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Original Research: Pulmonary Procedures |

Negative Predictive Value of Transthoracic Core-Needle BiopsyNegative Predictive Value of Transthoracic Biopsy: A Multicenter Study FREE TO VIEW

Clara Fontaine-Delaruelle, MD; Pierre-Jean Souquet, MD, FCCP; Delphine Gamondes, MD; Eric Pradat, MD; Aurélie De Leusse, MD; Gilbert R. Ferretti, MD, PhD; Sébastien Couraud, MD
Author and Funding Information

From the Service de pneumologie (Drs Fontaine-Delaruelle, Souquet, and Couraud) and Service d’imagerie (Dr De Leusse), Hospices Civils de Lyon Cancer Institute, CH Lyon Sud, Pierre-Bénite; Faculté de médecine Lyon Est (Dr Fontaine-Delaruelle), Université Lyon 1, 69003 Lyon; EMR 3738 Ciblage thérapeutique en oncologie (Drs Souquet and Courand), Faculté de médecine Lyon Sud, Université Lyon 1, 69495, Pierre-Bénite; Service d’imagerie (Dr Gamondes), Hospices Civils de Lyon, CH Louis Pradel, Bron; Pôle IMER (Dr Pradat), CH Lyon Sud 69495, Pierre-Bénite; Clinique universitaire de radiologie et imagerie médicale (Dr Ferretti), Centre hospitalier universitaire Grenoble, 38043 Grenoble; and Université de Grenoble Alpes (Dr Ferretti), 38000 Grenoble, France.

CORRESPONDENCE TO: Sébastien Couraud, MD, Centre Hospitalier Lyon Sud, Service de Pneumologie Aiguë Spécialisée et Cancérologie Thoracique, 165 chemin du grand Revoyet, 69495 Pierre Bénite CEDEX, France; e-mail: sebastien.couraud@chu-lyon.fr


This study was presented at the 18th French Conference in Respiratory Medicine, January 2014, Marseille, France, and the 20th European Congress of Radiology, March 2014, Vienna, Austria.

FUNDING/SUPPORT: English rewording of the manuscript was supported by a grant from the Bibliothèque scientifique de l’Internat de Lyon and les Hospices Civils de Lyon.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):472-480. doi:10.1378/chest.14-1907
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BACKGROUND:  Specimens collected by CT scan-guided transthoracic core-needle biopsy (TTNB) are frequently used for the diagnosis of lung nodules, but the clinical value of negative results has not been sufficiently investigated. We sought to determine the negative predictive value (NPV) of TTNB specimens and investigate predictive factors of negative results.

METHODS:  All consecutive TTNBs performed in three centers between 2006 and 2012 were included. The medical charts of patients with nonmalignant TTNB specimens were reviewed and classified as true or false negatives. Binary logistic regression was used for multivariate analysis.

RESULTS:  Overall, findings from 980 TTNB specimens were included. Malignant disease was found in 79% (n = 777) of the cases, nonmalignant disease in 6% (n = 54), and “negative” results in 15% (n = 149). For the diagnosis of malignant disease, NPV was 51%. Estimated sensitivity, specificity, and accuracy were 89%, 99%, and 90%, respectively. The complication rate was 34% (life-threatening complication in 6%). In multivariate analysis, predictive factors for a false-negative result were radiologist experience (adjusted OR [AOR], 0.996; 95% CI, [0.994-0.998]), occurrence of a complication during the procedure (AOR, 1.958; 95% CI, [1.202-3.187]), and moderate to high maximum standardized uptake value on PET scan (AOR, 7.657; 95% CI, [1.737-33.763]). In 24 cases, a second TTNB was performed at the same target. The complication rate was 33%, and TTNB specimens provided diagnosis in 95% of cases with a 67% NPV.

CONCLUSIONS:  One-half of all “negative” TTNB specimen results were falsely negative for malignant diagnosis. Findings in tissue collected from a second TTNB at the same target provided a final diagnosis in most cases without increasing complication rates.

Figures in this Article

With advances in CT imaging and the growing interest of lung cancer screening, the management of lung nodules is becoming increasingly challenging.13 Although observation strategy or direct surgical resection could be proposed if cancer probability is respectively low or high, many decision-making algorithms include a nodule-sampling step. There are various ways to sample such nodules, including flexible bronchoscopy (including electromagnetic navigation), radial endobronchial ultrasonography, surgery (thoracotomy or thoracoscopy), and transthoracic CT scan-guided sampling (ie, transthoracic CT scan-guided core-needle biopsy [TTNB] or fine-needle aspiration).4,5 Although the technique of biopsy is quite similar, TTNB and fine-needle aspiration (FNA) differ in that the latter provides cytologic samples while the former provides larger samples, allowing histologic and biomolecular analysis.57 TTNB is considered as the standard technique, particularly for peripheral lung lesions, bronchoscopically inaccessible lung lesions, and central (hilar or mediastinal) masses.2,4,5,79 Although the TTNB complication rate appears noteworthy (around 20% for pneumothorax and 7% for hemoptysis), the intervention is nonetheless considered safe because these complications are mostly asymptomatic or low grade.7,9,10

Specimens obtained via TTNB offer 90% sensitivity and 97% specificity for the diagnosis of thoracic malignancy.5 Although TTNBs are frequently performed in daily practice worldwide, information is lacking for TTNB specimens that do not give malignant results. Indeed, TTNB specimens may result in a diagnosis of nonmalignant disease or show a “negative” result (no disease identified in the samples considered).8,9 Only a handful of studies have reported outcomes occurring after a negative or a nonmalignant TTNB specimen. All were limited by a very low number of cases or focused only on specific lesions, such as benign or ground-glass opacities.9,1114 However, the frequency of negative or nonmalignant results raises very practical questions on the risk factors for the negative predictive value (NPV) of TTNB.

Thus, in the present study, we investigated negative and nonmalignant results of TTNB from a large retrospective cohort. We sought to estimate the NPV of TTNB and comprehensively assess predictive factors for false-negative results.

Population

The hospital databases of three centers (Lyon Sud hospital, Lyon; Louis Pradel hospital, Lyon; and Grenoble hospital, Grenoble, all located in France) were used to retrospectively select all TTNBs performed in patients over 18 years of age between January 1, 2006, and December 31, 2012 (7 years). The TTNB reports were then reviewed to exclude FNAs as well as core biopsies to organs other than the lung, the mediastinum, or the pleura. The remaining TTNB reports were subsequently reviewed. Those without any sampling performed or for which a pathologic report was not available were excluded.

The selected TTNB specimens were classified as follows: (1) “malignant disease” for cases of histologically proven malignancy (including hematologic cancers); (2) “nonmalignant disease” for those with an identified but nonmalignant disease; and (3) “inconclusive (negative) result” for those with no disease diagnosed and/or with poor material collected in the biopsy procedure. Malignant results were not further investigated.

Data Collection and Outcome Definitions

Additional data were collected through medical charts for all patients with at least one TTNB specimen finding of a nonmalignant disease or negative result, including patient medical history, date of last contact or date of death, and the strategy followed to obtain a final diagnosis. Final diagnosis was defined as the diagnosis finally retained by the clinician, based on either findings from a second biopsy specimen, any other test, or the follow-up of the considered nodule. The following variables were recorded: target type (solid, ground-glass opacity, or mixed), and length of needle path. Unfortunately, the quality of recording was very different between centers, and we had to deal with too many missing values. Therefore, these variables were not considered in the study.

Additionally, we computed an operator experience index: All TTNBs performed by each radiologist during the study period were noted and summed, then classified into three categories (< 20 TTNBs, between 21 and 99 TTNBs, and > 100 TTNBs).

Ethical Consideration

This study was categorized as noninterventional by the Lyon Sud-Est IV ethics committee (reference number L13-102). The database was declared to the national information registry authority (reference number HCL13-84), as required by French laws.

TTNB Process

All TTNBs were performed by senior board-certified radiologists. All centers follow the same guidelines for diagnosis work-up of lung cancer and, thus, have similar indications for TTNB. Patient position was determined according to the location of the target in the thorax. Coaxial systems using automated or semiautomated core-biopsy needles were used. All TTNBs were performed under CT scan guidance. Once the biopsy was completed, a whole-thoracic CT scan was performed to check for acute complications such as pneumothorax or bleeding.

Adverse Events

Acute complications were recorded based on the opinions of the radiologists. Of note: We did not take simple alveolar hemorrhage (defined as localized lung bleeding observed at CT imaging during the TTNB but without hemoptysis or other symptoms) into consideration. Hemoptysis severity (minor, moderate, or major) and hemothorax severity (minor or major) were assessed by the radiologist. Death or life-threatening events such as drained pneumothorax, major hemoptysis, and major hemothorax were defined as severe adverse events (SAEs). In the three centers, the procedure was similar in case of occurrence of a complication. If the complication was not symptomatic or well tolerated, the TTNB was continued until obtaining at least one sample. If the contrary occurred, it was immediately stopped.

Statistical Analysis

The normal distribution of continuous variables was assessed by the Kolmogorov-Smirnov test. Nonnormally distributed continuous variables were expressed as median and interquartile range. Differences in distribution of nonnormally distributed continuous variables were assessed by the independent-samples Mann-Whitney U test for variables with two samples and the independent-samples Kruskal-Wallis test for variables with more than two samples. Categorical variables were expressed as percentages. Comparisons of such variables used a χ2 test or an exact Fisher test if the expected effect was less than five in at least one cell.

A binary logistic model was used (entry method) to compute ORs for the prediction of a false-negative result. A nonadjusted univariate model was set first, then relevant or significant variables were entered into a multivariate adjusted model.

Sensitivity, specificity, and predictive values for malignant disease diagnosis were computed, as appropriate. The accuracy rate was computed as the proportion of tests considered true (negative and positive) divided by the total number of tests performed. Since positive TTNB specimens were not reviewed, calculated sensitivity, specificity, accuracy, and positive predictive values (PPVs) are estimations. To express the uncertainty of estimated probabilities, 95% Wilson CIs were reported. Therefore, a “true positive” was defined as a TTNB specimen leading to the diagnosis of a malignant histologic finding. A “true negative” was defined as nonmalignant or negative findings in a TTNB specimen with a nonmalignant final diagnosis. A “false negative” was defined as nonmalignant or negative findings in a TTNB specimen with a malignant final diagnosis.

Missing values were reported as such. All tests were two-sided, and a P value of .05 was considered significant. All statistics analyses were performed with SPSS Statistics, version 20 (IBM Corporation).

Population

Study case inclusion and exclusion are summarized in Figure 1. Overall, 1,549 consecutive, percutaneous biopsies were performed during the study period in the participating centers; findings from 980 TTNBs (in 939 patients) were included in the final analysis. The principal characteristics of the analyzed TTNBs are shown in Table 1. TTNBs were performed by 36 different radiologists. During the study period, 25 of them performed < 20 TTNBs (16% of all TTNBs), seven performed 21 to 99 TTNBs (23%), and three performed more than 100 TTNBs (62%).

Figure Jump LinkFigure 1 –  Inclusion/exclusion flowchart for the study. FNAB = fine-needle aspiration biopsy; TTNB = transthoracic CT scan-guided core-needle biopsy.Grahic Jump Location
Table Graphic Jump Location
TABLE 1 ]  Main Characteristics of the Analyzed TTNBs (N = 980)

IQR = interquartile range; Med = median lobe; TTNB = transthoracic CT scan-guided core-needle biopsy.

a 

Calculated on the 939 patients.

b 

Number of TTNBs performed during the study period.

c 

Calculated on the 203 TTNB with a nonmalignant result.

TTNB Specimens: Main Results

Malignant disease was found in samples from 777 TTNBs (79%), nonmalignant disease in 54 (6%), and negative results (including poor sampling) in 149 (15%) (Table 2). Among the 203 (21%) TTNB specimens with nonmalignant or negative results, 188 benefited from a final diagnosis (e-Fig 1) by way of an additional histologic proof (n = 80) or results from other examinations, clinical findings, or follow-up (n = 108). Overall, 93 additional cancers were finally diagnosed through subsequent investigations (49% of the 203 initially negative or nonmalignant TTNB specimens). Additional invasive examinations were performed in 43% of the 203 patients with negative or nonmalignant TTNB samples. These interventions included thoracic surgery (including collection of lung and mediastinal biopsy samples and surgical excision in 50% [n = 44]) or a second TTNB at the same target (27%, n = 24). Two patients underwent more than one invasive examination to reach a final diagnosis. When performed, the additional invasive interventions permitted a final diagnosis in 93% of cases (e-Table 1).

Table Graphic Jump Location
TABLE 2 ]  Initial and Final Diagnoses for the 980 Included TTNBs

NOS = not otherwise specified; NSCLC = non-small cell lung cancer. See Table 1 legend for expansion of other abbreviation.

TTNB Diagnostic Performance

For the diagnosis of thoracic malignancy, the TTNB NPV was 51% (ie, one nonmalignant or negative result in two was falsely negative [final diagnosis of cancer]). In comparison, estimated specificity, sensitivity, and accuracy were 99% (95% CI, [94%-100%]), 89% (95% CI, [87%-91%]), and 90% (95% CI, [88%-92%]), respectively (Table 3). It should be noted that one false-positive result was found randomly: in one patient, what was thought to be a thymic malignancy based on TTNB was later identified as a benign thymic hyperplasia after surgery.

Table Graphic Jump Location
TABLE 3 ]  TTNB Performance for the Diagnosis of Lung Malignancy or Any Disease at First TTNB and in Case of Second TTNB

Acc = accuracy; NPV = negative predictive value; PPV = positive predictive value; Se = sensitivity; Sp = specificity. See Table 1 legend for expansion of other abbreviation.

a 

Estimation (upper bound), since positive TTNB results were not reviewed.

b 

Excluding 15 TTNBs without final results.

Adverse Events

Overall, at least one complication occurred in one-third of the TTNB procedures (n = 329, 34%). The proportion of SAEs was 6% (n = 61) (e-Table 2). The TTNB-related mortality rate was 0.1% (n = 1).

Predictive Factor of Negative Results

Overall, 149 TTNB specimens were negative (ie, not malignant and not diagnosed with a benign disease). In the multivariate logistic regression model, independent predictive factors for a negative result were a target size ≤ 15 mm, radiologist experience, and the occurrence of a complication. The location of the target in the thorax tended toward but did not reach significance (Table 4).

Table Graphic Jump Location
TABLE 4 ]  Predictive Factor of Negative Result (n = 148) in Univariate and Multivariate Analysis

AOR = adjusted OR; Cont = continuous variable (per each increment of one unit); Ref = reference. See Table 1 legend for expansion of other abbreviation.

a 

AOR was additionally adjusted for age and sex.

Predictive Factors of False-Negative Results

Radiologist experience and the occurrence of a complication were both associated with false-negative risk, whereas target size, target locations in the thorax, needle size, and the number of samples taken were not (Table 5). In the multivariate model (adjusted for age, target size, number of biopsies, radiologist experience [all continuous], and complication occurrence [categorical]), only radiologist experience and the occurrence of a complication remained significant.

Table Graphic Jump Location
TABLE 5 ]  Predictive Factor of False-Negative Results in Univariate and Multivariate Analysis for All TTNBs Performed (n = 980)

See Table 1 and 4 legends for expansion of abbreviations.

a 

AOR was additionally adjusted for age and sex.

b 

Numbers of TTNBs performed during the study period by the same radiologist.

c 

Computed in another model adjusted for age, target size, number of biopsy samples (all continuous), and complication occurrence (categorical).

Some patient history variables were recorded only for negative and nonmalignant TTNB samples (n = 203). In this setting, a moderate to high maximum standardized uptake value (SUVmax) on the PET scan was highly predictive of accuracy in the multivariate model (Table 6).

Table Graphic Jump Location
TABLE 6 ]  Predictive Factor of False-Negative Results in Univariate and Multivariate Analysis in Patients With a Negative or Nonmalignant TTNB Only (n = 203)

SUVmax = maximum standardized uptake value. See Table 1 and 4 legends for expansion of other abbreviations.

a 

Additionally adjusted for age, target size (mm), radiologist experience (number of TTNBs performed during study period) (all continuous), sex, and complication occurrence (categorical).

b 

Current and former combined.

Second TTNB at Same Target

In 24 cases, a subsequent TTNB was performed at the same target site. The complication rate for cases with a second TTNB (33%) was similar to that of the overall group but with no SAEs (e-Table 3). The second TTNB was concordant with the final diagnosis in 95% of cases. The NPV for thoracic malignancy was 67% (Table 3).

In our study of findings from 980 TTNB specimens, we found a 51% NPV for a malignant disease diagnosis. Target size, the occurrence of a complication, and a less-experienced radiologist were significant independent predictors of a TTNB specimen with a negative result. However, only a less-experienced radiologist and the occurrence of a complication remained significantly associated with a false-negative result. A moderate to high SUVmax on the PET scan was also predictive of false-negative result. Finally, our results suggest that a second TTNB at a same target may be an excellent option for obtaining a final diagnosis without increasing risks.

Our results on the diagnostic performance of TTNB-obtained specimens for lung cancer are consistent with those previously reported in the literature. In a systematic review, Rivera et al5 found a sensitivity of 90% and a specificity of 97% for the diagnosis of peripheral bronchogenic carcinoma. However, their meta-analysis pooled studies on FNA with others on core-needle biopsy as well as different types of imaging for guidance (CT scan, fluoroscopy, and ultrasonography). Additionally, they reported a pooled NPV of 78%, which is higher than ours, but the studies they pooled were very heterogeneous in their definitions of TTNB “positivity.”5 For example, “suspicion of malignancy” was considered as a negative result for some studies (as in ours) but as a positive “malignant result” for others.7 Moreover, many of those studies considered both FNA and TTNB to define positivity, whereas we focused only on findings in core-biopsy specimens. The fact that high SUVmax on PET imaging is predictive of a false-negative result is consistent with current knowledge. Lung nodules with high or moderate SUV have greater risk for malignancy than those with low SUV.2 Three studies found that small target size was a predictive factor of false-negative results.11,15,16 Two of them also demonstrated that large lesions (usually necrotic) were significant predictors of false-negative results.15,16 Finally, Tsukada et al17 did a retrospective analysis on 138 TTNB specimens and found that lesions were significantly larger in their TTNB “success group” (true positive and true negative) than in their “failure group” (false positive and false negative).17 However, in all these studies, TTNBs were performed by a single, highly experienced radiologist only. Additionally, only two of these studies11,17 found target size to be predictive in multivariate analysis. Our finding that the occurrence of a complication is predictive of both negative and false-negative results may be explained by the fact that when a complication occurs, the operator stops the process immediately.

Negative TTNB samples are a diagnostic challenge. Moreover, there is no clear consensus as to what diagnostic work-up should be initiated, with authors variably advising a repeat TTNB (on the same target) or a biopsy at another site if available.2,4,7,9 In our study, 24 patients had a second TTNB specimen collected from the same target, which provided a final diagnosis for 95% of them. Montaudon et al11 repeated eight TTNBs and found a 100% NPV from results taken at the second biopsy, results echoing those of Lee et al18 in a study on 24 cases. However, taking that NPV of the first TTNB sample is high, physicians should also consider other nodule-sampling techniques before repeating TTNB, especially instrumental-based bronchoscopy or surgery, depending on nodule location.

Our study has some limitations, the first of which is its retrospective design. Important, possibly confounding variables, such as target type and length of needle path were not systematically recorded and, thus, were excluded from our analysis. A second limitation is that we did not analyze outcome for malignant results, and all of them were considered true positives. This may result in an overestimation of sensitivity and PPV. However, false-positive rates in the literature are usually very low (eg, 1% in the analysis of Rivera et al5 when FNA and TTNB were pooled and 0% when TTNB was considered alone). Furthermore, a number of the malignant TTNBs in our study were missing mentions of important variables (eg, smoking, PET scan SUV, and personal history). Finally, our results from the second TTNB sample at same target may be affected by selection bias, since only “easy” processes may have been considered.

Our study also has strengths. First, we used a very conservative definition of a negative finding in a TTNB specimen. Second, the number of TTNBs included in our study is one of the highest published. Third, the multicentric design allowed us to explore a novel variable: radiologist experience. Finally, we excluded FNA to better focus on the gold standard examination: CT scan-guided core-needle biopsy, unlike numerous studies.5

In our large multicentric study of CT scan-guided TTNBs, we found that 49% of TTNB specimens with negative or nonmalignant results missed a cancer diagnosis. Radiologist experience and complications were associated with false-negative risk. A second biopsy on the same target did not increase the complication rate and permitted final diagnosis in 95% of cases.

Author contributions: C. F.-D. and S. C. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. C. F.-D., P.-J. S., D. G., E. P., A. D. L., G. R. F., and S. C. contributed to the study design, data interpretation, and the writing of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: The authors thank Kevin Erwin, PhD, for expert English rewording of the manuscript.

Additional information: The e-Figure and e-Tables can be found in the Supplemental Materials section of the online article.

FNA

fine-needle aspiration

NPV

negative predictive value

PPV

positive predictive value

SAE

severe adverse event

SUVmax

maximum standardized uptake value

TTNB

transthoracic CT scan-guided core-needle biopsy

Winer-Muram HT. The solitary pulmonary nodule. Radiology. 2006;239(1):34-49. [CrossRef] [PubMed]
 
Couraud S, Cortot AB, Greillier L, et al; French lung cancer screening statement taskforce; groupe d’Oncologie de langue française. From randomized trials to the clinic: is it time to implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the French intergroup (IFCT) and the groupe d’Oncologie de langue francaise (GOLF). Ann Oncol. 2013;24(3):586-597. [CrossRef] [PubMed]
 
van Klaveren RJ, Oudkerk M, Prokop M, et al. Management of lung nodules detected by volume CT scanning. N Engl J Med. 2009;361(23):2221-2229. [CrossRef] [PubMed]
 
Libby DM, Smith JP, Altorki NK, Pasmantier MW, Yankelevitz D, Henschke CI. Managing the small pulmonary nodule discovered by CT. Chest. 2004;125(4):1522-1529. [CrossRef] [PubMed]
 
Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e142S-e165S. [CrossRef] [PubMed]
 
Ferretti GR, Busser B, de Fraipont F, et al. Adequacy of CT-guided biopsies with histomolecular subtyping of pulmonary adenocarcinomas: influence of ATS/ERS/IASLC guidelines. Lung Cancer. 2013;82(1):69-75. [CrossRef] [PubMed]
 
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Birchard KR. Transthoracic needle biopsy. Semin Intervent Radiol. 2011;28(1):87-97. [CrossRef] [PubMed]
 
Montaudon M, Latrabe V, Pariente A, Corneloup O, Begueret H, Laurent F. Factors influencing accuracy of CT-guided percutaneous biopsies of pulmonary lesions. Eur Radiol. 2004;14(7):1234-1240. [CrossRef] [PubMed]
 
Doxtader EE, Mukhopadhyay S, Katzenstein AL. Core needle biopsy in benign lung lesions: pathologic findings in 159 cases. Hum Pathol. 2010;41(11):1530-1535. [CrossRef] [PubMed]
 
Li Y, Du Y, Yang HF, Yu JH, Xu XX. CT-guided percutaneous core needle biopsy for small (≤20 mm) pulmonary lesions. Clin Radiol. 2013;68(1):e43-e48. [CrossRef] [PubMed]
 
Yamauchi Y, Izumi Y, Nakatsuka S, et al. Diagnostic performance of percutaneous core needle lung biopsy under multi-CT fluoroscopic guidance for ground-glass opacity pulmonary lesions. Eur J Radiol. 2011;79(2):e85-e89. [CrossRef] [PubMed]
 
Yeow KM, Tsay PK, Cheung YC, Lui KW, Pan KT, Chou AS. Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures. J Vasc Interv Radiol. 2003;14(5):581-588. [CrossRef] [PubMed]
 
Hiraki T, Mimura H, Gobara H, et al. CT fluoroscopy-guided biopsy of 1,000 pulmonary lesions performed with 20-gauge coaxial cutting needles: diagnostic yield and risk factors for diagnostic failure. Chest. 2009;136(6):1612-1617. [CrossRef] [PubMed]
 
Tsukada H, Satou T, Iwashima A, Souma T. Diagnostic accuracy of CT-guided automated needle biopsy of lung nodules. AJR Am J Roentgenol. 2000;175(1):239-243. [CrossRef] [PubMed]
 
Lee IJ, Bae Y-A, Kim DG, et al. Percutaneous needle aspiration biopsy (PCNAB) of lung lesions: 5 years results with focusing on repeat PCNAB. Eur J Radiol. 2010;73(3):551-554. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Inclusion/exclusion flowchart for the study. FNAB = fine-needle aspiration biopsy; TTNB = transthoracic CT scan-guided core-needle biopsy.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Main Characteristics of the Analyzed TTNBs (N = 980)

IQR = interquartile range; Med = median lobe; TTNB = transthoracic CT scan-guided core-needle biopsy.

a 

Calculated on the 939 patients.

b 

Number of TTNBs performed during the study period.

c 

Calculated on the 203 TTNB with a nonmalignant result.

Table Graphic Jump Location
TABLE 2 ]  Initial and Final Diagnoses for the 980 Included TTNBs

NOS = not otherwise specified; NSCLC = non-small cell lung cancer. See Table 1 legend for expansion of other abbreviation.

Table Graphic Jump Location
TABLE 3 ]  TTNB Performance for the Diagnosis of Lung Malignancy or Any Disease at First TTNB and in Case of Second TTNB

Acc = accuracy; NPV = negative predictive value; PPV = positive predictive value; Se = sensitivity; Sp = specificity. See Table 1 legend for expansion of other abbreviation.

a 

Estimation (upper bound), since positive TTNB results were not reviewed.

b 

Excluding 15 TTNBs without final results.

Table Graphic Jump Location
TABLE 4 ]  Predictive Factor of Negative Result (n = 148) in Univariate and Multivariate Analysis

AOR = adjusted OR; Cont = continuous variable (per each increment of one unit); Ref = reference. See Table 1 legend for expansion of other abbreviation.

a 

AOR was additionally adjusted for age and sex.

Table Graphic Jump Location
TABLE 5 ]  Predictive Factor of False-Negative Results in Univariate and Multivariate Analysis for All TTNBs Performed (n = 980)

See Table 1 and 4 legends for expansion of abbreviations.

a 

AOR was additionally adjusted for age and sex.

b 

Numbers of TTNBs performed during the study period by the same radiologist.

c 

Computed in another model adjusted for age, target size, number of biopsy samples (all continuous), and complication occurrence (categorical).

Table Graphic Jump Location
TABLE 6 ]  Predictive Factor of False-Negative Results in Univariate and Multivariate Analysis in Patients With a Negative or Nonmalignant TTNB Only (n = 203)

SUVmax = maximum standardized uptake value. See Table 1 and 4 legends for expansion of other abbreviations.

a 

Additionally adjusted for age, target size (mm), radiologist experience (number of TTNBs performed during study period) (all continuous), sex, and complication occurrence (categorical).

b 

Current and former combined.

References

Winer-Muram HT. The solitary pulmonary nodule. Radiology. 2006;239(1):34-49. [CrossRef] [PubMed]
 
Couraud S, Cortot AB, Greillier L, et al; French lung cancer screening statement taskforce; groupe d’Oncologie de langue française. From randomized trials to the clinic: is it time to implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the French intergroup (IFCT) and the groupe d’Oncologie de langue francaise (GOLF). Ann Oncol. 2013;24(3):586-597. [CrossRef] [PubMed]
 
van Klaveren RJ, Oudkerk M, Prokop M, et al. Management of lung nodules detected by volume CT scanning. N Engl J Med. 2009;361(23):2221-2229. [CrossRef] [PubMed]
 
Libby DM, Smith JP, Altorki NK, Pasmantier MW, Yankelevitz D, Henschke CI. Managing the small pulmonary nodule discovered by CT. Chest. 2004;125(4):1522-1529. [CrossRef] [PubMed]
 
Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e142S-e165S. [CrossRef] [PubMed]
 
Ferretti GR, Busser B, de Fraipont F, et al. Adequacy of CT-guided biopsies with histomolecular subtyping of pulmonary adenocarcinomas: influence of ATS/ERS/IASLC guidelines. Lung Cancer. 2013;82(1):69-75. [CrossRef] [PubMed]
 
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