Dependent lesion positioning at CT-guided lung biopsy to reduce risk of pneumothorax

Is it a complication or a consequence - a new perspective on adverse outcomes in Interventional Radiology

The aim of the article is to introduce a new term in post-procedural events related to the procedure itself. All the Societies and Councils report these events as complications and they are divided in mild, moderate and severe or immediate and delayed.On the other hand the term error is known as the application of a wrong plan, or strategy to achieve a goal.For the first time, we are trying to introduce the term "consequence"; assuming that the procedure is the only available and the best fit to clinical indication, a consequence should be seen as an expected and unavoidable occurrence of an "adverse event" despite correct technical execution.

The effectiveness of the puncture channel plugging for reduction of complications after CT-guided percutaneous transthoracic needle biopsy

The effect of plugging the puncture channel with a mixture of hemocoagulase injection on the complications of CT-guided percutaneous transthoracic need biopsy (PTNB) was discussed. The medical records of PTNB were retrospectively studied from June 2017 to May 2022. In the study, the puncture channel of 626 patients were blocked, while remain 681 patients' were not. The Mantel Haenszel method performed layered analysis and evaluated the correlation of adjusted confounding factors. The Odds Ratio and its 95% confidence interval were calculated using the Woof method. The incidence of high-level pulmonary hemorrhage was significantly reduced in patients with lesions ≤ 2 cm and different needle lengths. Patients with different pleural-needle tip angle and perineedle emphysema were blocked, and the incidence of pneumothorax and thoracic implants was significantly reduced. Through puncture channel plugging, the incidence of pulmonary hemorrhage, pneumothorax and thoracic catheterization of PTNB under CT guidance was reduced.

Current investigative modalities for detecting and staging lung cancers: a comprehensive summary

This narrative review compares the advantages and drawbacks of imaging and other investigation modalities which currently assist with lung cancer diagnosis and staging, as well as those which are not routinely indicated for this. We examine plain film radiography, computed tomography (CT) (alone, as well as in conjunction with positron emission tomography (PET)), magnetic resonance imaging (MRI), ultrasound, and newer techniques such as image-guided bronchoscopy (IGB) and robotic bronchoscopy (RB). While a chest X-ray is the first-line imaging investigation in patients presenting with symptoms suggestive of lung cancer, it has a high positive predictive value (PPV) even after negative X-ray findings, which calls into question its value as part of a potential national screening programme. CT lowers the mortality for high-risk patients when compared to X-ray and certain scoring systems, such as the Brock model can guide the need for further imaging, like PET-CT, which has high sensitivity and specificity for diagnosing solitary pulmonary nodules as malignant, as well as for assessing small cell lung cancer spread. In practice, PET-CT is offered to everyone whose lung cancer is to be treated with a curative intent. In contrast, MRI is only recommended for isolated distant metastases. Similarly, ultrasound imaging is not used for diagnosis of lung cancer but can be useful when there is suspicion of intrathoracic lymph node involvement. Ultrasound imaging in the form of endobronchial ultrasonography (EBUS) is often used to aid tissue sampling, yet the diagnostic value of this technique varies widely between studies. RB is another novel technique that offers an alternative way to biopsy lesions, but further research on it is necessary. Lastly, thoracic surgical biopsies, particularly minimally invasive video-assisted techniques, have been used increasingly to aid in diagnosis and staging.

Biopsy-tract haemocoagulase injection reduces major complications after CT-guided percutaneous transthoracic lung biopsy

AIM

To determine whether the injection of haemocoagulase into the biopsy tract can reduce pneumothorax and pulmonary haemorrhage after computed tomography (CT)-guided percutaneous transthoracic lung biopsy (PTLB).

MATERIALS AND METHODS

A retrospective study was performed involving patients with undiagnosed pulmonary lesions scheduled for PTLB between January 2020 and March 2021. Patients were assigned to the haemocoagulase group or the non-haemocoagulase group. After CT-guided biopsies were performed with a 17 G coaxial system, patients in the haemocoagulase group received a haemocoagulase injection (0.2-0.5 units) in the biopsy tract as the sheath was withdrawn. Postoperative image studies were performed to evaluate complications, including pneumothorax and pulmonary haemorrhage. Factors, including the patient's position, lesion location, and pathological results, were evaluated to determine their associations with the complications.

RESULTS

A total of 100 patients were included, with 44 men and a mean age of 53 years old. The overall incidences of pneumothorax and pulmonary haemorrhage were 15% and 13%, respectively. The incidences of pneumothorax and pulmonary haemorrhage were statistically significantly lower in the haemocoagulase group (8% and 6%, respectively) than in the non-haemocoagulase group (22% and 20%, respectively; p=0.04 and 0.03, respectively). There was no statistically significant difference in haemoptysis between the haemocoagulase (6%) and non-haemocoagulase (2%) groups (p=0.23). There were also no statistically significant associations of pneumothorax or pulmonary haemorrhage with the patients' positions, lesion location, or pathological results.

CONCLUSION

Biopsy tract haemocoagulase injection reduced the incidences of postoperative pneumothorax and pulmonary haemorrhage after PTLB.

Abnormal Pulmonary Function Testing as an Independent Risk Factor for Procedural Complications During Transthoracic Needle Biopsies

BACKGROUND

Computed tomography (CT)-guided transthoracic needle biopsy is an important diagnostic tool for pulmonary nodules, offering a less invasive alternative to surgical procedures. This study aims to better risk stratify patients undergoing this procedure by analyzing the pulmonary function testing (PFT), imaging characteristics, and patient demographics most associated with complications.

PATIENTS AND METHODS

This retrospective study involved 254 patients undergoing transthoracic needle biopsies at 3 hospitals between October 2016 and December 2019. Demographic data, extent of emphysema, and target lesion characteristics were recorded. Complications were defined as minor (small pneumothorax, mild hemoptysis, or pulmonary hemorrhage) and major (pneumothorax requiring chest tube, hemothorax, rapid atrial fibrillation, or postprocedure hypotension or hypoxia).

RESULTS

There were 50 minor (20%) and 18 major complications (7%). As seen with prior studies, older age, increased distance to pleura, and smaller nodule size correlated with an increased risk of complications. Uniquely to our study, emphysema severity, seen on CT (P=0.008) and with decreased forced expiratory volume/forced vital capacity ratio, conferred an increased risk (62.94 vs. 68.74, P=0.05) of complications. Decreased Hounsfield unit of surrounding lung (a surrogate measure of emphysema) and decreased diffusion capacity (11.81 vs. 14.93, P=0.05) were associated with increased risk of major complications. Interestingly, body mass index and comorbidities had no correlation with complications.

CONCLUSION

In addition to previous well-described characteristics, we described physiological data (abnormal PFTs), imaging findings, and nodule location as risk factors of procedural complications. Obtaining preprocedural PFT, in addition to reviewing CT imaging and demographic data, may aid clinicians in better risk stratifying patients undergoing transthoracic needle biopsies.

Lung, Pleural, and Mediastinal Biopsies: From Preprocedural Assessment to Technique and Management of Complications

Biopsies of the lung, pleura, and mediastinum play a crucial role in the workup of thoracic lesions. Percutaneous image-guided biopsy of thoracic lesions is a relatively safe and noninvasive way to obtain a pathologic diagnosis which is required to direct patient management. This article reviews how to safely perform image-guided biopsies of the lung, pleura, and mediastinum, from the preprocedural assessment to reviewing intraprocedural techniques, and how to avoid and manage complications.

Comparison of CT-Guided Core Needle Biopsy in Pulmonary Ground-Glass and Solid Nodules Based on Propensity Score Matching Analysis

Purpose: To compare the diagnostic accuracy and safety of computed tomography (CT)-guided core needle biopsy (CNB) between pulmonary ground-glass and solid nodules using propensity score matching (PSM) method and determine the relevant risk factors. Methods: This was a single-center retrospective cohort study using data from 665 patients who underwent CT-guided CNB of pulmonary nodules in our hospital between May 2019 and May 2021, including 39 ground-glass nodules (GGNs) and 626 solid nodules. We used a 1:4 PSM analysis to compared the diagnostic yields and complications rates of CT-guided CNB between 2 groups. Results: After PSM, 170 cases involved in the comparison (34 GGNs vs 136 solid nodules) were randomly matched (1:4) by patient demographics, clinical history, lesion characteristics, and procedure-related factors. There was no statistically significant difference in the diagnostic yields and complications rates between 2 groups. Significant pneumothorax incidence increase was noted at small lesion size, deep lesion location, and traversing interlobar fissure (P < .05). Post-biopsy hemorrhage was a protective factor for pneumothorax (P < .05). The size/proportion of consolidation of GGN did not influence the diagnostic accuracy and complication incidence (P > .05). Conclusions: The accuracy and safety of CT-guided CNB were comparable for ground-glass and solid nodules and the size/proportion of consolidation of GGN may be not a relevant risk factor. The biopsy should avoid traversing interlobar fissure as far as possible. Smaller lesion size and deeper lesion location may lead to higher pneumothorax rate and post-biopsy hemorrhage may be a protective factor for pneumothorax.

Reducing Time and Patient Radiation of Computed Tomography-guided Thoracic Needle Biopsies With Single-rotation Axial Acquisitions: An Alternative to "CT Fluoroscopy"

PURPOSE

To investigate the effect on procedure time and patient radiation indices of replacing helical acquisitions for needle guidance during thoracic needle biopsy (TNB) with intermittent single-rotation axial acquisitions.

MATERIALS AND METHODS

This retrospective intervention study included 215 consecutive TNBs performed by a single operator from 2014 to 2018. Characteristics of patients, lesions, and procedures were compared between TNBs guided only by helical acquisitions initiated in the control room (helical group, n=141) and TNBs guided in part by intermittent single-rotation axial computed tomography controlled by foot pedal (single-rotation group, n=74). Procedure time and patient radiation indices were primary outcomes, complications, and radiologist radiation dose were secondary outcomes.

RESULTS

Patient, lesion, and procedural characteristics did not differ between helical and single-rotation groups. Use of single-rotation axial acquisitions decreased procedure time by 10.5 minutes (95% confidence interval [CI]: 8.2-12.8 min) or 27% (95% CI: 22%-32%; P<0.001). Patient dose in cumulative volume computed tomography dose index decreased by 23% (95% CI: 12%-33%) or 8 mGy (95% CI: 4.3-31.6 mGy; P=0.01). Dose-length product decreased by 50% (95% CI: 40%-60%) or 270 mGy cm (95% CI: 195-345 mGy cm; P<0.001). No operator radiation exposure was detected. Rate of diagnostic result, pneumothorax, hemoptysis, and hemorrhage did not differ between groups.

CONCLUSIONS

Replacing helical acquisitions with intermittent single-rotation axial acquisitions significantly decreases TNB procedure time and patient radiation indices without adversely affecting diagnostic rate, procedural complications, or operator radiation dose.

Safely Shortening the Observation Time After CT-Guided Lung Procedures

OBJECTIVE

To determine safety of shortened observation time without follow-up chest x-ray (CXR) after CT-guided transthoracic procedures (lung biopsy or fiducial placement) in patients without immediate postprocedural pneumothorax (PTX).

METHODS

Consecutive patients that underwent CT-guided procedures between January 5, 2015, and June 19, 2017, were included in this retrospective institutional review board-approved HIPAA-compliant study. Data regarding postprocedural course, complications, and clinical follow-up of the patients were obtained through a review of electronic medical records. Descriptive statistics were used.

RESULTS

There were 441 procedures for 409 patients performed; 82 procedures were excluded because of predefined criteria. In 312 of 336 asymptomatic procedures (92.9%), asymptomatic patients did not undergo CXR after procedure, with 7 of 312 of these patients (2.2%) diagnosed with delayed PTX 2 to 10 days after the procedure. In 24 of 336 procedures (7.1%), asymptomatic patients underwent CXR within 4 hours with no PTX detected, and despite that 1 of 24 of these patients (4.2%) presented with delayed PTX 7 days after procedure. When no immediate postprocedural PTX was present, rate of observation PTX and delayed PTX was 1 of 359 (0.3%) and 8 of 359 (2.2%), respectively. Average duration of monitoring for outpatients (n = 295) was 2.0 hours with median of 1.8 hours. In 23 of 359 (6.4%) procedures, the patient became symptomatic during postprocedural observation with 1 of 23 (4%) developing PTX.

CONCLUSIONS

Obtaining routine postprocedural CXRs in asymptomatic patients without immediate postprocedural PTX after CT-guided transthoracic procedures is likely not necessary given the low likelihood of PTX.

Pneumothorax Induced by Computed Tomography Guided Transthoracic Needle Biopsy: A Review for the Clinician

Percutaneous computed tomography (CT)-guided transthoracic needle biopsy (TTNB) is a valuable procedure for obtaining tissue or cells for diagnosis, which is especially indispensable in thoracic oncology. Pneumothorax and hemoptysis are the most common complications of percutaneous needle biopsy of the lung. According to reports published over the past decades, pneumothorax incidence in patients who underwent TTNB greatly varies. The morbidity of pneumothorax after CT-guided TTNB depends on several factors, including size and depth of lesions, emphysema, the number of pleural surfaces and fissure crossed, etc. Attention to biopsy planning and technique and post-biopsy precautions help to prevent or minimize potential complications. Many measures can be taken to help prevent the progression of a pneumothorax, which in turn might reduce the number of pneumothoraces requiring chest tube placement. A multitude of therapeutic options is available for the treatment of pneumothorax, varying from observation and oxygen treatment, simple manual aspiration, to chest tube placement. When a pneumothorax develops during the biopsy procedure, it can be manually aspirated after the needle is retracted back into the pleural space or by inserting a separate needle into the pleural space. Biopsy side down positioning of the patient after biopsy significantly reduces the incidence of pneumothorax and the requirement of chest tube placement. Aspiration in biopsy side down position is also recommended for treating pneumothorax when simple manual aspiration is unsuccessful or delayed pneumothorax occurred. Chest tube placement is an important treatment strategy for patients with a large or symptomatic pneumothorax. Clinicians are encouraged to understand the development, prevention, and treatment of pneumothorax. Efforts should be made to reduce the incidence of pneumothorax in biopsy planning and post-biopsy precautions. When pneumothorax occurs, appropriate treatment should be adopted to reduce the risk of worsening pneumothorax.