|Year : 2018 | Volume
| Issue : 7 | Page : 1509-1514
Application value of coaxial biopsy system in needle cutting biopsy for focal ground glass-like density nodule
Hualong Yu1, Chuanyu Zhang1, Shihe Liu1, Gang Jiang1, Shaoke Li1, Liang Zhang1, Enhao Kang2, Bingping Zhang1, Wenjian Xu1
1 Department of Radiology, The Affiliated Hospital of Qingdao University, 266101, Shandong, China
2 Department of Pathology, The Affiliated Hospital of Qingdao University, 266101, Shandong, China
|Date of Web Publication||19-Dec-2018|
Department of Radiology, The Affiliated Hospital of Qingdao University, Shandong 266101
Source of Support: None, Conflict of Interest: None
Objective: The objective of the study is to evaluate the clinical efficacy and accuracy of coaxial biopsy puncture applied to make a diagnosis in 76 patients diagnosed with focal ground-glass density nodule (GGN).
Materials and Methods: In total, 76 patients were diagnosed with pure GGN (pGGN), 24 males and 52 females, aged (52 ± 1.2) years on average (range: 47–72 years). All patients underwent computed tomography (CT)-guided coaxial biopsy puncture to localize the position and measure the size of pGGN. The maximal diameter of the pGGN and the length of puncture needle into the lung were quantitatively measured. The diagnostic accuracy rate of CT-guided biopsy was subsequently validated by histological pathological examination. The incidence of postoperative complications was observed after biopsy.
Results: The pGGN diameter was measured from 5 to 45 mm, 21 mm on average. The pGGN depth ranged from 0 to 48 mm with a mean depth of 15 mm. Compared with the final diagnosis, the sensitivity, specificity, and accuracy rates of CT-guided needle aspiration biopsy in the diagnosis of pGGN were calculated as 97.3% (54/56), 85.0% (17/20), and 93.4% (71/76), respectively. Fourteen cases (18.4%) suffered from slight pneumothorax, 17 (22.4%) with mild errhysis surrounding the biopsy needle or lesions.
Conclusion: CT-guided needle aspiration biopsy yields higher diagnostic accuracy and similar postoperative complications compared with the conventional histological diagnosis. For those undiagnosed by conventional CT scan and nontolerable of surgery, CT-guided needle aspiration biopsy serves as a safe and effective intervention.
Keywords: Coaxial biopsy puncture, diagnostic accuracy, ground-glass density nodule, high-resolution computed tomography
|How to cite this article:|
Yu H, Zhang C, Liu S, Jiang G, Li S, Zhang L, Kang E, Zhang B, Xu W. Application value of coaxial biopsy system in needle cutting biopsy for focal ground glass-like density nodule. J Can Res Ther 2018;14:1509-14
|How to cite this URL:|
Yu H, Zhang C, Liu S, Jiang G, Li S, Zhang L, Kang E, Zhang B, Xu W. Application value of coaxial biopsy system in needle cutting biopsy for focal ground glass-like density nodule. J Can Res Ther [serial online] 2018 [cited 2019 Jan 22];14:1509-14. Available from: http://www.cancerjournal.net/text.asp?2018/14/7/1509/247718
| > Introduction|| |
A ground-glass density nodule (GGN) is a circumscribed area of increased pulmonary attenuation with preservation of the bronchial and vascular margins. Along with the widespread application of low-dose and high-resolution computed tomography (CT) scan in screening of lung cancer, the diagnostic rate of pure GGN (pGGN) has been steadily elevated., The incidence of approximately 75% of regional pGGN is correlated with atypical adenomatous hyperplasia (AAH) and adenocarcinoma in situ, probably leading to hemorrhage, inflammation, fibrosis, and alternative benign pathological changes. Due to the atypical morphology of pGGN and relatively low sensitive of positron emission tomography, it is likely to make a misdiagnosis or miss the diagnosis. How to promote the diagnostic accuracy of pGGN remains a challenge to a majority of clinicians.,, CT-guided percutaneous needle cutting biopsy of the lung can obtain the histological samples, which is able to elevate the accuracy of clinical diagnosis. Consequently, it has become one of the most commonly-applied techniques to validate the diagnosis of complicated lung diseases in clinical practice.,,,, Nevertheless, the application of CT-guided coaxial biopsy in the diagnosis of solid pulmonary lesions, especially the ground glass-like density nodules has been rarely reported. This study was designed to retrospectively analyze the clinical data of 76 patients diagnosed with pGGN, aiming to investigate the accuracy and safety of the coaxial biopsy system in the diagnosis of pGGN.
| > Materials and Methods|| |
A total of 3726 subjects underwent CT-guided needle Cutting biopsy of the lung in our hospital between January 2012 and June 2014. Among them, 76 patients were eventually diagnosed with pGGN, 24 males and 52 females, aged (52 ± 1.2) years on average (range: 47–72 years). Pulmonary ground glass-like opacity (GGO) is manifested as a nonspecific finding on high-resolution spiral CT scan that indicates a partial filling of air spaces in the lungs by exudate or transudate, as well as interstitial thickening or partial collapse of lung alveoli. According to the formula: ([DGGO-D]/DGGO) × 100, in which DGGO represents the maximal diameter of pGGN including the range of ground glass-like density, and D denotes the maximal diameter of solid masses,, pGGN is defined as the percentage of ground glass-like density nodules exceeds 95%. The CT scan images of each individual were reviewed by two experienced radiologists from the thoracic department. The patients were enrolled after they reached a consensus.
Equipment and methods
Lightspeed 16-layer spiral CT scanner (Philips, Netherlands), Lightspeed NX spiral CT (GE Corporation, U.S.). Automatic biopsy gun, coaxial cutting biopsy needle of 17G × 13.8 cm and 18G × 15 cm (BARD Corporation, U.S.). Patients were required to lay in different puncture postures, such as in a supine position, prone position, or lateral position according to the locations of the pulmonary lesions. The self-designed grid frame combined with guiding lines by CT scan was utilized to perform mark localization on the body surface of the patients.
After routine skin disinfection and local anesthesia, the syringe needle was retained to identify the point of puncture. After repeated examination and confirmation, the trocar needle was rapidly inserted through the pleura to the proper position after adjustment of the angle and depth of the trocar needle. Subsequently, CT scan was carried out to confirm whether the trocar needle was within or on the margins of the lung lesions. Biopsy specimen was obtained and prepared for subsequent pathological examination. The collected tissues were fixed in 10% formalin for histological analysis. CT scan of the entire lung was performed to detect the incidence of pneumothorax, hemorrhage, and other complications. The patients were required to lay down for 2 h. Chest X-ray was performed at 3 h and next morning after the procedure.
The patients with slight pneumothorax symptoms below 20% of the lung capacity underwent no specific treatment and lay in bed with the puncture site downward. For those with pneumothorax above 30% of the lung capacity, immediate suction was adopted to mitigate the pneumothorax symptoms. Catheter drainage was delivered for a minority of patients.
The maximal diameter of the pGGN and the length of puncture needle into the lung tissues were quantitatively measured. The findings of pathological puncture were recorded. The incidence of puncture-related complications was calculated. All patients were diagnosed with malignant, suspicious malignant, benign lesions, and undiagnosed. Those diagnosed with malignant and suspicious malignant lesions were assigned into the positive group, and their counterparts diagnosed with benign masses or undiagnosed were allocated in the negative group. The results of needle Cutting biopsy were compared with the final results of pathological diagnosis. The final diagnosis was validated by the outcomes of surgical pathology. The patients nontolerable of surgery were subject to clinical and imaging follow-up for at least 2 years. The final diagnosis was determined based on the follow-up results. The diagnostic accuracy of percutaneous needle Cutting biopsy for malignant lung lesions was calculated by using the 2 × 2 table method. The diagnostic sensitivity, specificity, and accuracy of this technique were calculated according to the final diagnostic outcomes. The size of lesions was defined as the maximal diameter in triple directions. The puncture depth represented the length from the point of puncture to the lesional margins. The needle length referred to the distance between the pleura to the lesional margin along with the puncture direction.
The sensitivity, specificity, and accuracy rates of needle aspiration biopsy between patients with lesion diameter <2 cm and ≥2 cm, puncture depth <5 cm and ≥5 cm were statistically compared using the precise probability method. The effect of lesion size and puncture depth on the puncture outcomes was evaluated. The correlation between the risk of pneumothorax and hemorrhage, as well as the lesion size and needle length, was statistically analyzed by using the logistic regression analysis. SPSS 19.0 statistical software package was utilized for data analyses (SPSS Inc., Chicago, IL, U.S.). P < 0.05 was considered as statistical significance.
| > Results|| |
Size and distribution of pure ground-glass density nodule
A total of 76 patients diagnosed with pGGN, which were located in the superior lobe of left lung in 22 cases, the inferior lobe of left lung in 15, the superior lobe of right lung in 17, the middle lobe of right lung in 9, and the inferior lobe of right lung in 13, respectively. The pGGN diameter was measured from 5 to 45 mm, 21 mm on average. The pGGN depth was ranged from 0 to 48 mm with a mean depth of 15 mm.
Histological diagnosis of computed tomography-guided biopsy
CT-guided needle cutting biopsy was successfully performed in all patients, as illustrated in [Figure 1]. The length of obtained tumor tissues was measured from 0.5 to 1. cm. Needle cutting biopsy of the lung demonstrated that 51 cases were diagnosed with malignant lesions, 5 with suspicious malignant lesions, 14 with benign lesions, and 6 patients were undiagnosed. Among 51 cases of malignant pGGN, 25 patients were found to be highly-differentiated adenocarcinoma, 10 with moderately-differentiated adenocarcinoma, 16 with metastatic carcinoma, and 14 with benign pGGN. One patient was diagnosed with sclerosing hemangioma [Figure 2]a, and 13 presented with chronic inflammation [Figure 2]b. Two of them progressed into moderately-differentiated adenocarcinoma validated by surgery. Among five cases of suspicious malignant lesions, one was pathologically diagnosed with organized pneumonia, 1 with chronic inflammation, two with adenocarcinoma, and one with atypical AAH [Figure 2]c and [Figure 2]d. For six undiagnosed patients, one case was pathologically diagnosed with adenocarcinoma and the remaining five with chronic inflammation during subsequent follow-up.
|Figure 1: Intraoperative (a) and postoperative (b) computed tomography scan images revealing the focal ground-glass density nodule position and distribution|
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|Figure 2: (a) sclerosing hemangioma (b) chronic inflammation (c and d) atypical AAH|
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Accuracy rate of computed tomography-guided biopsy
By comparison with the final diagnosis, the sensitivity, specificity, and accuracy rates of CT-guided needle aspiration biopsy in the diagnosis of pGGN were calculated as 97.3% (54/56), 85.0% (17/20), and 93.4% (71/76), respectively. The sensitivity, specificity and accuracy rates of CT-guided biopsy puncture did not significantly differ according to varying pGGN size and needle length (all P > 0.05), illustrated in [Table 1] and [Table 2].
|Table 1: Computed tomography-guided needle cutting biopsy of lung lesions in different size|
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|Table 2: Computed tomography-guided needle cutting biopsy of the lung lesions in different puncture depth|
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Postoperative complications after computed tomography-guided biopsy
A total of 76 patients underwent puncture biopsy. Fourteen cases (18.4%) suffered from slight pneumothorax, 17 (22.4%) with mild errhysis surrounding the biopsy needle or lesions. No further treatment was implemented after clinical observation for 2 h. The correlation between the puncture-related complications and lesion size was demonstrated in [Table 3]. The incidence of pneumothorax was not significantly correlated with the needle length, whereas it was intimately associated with the lesion size. The risk of puncture needle hemorrhage was significantly correlated with needle length rather than lesion size.
|Table 3: Logistic regression analysis of risk factors of complications after computed tomography-guided puncture|
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| > Discussion|| |
Previous investigations , have reported the diagnostic significance of patients with GGO. GGO is defined as a partial filling of air spaces in the lungs by exudate or transudate, as well as interstitial thickening or partial collapse of lung alveoli. GGO is commonly observed in patients with early diffuse pulmonary infiltrative diseases. Although nonspecific in itself, the sign is always very significant. Particularly, it could represent a useful sign of active and treatable abnormality in some diffuse pulmonary diseases, such as idiopathic pulmonary fibrosis and sarcoidosis. The GGO may also be observed in pulmonary edema, desquamative pneumonitis, pneumocystis carinii pneumonia, alveolar proteinosis, hypersensitive pneumonitis, and drug-induced or radiation-induced lung disease. According to THE quantity and scope of GGO, it can be divided into focal GGO (fGGO) and diffusive GGO. The differential diagnosis of multiple causes of GGO includes pulmonary edema, infections including cytomegalovirus and pneumocystis carinii pneumonia, various noninfectious interstitial lung diseases, such as hypersensitivity pneumonitis, Hamman-Rich syndrome More Details, diffuse alveolar hemorrhage, and cryptogenic organizing pneumonia. Although GGO is relatively common in clinical practice, it is still a challenge to make an accurate differential diagnosis from benign and malignant lesions due to the atypical clinical symptoms and low specificity imaging features.
CT-guided percutaneous needle aspiration biopsy of the lung is gradually widely applied because of the high levels of safety, accuracy, and convenience. A majority of previous researches emphasize the application of CT-guided needle cutting biopsy in the solid pulmonary lesions. The use of CT-guided needle cutting biopsy in the diagnosis of focal ground-glass density nodule (fGGN) has been rarely reported. The present study aims to offer more clinical evidence for the application of this technique in the diagnosis of fGGN.
In previous investigations, the diagnostic accuracy of CT-guided needle cutting biopsy for pulmonary GGO is detected above 90%, ranging from 91% to 97%.,, In this study, the diagnostic rate was measured as 93.4%, which is consistent with previous findings. The diagnostic rate has been proven to be associated with the lesion size, puncture needle mode and the clinical experience of the surgeons. In this study, no statistical significance was identified when the CT-guided puncture biopsy was applied in the diagnosis of lung lesions in different size and puncture depth, probably associated with the surgical experience of the clinicians. It is convenient to obtain the large-size pathological changes, whereas the components of such tissues are complicated and diverse including benign lesions. During the puncture process, the obtained tissues cannot be used to validate the final diagnosis of the suspected pathological changes, whereas it has to be confirmed by surgical pathology. Consequently, the diagnostic accuracy for the large-size lesions is relatively low. Negative results cannot exclude the possibility of malignant pathological changes. In this investigation, the false-negative rate for the malignant lesions was measured as 6.8%. The pathological results are affected by multiple influencing factors including the incidence of pneumothorax during puncture, low quantity of obtained tissues, and inflammatory tissues surrounding the tumors. Therefore, nonspecific symptoms including hemorrhage, necrosis, inflammatory cell infiltration, and AAH should be considered based on individual situations. The secondary puncture is highly necessary for those highly suspected with malignant tumors on imaging and clinical manifestations whereas with negative biopsy puncture results. Surgical resection is recommended to avert the risk of disease progression and aggravation.
The most common complications of percutaneous needle cutting biopsy of the lung mainly include pneumothorax, hemorrhage, and hemoptysis. It is reported that the incidence of pneumothorax after CT-guided needle cutting biopsy is 8%–65%.,,,, The prevalence of pneumothorax has been proven to correlate with a variety of risk factors, such as lesion size and depth, puncture needle size, age, lung function, puncture frequency, and surgical experience of the surgeon. Compared with the statistics data reported previously, the incidence of pneumothorax in this investigation is relatively high, probably associated with the relatively small lesion diameter (26 mm on average). The difficulty in the localization of lesions is significantly elevated due to the small node size, thereby dramatically enhancing the risk of pneumothorax after surgery., The severity of puncture-induced injury to the normal lung and the incidence of pneumothorax are equally increased if the lung lesion is distant from the chest wall. The incidence of pneumothorax is extremely low if the lung lesion is proximal to the thoracic wall and has been rarely reported. The risk of pneumothorax is the highest for patients with lesions of 1–2 cm in depth, and the incidence of pneumothorax is declined for their counterparts with lesions of >5 cm in depth, suggesting that if the lesion is excessively proximal to the pleura, the risk of pneumothorax is likely to be elevated, probably because the shallow puncture depth induces less tension on the lung surface, and it is difficult to grasp the lung tissues using the needle, leading to an increased incidence of pneumothorax. In the investigation, the puncture depth was not significantly correlated with the risk of pneumothorax.
To minimize the incidence of pneumothorax after biopsy puncture, the lesion localization should be performed rapidly and precisely, and repeated puncture should be avoided. The direction of puncture needle should be properly adjusted outside the pleura. The puncture needle should be inserted into the pleura in an accurate and quick manner. Previous studies have demonstrated that the patients should change the body posture with the puncture site downward immediately after the puncture, which shortens the distance between splanchnoderm and parietal pleura and probably contributes to prevent the incidence of pneumothorax. Patients present with no evident symptoms and require no specific treatment when the pneumothorax with lung compression of below 20%. Relevant symptoms can restore after 1–2 weeks. When the pneumothorax with lung compression >30%, immediate suction treatment should be delivered. In this study, one patient with lung tissue compression of 50% was eventually restored after catheter drainage from the thoracic cavity.
Alveolar hemorrhage is a frequent complication of CT-guided puncture. No clinical interventions are required for asymptomatic patients with slight hemorrhage. Nevertheless, serious hemorrhage is likely to provoke the incidence of hemoptysis or hemothorax, even mortality of the patients. The incidence of alveolar hemorrhage after CT-guided lung needle cutting biopsy is reported up to 4%–30%.,,, In this investigation, all patients presented with hemorrhage surrounding the needle or lesions. Ten cases suffered from mild hemoptysis and restored without any specific treatment. Previous investigations have demonstrated that the incidence of needle hemorrhage is correlated with the lesion size, needle length, and puncture needle mode. Theoretically, the risk of puncture-induced injury to the blood vessels around the lesions, needle hemorrhage and hemoptysis is increased if the lesion size is smaller, the needle length is longer, and the puncture needle is thicker. Previous researchers have demonstrated that the incidence of needle hemorrhage is correlated with the lesion size. However, no significant correlation was observed between them in the present study. The potential causes include that the puncture is completed successfully in most of the GGN and repeated puncture is averted, prompting that the lesion size is possibly not an independent risk factor of hemorrhage complications if the first puncture is successfully performed. The findings in this study indicate that preoperative enhanced CT scan should be necessarily performed to understand lesional blood supply and avert the risk of the great arteries injury, which is of clinical significance for the success of biopsy puncture of the pulmonary lesions. In addition, the possibility of hemorrhagic tendency should be eliminated by performing preoperative coagulation function test and platelet count.
| > Conclusion|| |
CT-guided needle cutting biopsy yields higher diagnostic accuracy compared with the conventional histological diagnosis. The incidence of postoperative complications is similar to that of histological examination. For those undiagnosed by conventional CT scan and nontolerable of surgery, CT-guided needle aspiration biopsy serves as a safe and effective approach to obtain histological and pathological specimens.
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Conflicts of interest
There are no conflicts of interest.
| > References|| |
Lee HY, Lee KS. Ground-glass opacity nodules: Histopathology, imaging evaluation, and clinical implications. J Thorac Imaging 2011;26:106-18.
Nakata M, Saeki H, Takata I, Segawa Y, Mogami H, Mandai K, et al.
Focal ground-glass opacity detected by low-dose helical CT. Chest 2002;121:1464-7.
Kim HY, Shim YM, Lee KS, Han J, Yi CA, Kim YK, et al.
Persistent pulmonary nodular ground-glass opacity at thin-section CT: Histopathologic comparisons. Radiology 2007;245:267-75.
Park CM, Goo JM, Lee HJ, Lee CH, Chun EJ, Im JG, et al.
Nodular ground-glass opacity at thin-section CT: Histologic correlation and evaluation of change at follow-up. Radiographics 2007;27:391-408.
Kim TH, Kim SJ, Ryu YH, Chung SY, Seo JS, Kim YJ, et al.
Differential CT features of infectious pneumonia versus bronchioloalveolar carcinoma (BAC) mimicking pneumonia. Eur Radiol 2006;16:1763-8.
Hiraki T, Mimura H, Gobara H, Iguchi T, Fujiwara H, Sakurai J, et al.
CT fluoroscopy-guided biopsy of 1,000 pulmonary lesions performed with 20-gauge coaxial cutting needles: Diagnostic yield and risk factors for diagnostic failure. Chest 2009;136:1612-7.
Yeow KM, Tsay PK, Cheung YC, Lui KW, Pan KT, Chou AS, et al.
Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: Retrospective analysis of 631 procedures. J Vasc Interv Radiol 2003;14:581-8.
Yi-Feng Z, Li-Ming J, Wei-Min M, Zhi-Qiang H. Percutaneous computed tomography-guided lung biopsy of solitary nodular ground-glass opacity. J Cancer Res Ther 2015;11 Suppl 8:C231.
Montaudon M, Latrabe V, Pariente A, Corneloup O, Begueret H, Laurent F, et al.
Factors influencing accuracy of CT-guided percutaneous biopsies of pulmonary lesions. Eur Radiol 2004;14:1234-40.
Yang X, Ye X, Lin Z, Jin Y, Zhang K, Dong Y, et al.
Computed tomography-guided percutaneous microwave ablation for treatment of peripheral ground-glass opacity-lung adenocarcinoma: A pilot study. J Cancer Res Ther 2018;14:764-71.
Inoue D, Gobara H, Hiraki T, Mimura H, Kato K, Shibamoto K, et al.
CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions: Diagnostic yield in 83 lesions. Eur J Radiol 2012;81:354-9.
Engeler CE, Tashjian JH, Trenkner SW, Walsh JW. Ground-glass opacity of the lung parenchyma: A guide to analysis with high-resolution CT. AJR Am J Roentgenol 1993;160:249-51.
Kim TJ, Lee JH, Lee CT, Jheon SH, Sung SW, Chung JH, et al.
Diagnostic accuracy of CT-guided core biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol 2008;190:234-9.
Hur J, Lee HJ, Nam JE, Kim YJ, Kim TH, Choe KO, et al.
Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol 2009;192:629-34.
Remy-Jardin M, Giraud F, Remy J, Copin MC, Gosselin B, Duhamel A, et al.
Importance of ground-glass attenuation in chronic diffuse infiltrative lung disease: Pathologic-CT correlation. Radiology 1993;189:693-8.
Austin JH, Müller NL, Friedman PJ, Hansell DM, Naidich DP, Remy-Jardin M, et al.
Glossary of terms for CT of the lungs: Recommendations of the nomenclature committee of the fleischner society. Radiology 1996;200:327-31.
Yamauchi Y, Izumi Y, Nakatsuka S, Inoue M, Hayashi Y, Mukai M, et al.
Diagnostic performance of percutaneous core needle lung biopsy under multi-CT fluoroscopic guidance for ground-glass opacity pulmonary lesions. Eur J Radiol 2011;79:e85-9.
Zhang HD, Gao X, Liu CY, Liu Chen. Analysis of Risk Factors of Postoperative Complications after CT-Guided Biopsy of the Lung. Guiyang, Guizhou province: Guiyang Medical College XueBao; 2013. p. 412-4.
Charig MJ, Phillips AJ. CT-guided cutting needle biopsy of lung lesions – Safety and efficacy of an out-patient service. Clin Radiol 2000;55:964-9.
Ng YL, Patsios D, Roberts H, Walsham A, Paul NS, Chung T, et al.
CT-guided percutaneous fine-needle aspiration biopsy of pulmonary nodules measuring 10 mm or less. Clin Radiol 2008;63:272-7.
Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology 1997;202:97-103.
Khan MF, Straub R, Moghaddam SR, Maataoui A, Gurung J, Wagner TO, et al.
Variables affecting the risk of pneumothorax and intrapulmonal hemorrhage in CT-guided transthoracic biopsy. Eur Radiol 2008;18:1356-63.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]