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Chen X, Bian Y, Li H, Li S, Shi Z, Zhao Y, Li H, Yang Y. Efficacy of autologous blood patch injection for pneumothorax rate after CT-guided percutaneous transthoracic lung biopsy: a systematic review and meta-analysis. J Cardiothorac Surg 2024; 19:332. [PMID: 38877547 PMCID: PMC11177476 DOI: 10.1186/s13019-024-02781-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 04/29/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Pneumothorax is the most frequent complication after CT-guided percutaneous transthoracic lung biopsy (CT-PTLB). Many studies reported that injection of autologous blood patch (ABP) during biopsy needle withdrawal could reduce the pneumothorax and chest tube insertion rate after CT-PTLB, but the result is debatable. The aim of this systematic review and meta-analysis is to synthesize evidence regarding the efficacy of ABP procedure in patients receiving CT-PTLB. METHODS Eligible studies were searched in Pubmed, Embase and Web of Science databases. The inclusion criteria were studies that assessed the relationship between ABP and the pneumothorax and/or chest tube insertion rate after CT-PTLB. Subgroup analyses according to study type, emphysema status and ABP technique applied were also conducted. Odds ratio (OR) with 95% confidence interval (CI) were calculated to examine the risk association. RESULTS A total of 10 studies including 3874 patients were qualified for analysis. Our analysis suggested that ABP reduced the pneumothorax (incidence: 20.0% vs. 27.9%, OR = 0.67, 95% CI = 0.48-0.66, P < 0.001) and chest tube insertion rate (incidence: 4.0% vs. 8.0%, OR = 0.47, 95% CI = 0.34-0.65, P < 0.001) after CT-PTLB. Subgroup analysis according to study type (RCT or retrospective study), emphysema status (with or without emphysema), and ABP technique applied (clotted or non-clotted ABP) were also performed and we found ABP reduced the pneumothorax and chest tube insertion rate in all subgroups. CONCLUSIONS Our study indicated that the use of ABP was effective technique in reducing the pneumothorax and chest tube insertion rate after CT-PTLB.
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Affiliation(s)
- Xin Chen
- Department of General Surgery, The People's Hospital of Fengqing, Lincang, 675900, PR China
| | - Yungui Bian
- Department of Thoracic Surgery, The People's Hospital of Fengqing, Lincang, 675900, PR China
| | - Hai Li
- Department of Stomatology, The People's Hospital of Fengqing, Lincang, 675900, PR China
| | - Shurong Li
- Department of Clinical Laboratory, The People's Hospital of Fengqing, Lincang, 675900, PR China
| | - Zhaowen Shi
- Department of General Surgery, The People's Hospital of Fengqing, Lincang, 675900, PR China
| | - Yunping Zhao
- Department of Thoracic Surgery I, The First Affiliated Hospital of Kunming Medical University, No.295 Xichang Road, Wuhua District, Kunming, Yunnan Province, 650032, PR China
| | - Haibin Li
- Department of Thoracic Surgery I, The First Affiliated Hospital of Kunming Medical University, No.295 Xichang Road, Wuhua District, Kunming, Yunnan Province, 650032, PR China
| | - Yanlong Yang
- Department of Thoracic Surgery I, The First Affiliated Hospital of Kunming Medical University, No.295 Xichang Road, Wuhua District, Kunming, Yunnan Province, 650032, PR China.
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Bourgeais G, Frampas E, Liberge R, Nicolas A, Defrance C, Blanc FX, Coudol S, Morla O. Pneumothorax Incidence with Normal Saline Instillation for Sealing the Needle Track After Computed Tomography-Guided Percutaneous Lung Biopsy. Cardiovasc Intervent Radiol 2024; 47:604-612. [PMID: 38263525 DOI: 10.1007/s00270-023-03648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/11/2023] [Indexed: 01/25/2024]
Abstract
PURPOSE To determine whether instillation of normal saline solution for sealing the needle track reduces incidence of pneumothorax and chest tube placement after computed tomography-guided percutaneous lung biopsy. MATERIALS AND METHODS A total of 242 computed tomography-guided percutaneous lung biopsies performed at a single institution were retrospectively reviewed, including 93 biopsies in which the needle track was sealed by instillation of 3-5 ml of normal saline solution during needle withdrawal (water seal group) and 149 biopsies without sealing (control group). Patient and lesion characteristics, procedure-specific variables, pneumothorax and chest tube placement rates were recorded. RESULTS Baseline characteristics were comparable in both groups. There was a statistically significant decrease in the pneumothorax rate (19.4% [18/93] vs. 40.9% [61/149]; p < 0.001) and a numerically lower chest tube placement rate without significant reduction (4.3% [4/93] vs. 10.7% [16/149]; p = 0.126) with using normal saline instillation for sealing the needle track versus not using sealant material. Using a multiple logistic regression analysis, using normal saline instillation to seal the needle track, having a senior radiologist as operator of the procedure and putting patients in prone position were significantly associated with a decreased risk of pneumothorax. The presence of emphysema along the needle track was significantly associated with an increased risk of pneumothorax. No complication was observed due to normal saline injection. CONCLUSION Normal saline solution instillation for sealing the needle track after computed tomography-guided percutaneous lung biopsy is a simple, low-cost and safe technique resulted in significantly decreased pneumothorax occurrence and a numerically lower chest tube placement rate, and might help to reduce both hospitalization risks and costs for the healthcare system. Level of evidence 3 Non-controlled retrospective cohort study.
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Affiliation(s)
- Geoffrey Bourgeais
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France.
| | - Eric Frampas
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Renan Liberge
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Aymeric Nicolas
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - Claire Defrance
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France
| | - François-Xavier Blanc
- Department of Pneumology, Nantes University Hospital, Boulevard Jacques-Monod, 44093, Saint-Herblain, France
| | - Sandrine Coudol
- Nantes Université, CHU Nantes, Pôle Hospitalo-Universitaire, 11: Santé Publique, Clinique Des Données, INSERM, CIC 1413, 44000, Nantes, France
| | - Olivier Morla
- Department of Radiology, Nantes University Hospital, 1 Place Alexis Ricordeau, 44093, Nantes, France
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Li T, Zhang Q, Li W, Liu Y. Autologous blood patch intraparenchymal injection reduces the incidence of pneumothorax and the need for chest tube placement following CT-guided lung biopsy: a systematic review and meta-analysis. Eur J Med Res 2024; 29:108. [PMID: 38336678 PMCID: PMC10854056 DOI: 10.1186/s40001-024-01707-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE To assess the effectiveness of autologous blood patch intraparenchymal injection during CT-guided lung biopsies with a focus on the incidence of pneumothorax and the subsequent requirement for chest tube placement. METHODS A comprehensive search of major databases was conducted to identify studies that utilized autologous blood patches to mitigate the risk of pneumothorax following lung biopsies. Efficacy was next assessed through a meta-analysis using a random-effects model. RESULTS Of the 122 carefully analyzed studies, nine, representing a patient population of 4116, were incorporated into the final analysis. Conclusion deduced showed a noteworthy reduction in the overall incidence of pneumothorax (RR = 0.65; 95% CI 0.53-0.80; P = 0.00) and a significantly decline in the occasion for chest tube placement due to pneumothorax (RR = 0.45; 95% CI 0.32-0.64; P = 0.00). CONCLUSIONS Utilizing autologous blood patch intraparenchymal injection during the coaxial needle retraction process post-lung biopsy is highly effective in diminishing both the incidence of pneumothorax and consequent chest tube placement requirement.
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Affiliation(s)
- Teng Li
- Department of Interventional Radiology, The People's Hospital of Weifang, 151 Guangwen Street, Weifang, 261041, Shandong, China
| | - Qiang Zhang
- Department of Nuclear Medicine, The People's Hospital of Weifang, 151 Guangwen Street, Weifang, 261041, Shandong, China
| | - Wenjun Li
- Department of Interventional Radiology, The People's Hospital of Weifang, 151 Guangwen Street, Weifang, 261041, Shandong, China
| | - Yun Liu
- Department of Hematology, The People's Hospital of Weifang, 151 Guangwen Street, Weifang, 261041, Shandong, China.
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Yang Y, Ma J, Peng Z, Zhou X, Du N, Zhang W, Yan Z. Pneumothorax and pulmonary hemorrhage after C-arm cone-beam computed tomography-guided percutaneous transthoracic lung biopsy: incidence, clinical significance, and correlation. BMC Pulm Med 2024; 24:33. [PMID: 38218792 PMCID: PMC10787482 DOI: 10.1186/s12890-023-02822-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024] Open
Abstract
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.
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Affiliation(s)
- Yanjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Zhijie Peng
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xin Zhou
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Nan Du
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Institute of Medical Imaging, Shanghai, China.
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Institute of Medical Imaging, Shanghai, China.
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Wu HM, Wen YL, He XY, Deng ZP. Selective bronchial occlusion for the prevention of pneumothorax after transbronchial lung cryobiopsy in a pulmonary alveolar proteinosis patient: a case report. Front Med (Lausanne) 2023; 10:1265373. [PMID: 38162886 PMCID: PMC10756706 DOI: 10.3389/fmed.2023.1265373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024] Open
Abstract
The diagnosis of pulmonary alveolar proteinosis (PAP) is based on biopsies. Compared with other methods of taking biopsies, transbronchial lung cryobiopsy (TBLC) has a higher diagnostic rate and the likelihood of pneumothorax. Selective bronchial occlusion (SBO) is an effective technique for treating intractable pneumothorax. However, there are no data available about SBO for the prevention of pneumothorax after TBLC in a PAP patient. A 49-year-old man complained of recurrent cough and tachypnea, and his symptoms did not fully resolve until the diagnosis was confirmed, and he was treated with whole lung lavage. Our patient was ultimately diagnosed with PAP by TBLC but not multiple tests for the bronchoalveolar lavage fluid (BALF). The patient was discharged quickly after whole lung lavage due to the fact that he did not develop pneumothorax under SBO. This case illustrates that TBLC is a supplementary examination for PAP, especially for those in whom BALF results fail to confirm a diagnosis. Moreover, our report highlights that SBO is necessary to effectively prevent pneumothorax during and after multiple TBLCs in PAP patients.
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Affiliation(s)
| | | | | | - Zhi-Ping Deng
- Department of Respiratory and Critical Care Medicine, Zigong First People’s Hospital, Zigong, Sichuan, China
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Hafeez A, Nadeem N, Iqbal J, Qureshi A, Shakeel A, Zafar U. Concordance Between Resident and Attending Radiologist in Reporting Pneumothorax on Intensive Care Unit and Emergency Room Chest Radiographs. Cureus 2022; 14:e29672. [PMID: 36320981 PMCID: PMC9616555 DOI: 10.7759/cureus.29672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs. Materials and methods This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the “Comments” section of the picture archiving and communication system (PACS). Further entries were made in the department’s “Panic Logbook.” Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement. Results Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph. The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out. Conclusion In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008).
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Lingegowda D, Gupta B, Gehani A, Sen S, Ghosh P. Optimization of the Lung Biopsy Procedure: A Primer. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1740456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractImage-guided lung biopsy plays a very important role in the diagnosis and management of lung lesions. As a diagnostic tool, it demands a high diagnostic yield and a low complication rate. It is imperative to balance the diagnostic yield and patient safety during lung biopsies. The aim of this article is to review the standard practice guidelines of lung biopsy, to describe the techniques used to minimize the complications associated with lung biopsy, and to describe the management of complications.
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Affiliation(s)
| | - Bharat Gupta
- Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
| | - Anisha Gehani
- Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
| | - Saugata Sen
- Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
| | - Priya Ghosh
- Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
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Najafi A, Al Ahmar M, Bonnet B, Delpla A, Kobe A, Madani K, Roux C, Deschamps F, de Baère T, Tselikas L. The PEARL Approach for CT-guided Lung Biopsy: Assessment of Complication Rate. Radiology 2021; 302:473-480. [PMID: 34726537 DOI: 10.1148/radiol.2021210360] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Percutaneous CT-guided biopsy of lung nodules is an established method with high diagnostic accuracy but a high rate of pneumothorax and chest tube insertion compared with endobronchial methods. Purpose To investigate the effect of a protocol combining patient positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching (PEARL) on complication rate after percutaneous CT-guided lung biopsy, especially chest tube insertion. Materials and Methods In a secondary analysis of both prospectively and retrospectively acquired data from December 2019 to November 2020, consecutive participants underwent biopsy with use of the PEARL protocol (prospective data) and were compared with patients who underwent biopsy at the same tertiary cancer center according to the standard method without any additional techniques (controls, retrospective data). Patient demographics, lesion characteristics, intraprocedural data, complications, and histologic results were recorded and compared. Results One hundred patients in the control group (mean age ± standard deviation, 63 years ± 12; 61 men) and 100 participants in the PEARL group (mean age, 64 years ± 12; 48 men) were evaluated. No differences were found in patient and lesion characteristics. The emphysema rate was 47 of 100 patients (47%) in both groups. The rate of pneumothorax was 37 of 100 patients (37%) in the control group versus 16 of 100 (16%) in the PEARL group (P = .001). Of the pneumothoraxes that occurred, fewer were during the intervention in the PEARL group, with 21 of 37 onsets (57%) in the control group versus three of 16 onsets (19%) in the PEARL group (P < .001). A chest tube was inserted in 13 of 100 patients (13%) in the control group and only in one of 100 (1%) in the PEARL group (P = .002). Histologic findings were diagnostic in 94 of 100 patients (94%) in the control group and 95 of 100 (95%) in the PEARL group (P > .99). Conclusion During CT-guided percutaneous lung biopsy, a protocol of positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching, or PEARL, reduced rates of pneumothorax and chest tube insertion. © RSNA, 2021.
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Affiliation(s)
- Arash Najafi
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Marc Al Ahmar
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Baptiste Bonnet
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Alexandre Delpla
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Adrian Kobe
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Khaled Madani
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Charles Roux
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Frédéric Deschamps
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Thierry de Baère
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
| | - Lambros Tselikas
- From the Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, Île-de France, France
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Zlevor AM, Mauch SC, Knott EA, Pickhardt PJ, Mankowski Gettle L, Mao L, Meyer CA, Hartung MP, Kim DH, Lubner MG, Hinshaw JL, Foltz ML, Ziemlewicz TJ, Lee FT. Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies. J Vasc Interv Radiol 2021; 32:1319-1327. [PMID: 34229043 DOI: 10.1016/j.jvir.2021.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To evaluate the outcomes of computed tomography (CT) fluoroscopy-guided core lung biopsies with emphasis on diagnostic yield, complications, and efficacy of parenchymal and pleural blood patching to avoid chest tube placement. METHODS This is a single-center retrospective analysis of CT fluoroscopy-guided percutaneous core lung biopsies between 2006 and 2020. Parenchymal blood patching during introducer needle withdrawal was performed in 74% of cases as a preventive measure, and pleural blood patching was the primary salvage maneuver for symptomatic or growing pneumothorax in 60 of 83 (72.2%) applicable cases. RESULTS A total of 1,029 patients underwent 1,112 biopsies (532 men; mean age, 66 years; 38.6%, history of emphysema; lesion size, 16.7 mm). The diagnostic yield was 93.6% (1,032/1,103). Fewer complications requiring intervention were observed in patients who underwent parenchymal blood patching (5.7% vs 14.2%, P < .001). Further intervention was required in 83 of 182 pneumothorax cases, which included the following: (a) pleural blood patch (5.4%, 60/1,112), (b) chest tube placement without a pleural blood patch attempt (1.5%, 17/1,112), and (c) simple aspiration (0.5%, 6/1,112). Pleural blood patch as monotherapy was successful in 83.3% (50/60) of cases without need for further intervention. The overall chest tube rate was 2.6% (29/1,112). Emphysema was the only significant risk factor for complications requiring intervention (P ≤ .001). CONCLUSIONS Parenchymal blood patching during introducer needle withdrawal decreased complications requiring intervention. Salvage pleural blood patching reduced the frequency of chest tube placement for pneumothorax.
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Affiliation(s)
- Annie M Zlevor
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Scott C Mauch
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Emily A Knott
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | | | - Lu Mao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | | | - Michael P Hartung
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - David H Kim
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | - J Louis Hinshaw
- Department of Radiology, University of Wisconsin, Madison, Wisconsin; Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Marcia L Foltz
- Department of Radiology, University of Wisconsin, Madison, Wisconsin
| | | | - Fred T Lee
- Department of Radiology, University of Wisconsin, Madison, Wisconsin; Department of Urology, University of Wisconsin, Madison, Wisconsin; Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin.
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Efficacy of Tract Embolization After Percutaneous Pulmonary Radiofrequency Ablation. Cardiovasc Intervent Radiol 2021; 44:903-910. [PMID: 33492452 DOI: 10.1007/s00270-020-02745-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE To evaluate the efficacy of tract embolization technique using gelatin sponge slurry with iodinated contrast medium (GSSI) to reduce the incidence of pneumothorax and chest tube placement after computed tomography-guided lung radiofrequency ablation (RFA). MATERIALS AND METHODS In this single-institute retrospective study, we examined all patients with metastatic cancer treated from January 2016 to December 2019 by interventional radiologists with computed tomography-guided lung RFA. Since 2017 in our institution, we have applied a tract embolization technique using GSSI for all RFA. Patients were included into those who underwent lung RFA performed either with GSSI (Group A) or without GSSI (Group B). Univariate and multivariate analyses were performed between the two groups to identify risk factors for pneumothorax and chest tube placement, including patient demographics and lesion characteristics. RESULTS This study included 116 patients (54 men, 62 women; mean age, 65 ± 11 years) who underwent RFA. Group A comprised 71 patients and Group B comprised 45 patients. Patients who underwent tract embolization had a significantly lower incidence of pneumothorax (Group A, 34% vs. Group B, 62%; p < 0.001) and chest tube insertion (Group A, 10% vs. Group B, 29%; p < 0.01). No embolic complications occurred. The hospitalization stay was significantly shorter in patients who underwent tract embolization (mean, 1.04 ± 0.2 days; p = 0.02). CONCLUSION Tract embolization after percutaneous lung RFA significantly reduced the rate of post-RFA pneumothorax and chest tube placement and was safer than the standard lung RFA technique.
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Herbst RS, Aisner DL, Sonett JR, Turk AT, Weintraub JL, Lindeman NI. Practical Considerations Relating to Routine Clinical Biomarker Testing for Non-small Cell Lung Cancer: Focus on Testing for RET Fusions. Front Med (Lausanne) 2021; 7:562480. [PMID: 33553195 PMCID: PMC7859651 DOI: 10.3389/fmed.2020.562480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/03/2020] [Indexed: 11/15/2022] Open
Abstract
For patients with advanced non–small cell lung cancer, genomic profiling of tumors to identify potentially targetable alterations and thereby inform treatment selection is now part of standard care. While molecular analyses are primarily focused on actionable biomarkers associated with regulatory agency-approved therapies, there are a number of emerging biomarkers linked to investigational agents in advanced stages of clinical development will become approved agents. A particularly timely example is the reported data and US Food and Drug Administration approval of highly specific small molecule inhibitors of the proto-oncogene tyrosine-protein kinase receptor RET indicate that testing for tumor RET gene fusions in patients with NSCLC has become clinically important. As the number of biomarkers to be tested in NSCLC grows, it becomes increasingly important to optimize and prioritize the use of biopsy tissue, in order to both continue to allow accurate histopathological diagnosis and also to support concurrent genomic profiling to identify perhaps relatively uncommon genetic events. In order to provide practical expert consensus guidance to optimize processes facilitating genomic testing in NSCLC and to overcome barriers to access and implementation, a multidisciplinary advisory board was held in New York, on January 30, 2019. The panel comprised physicians involved in sample procurement (interventional radiologists and a thoracic surgeon), surgical pathologists specializing in the lung, molecular pathologists, and thoracic oncologists. Particular consideration was given to the key barriers faced by these experts in establishing institutional genomic screening programs for NSCLC. Potential solutions have been devised in the form of consensus opinions that might be used to help resolve such issues.
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Affiliation(s)
- Roy S Herbst
- Section of Medical Oncology, Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, CT, United States
| | - Dara L Aisner
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Joshua R Sonett
- Division of Thoracic Surgery, Lung Transplant Program, Columbia University Medical Center, New York, NY, United States
| | - Andrew T Turk
- Department of Pathology and Cell Biology, Columbia University, New York, NY, United States
| | - Joshua L Weintraub
- Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Neal I Lindeman
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States
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12
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Chung C, Kim Y, Park D. Transthoracic Needle Biopsy: How to Maximize Diagnostic Accuracy and Minimize Complications. Tuberc Respir Dis (Seoul) 2020; 83:S17-S24. [PMID: 33272004 PMCID: PMC7837377 DOI: 10.4046/trd.2020.0156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/13/2022] Open
Abstract
Although transthoracic needle biopsy (TTNB) was introduced for lung biopsy about 40 years ago, it is still mainstay of pathologic diagnosis in lung cancer, because it is relatively inexpensive and can obtain tissue regardless of the tumor-bronchus relationship. With several technological advances, proceduralists can perform TTNB more safely and accurately. Utilizing ultrasound-guided biopsy for peripheral lesions in contact with the pleura and rapid on-site evaluation during the procedure are expected to make up the weakness of TTNB. However, due to the inherent limitations of the percutaneous approach, the incidence of complications such as pneumothorax or bleeding is inevitably higher than that of other lung biopsy techniques. Thorough understating of each biopsy modality and additional technique are fundamental for maximizing diagnostic accuracy and minimizing the complications.
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Affiliation(s)
- Chaeuk Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Yoonjoo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Dongil Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
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13
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Sheth RA, Baerlocher MO, Connolly BL, Dariushnia SR, Shyn PB, Vatsky S, Tam AL, Gupta S. Society of Interventional Radiology Quality Improvement Standards on Percutaneous Needle Biopsy in Adult and Pediatric Patients. J Vasc Interv Radiol 2020; 31:1840-1848. [DOI: 10.1016/j.jvir.2020.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/13/2022] Open
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Turgut B, Duran FM, Bakdık S, Arslan S, Tekin AF, Esme H. Effectiveness of autologous blood injection in reducing the rate of pneumothorax after percutaneous lung core needle biopsy. ACTA ACUST UNITED AC 2020; 26:470-475. [PMID: 32755876 DOI: 10.5152/dir.2020.19202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE To assess the effectiveness and safety of autologous intraparenchymal blood patch (IBP) application in reducing the frequency of pneumothorax (PTX) after percutaneous transthoracic pulmonary core needle biopsy. METHODS The records of patients who underwent the transthoracic pulmonary core needle biopsy procedure under CT guidance between January 2015 and October 2018 were screened retrospectively. Patients whose traversed pulmonary parenchymal length was ≥20 mm during biopsy were included in the study irrespective of lesion size. The IBP procedure was made a department policy in November 2017; patients who underwent biopsy after this date comprised the IBP group, while those who underwent the procedure before this date comprised the control group. IBP recipients received 2-5 mL of autologous blood injection to the needle tract. Demographic data, procedural reports, tomography images, and the follow-up records of patients were assessed. RESULTS A total of 262 patients were included in the study. Of the 91 patients that received an IBP, PTX developed in 13 (14.1%), with 7 (7.7%) requiring a thoracic tube. Of the 171 patients who did not receive an IBP, PTX developed in 45 (26.3%), with 19 (11.1%) requiring a thoracic tube. Patients who received an autologous IBP showed a significantly lower rate of PTX development versus those who did not (P = 0.01). Similarly, a significantly lower number of patients who received the blood patch required chest tube placement (P = 0.015). CONCLUSION Autologous IBP is a safe, inexpensive and easy to use method that reduces the rate of PTX development and thoracic tube application after percutaneous core needle biopsies of the lung.
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Affiliation(s)
- Bekir Turgut
- Department of Radiology, University of Health Sciences Konya Training and Research Hospital, Konya, Turkey
| | - Ferdane Melike Duran
- Department of Thoracic Surgery, University of Health Sciences Konya Training and Research Hospital, Konya, Turkey
| | - Süleyman Bakdık
- Department of Radiology, Necmettin Erbakan University Training and Research Hospital, Konya, Turkey
| | - Serdar Arslan
- Department of Radiology, University of Health Sciences Konya Training and Research Hospital, Konya, Turkey
| | - Ali Fuat Tekin
- Department of Radiology, University of Health Sciences Konya Training and Research Hospital, Konya, Turkey
| | - Hıdır Esme
- Department of Thoracic Surgery, University of Health Sciences Konya Training and Research Hospital, Konya, Turkey
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15
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Türk Y, Küskün A, Devecioğlu İ. Novel Use of Extrapleural Autologous Blood Injection in CT-Guided Percutaneous Lung Biopsy and its Comparison to Intraparenchymal Autologous Blood Patch Injection: A Single-Center, Prospective, Randomized, and Controlled Clinical Trial. Cardiovasc Intervent Radiol 2020; 43:1315-1322. [PMID: 32676959 DOI: 10.1007/s00270-020-02585-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/26/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the rate of iatrogenic pneumothorax and the need for intervention with extrapleural autologous blood injection (EPABI) along with intraparenchymal autologous blood patch injection (IABPI) or IABPI-only in CT-guided percutaneous lung biopsy. MATERIALS AND METHODS One hundred and thirty-nine participants were referred for CT-guided percutaneous lung biopsy, and 81 were randomized into study (EPABI + IABPI, n = 40) and control (IABPI-only, n = 41) groups. In the study group, ~5 ml of autologous blood was injected into the extrapleural space before passing through the parietal and visceral pleura. The primary outcome was the incidence of pneumothorax in two cohorts within 2 weeks after the procedure. RESULTS In the per-protocol population, pneumothorax rates were 5.9% and 25.7% in the study and control groups, respectively. The difference between the two groups was -19.8% (95% CI: -36.3%, 3.32%) (p = 0.025). On the other hand, in the population with no intraprocedural deviations, pneumothorax rates were 3.2% and 17.2% in the study and control groups, respectively. The difference between the two groups was -14.0% (95% CI: -29.1%, 1.07%) (p = 0.083). In the control group, 3.45% of the cases required aspiration, while no intervention was required in the study group. CONCLUSION The EPABI application along with IABPI is a promising method to decrease the incidence of pneumothorax following CT-guided percutaneous lung biopsy.
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Affiliation(s)
- Yaşar Türk
- Radiology Department, Medical Faculty, Tekirdağ Namık Kemal University, Namik Kemal Mh., Kampus Cd., 59100, Suleymanpasa, Tekirdağ, Turkey.
| | - Atakan Küskün
- Radiology Department, Kırklareli State Hospital, Yayla Mh, 39000, Kırklareli, Turkey
| | - İsmail Devecioğlu
- Biomedical Engineering Department, Çorlu Engineering Faculty, Tekirdağ Namık Kemal University, Silahtaraga Mh., Çorlu, Tekirdağ, Turkey
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16
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Huo YR, Chan MV, Habib AR, Lui I, Ridley L. Pneumothorax rates in CT-Guided lung biopsies: a comprehensive systematic review and meta-analysis of risk factors. Br J Radiol 2020; 93:20190866. [PMID: 31860329 DOI: 10.1259/bjr.20190866] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This systematic review and meta-analysis investigated risk factors for pneumothorax following CT-guided percutaneous transthoracic lung biopsy. METHODS A systematic search of nine literature databases between inception to September 2019 for eligible studies was performed. RESULTS 36 articles were included with 23,104 patients. The overall pooled incidence for pneumothorax was 25.9% and chest drain insertion was 6.9%. Pneumothorax risk was significantly reduced in the lateral decubitus position where the biopsied lung was dependent compared to a prone or supine position [odds ratio (OR):3.15]. In contrast, pneumothorax rates were significantly increased in the lateral decubitus position where the biopsied lung was non-dependent compared to supine (OR:2.28) or prone position (OR:3.20). Other risk factors for pneumothorax included puncture site up compared to down through a purpose-built biopsy window in the CT table (OR:4.79), larger calibre guide/needles (≤18G vs >18G: OR 1.55), fissure crossed (OR:3.75), bulla crossed (OR:6.13), multiple pleural punctures (>1 vs 1: OR:2.43), multiple non-coaxial tissue sample (>1 vs 1: OR 1.99), emphysematous lungs (OR:3.33), smaller lesions (<4 cm vs 4 cm: OR:2.09), lesions without pleural contact (OR:1.73) and deeper lesions (≥3 cm vs <3cm: OR:2.38). CONCLUSION This meta-analysis quantifies factors that alter pneumothorax rates, particularly with patient positioning, when planning and performing a CT-guided lung biopsy to reduce pneumothorax rates. ADVANCES IN KNOWLEDGE Positioning patients in lateral decubitus with the biopsied lung dependent, puncture site down with a biopsy window in the CT table, using smaller calibre needles and using coaxial technique if multiple samples are needed are associated with a reduced incidence of pneumothorax.
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Affiliation(s)
- Ya Ruth Huo
- Bankstown-Campbelltown Hospital, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Michael Vinchill Chan
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia.,University of Sydney, Faculty of Medicine, Sydney, Australia
| | - Al-Rahim Habib
- University of Sydney, Faculty of Medicine, Sydney, Australia
| | - Isaac Lui
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
| | - Lloyd Ridley
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
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Renier H, Gérard L, Lamborelle P, Cousin F. Efficacy of the tract embolization technique with gelatin sponge slurry to reduce pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy. Cardiovasc Intervent Radiol 2019; 43:597-603. [PMID: 31792589 DOI: 10.1007/s00270-019-02387-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/25/2019] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Hadrien Renier
- Department of Imaging, Centre Hospitalier Universitaire de Liège, Avenue de l'Hôpital 1, 4000, Liège, Belgium
| | - Laurent Gérard
- Department of Imaging, Centre Hospitalier Universitaire de Liège, Avenue de l'Hôpital 1, 4000, Liège, Belgium
| | - Pierre Lamborelle
- Department of Imaging, Centre Hospitalier Universitaire de Liège, Avenue de l'Hôpital 1, 4000, Liège, Belgium
| | - François Cousin
- Department of Nuclear Medicine and Cancer Imaging, Centre Hospitalier Universitaire de Liège, Avenue de l'Hôpital 1, 4000, Liège, Belgium.
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Chae KJ, Hong H, Yoon SH, Hahn S, Jin GY, Park CM, Goo JM. Non-diagnostic Results of Percutaneous Transthoracic Needle Biopsy: A Meta-analysis. Sci Rep 2019; 9:12428. [PMID: 31455841 PMCID: PMC6711972 DOI: 10.1038/s41598-019-48805-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
Non-diagnostic results can affect the diagnostic performance of percutaneous transthoracic needle biopsy (PTNB) but have not been critically meta-analyzed yet. To meta-analyze the incidence and malignancy rate of non-diagnostic results, 3-by-2 table approaches rather than the conventional 2-by-2 approaches are needed to know its impact on the diagnostic performance of PTNB. A systematic literature search identified studies evaluating the diagnostic performance of PTNB with extractable outcomes. A total of 143 studies with 35,059 biopsies were included. The pooled incidence of non-diagnostic results was 6.8% (95% CI, 6.0-7.6%; I2 = 0.91). The pooled malignancy rate of non-diagnostic results was 59.3% (95% CI, 51.7-66.8%; I2 = 0.80), and was correlated with the prevalence of malignancy (correlation coefficient, 0.66; 95% CI, 0.42-0.91). Pooled percentage decrease of sensitivity and specificity due to non-diagnostic results were 4.5% (95% CI, 3.2-5.7%; I2 = 0.64) and 10.7% (95% CI, 7.7-13.7%; I2 = 0.70), respectively, and the pooled incidence of non-diagnostic results was 4.4% (95% CI, 3.2-5.8%; I2 = 0.83) in lesions ultimately diagnosed as malignancies and 10.4% (95% CI, 7.5-13.8%; I2 = 0.74) in benign disease. In conclusion, non-diagnostic results averagely occurred in 6.8% of PTNB and more than half of the results were malignancies. The non-diagnostic results decreased specificity and sensitivity by 10.7% and 4.5%, respectively, demanding efforts to minimize the non-diagnostic results in PTNB.
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Affiliation(s)
- Kum Ju Chae
- Department of Radiology, Institute of Medical Science, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea
| | - Hyunsook Hong
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Seokyung Hahn
- Department of Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gong Yong Jin
- Department of Radiology, Institute of Medical Science, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, South Korea
| | - Chang Min Park
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Mo Goo
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
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19
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Diagnostic outcome and safety of CT-guided core needle biopsy for mediastinal masses: a systematic review and meta-analysis. Eur Radiol 2019; 30:588-599. [DOI: 10.1007/s00330-019-06377-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/13/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022]
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20
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Accuracy and complications of CT-guided pulmonary core biopsy in small nodules: a single-center experience. Cancer Imaging 2019; 19:51. [PMID: 31337425 PMCID: PMC6651998 DOI: 10.1186/s40644-019-0240-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/16/2019] [Indexed: 01/05/2023] Open
Abstract
Background Computed tomography (CT)-guided pulmonary core biopsies of small pulmonary nodules less than 15 millimeters (mm) are challenging for radiologists, and their diagnostic accuracy has been shown to be variable in previous studies. Common complications after the procedure include pneumothorax and pulmonary hemorrhage. The present study compared the diagnostic accuracy of small and large lesions using CT-guided core biopsies and identified the risk factors associated with post-procedure complications. Methods Between January 1, 2016, and December 31, 2017, 198 CT-guided core biopsies performed on 195 patients at our institution were retrospectively enrolled. The lesions were separated into group A (< or = 15 mm) and group B (> 15 mm) according to the longest diameter of the target lesions on CT. Seventeen-gauge introducer needles and 18-gauge automated biopsy instruments were coaxially used for the biopsy procedures. The accuracy and complications, including pneumothorax and pulmonary hemorrhage, of the procedures of each group were recorded. The risk factors for pneumothorax and pulmonary hemorrhage were determined using univariate analysis of variables. Results The diagnostic accuracies of group A (n = 43) and group B (n = 155) were 83.7 % and 96.8 %, respectively (p = 0.005). The risk factors associated with post-biopsy pneumothorax were longer needle path length from the pleura to the lesion (p = 0.020), lesion location in lower lobes (p = 0.002), and patients with obstructive lung function tests (p = 0.034). The risk factors associated with post-biopsy pulmonary hemorrhage were longer needle path length from the pleura to the lesion (p < 0.001), smaller lesions (p < 0.001), non-pleural contact lesions (p < 0.001), patients without restrictive lung function tests (p = 0.034), and patients in supine positions (p < 0.003). Conclusion CT-guided biopsies of small nodules equal to or less than 15 mm using 17-gauge guiding needles and 18-gauge biopsy guns were accurate and safe. The biopsy results of small lesions were less accurate than those of large lesions, but the results were a reliable reference for clinical decision-making. Understanding the risk factors associated with the complications of CT-guided biopsies is necessary for pre-procedural planning and communication.
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21
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Perl RM, Risse E, Hetzel J, Bösmüller H, Kloth C, Fritz J, Horger M. The effect of intraparenchymal blood patching on the rate of pneumothorax in patients undergoing percutaneous CT-guided core biopsy of the lung. Eur J Radiol 2019; 116:14-20. [PMID: 31153555 DOI: 10.1016/j.ejrad.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/26/2019] [Accepted: 04/18/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE To assess the effect of intraparenchymal blood patching (IBP) as well as tumor- and operator-related risk factors on the rate of pneumothoraxes after percutaneous CT-guided core needle biopsy of the lung. MATERIALS AND METHODS We performed a retrospective analysis of 868 CT-guided lung biopsies that were conducted at our institution between 2003 and 2018, of which 419 (48%) received an IBP. Outcome variable included the rates of pneumothorax and chest tube placement, as well as lesion size (<3 cm versus ≥3 cm long axis diameter), lesion depth (≤2 cm, >2-4 cm, >4-5 cm and >5 cm distance to the pleura), location within the lungs (upper lobe, lower lobe, middle lobe), needle caliber (13 G, 15 G, 17 G, 19 G), number of samples taken (1-3 versus ≥4 samples), and experience of the performing physician. RESULTS The rate of pneumothorax was significantly (p < 0.05) lower in the group with IBP (10.7%) compared to the group without IBP (15.4%). The number of post-interventional chest tube placements was also lower in the IBP group (3.1% vs. 5.8%) but not statistically significant. The lesion size correlated negatively with the rate of pneumothoraxes, whereas in both groups (±IBP) lesions ≥ 3 cm showed a significantly lower rate of pneumothorax (p < 0.05). With increasing lesion depth, the pneumothorax rate increased with (p < 0.01) and without (p < 0.001) IBP. The rate of pneumothorax was significantly lower (p < 0.05) for 17 G needles with IBP, but not for other calibers. For biopsies in the lower lobe, the pneumothorax rate reduced significantly (p < 0.001) with IBP. In case of ≥4 tissue samples, the pneumothorax rate was significantly lower with IBP (p < 0.01). For experienced operators, the overall pneumothorax rate was significantly lower compared to less experienced operators (p < 0001). CONCLUSIONS IBP significantly reduces the rate of pneumothorax following CT-guided lung biopsies in particular for lesions located deeper in the lungs, when ≥4 samples are taken, when samples are taken by less-experienced operators, and when sampling from the lower lobes.
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Affiliation(s)
- R M Perl
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany.
| | - E Risse
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
| | - J Hetzel
- Department of Internal Medicine II, Eberhard Karls University, Tübingen, Germany
| | - H Bösmüller
- Institute of Pathology and Neuropathology and Comprehensive Cancer Center, Eberhard Karls University, Tübingen, Germany
| | - C Kloth
- Department for Diagnostic and Interventional Radiology, University Hospital Ulm, Germany
| | - J Fritz
- Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiological Science, 601 N. Caroline Street, JHOC 3140A, Baltimore, MD, 21287, United States
| | - M Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University, Tübingen, Germany
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Effect of Needle-Tract Bleeding on Pneumothorax and Chest Tube Placement Following CT Guided Core Needle Lung Biopsy. J Belg Soc Radiol 2019; 103:21. [PMID: 30972378 PMCID: PMC6450251 DOI: 10.5334/jbsr.1591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Bleeding in the biopsy tract has been studied for its ability to decrease the risk of pneumothorax with indefinite results in the previous studies. Purpose: To investigate the risk factors for needle-tract bleeding (NTB) and the possible effect of NTB on the pneumothorax and resultant chest tube placement after CT-guided cutting needle biopsy (CT-CNB) of pulmonary lesions. Methods: Predictive variables for NTB and the effect of NTB on the development of pneumothorax and consequent chest tube placement were retrospectively determined in 416 patients who had undergone an 18-gauge non-coaxial CT-CNB (338 men and 78 women; average age, 59.3 years). Patient-related parameters were age, gender, patient position, and severity of pulmonary emphysema. Lesion-related variables were size, localization, and contour characteristics of the lesion. Procedure-related variables were the presence of atelectasis, pleural tag, and fissure in the needle-tract, length of the aerated lung parenchyma crossed by needle, needle entry angle, number of pleural punctures, the experience of the operator, and procedure duration. All variables were analyzed by x2 test and logistic regression analysis. Results: NTB was demonstrated in 142 of 421 (33.7%) procedures. The predictive variables of NTB were smaller lesion size (p = 0.011) and greater lesion depth (p = 0.002). In patients without emphysema around the lesion, the pneumothorax developed in 44/190 cases (23.1%) without NTB and in 12/95 procedures (12.6%) with NTB (p < 0.001). Conclusion: NTB may have a preventive effect on pneumothorax development, particularly in the absence of emphysema around the lesion.
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Huo YR, Chan MV, Habib AR, Lui I, Ridley L. Post-Biopsy Manoeuvres to Reduce Pneumothorax Incidence in CT-Guided Transthoracic Lung Biopsies: A Systematic Review and Meta-analysis. Cardiovasc Intervent Radiol 2019; 42:1062-1072. [PMID: 30863965 DOI: 10.1007/s00270-019-02196-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 03/04/2019] [Indexed: 12/11/2022]
Abstract
This systematic review and meta-analysis investigated post-biopsy manoeuvres to reduce pneumothorax following computed tomography-guided percutaneous transthoracic lung biopsy. Twenty-one articles were included with 7080 patients. Chest drain insertion rates were significantly reduced by ninefold with the normal saline tract sealant compared to controls (OR 0.11, 95% CI 0.02-0.48), threefold with the rapid rollover manoeuvre to puncture site down (OR 0.34, 95% CI 0.18-0.63), threefold with the tract plug (OR 0.33, 95% CI 0.22-0.48) and threefold with the blood patch (OR 0.39, 95% CI 0.26-0.58). The absolute chest drain insertion rates were the lowest in the normal saline tract sealant (0.8% vs 7.3% for controls), rapid rollover (1.9% vs 5.2%), deep expiration and breath-hold on needle extraction (0.9% vs 1.8%) and standard rollover versus no rollover (2.6% vs 5.2%). These findings highlight post-biopsy manoeuvres which could help reduce pneumothorax and chest drain insertions following lung biopsies. LEVEL OF EVIDENCE: Level 1/no level of evidence, systematic review.
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Affiliation(s)
- Ya Ruth Huo
- NSW Health, Bankstown-Campbelltown Hospital, Sydney, Australia
| | - Michael Vinchill Chan
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia. .,Faculty of Medicine, University of Sydney, Sydney, Australia.
| | - Al-Rahim Habib
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Isaac Lui
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
| | - Lloyd Ridley
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
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Maybody M, Muallem N, Brown KT, Moskowitz CS, Hsu M, Zenobi CL, Jihad M, Getrajdman GI, Sofocleous CT, Erinjeri JP, Covey AM, Brody LA, Yarmohammadi H, Deipolyi AR, Bryce Y, Alago W, Siegelbaum RH, Durack JC, Gonzalez-Aguirre AJ, Ziv E, Boas FE, Solomon SB. Autologous Blood Patch Injection versus Hydrogel Plug in CT-guided Lung Biopsy: A Prospective Randomized Trial. Radiology 2018; 290:547-554. [PMID: 30480487 DOI: 10.1148/radiol.2018181140] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare the effect of autologous blood patch injection (ABPI) with that of a hydrogel plug on the rate of pneumothorax at CT-guided percutaneous lung biopsy. Materials and Methods In this prospective randomized controlled trial ( https://ClinicalTrials.gov , NCT02224924), a noninferiority design was used for ABPI, with a 10% noninferiority margin when compared with the hydrogel plug, with the primary outcome of pneumothorax rate within 2 hours of biopsy. A type I error rate of 0.05 and 90% power were specified with a target study population of 552 participants (276 in each arm). From October 2014 to February 2017, all potential study participants referred for CT-guided lung biopsy (n = 2052) were assessed for enrollment. Results The data safety monitoring board recommended the trial be closed to accrual after an interim analysis met prespecified criteria for early stopping based on noninferiority. The final study group consisted of 453 participants who were randomly assigned to the ABPI (n = 226) or hydrogel plug (n = 227) arms. Of these, 407 underwent lung biopsy. Pneumothorax rates within 2 hours of biopsy were 21% (42 of 199) and 29% (60 of 208); chest tube rates were 9% (18 of 199) and 13% (27 of 208); and delayed pneumothorax rates within 2 weeks after biopsy were 1.4% (three of 199) and 1.5% (three of 208) in the ABPI and hydrogel plug arms, respectively. Conclusion Autologous blood patch injection is noninferior to a hydrogel plug regarding the rate of pneumothorax after CT-guided percutaneous lung biopsy. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Majid Maybody
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Nadim Muallem
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Karen T Brown
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Chaya S Moskowitz
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Meier Hsu
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Christina L Zenobi
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Marwah Jihad
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - George I Getrajdman
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Constantinos T Sofocleous
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Joseph P Erinjeri
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Anne M Covey
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Lynn A Brody
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Hooman Yarmohammadi
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Amy R Deipolyi
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Yolanda Bryce
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - William Alago
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Robert H Siegelbaum
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Jeremy C Durack
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Adrian J Gonzalez-Aguirre
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Etay Ziv
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - F Edward Boas
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
| | - Stephen B Solomon
- From the Departments of Radiology (M.M., N.M., K.T.B., C.L.Z., M.J., C.I.G., C.T.S., J.P.E., A.M.C., L.A.B., H.Y., A.R.D., Y.B., W.A., R.H.S., J.C.D., A.J.G., E.Z., F.E.B., S.B.S.) and Epidemiology and Biostatistics (C.S.M., M.H.), Memorial Sloan Kettering Cancer Center, 1275 York Ave, M276C, New York, NY 10065
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Özturan İU, Doğan NÖ, Alyeşil C, Pekdemir M, Yılmaz S, Sezer HF. Factors predicting the need for tube thoracostomy in patients with iatrogenic pneumothorax associated with computed tomography-guided transthoracic needle biopsy. Turk J Emerg Med 2018; 18:105-110. [PMID: 30191189 PMCID: PMC6107931 DOI: 10.1016/j.tjem.2018.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 01/05/2023] Open
Abstract
Objectives Traumatic iatrogenic pneumothorax occurs most often after a transthoracic needle biopsy. Since this procedure has become a common outpatient intervention, emergency department admissions of post-biopsy pneumothorax patients have increased. The aim of this study was to determine the factors that predict the need for tube thoracostomy in patients with post-biopsy pneumothorax in the emergency department. Methods A retrospective cross-sectional study was conducted on 191 patients with post-biopsy pneumothorax who were admitted to the emergency department between 2010 and 2017. Patient characteristics, clinical findings at the emergency department presentation, and procedural and radiological features were reviewed. A multivariate logistic regression model was constructed using the variables from univariate comparisons to determine the need for tube thoracostomy in patients with iatrogenic pneumothorax, and the effect sizes were demonstrated with odds ratios. Results Tube thoracostomies were performed on 69 out of 191 patients (36.1%). A total of 122 patients (63.9%) were treated with supplemental oxygen therapy without any other intervention, and 126 patients (66.0%) were hospitalized. In the multivariate model, the variables predicting the need for a tube thoracostomy were decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation and increased pleura–lesion distance. A distance of 19.7 mm predicted the need with a sensitivity of 69.6% and a specificity of 62.3%. Conclusion Decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation, and increased pleura-lesion distance may predict the need for a tube thoracostomy in patients with post-biopsy pneumothorax.
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Affiliation(s)
- İbrahim Ulaş Özturan
- Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey
| | - Nurettin Özgür Doğan
- Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey
| | - Cansu Alyeşil
- Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey
| | - Murat Pekdemir
- Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey
| | - Serkan Yılmaz
- Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey
| | - Hüseyin Fatih Sezer
- Kocaeli University, Faculty of Medicine, Department of Thoracic Surgery, Kocaeli, Turkey
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Tavare AN, Hare SS, Miller FNA, Hammond CJ, Edey A, Devaraj A. A survey of UK percutaneous lung biopsy practice: current practices in the era of early detection, oncogenetic profiling, and targeted treatments. Clin Radiol 2018; 73:800-809. [PMID: 29921442 DOI: 10.1016/j.crad.2018.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/04/2018] [Indexed: 11/28/2022]
Abstract
AIM To ascertain current percutaneous lung biopsy practices around the UK. MATERIALS AND METHODS A web-based survey was sent to all British Society of Thoracic Imaging (BSTI) and British Society of Interventional Radiology (BSIR) members (May 2017) assessing all aspects of lung biopsy practice. Responses were collected anonymously. RESULTS Two hundred and thirty-nine completed responses were received (28.8% response rate). Of the respondents, 48.5% worked in a teaching hospital and 51.5% in a district general hospital, while 32.6% (78/239) were specialist thoracic radiologists, 29.2% (70/239) "general" radiologists with a thoracic subspecialty interest, and 28% (67/239) interventional radiologists. Of the respondents, 30.1% (72/239) did not require pre-biopsy lung function tests (PFTs); 45.6% (108/237) stopped aspirin before the procedure; 97.5% primarily use computed tomography (CT) guidance for biopsy and 88.7% (212/239) perform core needle biopsy (CNB); and 86.6% of radiologists use a co-axial technique. There was wide variation in the number of samples routinely taken with most radiologists performing 1-2 passes (55.9%) or 3-4 passes (40.8%). Sixty-four percent reported using chest drain prevention techniques to minimise the impact of iatrogenic pneumothorax, with needle aspiration most frequent (43.9%). Timing of post-biopsy chest radiography (CXR), performed by 95.8% (228/239), also varied greatly: most commonly at either 1 hour (23%), 2 hours (24.7%), or 4 hours (22.6%). Moreover, the time of patient discharge after uncomplicated biopsy was variable, although the majority (66.1%) discharge patients after ≥4 hours. CONCLUSION There are striking variations among surveyed UK radiologists performing lung biopsy in decision-making, pre-biopsy work-up, post-biopsy monitoring, management of pneumothorax, and discharge. The results suggest a need for new updated national percutaneous lung biopsy guidelines.
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Affiliation(s)
- A N Tavare
- Radiology Department, Barnet Hospital, Royal Free London NHS Foundation Trust, UK
| | - S S Hare
- Radiology Department, Barnet Hospital, Royal Free London NHS Foundation Trust, UK
| | - F N A Miller
- Radiology Department, Kings College Hospital NHS Foundation Trust, UK
| | - C J Hammond
- Department of Vascular Radiology, Leeds Teaching Hospitals NHS Trust, UK
| | - A Edey
- Radiology Department, North Bristol NHS Trust, Southmead Hospital, UK
| | - A Devaraj
- Radiology Department, Royal Brompton & Harefield NHS Trust, UK.
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Fintelmann FJ, Sharma A. Sampling of Suspicious Solitary Pulmonary Nodules: Percutaneous Needle Biopsy and Preoperative Localization. Semin Roentgenol 2017; 52:173-177. [DOI: 10.1053/j.ro.2017.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Nonclotted Blood Patch Technique Reduces Pneumothorax and Chest Tube Placement Rates After Percutaneous Lung Biopsies. J Thorac Imaging 2017; 31:243-6. [PMID: 27105052 DOI: 10.1097/rti.0000000000000215] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to determine whether autologous nonclotted blood patch decreases pneumothorax and chest tube placement rates in computed tomography-guided biopsies of the lung. MATERIALS AND METHODS Percutaneous computed tomography-guided lung biopsies performed over a period of 6 years were retrospectively reviewed to determine the overall rates of pneumothorax and chest tube placement and rates before and after the autologous nonclotted blood patch procedure was instituted as a departmental policy. The effect of the intervention was only assessed in patients in whom a blood patch could be applied, therefore only when the needle traversed an aerated lung and only when the needle remained in the lung at the end of the study. RESULTS There was a statistically significant decrease in both the rate of pneumothorax [28% (69/245) vs. 42% (80/189); P=0.002] and chest tube placement [4% (10/245) vs. 16% (30/189); P<0.001] in patients who received nonclotted blood patch versus those who did not. Blood patch was performed in 222/312 (71%) eligible patients after the introduction of the blood patch policy. After policy introduction, there was a decreased rate of pneumothorax, with a rate of 32% (101/312) versus 40% (49/122) (P=0.12) and a statistically significant decrease in departmental chest tube placement rates of 6% (20/312) versus 16% (20/122) (P=0.001). CONCLUSIONS Nonclotted autologous blood patch for percutaneous lung biopsy resulted in significantly decreased pneumothorax and chest tube placement rates in our patient population.
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Abstract
PURPOSE This study aimed to assess the current practice patterns of radiologists performing percutaneous lung biopsies. MATERIALS AND METHODS This cross-sectional study used a web-based survey sent to the Society of Thoracic Radiology membership from August to October 2015. Responses were collected anonymously, and results were tallied. RESULTS A total of 244 Society of Thoracic Radiology members responded to the survey. One hundred thirty-seven radiologists regularly perform percutaneous lung biopsies, of whom 102 (74%) practice at an academic teaching hospital. Computed tomography (CT) and CT fluoroscopy were the modalities of choice for image guidance, preferred by 82 (60%) and 48 (35%) respondents, respectively. Twenty (15%) respondents preferred fine-needle aspiration (FNA) alone, 57 (42%) preferred core needle biopsy (CNB) alone, and 59 (43%) preferred both FNA and CNB in the same setting. On-site cytology was routinely requested by 70 (71%) respondents with access to such services. In cases of suspected lung cancer, 79 (60%) respondents estimated sending tissue for molecular analysis >25% of the time. Forty-three (32%) respondents reported using intraprocedural preventive measures to minimize risk of pneumothorax. CONCLUSIONS Among surveyed radiologists who perform percutaneous lung biopsies, most utilize CT guidance with either CNB alone or in conjunction with FNA. A small minority routinely performs FNA alone, which may negatively impact diagnostic accuracy and provide insufficient tissue for molecular profiling. Education of all radiologists regarding the importance of routinely acquiring and sending greater amounts of tissue for molecular/genomic assessment of suspected lung cancer is needed.
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Graffy P, Loomis SB, Pickhardt PJ, Lubner MG, Kitchin DR, Lee FT, Hinshaw JL. Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT-Guided Needle Biopsy. J Vasc Interv Radiol 2017; 28:608-613.e1. [PMID: 28185770 DOI: 10.1016/j.jvir.2016.12.1217] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 12/16/2016] [Accepted: 12/18/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To investigate whether an autologous intraparenchymal blood patch (IPB) reduces the rate of pneumothorax-related complications associated with computed tomography (CT)-guided lung biopsies. MATERIALS AND METHODS This study included 834 patients: 482 who received an IPB and 352 who did not. Retrospective review was performed of all CT-guided lung biopsies performed at a single institution between August 2006 and September 2013. Patients were excluded if no aerated lung was crossed. The rate of pneumothorax, any associated intervention (eg, catheter placement, aspiration), chest tube placement, and chest tube replacement requiring hospital admission were compared by linear and multiple regression analysis. RESULTS Patients who received an IPB had a significantly lower rate of pneumothorax (145 of 482 [30%] vs 154 of 352 [44%]; P < .0001), pneumothorax-related intervention (eg, catheter aspiration, pleural blood patch, chest tube placement; 43 of 482 [8.9%] vs 85 of 352 [24.1%]; P < .0001), and chest tube placement along with other determinants requiring hospital admission (18 of 482 [3.7%] vs 27 of 352 [7.7%]; P < .0001). No complications related to the IPB were noted in the study group. CONCLUSIONS Autologous IPB placement is associated with a decreased rate of pneumothorax and associated interventions, including chest tube placement and hospital admission, after CT-guided lung biopsies, with no evidence of any adverse effects. These results suggest that an IPB is safe and effective and should be considered when aerated lung is traversed while performing a CT-guided lung biopsy.
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Affiliation(s)
- Peter Graffy
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252.
| | - Scott B Loomis
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
| | - Douglas R Kitchin
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
| | - Fred T Lee
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
| | - J Louis Hinshaw
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Mail Code 3252, Madison, WI 53792-3252
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Muruganandan S, Kumar S, Lee YCG. Blood Patch for Pneumothorax: a Literature Review. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0163-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ahrar JU, Gupta S, Ensor JE, Mahvash A, Sabir SH, Steele JR, McRae SE, Avritscher R, Huang SY, Odisio BC, Murthy R, Ahrar K, Wallace MJ, Tam AL. Efficacy of a Self-expanding Tract Sealant Device in the Reduction of Pneumothorax and Chest Tube Placement Rates After Percutaneous Lung Biopsy: A Matched Controlled Study Using Propensity Score Analysis. Cardiovasc Intervent Radiol 2016; 40:270-276. [PMID: 27826786 DOI: 10.1007/s00270-016-1489-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/26/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the use of a self-expanding tract sealant device (BioSentry™) on the rates of pneumothorax and chest tube insertion after percutaneous lung biopsy. MATERIALS AND METHODS In this retrospective study, we compared 318 patients who received BioSentry™ during percutaneous lung biopsy (treated group) with 1956 patients who did not (control group). Patient-, lesion-, and procedure-specific variables, and pneumothorax and chest tube insertion rates were recorded. To adjust for potential selection bias, patients in the treated group were matched 1:1 to patients in the control group using propensity score matching based on the above-mentioned variables. Patients were considered a match if the absolute difference in their propensity scores was ≤equal to 0.02. RESULTS Before matching, the pneumothorax and chest tube rates were 24.5 and 13.1% in the control group, and 21.1 and 8.5% in the treated group, respectively. Using propensity scores, a match was found for 317 patients in the treatment group. Chi-square contingency matched pair analysis showed the treated group had significantly lower pneumothorax (20.8 vs. 32.8%; p = 0.001) and chest tube (8.2 vs. 20.8%; p < 0.0001) rates compared to the control group. Sub-analysis including only faculty who had >30 cases of both treatment and control cases demonstrated similar findings: the treated group had significantly lower pneumothorax (17.6 vs. 30.2%; p = 0.002) and chest tube (7.2 vs. 18%; p = 0.001) rates. CONCLUSIONS The self-expanding tract sealant device significantly reduced the pneumothorax rate, and more importantly, the chest tube placement rate after percutaneous lung biopsy.
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Affiliation(s)
- Judy U Ahrar
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA. .,Unit 1471, Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, PO Box 301402, Houston, TX, 77230-1402, USA.
| | - Sanjay Gupta
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Joe E Ensor
- The Houston Methodist Cancer Center, Houston Methodist Research Institute, Houston, TX, USA
| | - Armeen Mahvash
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Sharjeel H Sabir
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Joseph R Steele
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Stephen E McRae
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Rony Avritscher
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Steven Y Huang
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ravi Murthy
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Michael J Wallace
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Alda L Tam
- Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Baadh AS, Hoffmann JC, Fadl A, Danda D, Bhat VR, Georgiou N, Hon M. Utilization of the track embolization technique to improve the safety of percutaneous lung biopsy and/or fiducial marker placement. Clin Imaging 2016; 40:1023-8. [DOI: 10.1016/j.clinimag.2016.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/27/2016] [Accepted: 06/14/2016] [Indexed: 12/17/2022]
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Li Y, Du Y, Luo TY, Yang HF, Yu JH, Xu XX, Zheng HJ, Li B. Usefulness of normal saline for sealing the needle track after CT-guided lung biopsy. Clin Radiol 2015; 70:1192-7. [PMID: 26175218 DOI: 10.1016/j.crad.2015.06.081] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 04/06/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
AIM To determine whether the use of normal saline for sealing the needle track can reduce the incidence of pneumothorax and chest tube placement after computed tomography (CT)-guided lung biopsy. MATERIALS AND METHODS A prospective, randomised, controlled trial enrolling 322 patients was conducted. All patients were randomly assigned to one of two groups: those in whom the needle track was not sealed with normal saline (n=161, Group A) and those who did receive normal saline (n=161, Group B). CT-guided biopsy was performed with coaxial technique. Normal saline, which ranged from 1-3 ml, was injected while the trocar needle was being withdrawn. Patient characteristics, lesion, and procedure variables were analysed as potential risk variables for occurrence of pneumothorax and chest tube placement. RESULTS The incidence of pneumothorax was 26.1% in Group A and 6.2% in Group B (p<0.001). Nine patients in Group A and one patient in Group B required chest tube placement (p=0.010). Using multiple logistic regression analysis, smaller lesion size, greater needle-pleural angle, longer lesion-pleural distance, presence of emphysema, and no sealing the needle track with normal saline were significantly associated with an increased risk of pneumothorax, and that the latter three factors were also associated with an increased risk of pneumothorax requiring chest tube placement. CONLUSION Normal saline for sealing the needle track significantly reduces the incidence of pneumothorax and prevents subsequent chest tube placement after CT-guided lung biopsy.
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Affiliation(s)
- Y Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Chongqing City, 400016, China; Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - Y Du
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - T Y Luo
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Chongqing City, 400016, China.
| | - H F Yang
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - J H Yu
- Department of Ultrasound, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - X X Xu
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - H J Zheng
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
| | - B Li
- Department of Radiology, The Affiliated Hospital of North Sichuan Medical College, 63 Wenhua Road, Nanchong City, Sichuan Province, 637000, China
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The Effect of Needle Gauge on the Risk of Pneumothorax and Chest Tube Placement After Percutaneous Computed Tomographic (CT)-Guided Lung Biopsy. Cardiovasc Intervent Radiol 2015; 38:1595-602. [DOI: 10.1007/s00270-015-1097-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
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Rapid needle-out patient-rollover approach after cone beam CT-guided lung biopsy: effect on pneumothorax rate in 1,191 consecutive patients. Eur Radiol 2015; 25:1845-53. [PMID: 25636421 DOI: 10.1007/s00330-015-3601-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 01/04/2015] [Accepted: 01/15/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To investigate the effect of rapid needle-out patient-rollover approach on the incidence of pneumothorax and drainage catheter placement due to pneumothorax in C-arm Cone-beam CT (CBCT)-guided percutaneous transthoracic needle biopsy (PTNB) of lung lesions. METHODS From May 2011 to December 2012, 1227 PTNBs were performed in 1191 patients with a 17-gauge coaxial needle. 617 biopsies were performed without (conventional-group) and 610 with rapid-rollover approach (rapid-rollover-group). Overall pneumothorax rates and incidences of pneumothorax requiring drainage catheter placement were compared between two groups. RESULTS There were no significant differences in overall pneumothorax rates between conventional and rapid-rollover groups (19.8% vs. 23.1%, p = 0.164). However, pneumothorax rate requiring drainage catheter placement was significantly lower in rapid-rollover-group (1.6%) than conventional-group (4.2%) (p = 0.010). Multivariate analysis revealed male, age > 60, bulla crossed, fissure crossed, pleura to target distance > 1.3 cm, emphysema along needle tract, and pleural punctures ≥ 2 were significant risk factors of pneumothorax (p < 0.05). Regarding pneumothorax requiring drainage catheter placement, fissure crossed, bulla crossed, and emphysema along needle tract were significant risk factors (p < 0.05), whereas rapid-rollover approach was an independent protective factor (p = 0.002). CONCLUSIONS The rapid needle-out patient-rollover approach significantly reduced the rate of pneumothorax requiring drainage catheter placement after CBCT-guided PTNB. KEY POINTS • The rapid-rollover approach had little beneficial effect on overall pneumothorax rate. • The rapid-rollover approach significantly reduced drainage catheter placement due to pneumothorax. • The strongest risk factor was pleural punctures ≥ 2 per procedure. • Emphysema along the needle tract was a stronger risk factor than fissure-crossed.
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Risk Factors for Pneumothorax Complicating Radiofrequency Ablation for Lung Malignancy: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2014; 25:1671-81.e1. [DOI: 10.1016/j.jvir.2014.07.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/13/2014] [Accepted: 07/23/2014] [Indexed: 11/23/2022] Open
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