The present report aimed to improve both clinicians and patients’ understanding of the risk of CT-guided biopsy, as well as the importance role of patient-physician relationship in medical decision making.
The radiographical features of pulmonary nodules including short axis, contour, concavity, texture, location, fissure attachment, lobulation; while spiculation can be used with size-based measures to enhance prediction accuracy and to reduce false-positives[4]. Positron Emission Tomography-CT (PET-CT) plays an important role in the diagnosis, staging, response assessment and follow-upfor non-small cell lung cancer (NSCLC)patients [5]. The diagnostic accuracy of contrast-enhanced CT and PET-CT is 0.58 and 0.9 respectively in identifying malignant solitary pulmonary nodules (diameter range 8-30 mm)[6].
In addition to the radiological images, percutaneous fine-needle biopsy is widely used for cytological diagnosis of bronchogenic carcinoma. We searched PubMed, Web of Science, Scopus, Embase and Google Scholar for relevant reports up to January 2020. Key words and MeSH terms in title or abstract including “biopsy” or “puncture” or “CT-guided” and “pulmonary” or “lung” were used. No restriction was made regarding the publication language. Finally a total of 15 studies indicating the performance of CT-guided transthoracic needle biopsy were summarized in Table 1.The diagnostic accuracy of CT-guided aspiration biopsy of large nodules (>1.5 cm) and small nodules (≤1.5 cm) was 96% and 74%, respectively[7].In addition, the diagnostic accuracy of CT-guided needle biopsy was significantly improved for large (> 10 mm) lesion size and short (< or = 40 mm) needle path length[9]. Factors such as the acquisition of two or fewer specimens, lesions in the lower lobe, malignant lesions, and lesions measuring ≤ 1.0 cm or ≥ 3.1 cm significantly increased the rate of diagnostic failure[10]. Core biopsy is a preferred method as it gives a higher percentage of representative samples than fine-needle aspiration biopsy[12].Furthermore, the major complication rates for core biopsy and fine needle aspiration were 5.7 % and 4.4 %, respectively. Smaller nodule diameter, larger needle diameter and increased traversed lung parenchyma were risk factors for complications[22].Based on the available evidence, CT-guided percutaneous lung biopsy for pulmonary nodules is afeasible and efficient diagnostic method.
However, dissemination of cancer cells along needle track can make a potentially resectable localized lung cancer to be unresectable. Previous reports of lung tumor dissemination or implantation after biopsy were summarized in Table 2.The largest reported sample from Japan indicated that the incidence of tumor seeding at the site of the puncture route after fine-needle biopsy was about 0.06%[34]; whereas the interval between the initiation of biopsy and the diagnosis of implantation/metastasis was reported to be 4-13 months[26, 30, 36]. Therefore, post-biopsy radiographic examination was necessary.Furthermore, transthoracic fine-needle biopsy should not be performed in patients with sub-pleural pure solid nodules who were suspected of having NSCLC[40]. Other studies showed that CT-guided lung biopsy with a coaxial needle did not seem to cause pleural dissemination or pleural recurrence[35,41]; whereas visceral pleural invasion was responsible for tumor relapse.
On the other hand, chest wall implantation of lung adenocarcinoma at the drainage tube site has also been reported[43]. To prevent such tumor seeding at the time of thoracotomy, the pleural cavity should be washed out routinely with a massive volume of saline prior to closure of the chest wall. Despite the reports of malignant spread along the needle track, preoperative biopsy does not affect the survival in stage I NSCLC patients[44]. In addition, subcutaneous implantation of tumor cells along the needle track has also been reported in bladder, urethra, and prostate, adrenal, pancreatic, thyroid, parathyroid, and hepatocellularcarcinoma[28, 45-52]. Therefore, percutaneous fine-needle biopsy of the suspicious malignant lesions as indicated in radiographical images should not be performed indiscriminately but be reserved.
Moreover, the patient-physician trust is the foundation of clinical practice. The incidence of patient-reported regret over the decision to major abdominal and thoracic operations is 37%[53]. The factors most often associated with regret include type of surgery, disease-specific quality of life[54], decisional conflict and lower satisfaction with the decision, adverse physical health outcomes, and greater anxiety levels[55].
Furthermore, healthcare workplace violence is an underreported problem that has been largely ignored. Deterioration of patient-physician relationship had worsened and the violence against the healthcare workers emerged as a visible risk to reasonable decision-making[56]. One of the most prominent forces driving patient-physician mistrust is a patient perception of injustice within the medical sphere due to knowledge imbalances and conflicts of interest. The mistrust leads to attacks against physicians[57]. A cross-sectional survey indicated that 34.4% of healthcare workers reported verbal or physical violence in the preceding 12 months, along with 13.5% of physical assault[58]. A meta-analysis showed that the prevalence of healthcare workplace violence is especially high in Asian and North American countries[59]. On the contrary, patients are also afraid that an important diagnosis will be missed or delayed through laziness, or incompetence of the physicians[60]. Moral, regulatory and legal responses are needed to restore the patient-physician trust. Generally speaking, surgical decision-making is impaired by time constraints, uncertainty, complexity, decision fatigue, hypothetical-deductive reasoning and bias. Integration of artificial intelligence with surgical decision-making has the potential to diminish overtreatment[61].
For the present case, a timely minimally invasive lobectomy was recommended on his first admission after multidisciplinary evaluation. However, the physicians intentionally gave upthe operation to avoid potential patient-physician conflict, as the patient declared that he would demand compensation if the lesion turned out to be benign. In the real-world settings, some doctors do not know how to face the complex relationship with their patients. Meanwhile,the fear of violence impairs the decision-making deliberately. Therefore, the choice of treatment is only partly provided based on the publishedofficial guidelines and consensus recommendations.
In summary, tumor implantation or dissemination afterfine-needle biopsy is somewhatinevitable and unpreventable. A timely operation should always be considered for radiographicalmalignantandresectable lung lesions, providing that the potential patient-physician conflict could be avoided efficiently.