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CT and PET/CT fusion for lung cancer biopsy planning
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  1. Mikhail Cherkashin,
  2. Mikhail Aniskhin,
  3. Natalia Berezina,
  4. Denis Puchkov
  1. Oncology Department, Medical institute n.a. Berezin Sergey, Saint-Petersburg, Russia
  1. Correspondence to Dr Mikhail Cherkashin, mikhail.a.cherkashin{at}gmail.com

https://doi.org/10.1136/bcr-2017-221972

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    Description

    A 79-year-old man presented with colorectal cancer T4aN0M0 (surgery at 2016) and a newly diagnosed (by chest CT scan) left lung tumour (77×35×51 mm) with hydrothorax in March 2017. Initially, case was suspected as metastatic and 18-fluorodeoxyglucose whole body positron emission tomography (PET)/CT for staging was performed. Multiple mediastinal, bone and brain metastases were found. For tumour biology, verification core needle (18G) lung biopsy was planned. Due to atelectasis, which was detected with metabolic active focus in its caudal part, we decided to fuse PET/CT and biopsy native CT images on the scanner console for clear target visualisation (figure 1A,B). Biopsy was performed without any complications (figure 1C, see online supplementary video), and unfortunately lung adenocarcinoma was verified (immunohistotype thyroid transcription factor (+), cytokeratin (CK) 7 (+), CK20 (−), CDX2 (−), Villin (−)). By molecular genetics test, ex19del mutation in epidermal growth factor receptor gene was identified. In May 2017, gefitinib target therapy was started. Currently, the patient is continuing the target therapy and has achieved good disease control. A CT scan on 11 July 2017 showed a tumour mass with dimensions 26×46×50 mm (regression by Response Evaluation Criteria In Solid Tumours criteria), and no hydrothorax recurrence signs were found. Brain metastases were radiated by Gamma knife.

    Supplementary video

    CT-guided core needle biopsy. Coaxial 18 G needle placed into the suspected target.
    Figure 1
    Figure 1

    (A) Chest CT scan. Tumour mass within atelectasis (arrow). (B) Positron emission tomography/CT scan. Metabolic active focus within atelectasis (arrow). (C) Chest CT scan. Biopsy needle placed into metabolic active area (arrow).

    PET/CT–CT fusion is usually suitable for lung cancer radiotherapy planning.1 But image fusion for biopsy, in our view, is not a common technique. In our case, image fusion allows to obtain specific tissue samples for clear pathology verification and genetic testing, which helps to develop personalised treatment approach. For the future, if we will have disease control deterioration, the next possible therapeutic option for this patient is anti-programmed death-ligands immunotherapy.2

    Learning points

    • In case of lung atelectasis around tumour mass, positron emission tomography/CT is a possible option to identify a target for biopsy.

    • Cognitive fusion on the CT console during biopsy allows to precision needle placement into metabolic active tumour.

    Acknowledgments

    Authors would like to acknowledge Nikita Berezin for video and images processing

    References

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      . A phase II comparative study of gross tumor volume definition with or without PET/CT fusion in dosimetric planning for non-small-cell lung cancer (NSCLC): primary analysis of Radiation Therapy Oncology Group (RTOG) 0515. Int J Radiat Oncol Biol Phys 2012;82:435–41.doi:10.1016/j.ijrobp.2010.09.033
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      1. Masters GA,
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      . Systemic therapy for stage IV non-small-cell lung cancer: American Society of Clinical Oncology Clinical practice guideline update. J Clin Oncol 2015;33:3488–515.doi:10.1200/JCO.2015.62.1342
      OpenUrlAbstract/FREE Full Text
    View Abstract

    Footnotes

    • Contributors MC, concept, design, biopsy performing, supervision, processing, writing manuscript and critical analysis. MA, concept, design, patient care, writing manuscript and critical analysis. NB, supervision,writing manuscript and critical analysis. DP, concept, imaging support, writing manuscript and critical analysis.

    • Funding None declared

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.