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INTRODUCTION

A 80-year-old male developed increasing shortness of air (SOA), and a 5-cm left hilar mass is found on computed tomography (CT) compressing the central airway. He has known chronic obstructive pulmonary disease (COPD). A positron emission tomographic (PET) scan identifies SUV-positive mediastinal lymph nodes and contralateral smaller nodules. Magnetic resonance imaging (MRI) of the brain shows a 2.5-cm mass.

The patient does not wish to undergo diagnostic or therapeutic bronchoscopy. Radiation oncology is consulted and asks for a tissue diagnosis before any radiation treatment.

Learning Objectives

  1. What is the role of interventional radiology (IR) in diagnosing lung cancer?

  2. Can IR treat lung cancer?

  3. Can IR palliate lung cancer symptoms?

DIAGNOSTICS OF LUNG CANCER

Diagnostic radiology has been the mainstay of the diagnosis of lung cancer, with screening chest radiographs and CT. Early detection has led to initiation of therapy at a stage where the disease is still vulnerable to treatment for cure and not palliation. However, the specifics of treatment require pathologic diagnosis of tissue samples.

Interventional radiology started the fluoroscopically guided placement of small needles into both peripheral and central lesions. The first needle biopsy was reported in Germany shortly after the discovery of x-rays, but Martin and Ellis from the Memorial Hospital in New York are credited for the development of the needle aspiration technique in 1930 using an 18-gauge needle.1 The technique did not gain traction initially because the techniques of cytologic preparation of these small tissue specimens had not been sufficiently developed. It was not until the 1950s that the tissue preparation began to be more sophisticated. With the development of cross-sectional imaging and IR in the 1960s, the use of this technique became standard practice. Today, these needles are typically 22 or 20 gauge. Fine-needle aspirates are utilized to detect the presence of metastatic disease rather than primary lung cancer. The diagnostic accuracy depends on the technique utilized and cooperation and presence of a pathology team at the time of biopsy to evaluate the adequacy of the sample for diagnosis.

The puncture site is obviously determined by the site of the tumor. The most direct and shortest distance is determined, and the skin site is sterilized and anesthetized with lidocaine. Under imaging guidance, the needle is advanced until the tip is seen to move the lesion or to move with the lesion when the fluoroscopy unit is tilted from side to side. A 20-gauge needle can be placed and a 22-gauge needle placed coaxially within it. Multiple biopsies can then be obtained with a single needle placement.

The risks of lung biopsy to the patient include bleeding if a large vessel is crossed or a smaller amount of bleeding due to the extraction of tissue. Minor hemoptysis will likely occur if the lesion becomes more indistinct in appearance. Tumor seeding of the biopsy tract is possible, but ...

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