Clinical Usefulness of CT-fluoroscopic Lung Biopsy Key words: CT-detected lung cancer, CT-fluoroscopy, CT-fluoroscopic lung biopsy
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1 Clinical Usefulness of CT-fluoroscopic Lung Biopsy Key words: CT-detected lung cancer, CT-fluoroscopy, CT-fluoroscopic lung biopsy
2 Fig. 1. CT-fluoroscopy devices (from reference 12).
3 肺 癌: Table 第36巻, 6号1996年10月 1. Patients 777 characteristics. Ad: adenocarcinoma, Sq. c.c: Squamous cell carcinoma, CT-fluoro. : CT-fluoroscopy guided lung biopsy Sm. c. c Small cell carcinoma, Fig. 2. Case 3 a) Very small nodule, 4mm in diameter, was accidentally discovered from a CT taken for evaluation of dull chest pain ( right). The nodule was not detectable by conventional chest X-ray, A-P view. b) A series of real-time CT images of CT-fluoroscopic lung biopsy. After penetrating the target lesion with a biopsy needle, the needle is brought to the core of the lesion, where ( arrow) the biopsy is performed while observing the CT-fluoroscopy. a) b)
4 778 CT-fluoroscopy装 Fig.3. 置 の 有 用 性 と問 題 点 Case 4 a) Plain chest X-ray shows a massive lesion in the right lower lung and, a solitary nodule in the left lower lung( arrow). b) The CT image in a prone position shows the tip of the needle entering the lesion in the left lower lobe, avoiding the bulla( arrow). a) b) Fig.4. Case 5 a) Chest CT shows pulmonarynodulewith spicular formation in the right upper lobe (arrow), but this lesion was not detected by the chest X-ray taken at the same time. b) Real-time CT image of the CT-fluoroscopic lung biopsy shows the needle entering the nodule from the back. a) 腔 鏡 下 肺 部 分 切 除 を行 いlocalized 病 理 診 断 が 得 ら れ た.切 イ ズ は4 5mmで 症 例4:54歳 右S6原 除標 本 で の小 結 節 の サ あ っ た. の 男 性. 発 の 腺 癌 と 診 断 さ れ,手 査 入 院 と な っ た.他 た も の の 対 側S8の た め にCT透 術 目的 に て 精 臓 器 に は 転移 は認 め な か っ 結 節 影(Fig.3a矢 頭)の 評 価 の 視 下 肺 生 検 が 行 わ れ た.病 変 に 接 し て 気 腫 性 病 変 が 存 在 し,な b) atelectasisの おかつ病変 は胸膜 に 接 す る 末 梢 に 存 在 す る た め,CT透 視下 肺生検 の
5 肺 癌: 第36巻, 6号 Fig 年10月 Case 6 a) Chest X-ray and CT image show a small nodule, 5mm in diameter in the right lower lobe( arrow). b) The real-time series of CT images of CT-fluoroscopic lung biopsy. Biopsy was performed as described in case 3. a) b) が ほ ぼ 上 大 静 脈 の 後 面 に 位 置 し て い る こ とや 気 よ い 適 応 と判 断 さ れ た. Fig.3bは 同 結 節 病 変 に 接 す る 気 腫 性 病 変(矢 頭) 腫 性 病 変 が 隣 接 し て い る こ と も あ り,背 を避 け て 生 検 針 が 刺 入 して い る とこ ろ を示 し て 経 皮 肺 針 生 検 を 行 っ た(Fig.4b).得 い る.組 の 細 胞 診 の 結 果 は 腺 癌 で あ っ た. stage 織 診 で は 高 分 化 型 腺 癌 で あ っ た た め, IVと 判 断 し手 術 非 適 応 と な っ た. 症 例5:59歳 症 例6:80歳 右 腋 窩 の 腫 瘤 が 次 第 に 増 大 傾 向 を 認 め た ため 胸 部X線 単 純 写 真 で は,右 下 肺 野 の 小 結 節 影(Fig. 5a右 原 発 巣 を 検 索 す る た め,当 れ,確 科 入 院 と な っ た.胸 単 純 写 真 で は 異 常 を 指 摘 で き な か っ た が, 全 身 検 索 の 一 貫 と し て の 胸 部CT検 に ス ピ キ ュ ラ を 形 成 し,な 伴 っ た 径 cmの の 女 性. 転 倒 し て 右 前 胸 部 を 打 撲 し近 医 を 受 診 し た. の 男 性. 某 医 で 生 検 を 受 け,腺 癌 の 病 理 診 断 が 得 ら れ た. 部X線 部か ら られ た検 体 査 で,右 上 葉 おかつ胸膜 陥入像 を 結 節 影 を 認 め,ま た 同 病 矢 頭)を 指 摘 さ れ た.転 移 性 肺 癌 な ど が 疑 わ 定 診 断 を 目 的 と し て 当 科 入 院 と な っ た. 直 径 が5mm程 で あ り,気 度 で 且 つ 末 梢 に 存 在 す る結 節 病 変 管 支 鏡 で は 病 変 に 到 達 で き ず,そ の 近 傍 を キ ュ レ ッ ト した が 確 定 診 断 は 得 られ な か っ た.CT透 視 下 肺 針 生 検 で は(Fig.5b),生 検針 は 変 の 縦 隔 側 に 接 し て 気 腫 性 病 変 も認 め た(Fig.4a 病 変 へ 命 中 を し た こ と が 観 察 で き た が 組 織 診, 矢 頭).TBLBの 細 胞 診 と も に 陽 性 所 見 は 得 ら れ な か っ た.最 で き ず,上 際 は 同 病 変 はX線 透視 では確認 大 静 脈 に 注 意 しな が ら その 近 傍 を生 検 したが 病 理 学 的 検 査 結 果 は 陰性 で あ っ た CT透 視 下 肺 生 検 で は,前 方 か ら の 到 達 は 病 変 終 的 に は 胸 腔 鏡 下 肺 生 検 に よ り良 性 の 肉 芽 腫 との 病 理 診 断 が 得 ら れ た. CT透 視 下 肺 生 検 の 合 併 症 と し て は 気 胸 が7例
6 Table2. Radiological exposure of operator's skilufull arm measured by TLD (Thermoluminescence Dosimeter). (unit: msv) The values were measured under the condition on CT-fluoroscopy at 80KV, 30mA/s,
7
8 1) Fontana RS, Sanderson DR, Woolner LB, et al: Screening for Lung Cancer. A Critique of the Mayo Lung Project. Cancer 67: , ) Charles R, Smart MD: Annual Screening Using Chest X-ray Examination for the Diagnosis of Lung cancer. Cancer 72: , ) Sobue T, Suzuki T, Naruke T, et al: A case control study for evaluating lung cancer screening in Japan.IntJ Cancer 50: , ) Naruke T, Asamura H, Kondo H, et al: Thoracoscopy for staging of lung cancer. Ann Thorac Surg 56: , ) Sakai T, Hayashi N, Kimoto T, et al: CT guided biopsy of the chest: Usefulness of Fine-Needle Core Biopsy Conbined with Frozen-Section Pathologic Diagnosis. Radiology 190: , ) ICRP-60, Recommendations of the Inter- national Comission on Radiological Pro- The International Commission on tection, Radiological Protection, Pergamon Press; New York, ) Katada K, Anno H, Koga S, et al: Initial trial with CT fluoroscopy (ab). Radiology 190: 662, 1993.
9 Clinical Usefulness of CT-fluoroscopic Lung Biopsy Hiroaki Nakamura First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus Okinawa, Japan The recent increase in the incidence of"ct-detected lung cancer" demands further development in diagnostic methodology. CT-fluoroscopy is a new device to make visible even a small lesion, for which it has been adopted in performing lung biopsy while observing the lesion in real time. As this CT-fluoroscopic lung biopsy method could be very useful for diagnosis of"ctdetected lung cancer", we attempted to determine the merits and limitation of this new technique. In this study percutaneous lung biopsy was performed using a 21G needle while observing the lesion in real time. We estimated the extent of radiological exposure of the operators using a thermoluminescence docimeter (TLD). It was possible to exermine lesions as small as 4mm in diameter. The diagnosis was confirmed by histopathology, in 5 out of 7 cases. Pneumothorax occurred in 4 cases, but none of them required any treatment. We estimated the extent of radiological exposure of the operator's middle finger, back of the hand and forearm. The middle finger was found to be the most exposed part with a maximum exposure value of 34mSV in one case. It can be concluded that in spite of the small numbers of cases this technique was found to be exceedingly useful for the diagnosis of very small"ct-detected lung cancer". Another point to be added is that none of the complications required any treatment. The most significant problem with the method was the greater radiological exposure of part of the operator's body, which should be considered carefully in future.
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