Sub-centimeter Lung Nodule Biopsies

This article from the November issue of the American Journal of Roentgenology discusses the results of 305 CT guided core biopsies / aspirations of small lung nodules, less than 1.0 cm in diameter, over 13 years.

The only major variable that decided success was aspiration instead of core biopsy.

I have been very clear about doing core biopsies for lesions in the body as against FNAC / aspiration for many years now. Tissue today is needed for so much more than just establishing a diagnosis that if we are going to put a needle in the lungs, or other parts of the body, it would be a travesty to come away with only cells, without tissue.

Here is an example of a 7.5 mm lung nodule biopsied earlier this year that turned out to be tuberculosis on histopathology.

Biopsy of 7.5 mm lung nodule

Biopsy of 7.5 mm lung nodule

The Vanishing Art of Clinical Science – Hyposkilia

This has been written by Dr. Anisha Sawkar Tandon, a consultant radiologist at the St. John’s Medical College, Bengaluru. You can reach her at anisha.sawkar at gmail.com

I am a practicing radiologist. Over the past few years I have noticed a disturbing trend that threatens to destroy the very nature of medicine. I have been witnessing increasing referrals for radiological investigations even before a clinical history has been taken. We radiologists are familiar with the experience of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the referring clinician for more information, there have been innumerable instances where they simply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

Here is an example of one of the situations that I was confronted with when reporting an MRI of the brain of a 58-years old lady who was sent from the emergency department. The referral form mentioned, “Rule out cerebral venous thrombosis (CVT)”. These were the only words of “history” provided. The MRI brain not only had no signs of CVT, but there were some symmetric basal ganglia changes that favored a metabolic encephalopathy, likely related to chronic liver disease. Since the Emergency department is easily accessible with a phone call, I could immediately contact them and ask for more details.

At first, since their question was “rule out CVT”, I attempted to elicit some history related to CVT. The disturbing answer that I got was, “The patient basically has altered sensorium and since CVT is one of the conditions that could cause CVT, we just wanted to rule it out!” I tried to find out more about the altered sensorium and the information I got in response was, “She basically looks like a psychiatric case and also has diabetes and hypertension”. After obtaining this invaluable information, I explained my findings and requested them to assess whether the patient had some form of liver dysfunction since the findings were definitely “metabolic” and not “psychiatric”.

These events had occurred at 6 pm in the evening. The next day, when I decided to follow up on what had happened to my patient, I found this sequence of events that had unfolded after my MRI brain report. The patient, had, at 7 pm undergone an ultrasound of the abdomen, which showed cirrhosis of liver with portal hypertension and ascites and suspicious nodules in the liver. At 8 pm, the patient had undergone a CT scan of the abdomen that confirmed the cirrhosis with regenerative nodules, portal hypertension and ascites. Meanwhile the results of the liver function tests showed findings consistent with chronic liver disease and the patient was known to be HbsAg positive for 5 years. The next morning, a clinical examination by a gastroenterologist and neurologist concluded that the patient was, in fact, in hepatic encephalopathy.

If you analyze this case, it worked out beautifully for the radiologist. What else could a radiologist ask for? An MRI brain, an ultrasound abdomen and a triple phase CT scan of the abdomen in one patient in one evening! What about the patient though? It’s scary to think that not one, but all of the above investigations could have been avoided by just basic history taking and an adequate clinical examination.

I understand that in a busy ER, not every patient with altered sensorium is going to undergo a 30 minutes detailed neurological exam, but a 30 minutes exam wouldn’t be needed if the simple task of talking to the patient had been accomplished which would have brought out the known Hepatitis B status. Whenever I see this kind of situation, I am appalled at what medicine has come to. There are so many more such instances in which an ultrasound of the abdomen is the first time that a large laparotomy scar has been noticed, or an MRI brain study is the first time when a craniotomy has been discovered and the referring clinician has had no knowledge of the same. It’s a different situation when such cases have been directly referred by some remote village primary health center “(PHC) and then perhaps the lack of knowledge by the referring physician can be overlooked. But it’s acutely disturbing when these cases are referred by our own colleagues, specialists in their fields and the first person to touch the patient’s hurting abdomen is a radiologist.

As a radiologist who wishes her field to thrive, I should have no cause for complaint. But as a doctor and a clinical radiologist, I am concerned about the kind of medicine we practice today, where the end result is unnecessary investigations and ultimately a burden on the patient and the system.

I would like to end by quoting Sir Robert Hutchison who said the following words, which sadly are very pertinent today

“From inability to leave well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Managing a Pneumothorax – The Fear is Mostly in the Mind

Two weeks ago, in Beirut, I was speaking on the impact of modern imaging in pulmonary medicine, to a group of chest physicians from Egypt. The moment I started speaking on CT guided lung biopsies, a physician got up and started talking about the dreaded risk of pneumothorax. I have had similar reactions in other towns in India, including tier I cities like Delhi.

I explained to him that while a pneumothorax is not uncommon during CT guided biopsies, there are many ways to mitigate its seriousness; single puncture, minimal trauma, bleeding along the tract during withdrawal and arguably puncture side down for a few minutes are measures that reduce the severity and incidence of or prevent the occurrence of pneumothorax.

But even if a pneumothorax does occur, it is a slow event that takes its own time to increase, if it does. If a pneumothorax occurs during the procedure, it can be aspirated at the same time and more often than not, that cares of the problem and we can even continue with the procedure (Figure 1). In case the pneumothorax occurs after we have washed out as a delayed complication, then we can still aspirate it using an over the needle catheter. A recent video describing this procedure has been posted on The New England Journal of Medicine site. While this video shows the technique to be used in patients with spontaneous pneumothorax and describes a blind approach, we can use this simple procedure to aspirate under CT guidance as well and then check the status immediately on the CT scan table.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

In the worst case scenario, an interventional radiologist should be able to put a tube in as well, despite the fact that the need to do this would be very low in experienced hands.

How Fast is a Fast Response

This is a 29-years old lady who has a 4-months old child. A month after her pregnancy, she started getting some backache and chest pain and was feeling lethargic. She saw her family physician, who attributed all her symptoms and signs to post-pregnancy related issues and put her on standard symptomatic treatment, including vitamin D3 and B12 supplementation.

She did not improve and went to another family physician, who did not take her seriously as well and so she changed to a third family physician.

This last physician was concerned. She had been having fever and basic tests showed a raised ESR. According to him, she “did not look well”. He ordered a Mantoux and a CT scan of the chest both at the same time.

Her CT scan done on Mar 15, 2013, showed enlarged necrotic mediastinal nodes (Fig. 1), pericardial effusion and thickening (Figs. 1,2) and pleural effusions bilaterally (Figs. 2, 3).

Axial contrast-enhanced CT scan shows enlarged necrotic subcarinal and right hilar lymph nodes (red arrows) and pericardial effusion (blue arrow)

Axial contrast-enhanced CT scan shows enlarged necrotic subcarinal and right hilar lymph nodes (red arrows) and pericardial effusion (blue arrow)

Axial contrast-enhanced CT scan shows pericardial effusion (blue arrow) with thickening with left pleural effusion (white arrow)

Axial contrast-enhanced CT scan shows pericardial effusion (blue arrow) with thickening with left pleural effusion (white arrow)

Axial contrast-enhanced CT scan shows bilateral pleural effusions (white arrows)

Axial contrast-enhanced CT scan shows bilateral pleural effusions (white arrows)

She was asked to see a chest physician immediately. Her family came to see me and I advised the same.

In the mean time her Mantoux came strongly positive.

The chest physician started her immediately on first-line anti-tuberculous therapy with steroids for the pericardial effusion. Given the high incidence of primary multi-drug resistant tuberculosis in our country, he cautioned them that in case she did not improve clinically, she would need a CT guided subcarinal node biopsy and she was asked to see me again if that situation were to arise. There was no way to confirm the diagnosis at this time. The pleural fluid was too little and was unlikely to yield any results.

The next day, they called me and insisted on getting the biopsy done. Their reasoning was logical – they wanted to confirm the diagnosis and get material for culture and be sure that she was sensitive to first-line drugs. It is rare to find patients and families with such sensibilities.

I checked with the chest physician who agreed. If a patient wants a biopsy for confirmation, that is a request to be respected.

I posted her for a biopsy on 22 Mar, 2013. After standard counseling and explanations, I positioned her in the prone position to perform an extrapleural, CT guided subcarinal node biopsy. Lo and behold! The preliminary scans showed that the node had mildly regressed in size, the pleural effusions had regressed and the pericardial effusion had partly regressed.

I immediately called in the relatives and had the patient turn over and sit up. I explained to them that the partial regression meant response to treatment and that it made no sense to perform the biopsy at this point in time. They too agreed…they were so happy and relieved…these are the times when it is so gratifying to be a physician advising a patient. I repeated another contrast enhanced CT to document these findings (Figs. 4-6).

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show partial regression of the subcarinal node.

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show partial regression of the subcarinal node.

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show partial regression of the pericardial effusion.

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show partial regression of the pericardial effusion.

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show complete regression of the pleural effusions.

Axial contrast enhanced CT scans of 15 Mar and 22 Mar show complete regression of the pleural effusions.

This is one of the fastest and quickest responses to tuberculosis that I have encountered.

Update 1:

A query on Facebook where I had posted this article asked whether there is an increased incidence of tuberculosis in the post-partum period. There is and this Pubmed link has the data.

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