Logistic regression analysis and a risk prediction model of pneumothorax after CT-guided needle biopsy

Development of a machine learning model for predicting pneumothorax risk in coaxial core needle biopsy (≤3 cm)

PURPOSE

The aim is to devise a machine learning algorithm exploiting preoperative clinical data to forecast the hazard of pneumothorax post-coaxial needle lung biopsy (CCNB), thereby informing clinical decision-making and enhancing perioperative care.

METHOD

This retrospective analysis aggregated clinical and imaging data from patients with lung nodules (≤3 cm) biopsies. Variable selection was done using univariate analysis and LASSO regression, with the dataset subsequently divided into training (80 %) and validation (20 %) subsets. Various machine learning (ML) classifiers were employed in a consolidated approach to ascertain the paramount model, which was followed by individualized risk profiling showcased through Shapley Additive eXplanations (SHAP).

RESULTS

Out of the 325 patients included in the study, 19.6% (64/325) experienced postoperative pneumothorax. High-risk factors determined were Cancer, Lesion_type, GOLD, Size, and Depth. The Gaussian Naive Bayes (GNB) classifier demonstrated superior prediction with an Area Under the Curve (AUC) of 0.82 (95% CI 0.71-0.94), complemented by an accuracy rate of 0.8, sensitivity of 0.71, specificity of 0.84, and an F1 score of 0.61 in the test cohort.

CONCLUSION

The formulated prognostic algorithm exhibited commendable efficacy in preoperatively prognosticating CCNB-induced pneumothorax, harboring the potential to refine personalized risk appraisals, steer clinical judgment, and ameliorate perioperative patient stewardship.

Intravenous Opioid Medication with Piritramide Reduces the Risk of Pneumothorax During CT-Guided Percutaneous Core Biopsy of the Lung

PURPOSE

CT-guided percutaneous core biopsy of the lung is usually performed under local anesthesia, but can also be conducted under additional systemic opioid medication. The purpose of this retrospective study was to assess the effect of intravenous piritramide application on the pneumothorax rate and to identify risk factors for post-biopsy pneumothorax.

MATERIALS AND METHODS

One hundred and seventy-one core biopsies of the lung were included in this retrospective single center study. The incidence of pneumothorax and chest tube placement was evaluated. Patient-, procedure- and target-related variables were analyzed by univariate and multivariable logistic regression analysis.

RESULTS

The overall incidence of pneumothorax was 39.2% (67/171). The pneumothorax rate was 31.5% (29/92) in patients who received intravenous piritramide and 48.1% (38/79) in patients who did not receive piritramide. In multivariable logistic regression analysis periinterventional piritramide application proved to be the only independent factor to reduce the risk of pneumothorax (odds ratio 0.46, 95%-confidence interval 0.24, 0.88; p = 0.018). Two or more pleura passages (odds ratio 3.38, 95%-confidence interval: 1.15, 9.87; p = 0.026) and prone position of the patient (odds ratio 2.27, 95%-confidence interval: 1.04, 4.94; p = 0.039) were independent risk factors for a higher pneumothorax rate.

CONCLUSION

Procedural opioid medication with piritramide proved to be a previously undisclosed factor decreasing the risk of pneumothorax associated with CT-guided percutaneous core biopsy of the lung. LEVEL OF EVIDENCE 4: small study cohort.

[Analysis of Influencing Factors of Complications for CT-guided Percutaneous Lung Biopsy]

BACKGROUND

Computed tomography guided percutaneous lung biopsy (CT-PLB) is a widely used method for the diagnosis of lung lesions. However, it is invasive, and the most common complications are pneumothorax and pulmonary hemorrhage, which can be life-threatening in severe cases. Therefore, the aim of this study is to analyze the independent risk factors affecting the occurrence of different complications of CT-PLB, so as to reduce the incidence of complications.

METHODS

The 605 patients with complete clinical data who underwent CT-PLB in our hospital from May 2018 to December 2019 were retrospectively analyzed. According to the location of the lesions, they were divided into subpleural group and non-subpleural group. The patients were divided into pneumothorax group, pulmonary hemorrhage group, pneumothorax with pulmonary hemorrhage group and non-pneumothorax/pulmonary hemorrhage group according to the complications. The risk factors affecting the incidence of different complications and the independent risk factors of each complication were analyzed.

RESULTS

The incidence of pneumothorax was 34.1%, the incidence of pulmonary hemorrhage was 28.1%, and the incidence of pneumothorax complicated with pulmonary hemorrhage was 10.8% (63 cases). The independent risk factor affecting the incidence of subpleural pneumothorax was lesion size (P=0.002). The independent risk factors affecting the occurrence of pneumothorax in the non-subpleural group were plain scan CT value (P=0.035), length of needle through lung tissue (P=0.003), and thickness of needle through chest wall (P=0.020). Independent risk factors affecting the occurrence of pulmonary hemorrhage in the non-subpleural group were length of needle through lung tissue (P<0.001), △CT value of needle travel area (P=0.001), lesion size (P=0.034) and body position (P=0.014). The independent risk factors affecting the co-occurrence of pneumothorax and pulmonary hemorrhage were the length of needle through lung tissue (P<0.001) and the △CT value of needle travel area (P<0.001).

CONCLUSIONS

CT-PLB is a safe and effective diagnostic method, which of high diagnostic value for lung lesions. Selecting the appropriate puncture program can reduce complications such as pneumothorax and pulmonary hemorrhage, and improve diagnosis and treatment efficiency.

Safety, feasibility, and effectiveness of a CT-guided transthoracic lung and pleural biopsy - a single-centre experience with own low-dose protocol

Purpose

To assess the efficacy and safety of a low-dose, computed tomography (CT)-guided transthoracic biopsy of lung and pleural lesions.

Material and methods

A total of 135 low-dose, CT-guided transthoracic lung and pleural lesions biopsies were performed. A cutting needle was utilized in 124 cases, and fine needle aspiration biopsy was performed in 14 cases. In all cases, 14- to 22-gauge biopsy needles were used.

Results

Diagnostic material was obtained in 111 (82.2%) patients. In 97 (71.8%) cases neoplastic lesions were found, predominantly adenocarcinoma and non-small cell carcinoma. In 14 (12.6%) cases non atypical cells were reported. Biopsy failed to obtain material suitable for histopathological examination in 24 (17.7%) cases. Complications occurred in 31 patients, including pneumothorax in 28 patients and haematoma in 3 cases.

Conclusions

Based on the obtained results, it can be stated that low-dose, CT-guided transthoracic biopsy of lung and pleural tissues is an accurate and safe procedure. Also, it is linked to a low risk of complications such as a small pneumothorax.

Evaluation of preventive tract embolization with standardized gelatin sponge slurry on chest tube placement rate after CT-guided lung biopsy: a propensity score analysis

BACKGROUND

To evaluate the effect of tract embolization (TE) with gelatin sponge slurries during a percutaneous lung biopsy on chest tube placement and to evaluate the predictive factors of chest tube placement.

METHODS

Percutaneous CT-guided lung biopsies performed with (TE) or without (non-TE) tract embolization or between June 2012 and December 2021 at three referral tertiary centers were retrospectively analyzed. The exclusion criteria were mediastinal biopsies, pleural tumors, and tumors adjacent to the pleura without pleural crossing. Variables related to patients, tumors, and procedures were collected. Univariable and multivariable analyses were performed to determine risk factors for chest tube placement. Furthermore, the propensity score matching analysis was adopted to yield a matched cohort.

RESULTS

A total of 1157 procedures in 1157 patients were analyzed, among which 560 (48.4%) were with TE (mean age 66.5 ± 9.2, 584 men). The rates of pneumothorax (44.9% vs. 26.1%, respectively; p < 0.001) and chest tube placement (4.8% vs. 2.3%, respectively; p < 0.001) were significantly higher in the non-TE group than in the TE group. No non-targeted embolization or systemic air embolism occurred. In the whole population, two protective factors for chest tube placement were found in univariate analysis: TE (OR 0.465 [0.239-0.904], p < 0.05) and prone position (OR 0.212 [0.094-0.482], p < 0.001). These data were confirmed in multivariate analysis (p < 0.001 and p < 0.0001 respectively). In the propensity matched cohort, TE reduces significatively the risk of chest tube insertion (OR = 0.44 [0.21-0.87], p < 0.05).

CONCLUSIONS

The TE technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy.

CRITICAL RELEVANCE STATEMENT

The tract embolization technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy.

KEY POINTS

1. Use of tract embolization with gelatine sponge slurry during percutaneous lung biopsy is safe. 2. Use of tract embolization significantly reduces the risk of chest tube insertion. 3. This is the first multicenter study to show the protective effect of tract embolization on chest tube insertion.

Risk prediction model of self-reported hypertension for telemedicine based on the sociodemographic, occupational and health-related characteristics of seafarers: a cross-sectional epidemiological study

OBJECTIVES

High blood pressure is a common health concern among seafarers. However, due to the remote nature of their work, it can be difficult for them to access regular monitoring of their blood pressure. Therefore, the development of a risk prediction model for hypertension in seafarers is important for early detection and prevention. This study developed a risk prediction model of self-reported hypertension for telemedicine.

DESIGN

A cross-sectional epidemiological study was employed.

SETTING

This study was conducted among seafarers aboard ships. Data on sociodemographic, occupational and health-related characteristics were collected using anonymous, standardised questionnaires.

PARTICIPANTS

This study involved 8125 seafarers aged 18-70 aboard 400 vessels between November 2020 and December 2020. 4318 study subjects were included in the analysis. Seafarers over 18 years of age, active (on duty) during the study and willing to give informed consent were the inclusion criteria.

OUTCOME MEASURES

We calculated the adjusted OR (AOR) with 95% CIs using multiple logistic regression models to estimate the associations between sociodemographic, occupational and health-related characteristics and self-reported hypertension. We also developed a risk prediction model for self-reported hypertension for telemedicine based on seafarers' characteristics.

RESULTS

Among the 4318 participants, 55.3% and 44.7% were non-officers and officers, respectively. 20.8% (900) of the participants reported having hypertension. Multivariable analysis showed that age (AOR: 1.08, 95% CI 1.07 to 1.10), working long hours per week (AOR: 1.02, 95% CI 1.01 to 1.03), work experience at sea (10+ years) (AOR: 1.79, 95% CI 1.33 to 2.42), being a non-officer (AOR: 1.75, 95% CI 1.44 to 2.13), snoring (AOR: 3.58, 95% CI 2.96 to 4.34) and other health-related variables were independent predictors of self-reported hypertension, which were included in the final risk prediction model. The sensitivity, specificity and accuracy of the predictive model were 56.4%, 94.4% and 86.5%, respectively.

CONCLUSION

A risk prediction model developed in the present study is accurate in predicting self-reported hypertension in seafarers' onboard ships.

Score to Predict the Occurrence of Pneumothorax After Computed Tomography-guided Percutaneous Transthoracic Lung Biopsy

PURPOSE

The main objective of this study was to identify risk factors for post-percutaneous transthoracic lung biopsy (PTLB) pneumothorax and to establish and validate a predictive score for pneumothorax occurrence to identify patients eligible for outpatient care.

MATERIAL AND METHODS

Patients who underwent PTLB between November 1, 2012 and March 1, 2017 were retrospectively evaluated for clinical and radiologic factors potentially related to pneumothorax occurrence. Multivariate logistic regression was used to identify risk factors, and the model coefficient for each factor was used to compute a score. Then, a validation cohort was prospectively evaluated from March 2018 to October 2019.

RESULTS

Among the 498 eligible patients in the study cohort, pneumothorax occurred in 124 patients (24.9%) and required drainage in 34 patients (6.8%). Pneumothorax risk factors were chronic obstructive pulmonary disease (OR 95% CI 2.28[1.18-4.43]), several passages through the pleura (OR 95% CI 7.71[1.95-30.48]), an anterior biopsy approach (OR 95% CI 6.36 3.82-10.58]), skin-to-pleura distance ≤30 mm (OR 95% CI 2.25[1.09-6.65]), and aerial effusion >10 mm (OR 95% CI 9.27 [5.16-16.65]). Among the 236 patients in the prospective validation cohort, pneumothorax occurred in 18% and 8% were drained. A negative score (<73 points) predicted a probability of pneumothorax occurrence of 7.4% and late evacuation of 2.5% (OR 95% CI respectively 0.18[0.08-0.39] and 0.15[0.04-0.55]) and suggested a reduced length of hospital stay (P=0.009).

CONCLUSION

This predictive score for pneumothorax secondary to PTLB has high prognostic performance and accuracy to direct patients toward outpatient management.

CLINICAL TRIALS

NCT03488043.

The risk of immediate pneumothorax after CT-guided lung needle biopsy: pleural tail sign as a novel factor

Background

Pneumothorax is the most frequent complication in computed tomography-guided lung needle biopsy (CT-LNB) and generally appears immediately or within an hour after CT-LNB. Preventing pneumothorax after CT-LNB requires a preoperative evaluation of risk factors. This study investigated risk factors for the occurrence of immediate pneumothorax after CT-LNB.

Methods

A total of 311 CT-LNB procedures were conducted for 290 patients (217 males and 73 females) with persistent solid or part-solid pulmonary lesions in this case-control study. We retrospectively evaluated immediate postbiopsy pneumothorax complications and associated risk factors. The possible risk factors for immediate pneumothorax were analyzed, including 12 parameters in demographics, radiological features, and procedural factors. Univariate and multivariate logistic regression analyses were used to investigate independent risk factors for the occurrence of immediate pneumothorax after CT-LNB.

Results

All CT-LNB procedures (100%) were technically successful. Immediate pneumothorax after CT-LNB occurred in 115 out of the 311 procedures (36.9%). Chest tube placement was required for 12.2% (14/115) of the pneumothoraces (14/311, 4.5% of the total number of CT-LNB procedures). The other pneumothoraces were treated conservatively. Independent risk factors of immediate pneumothorax included a lesion with pleural tail sign [PTS; odds ratio (OR) =3.021, 95% confidence interval (CI): 1.703-5.359; P<0.001], smaller lesion size (OR =0.827, 95% CI: 0.705-0.969; P=0.019), a lesion in the middle or lower lobe (OR =2.237, 95% CI: 1.267-3.951; P=0.006), a higher number of pleural punctures (OR =2.710, 95% CI: 1.399-5.248; P=0.003), and a deep-seated lesion (OR =1.622, 95% CI: 1.261-2.088; P<0.001).

Conclusion

PTS is a novel risk factor for immediate pneumothorax and may increase the immediate pneumothorax rate after CT-LNB. Practitioners should be vigilant of the risk of immediate pneumothorax after CT-LNB in lung lesions with PTS.

Low diffusion capacity of the lung predicts pneumothorax and chest drainage after CT-guided lung biopsy

OBJECTIVES

Complications after CT-guided lung biopsy is a burden both for the individual patient and for the overall healthcare. Pneumothorax is the most common complication. This study determined the association between lung function tests and pneumothorax and chest drainage following CT-guided lung biopsy in consecutive patients in a large university hospital.

RESULTS

We prospectively registered 875 biopsy procedures from 786 patients in one institution from January 27th 2012 to March 1st 2017 and recorded complications including pneumothorax with or without chest drainage. Lung function data from 637 patients undergoing 710 of the procedures were available. The association of lung function measures with pneumothorax with or without chest drainage was assessed using multivariable logistic regression analyses. Diffusion capacity for carbon monoxide (DLCO) below 4.70 mmol/min/kPa was associated with increased occurrence of pneumothorax and chest drainage after CT guided lung biopsy. We found no association between FEV₁, RV and occurrence of pneumothorax and chest drainage. We found low DLCO to be a risk factor of pneumothorax and chest drainage after CT-guided lung biopsy. This should be taken into account in planning and performing the procedure.

Development and validation of a prediction model of pneumothorax after CT-guided coaxial core needle lung biopsy

BACKGROUND

Pneumothorax is the most common complication of computed tomography-guided coaxial core needle biopsy (CCNB) and may be life-threatening. We aimed to evaluate the risk factors and develop a model for predicting pneumothorax in patients undergoing computed tomography-guided CCNB, and to further determine its clinical utility.

METHODS

Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for pneumothorax from 18 variables. A predictive model was established using multivariable logistic regression and presented as a nomogram based on a training cohort of 690 patients who underwent computed tomography-guided CCNB. The model was validated in 253 consecutive patients in the validation cohort and 250 patients in the test cohort. The area under the curve was used to determine the predictive accuracy of the proposed model.

RESULTS

The risk factors associated with pneumothorax after computed tomography-guided CCNB were sex, patient position, lung field, lesion contact with the pleura, lesion size, distance from the pleura to the lesion, presence of emphysema adjacent to the biopsy tract, and crossing fissures. The predictive model that incorporated these predictors showed good predictive performance in the training cohort [area under the curve, 0.71 (95% confidence interval: 0.67-0.75)], validation cohort [0.71 (0.64-0.78)], and internal test cohort [0.68 (0.60-0.75)]. The nomogram also provided excellent calibration and discrimination, and decision curve analysis (DCA) demonstrated its clinical utility.

CONCLUSIONS

The predictive model showed good performance for pneumothorax after computed tomography-guided CCNB and may help improve individualized preoperative prediction.

Preventive tract embolization with gelatin sponge slurry is safe and considerably reduces pneumothorax after CT-guided lung biopsy with use of large 16-18 coaxial needles

OBJECTIVE

To evaluate the clinical impact of the tract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy.

METHODS

We retrospectively compared coaxial needle CT-guided lung biopsies performed without embolization (100 patients) and with the tract embolization technique using a mixture of iodine and gelatin sponge slurry (105 patients) between June 2012 and July 2020. Uni- and multivariate analyses were performed between groups to determine risk factors of pneumothorax.

RESULTS

Patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax ((17.1% vs 39%, p < 0.001). In univariate analysis, tract embolization (OR = 0.32, CI = 0.17-0.61 p<0.001) and nodule size >2 cm (OR = 0.33 CI = 0.14-0.8 p = 0.013) had a protective effect on pneumothorax. The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (OR = 3.35 IC = 1.44-8.21 p = 0.006 and OR = 4.36 CI = 1.98-10.29 p<0.001, respectively). In multivariate regression analysis, tract embolization had a protective effect of pneumothorax (OR = 0.25, CI = 0.12-0.51, p < 0.001). The puncture path lengths > 2-20 mm and >20 mm were risk factors for pneumothorax (p = 0.030 and p = 0.002, respectively).

CONCLUSIONS

The tract embolization technique using iodinated gelatin sponge slurry is safe and considerably reduces pneumothorax after percutaneous CT-guided lung biopsy. Our results suggest that it could be use in clinical routine.

ADVANCES IN KNOWLEDGE

The systemic use of gelatin sponge slurry is safe and reduces considerably the rate of pneumothorax upon needle removal when CT-guided core biopsies are performed using large 16-18G coaxial needles.

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.

Development of a risk prediction model of pneumothorax in percutaneous computed tomography guided transthoracic needle lung biopsy

INTRODUCTION

To retrospectively evaluate the incidence of and the risk factors for pneumothorax and intercostal catheter insertion (ICC) after CT-guided lung biopsy and to generate a risk prediction model for developing a pneumothorax and requiring an ICC.

METHODS

255 CT-guided lung biopsies performed for 249 lesions in 249 patients from August 2014 to August 2019 were retrospectively analysed using multivariate logistic regression analysis. Risk prediction models were established using backward stepwise variable selection and likelihood ratio tests and were internally validated using split-sample methods.

RESULTS

The overall incidence of pneumothorax was 30.2% (77/255). ICC insertion was required for 8.32% (21/255) of all procedures. The significant independent risk factors for pneumothorax were lesions not in contact with pleura (P < 0.001), a shorter skin-to-pleura distance (P = 0.01), the needle crossing a fissure (P = 0.004) and emphysema (P = 0.01); those for ICC insertion for pneumothorax were a needle through emphysema (P < 0.001) and lesions in the upper lobe (P = 0.017). AUC of the predictive models for pneumothorax and ICC insertion were 0.800 (95% CI: 0.745-0.856) and 0.859 (95% CI: 0.779-0.939) respectively. Upon internal validation, AUC of the testing sets of pneumothorax and ICC insertion were 0.769 and 0.822 on average respectively.

CONCLUSION

The complication rates of pneumothorax and ICC insertion after CT-guided lung biopsy at our institution are comparable to results from previously reported studies. This study provides highly accurate risk prediction models of pneumothorax and ICC insertion for patients undergoing CT-guided lung biopsies.

Nomogram model to predict pneumothorax after computed tomography-guided coaxial core needle lung biopsy

PURPOSE

To develop a predictive model to determine risk factors of pneumothorax in patients undergoing the computed tomography (CT)¹-guided coaxial core needle lung biopsy (CCNB).

METHODS

A total of 489 patients who underwent CCNBs with an 18-gauge coaxial core needle were retrospectively included. Patient characteristics, primary pulmonary disease, target lesion image characteristics and biopsy-related variables were evaluated as potential risk factors of pneumothorax which was determined on the chest X-ray and CT scans. Univariate and multivariate logistic regressions were used to identify the independent risk factors of pneumothorax and establish the predictive model, which was presented in the form of a nomogram. The discrimination and calibration of the model were evaluated as well.

RESULTS

The incidence of pneumothorax was 32.91 % and 31.42 % in the development and validation groups, respectively. Age, emphysema, pleural thickening, lesion location, lobulation sign, and size grade were identified independent risk factors of pneumothorax at the multivariate logistic regression model. The forming model produced an area under the curve of 0.718 (95 % CI = 0.660-0.776) and 0.722 (95 % CI = 0.638-0.805) in development and validation group, respectively. The calibration curve showed good agreement between predicted and actual probability.

CONCLUSIONS

The predictive model for pneumothorax after CCNBs had good discrimination and calibration, which could help in clinical practice.

CT Fluoroscopy Guided Thoracic Biopsies (CTTB) Are Highly Accurate and Safe: Outcomes and Predictive Modeling of Complications Utilizing Machine Learning

PURPOSE

CT guided transthoracic biopsy (CTTB) is an established, minimally invasive method for diagnostic evaluation of a variety of thoracic diseases. We assessed a large CTTB cohort diagnostic accuracy, complication rates, and developed machine learning models to predict complications.

MATERIALS AND METHODS

We retrospectively identified 796 CTTB patients in a tertiary hospital (5-year interval). We gathered and coded patient demographics, characteristics of each lesion biopsied, type of biopsy, diagnostic yield, type of diagnosis, and complication rates. Statistical analyses included summary statistics, multivariate logistic regression and machine learning (neural network) methods.

RESULTS

Seven hundred ninety-six CTTBs were performed (43% fine needle aspirations, 5% core biopsies, 52% both). Diagnostic yield was 97.0% (73.9% malignant, 23.1% benign). Complications occurred in 14.7% (12.7% minor, 2.0% major). The most common complication was pneumothorax (13.1%), mostly minor. Multivariate logistic regression models could predict severity of complications with accuracies ranging from 65.5% to 83.5%, with smaller lesion dimension the strongest predictor. Type of biopsy was not a statistically significant predictor. A neural network model improved accuracy to 77.0%-94.2%.

CONCLUSION

CTTB performed by thoracic radiologists in a tertiary hospital demonstrate excellent diagnostic yield (97.0%) with a low clinically important complication rate (2.0%). Machine learning methods including neural networks can accurately predict the likelihood of complications, offering pathways to potentially improve patient selection and procedural technique, in order to further optimize the risk-benefit ratio of CTTB.

First experience of efficacy and radiation exposure in 320-detector row CT fluoroscopy-guided interventions

OBJECTIVE

We investigated the efficacy and exposure to radiation in 320-detector row computed tomography fluoroscopy-guided (CTF-guided) interventions.

METHODS

We analysed 231 320-detector row CTF-guided interventions (207 patients over 2 years and 6 months) in terms of technical success rates, clinical success rates, complications, scanner settings, overall radiation doses (dose-length product, mGy*cm), patient doses of peri-interventional CT series, and interventional CT (including CTF), as a retrospective cohort study. The relationships between patient radiation dose and interventional factors were assessed using multivariate analysis.

RESULTS

Overall technical success rate was 98.7% (228/231). The technical success rates of biopsies, drainages, and aspirations were 98.7% (154/156), 98.5% (66/67), and 100% (8/8), respectively. The clinical success rate of biopsies was 93.5% (146/156). All three major complications occurred in chest biopsies. The median total radiation dose was 522.4 (393.4-819.8) mGy*cm. Of the total radiation dose, 87% was applied during the pre- and post-interventional CT series. Post-interventional CT accounted for 24.4% of the total radiation dose. Only 11.4% of the dose was applied by CTF-guided intervention. Multilinear regression demonstrated that male sex, body mass index, drainage, intervention time, and helical scan as post-interventional CT were significantly associated with higher dose.

CONCLUSION

The 320-detector row CTF interventions achieved a high success rate. Dose reduction in post-interventional CT provides patient dose reduction without decreasing the technical success rates.

ADVANCES IN KNOWLEDGE

This is the first study on the relationship between various interventional outcomes and patient exposure to radiation in 320-detector row CTF-guided interventions, suggesting a new perspective on dose reduction.

Predictors of pneumothorax and chest drainage after percutaneous CT-guided lung biopsy: A prospective study

OBJECTIVES

We present an analysis of predictors of pneumothorax, and pneumothorax requiring chest drainage after CT-guided lung biopsy, in one of the largest Scandinavian dataset presented.

METHODS

We prospectively registered 875 biopsy procedures from 786 patients in one institution from January 27, 2012, to March 1, 2017, and recorded complications including pneumothorax with or without chest drainage, and multiple variables we assumed could be associated with complications. We performed multivariable logistic regression analysis to identify predictors of pneumothorax and pneumothorax requiring chest drainage.

RESULTS

Of the biopsied lesions, 65% were malignant, 29% benign, and 6% inconclusive. Pneumothorax occurred in 39% of the procedures and chest drainage was performed in 10%. In multivariable analysis, significant predictors of pneumothorax were emphysema (OR 1.92), smaller lesion size (OR 0.83, per 1 cm increase in lesion size), lateral body position during procedure (OR 2.00), longer needle time (OR 1.09, per minute), repositioning of coaxial needle with new insertion through pleura (OR 3.04), insertion through interlobar fissure (OR 5.21), and shorter distance to pleura (OR 0.79, per 1 cm increase in distance). Predictors of chest drainage were emphysema (OR 4.01), lateral body position (OR 2.61), and needle insertion through interlobar fissure (OR 4.17).

CONCLUSION

Predictors of pneumothorax were emphysema, lateral body position, needle insertion through interlobar fissure, repositioning of coaxial needle with new insertion through pleura, and shorter distance to pleura. The finding of lateral body position as a predictor of pneumothorax is not earlier described. Emphysema, lateral body position, and needle insertion through interlobar fissure were also predictors of chest drainage.

KEY POINTS

• Pneumothorax is a frequent complication to CT-guided lung biopsy; a smaller fraction of these complications needs chest drainage. • Predictors for pneumothorax are emphysema, smaller lesion size, lateral body position, longer needle time, repositioning of coaxial needle with new insertion through pleura, needle insertion through the interlobar fissure, and shorter distance to pleura. • Predictors for requirement for chest drainage post CT-guided lung biopsy are emphysema, lateral body position, and needle insertion through the interlobar fissure.

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

OBJECTIVES

To evaluate the impact of patient positioning during CT-guided lung biopsy on patients' outcomes.

METHODS

In this retrospective, IRB-approved, HIPAA-compliant study, consecutive CT-guided lung biopsies performed on 5/1/2015-12/26/2017 were included. Correlation between incidence of pneumothorax, chest tube placement, pulmonary bleeding with patient, and procedure characteristics was evaluated. Lesion-trachea-table angle (LTTA) was defined as an angle between the lesion, trachea, and horizontal line parallel to the table. Lesion above trachea has a positive LTTA. Univariate and multivariate logistic regression analysis was performed.

RESULTS

A total of 423 biopsies in 409 patients (68 ± 11 years, 231/409, 56% female) were included in the study. Pneumothorax occurred in 83/423 (20%) biopsies with chest tube placed in 11/423 (3%) biopsies. Perilesional bleeding occurred in 194/423 (46%) biopsies and hemoptysis in 20/423 (5%) biopsies. Univariate analysis showed an association of pneumothorax with smaller lesions (p = 0.05), positive LTTA (p = 0.002), and lesions not attached to pleura (p = 0.026) with multivariate analysis showing lesion size and LTTA to be independent risk factors. Univariate analysis showed an association of increased pulmonary bleeding with smaller lesions (p < 0.001), no attachment to the pleura (p < 0.001), needle throw < 16 mm (p = 0.05), and a longer needle path (p < 0.001). Multivariate analysis showed lesion size, a longer needle path, and lesions not attached to the pleura to be independently associated with perilesional bleeding. Risk factors for hemoptysis were longer needle path (p = 0.002), no attachment to the pleura (p = 0.03), and female sex (p = 0.04).

CONCLUSIONS

Interventional radiologists can reduce the pneumothorax risk during the CT-guided biopsy by positioning the biopsy site below the trachea.

KEY POINTS

• Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy results in lower rate of pneumothorax, as compared with the lesion above the trachea. • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy does not affect rate of procedure-associated pulmonary hemorrhage or hemoptysis.

Pneumothorax and pulmonary hemorrhage after CT-guided lung biopsy: incidence, clinical significance and correlation

OBJECTIVES

To evaluate the incidence and clinical significance of pneumothorax (PTX) and pulmonary hemorrhage (PH) after CT-guided lung biopsy (CT-LB). To test correlations of PTX and chest tube insertion (CTI) with PH and other imaging and procedural parameters.

METHODS

Pre-procedural CT and CT-LB scans of 904 patients were examined. Incidence of PTX and PH and PH location (type-1 along needle track; type-2 perilesional) and severity according to its thickness (low grade < 6 mm; high grade > 6 mm) were recorded. PTX was considered clinically significant if treated with CTI, PH if treated with endoscopic/endovascular procedure. Binary logistic regression analyses were used to determine the effects of different imaging and procedural parameters on the likelihood to develop PTX, CTI and PH and to define their correlation.

RESULTS

PTX occurred in 306/904 cases (33.8%); CTI was required in 18/306 (5.9%). PH occurred in 296/904 cases (32.7%), and no case required treatment. Nodule-to-pleura distance (OR_PTX = 1.052; OR_CTI = 1.046; OR_PH 1.077), emphysema (OR_PTX = 1.287; OR_PH = 0.573), procedure time (OR_PTX = 1.019; OR_CTI = 1.039; OR_PH = 1.019), target size (OR_PTX = 0.982; OR_PH = 0.968) and needle gauge (OR_PTX = 0.487; OR_CTI = 4.311; OR_PH = 2.070) showed statistically significant correlation to PTX, CTI and PH. Type-1 PH showed a protective effect against PTX and CTI (OR_PTX = 0.503; OR_CTI = 0.416).

CONCLUSION

PTX and PH have similar incidence after CT-guided lung biopsy. PH along needle track may represent a protective factor against development of PTX and against PTX requiring CTI.

Association of Ang-2, vWF, and EVLWI with risk of mortality in sepsis patients with concomitant ARDS: A retrospective study

BACKGROUND/PURPOSE

This study aimed to determine the potential effects of angiopoietin-2 (Ang-2), von Willebrand factor (vWF), and extravascular lung water index (EVLWI) on the risk of mortality in sepsis patients with concomitant acute respiratory distress syndrome (ARDS).

METHODS

This retrospective study recruited 41 sepsis patients with concomitant ARDS from January 2015 to June 2018. Data of Ang-2 and vWF levels, EVLWI, and sequential organ failure assessment scores were collected at 0, 24, and 48 h after admission to the hospital.

RESULTS

The length of intensive care unit stay (P = 0.041) and Acute Physiology and Chronic Health Evaluation-2 (APACHE II) score (P = 0.003) were associated with the risk of mortality. Furthermore, increased Ang-2 levels and EVLWI at 24 h and 48 h were associated with an increased risk of mortality. Moreover, the APACHE II score at hospital admission significantly predicted the risk of mortality (area under the curve [AUC], 0.834; 95% confidence interval [CI], 0.665-0.983). Finally, the models containing a combination of Ang-2 level and EVLWI at 24 h (AUC, 0.908; 95% CI, 0.774-0.996) and Ang-2 level and EVLWI at 48 h (AUC, 0.981; 95% CI, 0.817-1.000) had high diagnostic values for predicting risk of mortality.

CONCLUSION

The study findings indicate that Ang-2 levels and EVLWI at 24 h and 48 h after admission are significantly associated with the risk of mortality.

Efficacy of the tract embolization technique with gelatin sponge slurry to reduce pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy

PURPOSE

To assess the efficacy of the tract embolization technique using gelatin sponge slurry after CT-guided lung biopsy to reduce pneumothorax and chest tube placement rates.

MATERIALS AND METHODS

We retrospectively compared 231 CT-guided lung biopsies performed with the tract embolization technique using gelatin sponge slurry (treated group) with 213 biopsies performed without embolization (control group). All procedures were performed at our institution between January 2014 and September 2018 by one of three experienced interventional radiologists using a 19-gauge coaxial needle. Multivariate analysis was performed between groups for risk factors for pneumothorax and chest tube placement, including patient demographics and lesion characteristics.

RESULTS

When comparing the two groups, there was no significant difference concerning age, gender, emphysema, lesion size, lesion location, lesion morphology, needle tract depth and biopsy-side down patient positioning. Compared to the control group, patients with gelatin sponge slurry tract embolization had statistically lower rates of pneumothorax (10% vs. 25.8%; p < 0.0001) and chest tube placement (3.5% vs. 12.2%; p = 0.0005). Using multiple logistic regression analysis, the only variable that had an influence on the pneumothorax rate was the group (OR 0.32, 95% CI 0.18-0.56, p < 0.0001), and the variables that had an influence on the chest tube insertion rates were the group (OR 0.21, 95% CI 0.08-0.51, p = 0.0006) and presence of emphysema (OR 3.50, 95% CI 1.53-8.03, p = 0.0031).

CONCLUSIONS

Tract embolization technique using gelatin sponge slurry after percutaneous CT-guided lung biopsy significantly reduces pneumothorax and chest tube placement rates.

LEVEL OF EVIDENCE

Level 3a.

Development and Validation of a Prediction Pneumothorax Model in CT-Guided Transthoracic Needle Biopsy for Solitary Pulmonary Nodule

Computed tomography-guided transthoracic needle biopsy (CT-TNB) is widely used in the diagnosis of solitary pulmonary nodule (SPN). However, CT-TNB-induced pneumothorax occurs frequently. This study aimed to establish a predictive model for pneumothorax following CT-TNB for SPN. The prediction model was developed in a cohort that consisted of 311 patients with SPN who underwent CT-TNB. An independent external validation cohort contained 227 consecutive patients. The least absolute shrinkage and selection operator (Lasso) regression analysis was used for data dimension reduction and predictors selection. Multivariable logistic regression was used to develop the predictive model, which was presented with a nomogram. Area under the curve (AUC) was used to determine the discrimination of the proposed model. The calibration was used to test the goodness-of-fit of the model, and decision curve analysis (DCA) was used for evaluating its clinical usefulness. Five variables (age, diagnosis of nodule, puncture times, puncture distance, and puncture position) were filtered by Lasso regression. AUC of the predictive model and the validation were 0.801 (95% CI, 0.738-0.865) and 0.738 (95% CI, 0.656-0.820), respectively. The model was well-calibrated (P > 0.05), and DCA demonstrated its clinical usefulness. Thus, this predictive model might facilitate the individualized preoperative prediction of pneumothorax in CT-TNB for SPN.

Transthoracic computed tomography-guided lung biopsy in the new era of personalized medicine

Computed tomography-guided lung biopsy is a valid and safe procedure for characterizing pulmonary nodules. In the past years, this technique has been mainly used to confirm the malignant nature of undetermined pulmonary lesions; however, today its role has been completely renewed. With the advent of target therapy and immunotherapy, it has arisen for lung cancer, in inoperable patients, the necessity to obtain adequate bioptical material to perform a correct molecular characterization of the lesion. Moreover, the possibility of acquired drug-resistance mechanisms makes it necessary in some cases to rebiopsy these lesions over time. For these reasons, it is likely that the request of computed tomography-guided lung biopsy will increase in the future, therefore every radiologist should be confident with its most important aspects.

Does Ipsilateral-Dependent Positioning During Percutaneous Lung Biopsy Decrease the Risk of Pneumothorax?

OBJECTIVE

The purpose of this study is to determine whether placing patients in an ipsilateral-dependent position during percutaneous CT-guided transthoracic biopsy reduces the pneumothorax rate.

MATERIALS AND METHODS

Between July 2013 and August 2017, a total of 516 patients (317 men and 199 women; mean age, 66.4 years) underwent core needle biopsies performed using 17- and 18-gauge needles. The overall pneumothorax rate and the rate of pneumothorax requiring drainage catheter insertion were compared between group A (patients placed in an ipsilateral-dependent position) and group B (patients placed in a position other than the ipsilateral-dependent position), with use of a chi-square test or Fisher exact test, as appropriate. Linear regression analysis and multiple regression analysis were performed for risk factors of pneumothorax, including patient characteristics (e.g., emphysema along the needle track), lesion characteristics (e.g., size and position), and biopsy technique characteristics (e.g., needle path length, needle-pleura angle, and fissure crossing).

RESULTS

For patients in group A and group B, the overall pneumothorax rate (21/94 [22.3%] and 95/422 [22.5%], respectively; p = 0.97) and the rate of pneumothorax requiring drainage catheter insertion (6/94 [6.4%] and 28/422 [6.6%], respectively; p = 0.90) were not statistically different. After multiple regression analysis, the only independent risk factors for pneumothorax and insertion of a drainage catheter were needle path length (p < 0.001 and p = 0.02, respectively), emphysema along the needle track (p = 0.01 and p < 0.001, respectively), and fissure crossing (p = 0.04 and p < 0.001, respectively).

CONCLUSION

Even though the pneumothorax rate does not appear to be reduced, with the limits of a retrospective evaluation considered, other advantages of the ipsilateral decubitus position exist, including protection of the contralateral lung in patients with severe hemoptysis.