Needle Aspiration Biopsy of Malignant
Lung Masses With Necrotic centers*
Improved Sensitivity With Ultrasonic Guidance
]iamn-Fong lbn, M.B.; lbn-Chyr Yang, M.B., F.C.C.E;
Dun-Bing Chang, M.B.; Yung-Chie Lee, M.B., F.C.C.E;
Sow-Hsong Kuo, M.B., F.C.C.E; and Kwen-Tay Luh, M.B., F.C.C.E
False-negative results from transthoracic needle aspiration
biopsy of malignant lung masses may occur if a central
necrotic area is present and is the source of the biopsy
material. The purpose of this study is to determine if the
use of ultrasonic guidance can improve the sensitivity of
lung needle biopsies in this circumstance. Sixty patients
with malignant lung masses underwent ultrasonic exami-
nation in an 18-month period. In 14 cases, ultrasound
showed that the mass had a large central necrotic area that
was at least halfthe diameter of the tumor. Under ultrasonic
P biopsy
ercutaneous transthoracic fine-needle aspiration
under fluoroscopy or computed tomography
(CT) guidance has been well accepted as a useful
technique to obtain tissue for histologic diagnosis of a
malignant lung mass.v" Both fluoroscopy and cr scan
can accurately guide the needle to the target tumor.
However, a large malignant lung mass may frequently
be associated with a central necrotic area; that area
can be so extensive that only a small, viable part of
the tumor remains. A biopsy specimen of the central
necrotic part of a malignant lung mass may result in a
false-negative result. Multiple punctures are some-
times needed to confirm the diagnosis." Contrast-
enhanced cr scan can be used to demonstrate the
viable part of a malignant lung mass with central
necrosis and direct the percutaneous biopsy to avoid
a false-negative result," Recently, it has been found
that ultrasound is also useful for guidance of a percu-
taneous biopsy of thoracic tumors," Chest ultrasound
can clearly depict the central necrotic area of a
malignant lung mass and the viable mural tumor for
biopsy This study assessed the applicability of ultra-
sound for evaluation of a malignant lung mass with
central necrosis and for guiding a percutaneous biopsy
to avoid a false-negative result.
MATERIALS AND METHODS
From January 1990 to July 1991,60 patients had peripheral lung
masses that required ultrasound examination and ultrasound-guided
needle aspiration biopsy in National Taiwan University Hospital.
Of these 60 patients, 14 (23 percent) bad a lung mass with a large
central necrotic area as demonstrated by ultraound; they were
*From the Departments of Internal Medicine (Drs. Pan, Yangand
Chang), Surgery (Dr. Lee), and Clinical Pathology (Drs. Kuo and
Luh), National Taiwan University Hospital, Taipei, Taiwan.
Manuscript received April 30; revision accepted September 15.
Reprint requests: Dr. Yang, National Taiwan University Hospital,
No. 7 Chung-Shan South Road, Taipei, 100, Taiwan, ROB
1452
guidance, needle biopsy specimens were taken from the
central necrotic area and from the tumor wall in each case.
Adequate biopsy specimens were obtained in all 14 patients.
In all cases, the mural biopsy material was diagnostic for
malignant tumor, while the biopsy specimen from the
necrotic center was nondiagnostic in 10 of 14 patients, No
complications occurred. We conclude that ultrasonically
guided lung biopsy is a useful and safe tool to avoid false-
negative needle biopsy specimens in malignant lung tumors
with necrotic centers. (Cheat 1993; 103:1452-56)
included in this study. The criteria for patient selection were as
foUows: (1) mass abutting the visceral pleura; (2) mass with a large
central necrotic area manifested as a focal heterogeneous echoden-
sity by ultrasound, and the diameter of the presumed central
necrotic area greater than, or equal to, 1/2 of the tumor; (3) the
patient had no conclusive histologic diagnosis by such a conventional
diagnostic approach as fiberoptic bronchoscopy with biopsy; (4)
patient had no known bleeding tendency or coagulopathy; and (5)
the patient was cooperative. There were 12 men and 2 women,
aged from 40 to 70 years (mean, 60 years). Five patients had tumors
in the right upper lobe, one in the right middle lobe, four in the
right lower lobe, two in the left upper lobe, and two in the left
lower lobe. Two patients had a central necrotic cavity visible on the
plain chest radiographs. All 14 patients also had contrast-enhanced
chest CT scans (Somatom DR; Siemens Medical System, Iselin,
NJ) and 8 patients had central cystic cavities thus documented.
All patients were examined by real-time, linear array and convex
ultrasound units with 3.75 MHz and 5.0 MHz transducers (Aloka
SSD 630 and Toshiba IOOA, Tokyo, Japan). The sonographic exam-
iners did not know the interpretation of chest radiographs and the
CT scan except the location of the tumor. The patients were put in
either the supine or prone position, according to the location of the
tumor. The ultrasound transducer was placed on the lesion site and
scanned through the intercostal space, adjusted in direction to get
the best view to demonstrate the tumor and nearby lung paren-
chyma. The sonographic images were recorded on films (Polaroid,
Polaroid Co, Cambridge, Mass) and analyzed for details of the
internal echodensities of the lung tumor. If large central heteroge-
neous echodensities were detected, central heterogeneous echo-
densities were then defined as hyperechoic, hypoechoic, or mixed
pattern by comparing their echogenicity with that of the peripheral
part of the tumor.
After assessment of the tumor location and demarcation of tumor
margin, informed consent was obtained and the lesion was subjected
to percutaneous transthoracic aspiration biopsy to both the pre-
sumed central necrotic part and the mass wall. The skin was then
prepared and local anesthetics were applied. A 22-gauge needle
with an outer sheath and an inner stylet was used for ultrasound-
guided aspiration biopsy.6.7 The aspirated material was submitted
for cytologic and histologic examinations, as well as microbiologic
examination if superimposed infection was suspected. When the
cytologic smears were inadequate, a repeated needle aspiration was
conducted. After needle aspiration, the patient had a routine chest
Needle Aspiration Biopsy of MalignantLung Masses (Pan et aI)
Table I-Characteristics of 14 Malignant Lung Masses With Central Necrotic Area and Results ofNeedk Aspiration Biopsies

Case No .! Tumor Size , Wall Thickness, Central Necros is Echo Pattern Aspiration Biopsy
Age, yr/Sex cm cm Diam eter, em of Central Necrosi s From Wall

1/69/M 13 x 15 2.0 8.0 Mixed Small-cell carcinoma

2167/M* 4x6 1.8 2.0 11yperechoic Ad...nocarcinoma
31581M* 4x7 1.5 2.0 11ype rechoic Metastatic carcinoma
4159/M* 5x7 1.4 4.0 11yp erechoic Squamous cell carcinoma
5/68/M* 9 x6 0.9 s.n 11ypoechoic Squamous cell carcinoma
61621M* 9 x7 o.s 5 .5 11yperechoic Squamous cell carcinoma
7/67/M 9 x6 1.2 6.0 Hypoechoic Lymphoma
81661M* 7 x6 0.8 5 .0 Hyp ereehoic Squamous cell carcinoma
91531F* 8 x6 1.1 4.0 11yperechoic Metastatic carcinoma
10170/M 8x6 1.0 5 .5 11yperechoic Small-cell carcinoma
11/521M* 7x5 0.9 5 .0 Mixed Squamous cell carcinoma
121621F* 11 x 7 0.8 8 .0 Mixed Squamous cell carcinoma
1315 11M * 7x6 0.9 4.7 Hypoeehoic Adenocarcinoma
14/40/M 6 x5 1.7 2.3 II yperechoic Small-cell carcinoma

*Represents the pati ent s whos...conditions could not be diagnosed by needl e aspiration biopsy spec imens from central neerotic portion of the
mass.
rad iographi c ...xamin ation on the next day to assess any potenti al
complications.
R E SULTS
A total of 14 patients who had malignant lung mass
with a large central necrosis as demonstrated by
ultrasound underwent ultrasound-guided aspiration
biopsy successfully from both the central portion and
peripheral wall portion of the mass. Table 1 summa-
rizes the age and sex of the patients, the mass sizes,
wall thicknesses, diameters of the necrotic area, echo
patterns of the central necrosis, and the final results
of aspiration biopsies. The mass sizes ranged from
4 X 6 em to 13 x 15 em . Their wall thicknesses ranged
from 0.8 to 2.0 em (average , 1.2 cm). The diameters
of the central necrotic areas ranged from 2.0 cm to 8 .0
cm. The echo patterns of the central necrotic parts
were hyperechoic in eight patients, hypo echoic in
three patients, and mixed patterns in three patients.
The ultrasound-guided percutaneous aspiration biopsy
was performed from the wall of the necrotic cavity
that was presumed to be the viable part of the tumor,
as well as the central portion with different echoden-
sitie s that were presumed to be a necrotic area. The
conditions of ten patients (71.4 percent) could not be
diagnosed by needle aspiration biopsy specimens from
the central portion, while confirming histologic diag-
noses were obtained in all 14 patients by needle
aspiration biopsy specimens from the tumor wall.
These included squamous cell carcinoma in six cases,

A B
FI(;l IRE 1. A 59-year-old man has a tumor with cavitation in the left lower lobe . (I"eft. A): Contrast-
enhanced (.1 of th e chest shows the tumor has a central hypodense part with vague peripheral
enhanceme nt. (Right, B): Sonography demonstrates the tumor has a ce ntral hyperechoic part (arrow)
indic ating the presence of central necro sis. The viabl e cavity wall (arrowhead) is about 1.4 em thick .
Ultra sound-guided aspiration biopsy specimen from central portion revealed necroti c tissue, and a
specimen from the peripheral wall revealed squamous cell carcinoma.

CHEST I 103 I 5 I MAY, 1993 1453

 FIGURE 2. A 62-year-old woman has a lohulated tumor in the right middle lohe. (I.£ft, A): Contrast-
enhanced cr of the chest shows the tumor has a central necrotic area with heterogeneous density and
peripheral enhancement. (Right, B): Sonography demonstrates the tumor has a central part with
heterogeneous echogenicity (arrow) indicating the presence of central necrosis. The viahle cavity wall is
rather thin (arrowhead), about 0.8 cm thick . The specimen of ultrasound-guided aspiration biopsy from
the central part of the tumor revealed severe necrotic tissue only. The specimen of aspiration biopsy from
the cavity wall (arrowhead) revealed squamous cell carcinoma.
small-cell carcinoma in three, adenocarcinoma in two, tissue without evidence of a malignant neoplasm . The
lymphoma in one, and metastatic carcinoma in two , patient was then treated with appropriate antibiotics
There was no relationship between the echo patterns as having a lung abscess, but no significant response
of the necrotic area and the final histologic cell types was noted . A second aspiration was performed two
as well as the diagnostic yield. weeks later from both the cavity wall and central
Figure 1 illustrates the CT and ultrasound images portion, and squamous cell carcinoma was diagnosed
of a 59-year-old man (patient 4). The chest radiograph by specimens obtained from the cavity wall.
of this patient shows a mass in the left lower lobe. Figure 3 presents the ultrasonographic image of a
Contrast-enhanced CT of the chest demonstrates the 51-year-old man (patient 13) with a mass in the right
tumor has a central necrotic cavity with vague periph-
eral enhancement (A, left). Ultrasound shows the
tumor has a central hyperechoic part with peripheral
viable wall about 1.4 cm in thickness (B, right).
Ultrasound-guided aspiration from the central portion
of tumor was nondiagnostic, while the specimen
obtained from the cavity wall revealed squamous cell
carcinoma. The histologic diagnosis was also con-
firmed by subsequent lobectomy.
Figure 2 illustrates the CT and ultrasound images
of a 62-year-old woman (patient 12). The chest radio-
gram of this patient shows a mass in the right middle
lobe. Contrast-enhanced CT of the chest shows the
tumor has a central necrotic part with heterogeneous
density and peripheral enhancement (A, left). The
sonography demonstrates the tumor has cavity for-
mation with heterogeneous echogenicity of the cavity
FIGURE 3. A 51-year-old man has a tumor in the right lower lobe .
content (B, right) . Ultrasound-guided aspiration from Chest ultrasound demonstrates the tumor has a central hypoechoic
the central part of the tumor obtained about 0.5 ml of necrotic part (arrow). The viable cavity wall (arrowhead) is about
pus-like material, which when cultured, grew Neisse- 0.9 cm thick . The specimen of ultrasound-guided aspiration biopsy
from the central part revealed numerous histiocytes with scattered
ria sicca and Streptococcus salioarius. The cytologic neutrophils, and the specimen obtained by aspiration biopsy from
smear of the aspirate showed a picture of necrotic the outer border of the cavity wall revealed adenocarcinoma.

1454 Needle Aspiration Biopsy of Malignant Lung Masses (Pan at a/)

lower lobe. The ultrasound demonstrated the tumor
had a central hypoechoic part. An ultrasound-guided
aspiration specimen obtained from the central portion
of the tumor revealed numerous histiocytes with
scattered neutrophils only However, the specimen
obtained from the peripheral wall portion showed
adenocarcinoma. The histologic diagnosis after sub-
sequent lobectomy was adenocarcinoma.
DISCUSSION
For over a century, after the first report of successful
percutaneous needle aspiration in the diagnosis of lung
carcinoma by Menetrier in 1886, the needle aspiration
technique has been used to obtain tissue proof of lung
neoplasms. This technique has been slow to gain
widespread usage because of understandable concern
regarding potential complications. More recently, be-
cause of widespread acceptance of cytologic
diagnosisf" and improved radiologic technique per-
mitting a biopsy guidance safely and accurately by
fluoroscopy or CT,13,14 this technique has attracted
more and more interest. 15
It is well known that larger neoplasms often have
areas of necrosis centrally, and solid viable tissue
peripherally This may cause a false-negative result by
fine-needle aspiration biopsy. Contrast-enhanced cr
guidance has been reported to have the capability of
avoidance of a negative percutaneous lung biopsy," but
cr scan does have some disadvantages, such as high
cost and lack of real-time monitoring of the biopsy
procedure.
In recent years, the technique of ultrasound-guided
aspiration biopsy has gradually gained acceptance as
a useful, reliable, and safe invasive procedure to
obtain specimens for histologic diagnosis of peripheral
pulmonary masses. 6 •16,17 Ultrasound offers several ad-
vantages. The method can clearly demonstrate the
tumor and differentiate it from the obstructive pneu-
monitis.? This study also found that ultrasound may
be useful in delineating the central area and the tumor
wall; this provides accurate guidance for percutaneous
needle aspiration from the peripheral wall portion.
These advantages can avoid a false-negative result by
needle aspiration biopsy In addition, the ultrasound
also provides real-time, continuous monitoring of the
biopsy procedure that helps provide a safe and suc-
cessful transthoracic biopsy." Bedside availability and
lack of radiation exposure are also pluses for this
convenient diagnostic procedure.
The major limitation of ultrasound-guided biopsy of
a lung mass is that the mass must be in contact with
the chest wall or an "acoustic window" must be
available." Otherwise, the ultrasound cannot visualize
the tumor, and ultrasound-guided biopsy is not possi-
ble. In this situation, fiberoptic brochoscopy with
biopsy or CT-guided biopsy will be the procedure of
choice. 14,18
In this study, three different types of echogenieities
indicated the central necrotic areas, namely: hypoe-
choic, hyperechoic, or mixed pattern. These may
represent different stages of tumor necrosis. It ap-
peared that the necrotic part at first was hyperechoic,
then became hypoechoic after total liquefaction, and
turned to a heterogeneous pattern if infection coex-
isted or there were multiple areas ofnecrosis. Although
further observations and more surgical specimens are
needed to confirm this, these early results may provide
useful information for ultrasonographers to avoid as-
piration biopsy from portions ofa malignant lung mass
with heterogeneous echodensities.
A central necrotic area may also be infected by
microorganisms and mimic a lung abscess. Two of the
patients (patients 12 and 13) had microorganisms
colonized in the necrotic cavity causing infection. One
patient underwent lobectomy after a complete staging
workup and was still alive after eight months follow-
up.
Ultrasound-guided biopsy is safe. All the patients
tolerated the procedures well and no complications
developed. Although all 14 patients had had a CT scan
of the chest before referral for biopsy, cr scan of the
chest is not a prerequisite procedure of ultrasound-
guided transthoracic biopsy.
Ultrasound examination is concluded to be useful
in demonstrating central necrotic area of a malignant
lung mass and for guiding a precise needle aspiration
biopsy to the viable part of tumor. A false-negative
result can possibly be avoided under ultrasound guid-
ance.
REFERENCES
1 Harter L~ Moss AA, Coldberg HI, Gross BH. Cf guided fine
needle aspiration for diagnosis of benign and malignant disease.
AJR 1983; 140:363-67
2 Van Sonnenberg E, Casola G, Ho M, Neff CC, Varnex RR,
Wittch GR, et a1. Difficult thoracic lesions: Cf-guided biopsy
experience in 150 cases. Radiology 1988; 167:457-61
3 Gohien R~ Stanley JH, Vujic I, Gobien BS. Thoracic biopsy:
cr guided of thin-needle aspiration. AJR 1984; 142:827-30
4 Gobien R~ Valicenti JF, Paris BS, Daniell C. Thin needle
aspiration biopsy: methods of increasing the accuracy of a
negative prediction. Radiology 1982; 145:603-05
5 Pinstein ML, Scott RL, Salazar J. Avoidance of negative percu-
taneous lung biopsy using contrast-enhanced CT. AJR 1983;
140:265-67
6 Yang PC, Luh KT, Shen JC, Kuo SM, Yan~ sa Peripheral
pulmonary lesions: ultrasonography and ultrasonically guided
aspiration biopsy. Radiology 1985; 155:451-56
7 YangPC, Luh KT, Wu HD, Chang DB, Lee LN, Kuo SHe Lung
tumors associated with obstructive pneumonitis: US studies.
Radiology 1990; 174:717-20
8 Tao tc, Pearson FG, Delarue xc, Langer 8, Sanders DE.
Percutaneous fine-needle aspiration biopsy: its value to clinical
practice, Cancer 1980; 45:1480-85
9 Deid JD, Carr AH. The validity and value of histological and
cytological classification of lung cancer. Cancer 19fH; 14:673-78
CHEST I 103 I 5 I MA~ 1993 1455
10 West<:ottJL. Percutaneous transthoracic needle biopsy. Radiol-
ogy 1988; 169:593-601
11 Hess FG Jr, Mcdowell EM, Trump BF. Pulmonary cytology:
current status of cytologic typing of respiratory tract tumors.
Am J Patholl981 ; 103:323-33
12 Thornbury JR, Burke Dp, Naylor B. Transthoracic needle
aspiration biopsy : accuracy of cytologic typing of malignant
neoplasms. AJR 1981; 136:719-24
13 Stevens GM , Weigen JF, Lillington GA. Needle aspiration
biopsy oflocalized pulmonary lesions with amplified fluoroscopic
guidance. AJR 1968; 103:561-71
14 Gobien Rp, Skucas J, Paris BS. cr assisted fluoroscopically
guided aspiration biopsy of central hilar and mediastinal masses.
Radiology 1981; 141:443-49
15 Sinner WN . Transthoracic needl e biops y of pulmonary lesions.
Cancer 1979; 43:1533-40
16 Cbandrasckhar AJ, Reyne s CJ, Churchill RJ. Ultrasonically
guided percutaneous biopsy of peripheral pulmonary masses.
Chest 1976; 70:627-30
17 Cinli 0, Hawkins HB . Aspiration biopsy of peripheral pulmo-
nar y masses using real-time sonographie guidance . AJR 1984;
142:1115-16
18 Richardson RH, Zavala DC, Jukerjee PK, Bed ell GN. The use
of fiberoptic bronchoscopy and brush biopsy in th e diagnos is of
suspected pulmonary malignancy. Am Rev Respir Dis 1974;
109:63-6

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