Percutaneous Transthoracic Lung Biopsy: Comparison Between C-Arm Cone-Beam CT and Conventional CT Guidance

Pneumothorax and pulmonary hemorrhage after C-arm cone-beam computed tomography-guided percutaneous transthoracic lung biopsy: incidence, clinical significance, and correlation

OBJECTIVE

This study aimed to assess the incidence and clinical significance of pneumothorax (PTX) and pulmonary hemorrhage (PH) after percutaneous transthoracic lung biopsy (PTLB) guided by C-arm cone-beam computed tomography (CBCT). Furthermore, this study aimed to examine the relationships between PTX and PH with demographics, clinical characteristics, imaging, and PTLB parameters.

METHODS

A retrospective analysis was conducted on 192 patients who underwent PTLB at our hospital between January 2019 and October 2022. Incidences of PTX and PH were recorded. PTX was considered clinically significant if treated with chest tube insertion (CTI), and PH if treated with bronchoscopes or endovascular treatments. The various factors on PTX and PH were analyzed using the Chi-squared test and Student t-test. Logistic regression analyses were then used to determine these factors on the correlation to develop PTX and PH.

RESULTS

PTX occurred in 67/192 cases (34.9%); CTI was required in 5/67 (7.5%). PH occurred in 63/192 cases (32.8%) and none of these cases required bronchoscopes or endovascular treatments. Lesion diameter (ORPTX = 0.822; ORPH = 0.785), presence of pulmonary emphysema (ORPH = 2.148), the number of samples (ORPH = 1.834), the use of gelfoam (ORPTX = 0.474; ORPH = 0.341) and ablation (ORPTX = 2.351; ORPH = 3.443) showed statistically significant correlation to PTX and PH.

CONCLUSIONS

CBCT-guided PTLB is a safe and effective method for performing lung biopsies. The use of gelfoam has been shown to reduce the occurrence of PTX and PH. However, caution should be exercised when combining radiofrequency ablation with PTLB, as it may increase the risk of PTX and PH.

Radiation dose of cone beam CT combined with shape sensing robotic assisted bronchoscopy for the evaluation of pulmonary lesions: an observational single center study

Background

Shape sensing robotic-assisted bronchoscopy (ssRAB) combined with radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography (CBCT) is a newer diagnostic modality for the evaluation of pulmonary lesions. There is limited data describing the radiation dose of CBCT combined with ssRAB. The purpose of this study was to describe the technical factors associated with the use of CBCT combined with ssRAB to biopsy pulmonary lesions.

Methods

We conducted a single center, prospective observational study of patients undergoing ssRAB combined with fixed CBCT for the pulmonary lesion biopsy. We report our patient demographics, and pulmonary lesion and procedure characteristics.

Results

A total of 241 ssRAB procedures were performed to biopsy 269 pulmonary lesions. The mean lesion size was measured in the following dimensions: anteroposterior (18.0±8.8 mm), transverse (17.2±10.5 mm), and craniocaudal (17.7±10.2 mm). A mean of 1.5±0.7 (median: 1, range: 1-4) CBCT spins were performed. The mean total fluoroscopy time (FT) was 5.6±2.9 minutes. The mean radiation dose of cumulative air kerma (CAK) was 63.5±46.7 mGy and the mean cumulative dose area product (DAP) was 22.6±16.0 Gy·cm2. Diagnostic yield calculated based on results at index bronchoscopy was 85.9%. There was a low rate of complications with 8 pneumothoraces (3.3%), 5 (2.1%) of which required chest tube placement.

Conclusions

We describe the use of ssRAB combined with CBCT to biopsy pulmonary lesions as a safe diagnostic modality with relatively low radiation dose that is potentially comparable to other image guided sampling modalities. Bronchoscopists should be cognizant of the radiation use during the procedure for both patient and staff safety.

C-Arm Cone-Beam CT Virtual Navigation versus Conventional CT Guidance in the Transthoracic Lung Biopsy: A Case-Control Study

C-arm cone-beam computed tomography (CBCT) virtual navigation-guided lung biopsy has been developed in the last decade as an alternative to conventional CT-guided lung biopsy. This study aims to compare the biopsy accuracy and safety between these two techniques and explores the risk factors of biopsy-related complications. A total of 217 consecutive patients undergoing conventional CT- or C-arm CBCT virtual navigation-guided lung biopsy from 1 June 2018 to 31 December 2019 in this single-center were retrospectively reviewed. Multiple factors (e.g., prior emphysema, lesion size, etc.) were compared between two biopsy techniques. The risk factors of complications were explored by using logistic regression. The patients’ median age and male-to-female ratio were 63 years and 2.1:1, respectively. Eighty-two (82) patients (37.8%) underwent conventional CT-guided biopsies, and the other 135 patients (62.2%) C-arm CBCT virtual navigation-guided biopsies. Compared with patients undergoing C-arm CBCT virtual navigation-guided lung biopsies, patients undergoing conventional CT-guided lung biopsies showed higher needle repositioning rate, longer operation time, and higher effective dose of X-ray (52.4% vs. 6.7%, 25 min vs. 15 min, and 13.4 mSv vs. 7.6 mSv, respectively; p < 0.001, each). In total, the accurate biopsy was achieved in 215 of 217 patients (99.1%), without a significant difference between the two biopsy techniques (p = 1.000). The overall complication rates, including pneumothorax and pulmonary hemorrhage/hemoptysis, are 26.3% (57/217), with most minor complications (56/57, 98.2%). The needle repositioning was the only independent risk factor of complications with an odds ratio of 6.169 (p < 0.001). In conclusion, the C-arm CBCT virtual navigation is better in percutaneous lung biopsy than conventional CT guidance, facilitating needle positioning and reducing radiation exposure. Needle repositioning should be avoided because it brings about more biopsy-related complications.

Cone-beam computed tomography versus computed tomography-guided ultrathin bronchoscopic diagnosis for peripheral pulmonary lesions: A propensity score-matched analysis

BACKGROUND AND OBJECTIVE

CBCT-guided TBB using a UTB under VBN is a useful method for the diagnosis of peripheral small pulmonary lesions. CBCT-guided TBB using UTB under VBN has been used as an alternative to CT-guided TBB. However, the advantage of CBCT-guided TBB using UTB under VBN over CT-guided TBB is still unknown. This study aimed to compare the diagnostic yield of CT-guided TBB and CBCT-guided TBB using a propensity score-matched analysis.

METHODS

Patients with peripheral pulmonary lesions ≤30 mm were included. Lesions whose bronchus could not be determined by CT were excluded. A UTB and biopsy forceps were advanced to the target bronchus under VBN, 2D-fluoroscopy and CT or CBCT. The CT-guided and CBCT-guided groups were matched for their propensity scores based on patient characteristics.

RESULTS

We retrospectively reviewed 93 patients in the CT-guided group and 79 patients in the CBCT-guided group for this study. Furthermore, 48 distinct examination pairs were generated by propensity score matching. In the overall diagnostic yield, the CBCT-guided group showed better results (72.9%) than did the CT-guided group (47.9%) (P = 0.012). The median examination time lasted for 43 (IQR: 37-51) min in the CBCT-guided group and 50 (IQR: 43-62) min in the CT-guided group. The examination time in the CBCT-guided group was significantly shorter than that of the CT-guided group (P = 0.001).

CONCLUSION

CBCT-guided TBB had a better diagnostic yield and shorter examination time than did CT-guided TBB.

The Diagnostic Value of CT-guided Percutaneous Co-axial Trans-thoracic Biopsy (PCTTB) and Evaluation of the Pathologic Examination

BACKGROUND

We investigated thoracic masses with Computed Tomography (CT)- guided Percutaneous Co-Axial Trans-Thoracic Biopsy (PCTTB).

METHODS

The retrospective data of 86 patients to whom CT-guided PCTTB had been applied were obtained. Eighty-four cases and their pathologic results were included in the study. Localization and appearance of the lesions, pathologic results, and complications were evaluated.

RESULTS

Diagnostic sensitivity of CT-guided PCTTB was 97.6%. In 60.7% of the cases, malign lesions and, in 39.3% of the cases, benign lesions were diagnosed. The mass size was on average greater than 2 cm, and one mass was detected as being more than ≥2 masses. Mainly, irregular contours were observed. Most of the malign tumors were primary malign tumors on both sides (91.7% on the right side and 88.9% on the left side). Squamous Cell Carcinoma (SCC) was the most often detected malign tumor on the right side, and adenocarcinoma was the most often detected malign tumor on the left side. In masses localized on the left inferior lobe, metastasis was often detected. When the number of the mass was ≥2 and the mass had the appearance of consolidation, metastasis was usually detected. Small and large masses were mainly localized on right and left upper lobes. In the small mass group, 75.0% of the cases were benign, and, in the large mass group, 64.5% of the cases were malign (p=0.031, χ2=4.666). Pneumothorax was the most commonly occurring complication (23.8%). In masses localized on the right lower lobe, the pneumothorax ratio increased in benign masses compared to malign masses. The hemorrhage detection rate was 13.0%, and hemoptysis occurred in 14.2% of the cases. Hemorrhage was detected during 11.8% of the large mass biopsies. In females, hemorrhage occurred more often than in males (p=0.026, r= 0.244).

CONCLUSION

CT-guided PCTTB is a safe method to utilize for lung biopsies. Co-axial method increased the diagnostic accuracy of CT-guided percutaneous trans-thoracic biopsies. A single cut also decreased the complication rates.

Ultrasound- Versus CT-Guided Subpleural Lung and Pleural Biopsy: An Analysis of Wait Times, Procedure Time, Safety, and Diagnostic Adequacy

PURPOSE

To compare the wait times, safety, and diagnostic adequacy of computed tomography (CT)-guided percutaneous lung biopsies with ultrasound (US) guidance for subpleural lung and pleural lesions.

METHODS

Consecutive CT- and US-guided biopsies performed at our institution between January 2018 and January 2019 were retrospectively reviewed. Biopsy wait times, lesion size, degree of pleural contact, procedure duration, number of needle passes, complications, and pathologic diagnosis were recorded and compared.

RESULTS

A total of 158 biopsies of subpleural or pleural-based lesions were reviewed. Forty-three cases utilized US guidance, while 115 cases used CT, 41 with conventional CT (CCT), and 74 with cone-beam CT guidance (CBCT). Overall, the mean lesion maximum axial diameter and length of pleural contact for US-guided biopsies was greater than for CT (4.8 ± 2.6 cm vs 3.2 ± 1.9 cm and 4.0 ± 2.5 cm vs 2.6 ± 1.7 cm, respectively, P < .001). Wait times for US-guided biopsies were significantly shorter than CCT by 10.9 days on average while being equivalent to CBCT. Procedure time was shorter for lesions localized with US than CT (29.5 ± 16.4 minutes vs 37.6 ± 19.5 minutes, P = .007) despite CT using less needle passes per lesion (3.5 ± 1.1 vs 3.1 ± 0.8, P = .034). Sample adequacy was equivalent for both modalities (88% for US and 92% for CT). The frequency of pneumothoraces was similar between US (12%) and CT (15%).

CONCLUSION

Ultrasound and CT guidance have similar safety and diagnostic adequacy for subpleural lung and pleural biopsies. Ultrasound guidance has shorter wait and procedure times.

Virtual Guidance of Percutaneous Transthoracic Needle Biopsy with C-Arm Cone-Beam CT: Diagnostic Accuracy, Risk Factors and Effective Radiation Dose

PURPOSE

C-arm cone-beam computed tomography-guided transthoracic lung core needle biopsy (CBCT-CNB) is a safe and accurate procedure for the evaluation of patients with pulmonary nodules. The purpose of our study was to evaluate the diagnostic performance, complication rates and effective radiation dose of CBCT-CNB with virtual guidance.

MATERIALS AND METHODS

We retrospectively collected data regarding 375 CBCT-CNBs performed with virtual guidance (XperGuide-Philips Healthcare, Best, The Netherlands) from January 2010 to June 2015 on 355 patients (mean age, 68.1 years ± 11.8; age range, 31-88 years). Patients were divided into groups and compared based on the diagnostic failure and lesion size (15 mm cutoff). Diagnostic performance, complication rate and effective radiation dose were investigated. Variables influencing diagnostic performance and complications were assessed using Student's T test and Pearson's χ² test.

RESULTS

The sensitivity, specificity, positive and negative predictive value and accuracy for patients subjected to CNBs were 96.8%, 100%, 100%, 100% and 97.2%, respectively. Considering risk factors for pneumothorax, no significant differences were found regarding patient and lesion characteristics. Perilesional hemorrhage occurred more frequently in older patients (p = 0.046) and in smaller lesions (p = 0.001). Hemoptysis was significantly more frequent in patients with perilesional hemorrhage (p = 0.01). Mean effective radiation dose in CBCT-CNB was 7.12 ± 8.78 mSv.

CONCLUSIONS

CBCT-CNB combined with virtual guidance is a reliable and accurate technique that allows exact localization of pulmonary lesions, effective preprocedural planning and real-time fluoroscopy altogether.

Chinese multidisciplinary expert consensus: Guidelines on percutaneous transthoracic needle biopsy

Biopsy has been used to diagnose thoracic diseases for more than a century. Percutaneous needle biopsy plays a crucial role in the diagnosis, staging, and treatment planning for tumors in the lungs, thoracic wall, hilum, and mediastinum. With the continuous improvement in imaging techniques, the range of clinical applications for percutaneous needle biopsy is also expanding. It has become important to improve Chinese professionals’ and technicians’ understanding of percutaneous transthoracic needle biopsy (PTNB) in order to standardize operating procedures and to strengthen perioperative management. However, there is currently no Chinese expert consensus that provides systematic standardization and guidance for PTNB in clinical practice. The Committee of Chinese Society of Interventional Oncology (CSIO) of the Chinese Anti‐Cancer Association (CACA) initiated a Chinese multidisciplinary expert consensus on PTNB. The consensus includes image‐guided methods, indications, contraindications, multidisciplinary team recommendations, biopsy procedures, daytime/outpatient biopsy, complications, pathological examination, and management of negative results.

Comparison of Conventional and Cone-Beam CT for Monitoring and Assessing Pulmonary Microwave Ablation in a Porcine Model

PURPOSE

To compare cone-beam computed tomography (CT) with conventional CT for assessing the growth and postprocedural appearance of pulmonary microwave ablation zones.

MATERIALS AND METHODS

A total of 17 microwave ablations were performed in porcine lung in vivo by applying 65 W for 5 minutes through a single 17-gauge antenna. Either CT (n = 8) or CBCT (n = 9) was used for guidance and ablation zone monitoring at 1-minute intervals. Postprocedural noncontrast images were acquired with both modalities. Three independent readers measured the length, width, cross-sectional area, and circularity of the ablation zones on gross tissue samples and CT and cone-beam CT images. The measurements were compared via linear mixed-effects models for postprocedural appearance and with a polynomial mixed effects model for ablation zone growth curves.

RESULTS

On postprocedural images, the differences between cone-beam CT and CT in mean length (3.84 vs 3.86 cm; Δ = -0.02; P = .70), width (2.61 vs 2.56 cm; Δ = 0.06; P = .46), area (7.84 vs 7.65 cm²; Δ = 0.19; P = .35), and circularity (0.85 vs 0.85; Δ = 0.01; P = .62) were not statistically significant after accounting for intersubject and interrater variability. Also, there was no significant difference between CT and cone-beam CT growth curves of the ablation zones during monitoring in terms of length (p_Int. = 1.00; p_Lin.Slope = 0.52; p_Quad.Slope = 0.69); width (p_Int. = 0.83; p_Lin.Slope = 0.98; p_Quad.Slope = 0.79), area (p_Int. = 0.47; p_Lin.Slope = 0.27; p_Quad.Slope = 0.57), or circularity (p_Int. = 0.54; p_Lin.Slope = 0.74; p_Quad.Slope = 0.80). Both CT and cone-beam CT overestimated gross pathologic observations of ablation length, width, and area (P < .001 for all).

CONCLUSIONS

Cone-beam CT was similar to conventional CT when assessing the growth, final size, and shape of pulmonary microwave ablation zones and may be useful for monitoring and evaluating microwave ablations in the lung.

Open Bronchus Sign on CT: A Risk Factor for Hemoptysis after Percutaneous Transthoracic Biopsy

Objective

We hypothesized that open bronchi within target pulmonary lesions are associated with percutaneous transthoracic needle biopsy (PTNB)-related hemoptysis. We sought to analyze and compare patient characteristics and target features as well as biopsy-related factors between patients with and without PTNB-related hemoptysis.

Materials and Methods

We retrospectively analyzed 1484 patients (870 males and 614 females; median age, 66 years) who had undergone 1569 cone-beam CT (CBCT)-guided PTNBs. Patient characteristics (sex, age, and pathologic diagnosis), nodule features (nodule type, size, location, and presence of an open bronchus in target nodules), and biopsy-related factors (biopsy needle size, pleura-to-target distance, blood test results, open bronchus unavoidability [OBU] index, etc.) were investigated. OBU index, which was assessed using the pre-procedural CBCT, was a subjective scoring system for the probability of needle penetration into the open bronchus. Univariate analysis and subsequent multivariate logistic regression analysis were conducted to reveal the independent risk factors for PTNB-related hemoptysis. For a subgroup of nodules with open bronchi, a trend analysis between the occurrence of hemoptysis and the OBU index was performed.

Results

The independent risk factors for hemoptysis were sex (female; odds ratio [OR], 1.918; p < 0.001), nodule size (OR, 0.837; p < 0.001), open bronchus (OR, 2.101; p < 0.001), and pleura-to-target distance (OR, 1.135; p = 0.003). For the target nodules with open bronchi, a significant trend between hemoptysis and OBU index (p < 0.001) was observed.

Conclusion

An open bronchus in a biopsy target is an independent predictor of hemoptysis, and careful imaging review may potentially reduce PTNB-related hemoptysis.

Risk factors for haemoptysis after percutaneous transthoracic needle biopsies in 4,172 cases: Focusing on the effects of enlarged main pulmonary artery diameter

OBJECTIVES

To evaluate the risk factors for haemoptysis after cone-beam computed tomography (CBCT)-guided percutaneous transthoracic needle biopsy (PTNB), particularly on whether the enlargement of main pulmonary artery diameter (mPAD) is a risk factor for PTNB-related haemoptysis.

METHODS

4,172 cases of CBCT-guided PTNBs in 3,840 patients were retrospectively included in this study. Various data including mPAD measured on preprocedural CT images were evaluated using logistic regression analyses to determine significant risk factors for both haemoptysis and severe haemoptysis, designated as when blood transfusion, vascular embolisation or cardiopulmonary resuscitation were required to manage patients with haemoptysis.

RESULTS

Haemoptysis occurred in 5.78 % (241/4172) of all PTNB procedures, while severe haemoptysis occurred in 0.18 % (7/4172). Female sex, history of antiplatelet or anticoagulative drugs, prolonged activated partial thromboplastin time, subsolid nodules, cavitary nodules and long pleura-to-target distance were revealed to be independent risk factors for haemoptysis, while mPAD enlargement (> 29.5 mm) was not. Regarding severe haemoptysis, however, mPAD enlargement was demonstrated to be an independent risk factor along with the presence of subsolid and cavitary target nodules.

CONCLUSION

mPAD enlargement was not a significant risk factor for PTNB-related haemoptysis; however, it was a significant risk factor for severe haemoptysis.

KEY POINTS

• mPAD enlargement was a significant risk factor for severe PTNB-related haemoptysis. • mPAD can be useful in screening high-risk patients for severe haemoptysis. • Subsolid or cavitary nodule was another significant risk factor for severe haemoptysis.

A Systematic Review and Meta-Analysis of C-Arm Cone-Beam CT-Guided Percutaneous Transthoracic Needle Biopsy of Lung Nodules

Background

A systematic review and meta-analysis of all available publications was performed to evaluate the diagnostic accuracy of percutaneous transthoracic needle biopsy (PTNB) using a C-Arm Cone-Beam CT (CBCT) system in patients with lung nodules.

Material/Methods

Thedatabases of PUBMED, OVID, EBSCO, EMBASE, and China National Knowledge Infrastructure (CNKI) were systematically searched for relevant original articles on the diagnostic accuracy of CBCT-guided PTNB for the diagnosis of nodules in the lungs. Diagnostic indices including sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and diagnostic score (DS) were calculated. Moreover,summary receiver operating characteristic curves (SROC) were constructed with Stata (version 13.0), Rev Man (version 5.3), and Meta-disc (version 1.4) software. Other clinical indices such as incidence of complications were also recorded.

Results

Eight studies met the inclusion and exclusion criteria for the meta-analysis. The pooled sensitivity, specificity, PLR, NLR, DOR, DS, and SROC with 95% confidence intervals were 0.96 (0.93–0.98), 1.00 (0.91–1.00), 711.15 (9.48–53325.89), 0.04 (0.02–0.07), 16585.29 (284.88–9.7e+05), 9.72 (5.65–13.78), and 0.99 (0.97–0.99), respectively. The incidence of pneumothorax and hemorrhage was 10–29.27% and 1.22–47.25%, respectively.

Conclusions

CBCT-guided PTNB has an acceptable rate of complications and is associated with a reasonable radiation exposure. Moreover, it is a highly accurate and safe technique for the diagnosis of lung nodules and can be recommended to be used in routine clinical practice.

Our transthoracic biopsy practices accompanied by the imaging process: The contribution of positron emission tomography usage to accurate diagnosis

OBJECTIVES

The objective of this study was to compare the results of transthoracic biopsies performed through the use of FDG PET/CT imaging with the results of transthoracic needle biopsy performed without using the FDG PET/CT imaging.

METHODS

The medical files of a total of 58 patients with pulmonary and mediastinal masses. A total of 20 patients, who were suspected of malignancy with the SUVmax value of over 2.5 in FDG PET/CT, underwent a biopsy process. Twelve patients with no suspicion of malignancy in accordance with CT images and with the SUVmax value below 2.5 underwent no biopsy procedure, and hence, they were excluded from the study. On the other hand, 26 patients directly went through a biopsy process with the suspicion of malignancy according to CT imaging, regardless of performing any FDG PET/CT imaging.

RESULTS

According to the biopsy results, the number of the patients diagnosed with cancer was 20 (43.5%), while the number of non-cancerous patients was 26 (56.5%). When these findings were considered, it was determined that the sensitivity of the whole TTNB (transthoracic needle biopsy) was 80.8%, and the specificity was found as 100%. The positive predictive value of the whole TTNB was 100%, while its negative predictive value was found to be 80%. The sensitivity in TTNB performed together with FDG PET/CT was 90.9%, whereas the specificity was 100%. The positive predictive value of TTNB with FDG PET/CT was 100%, while its negative predictive value was found to be 81.8%. The sensitivity in TTNB performed without the use of FDG PET/CT was 73.3%, whereas the specificity was determined as 100%.

CONCLUSIONS

Performing FDG PET/CT imaging process prior to a transthoracic biopsy as well as preferring FDG PET/CT for the spot on which the biopsy will be performed during the transthoracic biopsy procedure increases the rate of receiving accurate diagnosis.