Rationale and Objectives
Only a few studies have systematically evaluated risk factors for pneumothorax and pulmonary hemorrhage in computed tomographically (CT)-guided transthoracic lung biopsy (TLB). We evaluated the diagnostic yield of CT-guided TLB and determined risk factors for pneumothorax and hemorrhage.
Methods
One hundred seventy-two CT-guided TLBs were performed on 159 patients (mean age 66 ± 11 years; 72% male) using a 16-gauge core biopsy needle. Lesion and patient characteristics, lung function analysis, CT signs of emphysema, histopathologic diagnoses, and complications were recorded. Statistical analysis was performed with multivariate regression analysis.
Results
Histopathologic diagnosis was established in 153 cases (89%). Although lesion size was higher (47 ± 29 vs. 43 ± 35 mm, P = .191) and depth was lower (22 ± 23 vs. 6 ± 23mm, P = .350) in procedures with histopathologic diagnosis, no parameter showed significant impact on diagnostic yield. Sensitivity and specificity for detection of malignancy were 93% and 100%, respectively, whereas positive and negative predictive values were 100% and 88%. Overall accuracy was 95%. Pneumothorax occurred in 45 procedures (26%). Hemorrhage was recorded in 17 procedures (10%). There was higher frequency of pneumothorax in smaller lesions (35 ± 23 vs. 50 ± 31 mm, P = .003; odds ratio = .96) and greater depth (29 ± 29 vs. 20 ± 19 mm, P = .05; odds ratio = 1.03). CT signs of emphysema revealed higher incidence of hemorrhage (35% vs. 23%; P = .04; odds ratio=41.03). Other parameters were nonsignificant.
Conclusions
The high diagnostic yield of CT-guided TLB was not affected by lesion characteristics or emphysema. Pneumothorax rate was influenced by lesion size and depth. Hemorrhage was associated with CT signs of emphysema.
Shortly after clinical approval of computed tomography (CT) in 1975, Haaga and Alfidi ( ) reported the first CT-guided biopsy. Since then, CT has continuously improved and expanded the scope of thoracic lesions amenable to image-guided biopsy. Although efforts have been made to use ultrasound ( ) and magnetic resonance imaging ( ) as guiding tools in thoracic biopsies, CT-guided transthoracic lung biopsy (TLB) has become a widely accepted procedure for evaluation of intrapulmonary masses of unknown etiology. The method provides high diagnostic accuracy and has a relatively low complication rate. The spectrum of possible complications includes pulmonary hemorrhage, hemoptysis, air embolism ( ), heart arrest ( ), pericardial tamponade, neoplastic seeding ( ), pneumothorax, and even death ( ). According to the authors of numerous studies, the incidence of pneumothorax ranges from 10% to 54% ( ); thus, a number of attempts have been made to prevent procedure-related complications including use of thin or ultrathin needles ( ), respiratory gating ( ), lower angulation of the biopsy needle trajectory ( ), and precautions in positioning the patient during ( ) and after the procedure ( ). Furthermore, factors that are unrelated to the biopsy procedure, including patient age ( ), lesion size ( ), lesion depth ( ), presence of emphysema ( ), and obstructive lung disease ( ), have been identified as risk factors for pneumothorax and chest tube placement. Due to the fact that pneumothorax is the most common complication following CT-guided TLB, only a few studies have systematically evaluated risk factors for post-interventional pulmonary hemorrhage. Nevertheless, serious pulmonary hemorrhage following TLB has been described, which may lead to severe hemoptysis or even death ( ). Furthermore, results of previous studies concerning CT-guided TLB are difficult to compare owing to various statistical methods (univariate vs. multivariate analysis) and different biopsy systems, including fine-needle aspiration techniques and core biopsies, with some authors reporting inconsistent or even contradictory results ( ), indicating that the incidence of different TLB-related complications is a multivariate and complex problem and that pneumothorax and hemorrhage may be caused by different factors.
The purposes of this retrospective study were to evaluate the diagnostic yield of CT-guided TLB using a core system and to determine risk factors for procedure-related complications, including pneumothorax and pulmonary hemorrhage.
Materials and methods
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Patient Selection
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Biopsy Procedure
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Image Analysis
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Histopathologic Diagnosis and Follow-up
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Statistical Analysis
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Results
Patient Group
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Biopsy Procedure
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Histopathologic Diagnoses
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Table 1
Comparison of the Frequency of Definite Histopathological Diagnosis and Patient and Lesion Characteristics, Presence of Emphysema, Procedure-Related Features, and Lung Function Parameters (multivariate analysis)
TLB Procedures with Definite Histopathologic Diagnosis ( n = 153) TLB Procedures without Definite Histopathologic Diagnosis ( n = 19)P- Value Odds Ratio Patient characteristics Sex (% male) 72.5 78.9 .413 8.968 Age (y) 66.3 ± 10.5 62.6 ± 12.8 .206 1.082 Lesion characteristics Lesion size (mm) 46.5 ± 28.9 43.1 ± 34.9 .191 0.979 Pleural distance (mm) 21.7 ± 22.5 26.1 ± 23.0 .350 1.014 Side (% right-sided) 64.1 84.2 .421 2.796 CT lung morphology Presence of emphysema (%) 22.8 31.6 .516 1.871 Procedure-related characteristics Angle of needle tract (°) 71.8 ± 22.7 74.4 ± 21.3 .692 1.007 Patient position (% supine) 32.0 47.4 .868 1.175 Pulmonary function tests ⁎ FEV 1 (L) 1.74 ± .64 2.52 ± 1.09 .251 337.257 FEV 1 % 62.1 ± 20.1 72.0 ± 24.8 .623 0.919 FEV 1 /FVC ratio (%) 77.7 ± 20.3 74.8 ± 21.2 .057 0.906 ITGV (L) 3.87 ± 1.26 3.92 ± 1.14 .121 0.078 ITGV% 116.2 ± 32.2 113.3 ± 26.8 .140 1.097 FVC (L) 2.67 ± 0.89 3.70 ± 1.13 .806 0.398 FVC% 74.4 ± 18.5 85.7 ± 21.5 .858 1.027
FEV 1 , forced expiratory volume in 1 second; FEV 1 %, forced expiratory volume in 1 second, percentage of predicted value; FVC, forced vital capacity; FVC%, forced vital capacity, percentage of predicted value; ITGV, intrathoracic gas volume; ITGV%, intrathoracic gas volume, percentage of predicted value; TLB, transthoracic lung biopsy.
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Procedure-related Complications
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Table 2
Comparison of the Frequency of Pneumothorax and Patient and Lesion Characteristics, Presence of Emphysema, Procedure-Related Features, and Lung Function Parameters (Multivariate Analysis)
TLB Procedures with Pneumothorax ( n = 45) TLB Procedures without Pneumothorax ( n = 127)P- Value Odds Ratio Patient characteristics Sex (% male) 84.4 69.3 .070 19.45 Age (y) 67 ± 10 65 ± 11 .127 1.067 Lesion characteristics Lesion size (mm) 35.4 ± 23.3 49.8 ± 30.7.003 † 0.963 Pleural distance (mm) 28.8 ± 29.4 19.9 ± 19.2.049 † 1.027 Side (% right-sided) 71.1 64.6 .987 1.010 CT lung morphology Presence of emphysema (%) 29.5 21.8 .921 1.068 Procedure-related characteristics Angle of needle tract (°) 76.2 ± 18.9 70.7 ± 23.6 .684 1.005 Patient position (% supine) 15.6 40.2 .217 0.420 Pulmonary function tests ⁎ FEV 1 (L) 1.96 ± 0.71 1.77 ± 0.73 .502 8.265 FEV 1 % 65.6 ± 21.2 62.2 ± 20.6 .771 0.971 FEV 1 /FVC ratio (%) 74.6 ± 14.9 78.3 ± 21.8 .243 0.971 ITGV (L) 4.18 ± 1.39 3.77 ± 1.19 .421 0.432 ITGV% 122.4 ± 32.5 113.8 ± 31.2 .192 1.051 FVC (L) 3.07 ± 0.92 2.67 ± 0.96 .613 0.282 FVC% 81.0 ± 21.6 73.8 ± 17.9 .599 1.052
FEV 1 , forced expiratory volume in 1 second; FEV 1 %, forced expiratory volume in 1 second, percentage of predicted value; FVC, forced vital capacity; FVC%, forced vital capacity, percentage of predicted value; ITGV, intrathoracic gas volume; ITGV%, intrathoracic gas volume, percentage of predicted value; TLB, transthoracic lung biopsy.
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Table 3
Comparison of the Frequency of Pulmonary Hemorrhage and Patient and Lesion Characteristics, Presence of Emphysema, Procedure-Related Features, and Lung Function Parameters (Multivariate Analysis)
TLB Procedures with Pulmonary Hemorrhage ( n = 17) TLB Procedures without Pulmonary Hemorrhage ( n = 155)P- Value Odds Ratio Patient characteristics Sex (% male) 70.6 73.5 .799 0.483 Age (y) 66.1 ± 9.8 65.9 ± 10.9 .326 0.925 Lesion characteristics Lesion size (mm) 31.4 ± 16.8 47.6 ± 30.2 .155 0.958 Pleural distance (mm) 18.0 ± 16.7 22.7 ± 23.1 .546 0.982 Side (% right-sided) 70.6 65.8 .144 7.100 CT lung morphology Presence of emphysema (%) 35.3 22.5.041 † 41.033 Procedure-related characteristics Angle of needle tract (°) 78.0 ± 21.9 71.5 ± 22.5 .115 1.057 Patient position (% supine) 47.1 32.3 .484 2.340 Pulmonary function tests ⁎ FEV 1 (L) 1.77 ± 0.51 1.82 ± 0.75 .436 0.005 FEV 1 % 69.1 ± 25.3 62.6 ± 20.4 .835 1.046 FEV 1 /FVC ratio (%) 83.6 ± 22.3 76.9 ± 20.2 .100 1.091 ITGV (L) 3.43 ± 1.33 3.91 ± 1.24 .793 0.564 ITGV% 109.0 ± 33.8 116.4 ± 31.5 .907 1.008 FVC (L) 2.63 ± 0.94 2.77 ± 0.97 .698 8.342 FVC% 80.6 ± 25.4 2.78 ± 0.97 .907 1.025
FEV 1 , forced expiratory volume in 1 second; FEV 1 %, forced expiratory volume in 1 second, percentage of predicted value; FVC, forced vital capacity; FVC%, forced vital capacity, percentage of predicted value; ITGV, intrathoracic gas volume; ITGV%, intrathoracic gas volume, percentage of predicted value; TLB, transthoracic lung biopsy.
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Discussion
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Conclusion
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