Most cited paper of 2017 in European Radiology!

Most cited paper of 2017 in European Radiology!

Most cited paper of 2017 in European Radiology! 600 400 iDNA

Another moment worth celebrating for iDNA!

An article published in European Radiology, of which prof. Oudkerk was supervisor and co-author, has recently received the award for most cited article of 2017.1 The article is a meta-analysis that discusses two different kinds of needle biopsies for lung cancer and the corresponding complication rates. We’d like to take this opportunity to elaborate on the subject!

Diagnosis of cancer is generally done through taking a biopsy (taking a sample of tissue) from the suspected cancer tissue, which can be analysed to come to a definitive diagnosis. In the case of lung cancer this is more complicated than usual, since the lungs are difficult to operate on, with a relatively high risk of complications.

When the suspected cancer tissue (in lung cancer often called nodule) is conveniently located, it may be reached through the main airways and surgery is not necessary. More often, however, a more invasive surgical intervention is necessary. Since even after applying the latest nodule management protocols, many nodules in lung cancer screening still turn out to be benign, it should be a priority to ensure that the least invasive procedure with the smallest chance of complications is used. There are four different main techniques for taking a lung nodule biopsy, ordered from least to most invasive:

  • Transbronchial biopsy (bronchoscopy). This type of biopsy is performed through a fibreoptic bronchoscope (a long, thin tube that has a close-focusing telescope on the end for viewing) through the main airways of the lungs.
  • Needle biopsy. After a local anaesthetic is given, the doctor uses a needle that is guided through the chest wall into a suspicious area with computed tomography (CT or CAT scan) or fluoroscopy (a type of X-ray “movie”) to obtain a tissue sample. This type of biopsy may also be referred to as a closedtransthoracic, or percutaneous (through the skin) biopsy. There are two types of needle biopsies: fine needle aspiration (FNA) and core biopsy. Where FNA uses a very thin, hollow needle attached to a syringe to take out a small amount of fluid and very small pieces of tumour tissue, a core biopsy uses slightly larger needles that remove a small cylinder of tissue and requires use of local anaesthetics. The advantage of FNA is that the skin doesn’t need to be cut and often a diagnosis can be made on the same day. Processing core biopsy sample usually takes longer than FNA biopsies, which means results usually take longer too.
  • Thoracoscopic biopsy. After a general anaesthetic is given, an endoscope is inserted through the chest wall into the chest cavity. Various types of biopsy tools can be inserted through the endoscope to obtain lung tissue for examination. This procedure may be referred to as video-assisted thoracic surgery (VATS) biopsy. In addition to obtaining tissue for biopsy, therapeutic procedures, such as the removal of a nodule or other tissue lesion may be performed.
  • Open biopsy. After a general anaesthetic is given, the doctor makes an incision in the skin on the chest and surgically removes a piece of lung tissue. Depending on the results of the biopsy, more extensive surgery, such as the removal of a lung lobe may be performed during the procedure. An open biopsy is a surgical procedure and requires a hospital stay.

When lung cancer screening is a reality, there will be many nodules that require a needle biopsy. The publication to which prof. Oudkerk contributed investigated the differences in complications between the two different needle biopsy techniques, the core biopsy and the fine needle aspiration (FNA), and has now received the award for most cited paper from the journal European Radiology. Since it is likely that in the near future there will be an increase in lung nodules that require investigation, it is good to see that topics  related to lung cancer screening are still receiving attention.

Results from previous reports investigating the complication rates of core biopsies and FNA varied greatly and which technique was deemed safest was a matter of debate. This meta-analysis shed light on the outcomes of the studies and yielded a result where FNA was shown to have fewer minor complications. The difference between the two techniques with regard to major complications was found not to be significant.

The authors state that:

“In the specific context of diagnostic work-up of lung nodules detected in CT-screening FNA should be favoured over core biopsy. This is especially the case for 22-gauge needles, with which the risk of complications decreases greatly. Also, studies have shown that diagnostic yield does not decrease when using smaller FNA needles, and advances in FNA cytology have enabled subtyping of lung cancer in cytological material.”

The fact that this meta-analysis brings new evidence to the table in lung cancer treatment is good news for the development of the field. We are proud that we are working with prof. Oudkerk to continuously make an effort to advance optimal care for lung cancer patients and give them the best tools to fight this terrible disease.



  1. Heerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol. 2017;27(1):138-148. doi:10.1007/s00330-016-4357-8
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