential for the detection of malignancy.
1 Sanders DE, Thompson DW, Pudden BJE. Percutaneous aspiration lung biopsy. CMAJ 1971; 104:139 2 Tao tc, Delarue NC, Sanders D, Weisbrod GL. Bronchioloalveolar carcinoma: A correlative clinical and cytologic study. Cancer 1978; 42:2759 3 Tao Le, Robertson DI. Cytologic diagnosis of bronchial mucoepidermoid carcinoma by fine-needle aspiration biopsy. Acta Cyto11978; 22:221 4 180 tc, Pearson FG, Delarue NC, Langer B, Sanders DE. Percutaneous fine-needle aspiration biopsy. I. Its value to clinical practice. Cancer 1980; 45:1480 5 Tao tc, Sanders D, McLoughlin MJ, Weisbrod GL, 80 CS. Current concepts in Rne-needle aspiration biopsy cytology. Human Patholl980; 11:94 6 ToddTRJ, Weisbrod GL, Tao LC, Sanders DC. Aspiration needle biopsy of thoracic lesions. Ann Thorac Surg 1961;32:2 7 Tao tc, Pearson FG, Cooper JO, Sanders DE, Weisbrod GL, Donat EE. The cytopathology of thymoma. Acta Cytol 1984; 28:165 8 Tao LC, Weisbrod GL, Ritcey EL, Dves R. False
Transthoracic Percutaneous Fine Needle Aspiration Biopsy G. L. Wei&brod, M.D., University ofToronto, Cant.ula 330S
'Dercutaneous fine needle aspiration biopsy (PFNAB) has been performed in various ways since 1883, using largebore cutting needles, air-powered drills, and more recently thin-bore needles with various bevelled and non-bevelled ends and slots for cutting. We use a simple sharply bevelled 20 gauge spiral needle which provides a cytologic specimen by aspiration rather than a core of tissue for histologic examination. The procedure involves fluoroscopicallyguided biopsy with usually only 1 pass of the needle per patient at 1 time. The apparatus necessary includes spinal needles of various lengths and gauge, 50 ml syringe for suction, Cyto spray to fix the aspirate, and Mucolex pre· servative. The indications for the procedure vary from center to center; but I would like to emphasize the value of streamline ing the investigation of many types of intrathoracic lesions, thereby saving hospital days, by-passing laboratory procedures, and ultimately saving health costs. Most of the contraindications are relative with the only absolute ones being an uncooperative patient and a suspected hydatid cyst. A series of 1,993 patients who underwent the procedure a total of 2,421 times was analyzed. The most frequent complication was pneumothorax, occurring in 34%, with other complications being very uncommon. There were no deaths in the series. The value of repeat needle biopsies on the same lesion was shown by the fact that about % of those lesions eventually proved to be malignant with an initial negative needle biopsy showed malignant cells on the subsequent biopsy. The cytologic results were analyzed and broken down into those positive for malignancy, suggestive of malignancy, and negative fur malignancy. There were 818 cytologic negative for malignancy aspirates and these were subdivided into 5 groups: poor specimen negative, nonspecific inflammatory negative, semi-specific negative, specific organism negative, and benign tumor negative aspirates. There were 206 falsely negative for malignancy aspirates. Causes of falsely negative results would include experience of the radiologist and cytopathologist, pathological nature of the lesion, size and location of the lesion, type of needle used, and obstructive change distal to a more central tumor: There were 1,189 cytologic positive for malignancy aspirates. The cytologic-histologic correlation was 79% with squamous cell carcinoma, 82% with adenocarcinoma, 83% with bronchiolo-alveolar carcinoma, 77% with small cell anaplastic carcinoma, and 82% with metastatic tumor: There were 8 falsely positive aspirates for malignancy. The sensitivity of the procedure is 87%, the speci6city 98%, the positive predictive value 99%, and the negative predictive value 68%. This technique can beapplied to masses in the hilum of the lung and masses in the mediastinum. Needle biopsy is not in competition with tissue histopathology and the results ofboth procedures sometimes have to be analyzed together before a de6nite diagnosis can be made of certain lesions. If the cytopathology results differ from the tissue pathology, an explanation should always be sought for this discrepancy. Needle biopsy can be performed quickly and simply, a diagnostic result is often available within a few hours, and the morbidity is low and the mortality negligible, so I believe this procedure should be
IV Wortd Conference on Lung Cancer
performed early in the investigation of many types of intrathoracic lesions.
144:281-88 Tao ic, Weisbrod GL, Ritcey EL, Ilves R. False "false-positive'
Todd ra, Weisbrod GL, 180 LC, Sanders DE, et ale Aspiration needle biopsy of thoracic lesions. Ann Thor Surg 1981; 32
Weisbrod GL, Lyons OJ, Tao LC, Chamberlain OW Percutaneous fine-needle aspiration biopsy of mediastinal lesions. AJR 1984; 143:523-29 Sanders DE, Thompson O~ Pudden BJE. Percutaneous aspiration lung biopsy. CMAJ 1971;104:139-42 Herman PG, Hessel SJ. The diagnostic accuracy and complications of closed lung biopsies. Radiology 1977; 125:ll2l4 Sagel S, Ferguson TB, Forrest ~ et ale Percutaneous trans-thoracic aspiration needle biopsy. Ann Thor Surg 1978; 26:399-404
Lalli AF, McCormack LJ, Zelch M, et aleAspiration biopsies of chest lesions. Radiology 1978; 127:35-40 Sinner WN. 'fransthoracic needle biopsy of pulmonary lesions. Cancer 1979; 43:1533-40
lao tc, Sanders DE, McLoughlin MJ, Weisbrod GL, 80 CS. Current concepts in fine needle aspiration biopsy cytology. Human Patho1198O; 2:94-6 Berquist TH, Bailey PB, Cortese DA, Miller WE. 'Iransthoraeic needle biopsy-accuracy and complications in relation to location and type of lesion. Mayo Clin Proc1980; 55:475-81 Kucharczyk W, Weisbrod GL, Cooper JD, Todd L Cardiac tamponade as a complication of thin-needle aspiration lung biopsy. Chest 1982: 120-21 Thornbury JR, Burke D~ Naylor B. lhmstboracic needle aspiration biopsy: accuracy of cytologic typing of malignant neoplasms. AJR 1981; 136:719-24 Gobien ~ Valicenti JF, Paris DS, Daniell C. Thin-needle aspiration biopsy: methods of increasing the accuracy of a negative prediction. Radiology 1982; 145:603-09 Pinstein ML, Scott RL, Salazar J. Avoidance of negative percutaneous lung biopsy using contrast-enhanced AJR 1983; 140:265-67
Stevens GM, Jackman RJ. Out-patient needle biopsy oftbe lung: its safety and utility. Radiology 1984; 151:301-04 Ueberman ~ Hafez GR, Crummy AB. Histology from aspiration biopsy: Thrner needle experience. AJR 1982; 138:561-64 Gobien ~ Bourchard EA, Gobien BS, Valicenti JF, Vujic I. Thin needle aspiration biopsy of thoracic lesions: impact on hospital charges and patterns of patient care. Radiology 1983; 148:65-7 Khouri Nit: Stitic F~ Erozen YS, et ale Thmsthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR 1985;
results in diagnostic cytology. Acta Cytoll984; 28:450-56
,tn early and reliable differential diagnosis of pulmonary lesions can now be obtained by means of cytologic material from needle biopsies of the lung. The importance of computed tomography for the early detection and correct localization of small nodules was very well covered by Zerhouni, a well known expert in this field. Undoubtedly, many small nodules can be localized by means of computed tomography. However, this should not hide the importance of high quality standard radiographic procedures which usually give enough information. In the discussions of this topic it was stressed that short exposure times and higher voltage techniques (140-150 kV) should be used in chest radiography. Further, it was also pointed out that oblique views constitute an important element for the identification of small nodules in the lungs. Therefore, computed tomography should be considered a complement to standard routine examination. After identification of small nodules in the lungs, material can now be sampled from these for cytologic diagnosis with high accuracy. This topic was covered by Weisbrod and Tho. Needle biopsy is now performed everywhere in the world in large progressive centers for pulmonary diseases. The presentations by Weisbrod and Tao covered this subject very well but were limited to the use of the primarily introduced type of technique, the aspiration by thin needles. The use and advantages of the 0.8 mm thick screw needle technique was, however, also discussed. The general tendency is now to use fine needle aspiration or the 0.8 mm screw needle for sampling of cell material from the lungs. It has also been stressed that one should avoid thicker needles and particularly needles of the cutting type as these increase the rate of complications, such as bleeding and pneumothorax, considerably. In experienced hands, cytology is completely sufficient to obtain a reliable differential diagnosis.
CHEST I 89 I 4 I APRIL, 1986 I Supplement