Background: Postprogression repeat biopsies are critical in caring for patients with lung cancer with epidermal growth factor receptor (EGFR) mutations. However, hesitation about invasive procedures persists. We assessed safety and tissue adequacy for molecular profiling among repeat postprogression percutaneous transthoracic needle aspirations and biopsies (rebiopsies).
Materials and methods: All lung biopsies performed at our hospital from 2009 to 2017 were reviewed. Complications were classified by Society of Interventional Radiology criteria. Complication rates between rebiopsies in EGFR-mutants and all other lung biopsies (controls) were compared using Fisher's exact test. Success of molecular profiling was recorded.
Results: During the study period, nine thoracic radiologists performed 107 rebiopsies in 75 EGFR-mutant patients and 2,635 lung biopsies in 2,347 patients for other indications. All biopsies were performed with computed tomography guidance, coaxial technique, and rapid on-site pathologic evaluation (ROSE). The default procedure was to take 22-gauge fine-needle aspirates (FNA) followed by 20-gauge tissue cores. Minor complications occurred in 9 (8.4%) rebiopsies and 503 (19.1%; p = .004) controls, including pneumothoraces not requiring chest tube placement (4 [3.7%] vs. 426 [16.2%] in rebiopsies and controls, respectively; p < .001). The only major complication was pneumothorax requiring chest tube placement, occurring in zero rebiopsies and 38 (1.4%; p = .4) controls. Molecular profiling was requested in 96 (90%) rebiopsies and successful in 92/96 (96%).
Conclusion: At our center, repeat lung biopsies for postprogression molecular profiling of EGFR-mutant lung cancers result in fewer complications than typical lung biopsies. Coaxial technique, FNA, ROSE, and multiple 20-gauge tissue cores result in excellent specimen adequacy.
Implications for practice: Repeat percutaneous transthoracic needle aspirations and biopsies for postprogression molecular profiling of epidermal growth factor receptor (EGFR)-mutant lung cancer are safe in everday clinical practice. Coaxial technique, fine-needle aspirates, rapid on-site pathologic evaluation, and multiple 20-gauge tissue cores result in excellent specimen adequacy. Although liquid biopsies are increasingly used, their sensitivity for analysis of resistant EGFR-mutant lung cancers remains limited. Tissue biopsies remain important in this context, especially because osimertinib is now in the frontline setting and T790M is no longer the major finding of interest on molecular profiling.
摘要
背景。对于表皮生长因子受体(EGFR)突变型肺癌患者，病情进展后重复活检对于治疗至关重要。然而，我们对于是否应实施侵入性手术仍存有疑虑。因此，我们针对进展后重复经皮经胸针吸活检(二次活检)的病例评估了分子分析的安全性和组织充分性。
材料和方法。我们对 2009 年至 2017 年在我院进行的所有肺部活检病例进行了评估。我们将并发症按美国介入放射学会的标准进行分类。同时，采用 Fisher 精确检验方法对 EGFR 突变型肺癌二次活检的并发症发生率与所有其他肺活检(对照)的并发症发生率进行了对比。对分子分析的成功率进行了记录。
结果。在研究期间，9 名胸部放射科医生对 75 名 EGFR突变型肺癌患者实施了 107 次二次活检，并因其他适应症对 2 347 名患者实施了 2 635 次肺活检。采用计算机断层扫描引导技术、同轴技术及快速现场病理评估 (ROSE) 进行所有活检。默认程序是首先采用 22 号针实施细针针吸活检 (FNA)，随后采用 20 号组织芯进行活检。二次活检组中出现 9 例 (8.4%) 轻微并发症，对照组中出现 503 例轻微并发症 (19.1%; p = 0.004)，包括无需置入胸管的气胸 [二次活检组和对照组中分别为 4 例 (3.7%) 和 426 例 (16.2%)；p < 0.001]。唯一的主要并发症是需要置入胸管的气胸，其中二次活检组中为 0 例，对照组中为 38 例(1.4%; p = 0.4)。96 例 (90%) 二次活检需要进行分子分析，其中 92/96 例 (96%) 成功。
结论。在我们的研究中心内，相较于典型的肺活检，针对 EGFR 突变型肺癌的进展后分子分析而实施的重复肺活检所引发的并发症要少。由于采用同轴技术、FNA、ROSE 及多个 20 号组织芯活检，所以样本量充足。
实践意义:在日常临床实践中，为实施表皮生长因子受体 (EGFR) 突变型肺癌的进展后分子分析而进行的重复经皮经胸针吸活检是安全的。由于采用同轴技术、细针针吸活检、快速现场病理评估及多个 20 号组织芯活检，所以样本量充足。尽管液体活检得到日益广泛的应用，但其对 EGFR突变型肺癌耐药分析的灵敏性仍很有限。在这种情况下，组织活检仍非常重要，尤其是因为奥希替尼 (Osimertinib) 是如今医疗前线的主要用药，而T790M 不再是分子分析所关注的主要发现。
Keywords: Complications; Disease progression; Molecular targeted therapy; Needle biopsy; Non‐small cell lung cancer.
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