Feasibility and therapeutic implication of computed tomography-guided TruCut biopsy in cases of recurrent adenocarcinoma lung

Received: 20-Jan-2022, Manuscript No. M-51941; , Pre QC No. P-51941; Editor assigned: 22-Jan-2022, Pre QC No. P-51941; Reviewed: 15-Feb-2022, QC No. 51941; Revised: 28-Feb-2022, Manuscript No. 51941; Published: 10-Mar-2022

Introduction

Lung cancer is one of the leading causes of cancer deaths worldwide. The common histologic types are Adenocarcinoma (ADC), Squamous Cell Carcinoma (SCC) and Small Cell Lung Cancer (SCLC). Clinical staging is performed with noninvasive diagnostic modalities, such as total body CT scan with contrast, and/or Positron Emission Tomography (PET). Diagnostic tissue biopsies may be obtained through percutaneous route with image-guided needle biopsy or bronchoscopic biopsy for endobronchial lesions or open biopsy if the former modalities could not obtain tissue. TruCut biopsy is a simple procedure, is relatively safe, rapid and a reliable technique for the diagnosis of lung lesions, particularly with the aid of a Computed Tomography (CT) scan [1]. Core biopsy not only distinguishes between benign and malignant lesions but also helps in tumour typing and molecular characterization of lung cancers, so customised targeted treatment is possible according to the tumour types. A common concept, in oncology as in microbiology, is that prolonged exposure to certain drugs can select a resistant population, either a neoplastic cell or a bacterium. Acquired resistance limits the great hopes of targeted therapies as well. The majority of patients experience it after a variable interval of time, because of a resistant clone that causes disease progression. A deeper understanding of molecular biology has made it possible in some cases to identify the specific mechanisms behind acquired resistance. So it is recommended to acquire tissue biopsy samples at recurrence, not only for the diagnosis of relapsed disease but also for additional molecular analysis [2,3]. Molecular analysis can be performed on surgical specimens, cytology cell blocks or small tissue biopsy specimens taken from the primary tumour or metastases. As needle size increases, the risk of complications also increases. Risk also depends on the location of the tumour. The most common complications include pneumothorax and bleeding. In case tissue is not obtainable, for molecular characterization of the recurrent disease, newer modalities like liquid biopsies such as Circulation Tumour Cells (CTC) or circulating tumour DNA (ctDNA) assays are promising alternatives [4,5]. So in this study, we tried to determine the feasibility and safety of CT guided lung biopsy of relapsed NSCLC and tried to determine its therapeutic implications, in comparison to where tissue biopsy was not feasible. Our aim here is to determine the feasibility and safety of CT guided lung biopsy of NSCLC (Adenocarcinoma) at recurrence. Finer molecular characterization through nextgeneration sequencing and immunohistochemistry and to find out the pros and cons of image-guided lung biopsy in comparison to liquid biopsy.

Methodology

Sixty-six non-small cell lung cancer (Adenocarcinoma) patients irrespective of the stage of presentation, who were being treated in our hospital, were enrolled in the study and followed up prospectively. Over time 12 patients were lost to follow up. All of the 54 patients on follow up eventually had recurrence/ progression of the disease, which was documented with contrast, enhanced CT scan. All of them were evaluated for trans-thoracic CT guided needle biopsy at progression. The feasibility of needle biopsy was studied according to the various tumour and patient-related factors and reasons for not being able to conduct needle biopsies were documented. Patients in whom, a needle biopsy was not possible for whatever reasons, were subjected to liquid biopsy. Between the liquid biopsies and needle biopsies, therapeutic implications were compared.

Pre-procedure evaluation and the procedure

Prothrombin Time (PT), International Normalized Ratio (INR), Activated Partial Thromboplastin Time (APTT), and platelet count was checked before a needle biopsy. Those patients, who were on aspirin or clopidogrel, were asked to discontinue it 5 days before the biopsy. Patients on oral anticoagulants were switched to low molecular weight heparin before 3 days, which in turn was withheld on the day of the procedure. CT studies were performed on 128 SLICE CT SCANNER [GE OPTIMA CT660] in all patients. Location of the lesions, location of fissures adjacent to the lung lesions or within the pathway of the biopsy needle trajectory, location of adjacent arteries and

veins were evaluated, in order to plan the needle trajectory. The angle of entry of the needle, route of entry and distance between skin and the lesion and the length of throw was documented on the CT scan monitor. Patients were positioned either in prone, supine or lateral position depending on the skin site entry point chosen. The breath-holding technique was followed during the procedure and it was explained to the patient and was practised beforehand. Patients were asked to avoid coughing and taking deep breaths during the procedure (Figures 1-3).

Figure 1: Representative case of percutaneous transthoracic core needle biopsy in a Relapsed NSCLC patient. Axial CT image (lung window) (5 mm section thickness) shows a mass in the right middle lobe; (a): Surface Markers; (b): Coaxial needle approach; (c): Advancement to lesion-Repeat CT scan obtained after needle insertion ensures that the needle tip (arrow) is located within the target mass

Figure 2: Representative case of percutaneous transthoracic core-needle biopsy in a Relapsed NSCLC. Patient. Axial CT image (lung window) (5 mm section thickness) shows mass in the right lower lobe; (a): Repeat CT scan obtained after needle insertion ensures that the needle tip (arrow) is located within the target mass; (b): Post Procedure-Pulmonary Hemorrhage

Figure 3: Representative case of percutaneous transthoracic core needle biopsy in a Relapsed NSCLC patient. Axial CT image (lung window) (5 mm section thickness) shows a mass in the left lower lobe (a case of multicentric recurrence); (a): Repeat CT scan obtained after needle insertion ensures that the needle tip (arrow) is located within the target mass; (b): Post Procedure-Minimal Pneumothorax.

Statistical evaluation

Quantitative data is represented in form of a percentage. Data analysis was done using Statistical Package for Social Sciences (SPSS) version 25.0.

Results

Baseline patient and tumour characteristics are mentioned in Table 1. All of the 54 patients on follow up eventually had recurrence/progression of the disease. Forty-six (n=46) of these 54 patients had a recurrence in the lung with or without other sites of metastasis. And the rest 8 patients had recurrences at distant sites only and did not involve lung at recurrence. Out of the 46 patients who had lung lesions at recurrence, 39 patients underwent trans-thoracic needle biopsy. Among them, viable tumour tissue could be obtained for 35 patients. Among the 7 patients who did not undergo needle biopsy, 3 had a poor general condition with low oxygen saturation. For 4 patients, lung lesions were close to the great vessels, which made them unfit for needle biopsies. Patients in whom viable tissue could not be acquired through needle biopsy, or whose who could not undergo needle biopsy because of technical issues, or those who did not have a lung lesion at recurrence and other lesions were not amenable for biopsy, were subjected to liquid biopsy.

Tab. 1. Patient characteristics