Abstract
In our recent article (1) we summarized our experience of CT-guided needle aspiration and biopsy in a large cohort of patients referred for suspicious pulmonary lesions. The choice between fine needle aspiration (FNA), core needle biopsy (CNB), or both was based solely on clinical judgment, individualizing harms and benefits for each patient. The notion that we disregard CNB compared to FNA is not valid. What we actually demonstrate is that, after adjusting for lesion size, omission of FNA may result in lower diagnostic performance. This effect is expected given that combining FNA and CNB greatly improves the diagnostic yield, especially for malignant lesions. (2). Our risk-stratified approach resulted in a large saving of resources (and cost) given that FNA alone comprised 64% of the procedures, without compromising efficacy. Indeed, only 3.4% of our procedures gave insufficient sample, which is remarkably similar to previous data (12/350, 3.4%) on combined FNA/CNB procedures where sampling adequacy was on-site assessed by a cytopathologist (2).
Our data (1) indicate that after adjusting for lesion size, combining CNB/FNA versus FNA alone would yield more frequently a malignant diagnosis than a non-specific benign process (adjusted OR 2.43; 95% CI 1.50–3.96, P < 0.001) but this difference should not be used as indicative of inferiority of FNA: it may simply signify that more suspicious lesions (clinically and radiologically) were more likely to be selected and sampled using both techniques.
The presence of an “on-site” cytopathologist would definitely aid the diagnostic process, but significant economic and personnel constraints apply in our setting. We again emphasize that a non-specific benign diagnosis does not exclude malignancy, unless complemented by further clinical and radiologic follow-up. Within the limitations imposed in our setting, our results (1) indicate that selection based on a risk-oriented clinical practice constrained costs without compromising efficacy.