Complications of CT-guided transthoracic lung biopsy : A short report on current literature and a case of systemic air embolism

Efficacy of needle tract embolization using gelfoam in reducing incidence of pneumothorax in CT-guided transthoracic lung biopsies: a systematic review and meta-analysis

OBJECTIVE

Transthoracic CT-guided lung biopsy is associated with risk of pneumothorax, requiring chest tube placement at times. From available literature, we tried to compare the incidence rate of pneumothorax in cases undergoing CT-guided lung biopsy with versus without use of gelfoam slurry for tract occlusion.

METHODS

Databases like SCOPUS, PubMed, Google Scholar, and EMBASE were searched for original studies analysing the efficacy of gelfoam for needle tract embolization following CT-guided lung biopsy till September 2023. Bias in the selected studies was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Pooled odds ratio of the effect of gelfoam slurry on the rate of pneumothorax and chest tube placement following CT-guided lung biopsy was calculated and represented with 95% confidence intervals (95% CI) and prediction interval (PI).

RESULTS

Pooled analysis of six studies revealed that patients undergoing needle tract embolization when compared to non-embolized patients had a significantly decreased risk of pneumothorax with odds reduced by 59% (OR = 0.41, 95% CI = 0.25-0.66, P = .01; PI = -1.694 to 0.094). Also, it led to a significant reduction in severe pneumothorax requiring chest tube placement with reduced odds by 63% (OR = 0.37, 95% CI = 0.20-0.69, P = .01; PI = -1.855 to 0.115).

CONCLUSION

Needle tract embolization using gelfoam has a significant protective effect against pneumothorax as well as chest tube insertion in patients undergoing CT-guided lung biopsy.

ADVANCES IN KNOWLEDGE

Gelfoam needle tract embolization can effectively reduce the risk of pneumothorax and chest tube requirement after lung biopsy.

PROSPERO REGISTRATION ID

CRD42024505788.

FDG PET/CT Performed Prior to CT-Guided Percutaneous Biopsy of Lung Masses is Associated With an Increased Diagnostic Rate and Often Identifies Alternate Safer Sites to Biopsy

Purpose: To determine the benefit of a FDG PET/CT scan prior to CT-guided lung biopsy on the rate of diagnosis, rate of complication, and the identification of potentially safer biopsy sites. Methods: This retrospective observational cross-sectional study evaluated consecutive adult patients who underwent CT-guided lung biopsy in 2020 or 2021 at 2 Canadian tertiary care hospitals. These patients were grouped into those that had PET/CT performed within 8 weeks prior to biopsy, within 8 weeks after biopsy, or no PET/CT scan within this time frame. Biopsy complication rates and pathology diagnostic rates were compared. The PET/CT images of those performed after biopsy were reviewed to determine if alternate safer biopsy sites could be identified. Categorical variables were compared using Pearson chi square test (P < .05 significant). Results: 547 patients who had CT-guided lung biopsy were included. Patients with lung masses (≥3 cm) who had a PET/CT scan prior to biopsy had a higher diagnostic rate (90.8%) compared to those that did not (80.2%). The overall post-biopsy pneumothorax rate was 43.3% with 11.3% overall requiring chest tube insertion and 13.9% requiring hospitalization. There was no difference in complication rate for those who had PET/CT prior to biopsy and those that did not. 28.9% to 42.1% of patients who had PET/CT after biopsy had safer sites amenable to biopsy identified retrospectively outside of the lungs. Conclusion: PET/CT prior to CT-guided lung biopsy improves the diagnostic rate in 10.6% of patients with lung masses (≥3 cm) and identifies alternate safer sites to biopsy in 28.9% to 42.1% of patients (any size lesion).

Evaluating efficacy and safety of a novel registration-free CT-guided needle biopsy navigation system (RC 120): A multicenter, prospective clinical trial

BACKGROUND

Current percutaneous transthoracic needle biopsies (PTNB) navigation systems present challenges due to additional steps and limitations on the operating environment.

RESEARCH QUESTION

We developed a novel, registration-free navigation system for swift and precise CT-guided PTNB, eliminating the need for body surface markers and intraoperative registration. This study assesses its efficacy and safety.

METHODS

A prospective study was conducted on participants aged 18-80 years prepared for PTNB at two clinical centers, from December 2021 to August 2022. The primary endpoint was the success rate of biopsies within 2 needle adjustments, and the secondary endpoint was the success rate within a single adjustment. Safety endpoints were defined by adverse events occurrence.

RESULTS

The study included 98 patients (median age, 64 years, IQR 54-69 years, 71 men). The primary endpoint achieved a biopsy success rate of 98.98 %, and the secondary endpoint demonstrated 97.96 %. The overall success rate was 98.98 %, significantly exceeding the target value of 85 % (P < 0.0001). The median number of CT scans was 3, significantly fewer than predicted for the manual puncture scheme [3 (IQR 3-3) to 8 (IQR 6-8), P < 0.0001]. The average procedure duration was 18.0 min (IQR: 14.0-29.0 min). The most common adverse events were hemorrhage (14 instances) and pneumothorax (8 instances). Other adverse events included elevated blood pressure, hemoptysis, and other common events.

INTERPRETATION

Our registration-free navigation system proved to be an effective and safe system for assisting percutaneous lung biopsies in clinical practice.

Pulmonary artery air embolism with consequent primary respiratory alkalosis and secondary metabolic alkalosis following ventilation therapy: A case report

BACKGROUND

An air embolism is a rare complication that occurs after air enters blood vessels, causing almost no to mild symptoms in patients. Although uncommon, air embolism can be deadly. Critical care professionals should know the warning signs of air embolism and be prepared to carry out the necessary therapeutic interventions. To reduce morbidity and death, this clinical condition must be identified early. Here we are presenting a case of pulmonary artery air embolism as a consequence of contrast agent injection in a chest computed tomography study.

CASE PRESENTATION

A 70-year-old male patient were presented with pulmonary artery air embolism as a consequence of contrast agent injection in a chest computed tomography study. The patient experienced worsening respiratory symptoms that necessitated oxygen therapy, which resulted in respiratory alkalosis with secondary metabolic alkalosis. Following removal of the BiLevel positive airway pressure, the patient was switched to a 2-L nasal cannula, and his breathing rate increased to 34 breaths/min. After 8.5 hours of monitoring the patient's vital signs, the nasal cannula was removed, and the patient began breathing room air on his own. His vital signs then stabilized and arterial blood gas parameters returned to normal. The patient's condition improved, and he was discharged from the hospital after 9 days. Due to a high level of cytomegalovirus, the discharge prescriptions included valganciclovir film-coated tablets (900 mg, oral BID every 12 hours for 30 days) and apixaban (5 mg BID). The patient was then monitored at the outpatient clinic.

CONCLUSION

Although rare, an air embolism can cause minor symptoms if it is small in volume or can be fatal if large. After contrast-enhanced radiological studies, physicians should be aware of any signs of respiratory distress or worsening of symptoms in their patients. Additionally, patients should be mindful of the potential complications associated with ventilation therapy.

Path planning algorithm for percutaneous puncture lung mass biopsy procedure based on the multi-objective constraints and fuzzy optimization

Objective. The percutaneous puncture lung mass biopsy procedure, which relies on preoperative CT (Computed Tomography) images, is considered the gold standard for determining the benign or malignant nature of lung masses. However, the traditional lung puncture procedure has several issues, including long operation times, a high probability of complications, and high exposure to CT radiation for the patient, as it relies heavily on the surgeon's clinical experience.Approach.To address these problems, a multi-constrained objective optimization model based on clinical criteria for the percutaneous puncture lung mass biopsy procedure has been proposed. Additionally, based on fuzzy optimization, a multidimensional spatial Pareto front algorithm has been developed for optimal path selection. The algorithm finds optimal paths, which are displayed on 3D images, and provides reference points for clinicians' surgical path planning.Main results.To evaluate the algorithm's performance, 25 data sets collected from the Second People's Hospital of Zigong were used for prospective and retrospective experiments. The results demonstrate that 92% of the optimal paths generated by the algorithm meet the clinicians' surgical needs.Significance.The algorithm proposed in this paper is innovative in the selection of mass target point, the integration of constraints based on clinical standards, and the utilization of multi-objective optimization algorithm. Comparison experiments have validated the better performance of the proposed algorithm. From a clinical standpoint, the algorithm proposed in this paper has a higher clinical feasibility of the proposed pathway than related studies, which reduces the dependency of the physician's expertise and clinical experience on pathway planning during the percutaneous puncture lung mass biopsy procedure.

Air embolism as a rare complication of lung biopsy: A case report

Lung biopsy is an important interventional radiology procedure allowing the characterization of lesions with suspected malignancy. The most frequent complications are pneumothorax and hemorrhage. Air embolism is a rare but potentially fatal occurrence. In this case report, we present an air embolism after core needle CT-guided biopsy showing CT and MRI features that radiologists should expect in the everyday clinical practice.

Utility of artificial intelligence for detection of pneumothorax on chest radiopgraphs done after transthoracic percutaneous transthoracic biopsy guided by computed tomography

OBJETIVE

To assess the ability of an artificial intelligence software to detect pneumothorax in chest radiographs done after percutaneous transthoracic biopsy.

MATERIAL AND METHODS

We included retrospectively in our study adult patients who underwent CT-guided percutaneous transthoracic biopsies from lung, pleural or mediastinal lesions from June 2019 to June 2020, and who had a follow-up chest radiograph after the procedure. These chest radiographs were read to search the presence of pneumothorax independently by an expert thoracic radiologist and a radiodiagnosis resident, whose unified lecture was defined as the gold standard, and the result of each radiograph after interpretation by the artificial intelligence software was documented for posterior comparison with the gold standard.

RESULTS

A total of 284 chest radiographs were included in the study and the incidence of pneumothorax was 14.4%. There were no discrepancies between the two readers' interpretation of any of the postbiopsy chest radiographs. The artificial intelligence software was able to detect 41/41 of the present pneumothorax, implying a sensitivity of 100% and a negative predictive value of 100%, with a specificity of 79.4% and a positive predictive value of 45%. The accuracy was 82.4%, indicating that there is a high probability that an individual will be adequately classified by the software. It has also been documented that the presence of Port-a-cath is the cause of 8 of the 50 of false positives by the software.

CONCLUSIONS

The software has detected 100% of cases of pneumothorax in the postbiopsy chest radiographs. A potential use of this software could be as a prioritisation tool, allowing radiologists not to read immediately (or even not to read) chest radiographs classified as non-pathological by the software, with the confidence that there are no pathological cases.

[A clinical-radiomics nomogram for differentiating focal organizing pneumonia and lung adenocarcinoma]

OBJECTIVE

To evaluate the performance of a clinical-radiomics model for differentiating focal organizing pneumonia (FOP) and lung adenocarcinoma (LUAD).

METHODS

We retrospectively analyzed the data of 60 patients with FOP confirmed by postoperative pathology at the First Medical Center of the Chinese PLA General Hospital from January, 2019 to December, 2022, who were matched with 120 LUAD patients using propensity score matching in a 1∶2 ratio. The independent risk factors for FOP were identified by logistic regression analysis of the patients' clinical data. The cohort was divided into a training set (144 patients) and a test set (36 patients) by random sampling. Python 3.7 was used for extracting 1835 features from CT image data of the patients. The radiographic features and clinical data were used to construct the model, whose performance was validated using ROC curves in both the training and test sets. The diagnostic efficacy of the model for FOP and LUAD was evaluated and a diagnostic nomogram was constructed.

RESULTS

Statistical analysis revealed that an history of was an independent risk factor for FOP (P=0.016), which was correlated with none of the hematological findings (P > 0.05). Feature extraction and dimensionality reduction in radiomics yielded 30 significant labels for distinguishing the two diseases. The top 3 most discriminative radiomics labels were GraylevelNonUniformity, SizeZoneNonUniformity and shape-Sphericity. The clinical-radiomics model achieved an AUC of 0.909 (95% CI: 0.855-0.963) in the training set and 0.901 (95% CI: 0.803-0.999) in the test set. The model showed a sensitivity of 85.4%, a specificity of 83.5%, and an accuracy of 84.0% in the training set, as compared with 94.7%, 70.6%, and 83.3% in the test set, respectively.

CONCLUSION

The clinical-radiomics nomogram model shows a good performance for differential diagnosis of FOP and LUAD and may help to minimize misdiagnosis-related overtreatment and improve the patients' outcomes.

Safety and risk factors for bleeding complications of radial probe endobronchial ultrasound-guided transbronchial biopsy

BACKGROUND

Radial probe endobronchial ultrasound (radial EBUS) is widely used to diagnose pulmonary lesions; however, the diagnostic value of radial EBUS-guided transbronchial biopsy (TBB) varies, and its complications (especially the risk of bleeding) are not properly understood.

OBJECTIVES

In this study, we evaluated the diagnostic performance and rate of complication of this procedure, and investigated the risk factors associated with the procedure-related bleeding events.

DESIGN

A retrospective cohort study.

METHODS

This was a retrospective study that included consecutive patients who underwent radial EBUS-guided TBB. Radial EBUS was performed under moderate sedation in inpatients or outpatients. The severity of bleeding was graded using the standardized definitions of bleeding.

RESULTS

Of 133 patients (median age, 69 years; men 57.1%) included, 41 were outpatients (30.8%). The diagnostic accuracy, sensitivity, and specificity for malignancy were 76.1% (89/117), 71.1% (69/97), and 100% (20/20), respectively. The diagnostic accuracy ranged from 66.9% to 79.0%, depending on the classification of undiagnosed cases as either false negatives or true negatives. Twenty-seven patients (20.3%) developed complications (pneumothorax, 3; pneumonia, 5; complicated pleural effusion, 2; bleeding event grade 2 or higher, 21). Of the 41 outpatients, two developed complications (pneumothorax without intervention, 1; grade 2 bleeding event, 1). Of the 21 patients (15.8%) with procedure-related bleeding events, 18 had grade 2, and three had grade 3 bleeding complications. In multivariate analysis, a large size of ⩾30 mm (adjusted odds ratio (OR), 5.09; p = 0.03) and central lesion (adjusted OR, 3.67; p = 0.03) were significantly associated with the risk of grade 2 or higher bleeding events.

CONCLUSION

Our results suggest that radial EBUS-guided TBB is an accurate and safe method for diagnosing pulmonary lesions. Clinically significant procedure-related bleeding was rare. The central location and larger size (⩾30 mm) of pulmonary lesions were risk factors for grade 2 or higher bleeding events.

Radiomics as a non-invasive adjunct to Chest CT in distinguishing benign and malignant lung nodules

In an observational study conducted from 2016 to 2021, we assessed the utility of radiomics in differentiating between benign and malignant lung nodules detected on computed tomography (CT) scans. Patients in whom a final diagnosis regarding the lung nodules was available according to histopathology and/or 2017 Fleischner Society guidelines were included. The radiomics workflow included lesion segmentation, region of interest (ROI) definition, pre-processing, and feature extraction. Employing random forest feature selection, we identified ten important radiomic features for distinguishing between benign and malignant nodules. Among the classifiers tested, the Decision Tree model demonstrated superior performance, achieving 79% accuracy, 75% sensitivity, 85% specificity, 82% precision, and 90% F1 score. The implementation of the XGBoost algorithm further enhanced these results, yielding 89% accuracy, 89% sensitivity, 89% precision, and an F1 score of 89%, alongside a specificity of 85%. Our findings highlight tumor texture as the primary predictor of malignancy, emphasizing the importance of texture-based features in computational oncology. Thus, our study establishes radiomics as a powerful, non-invasive adjunct to CT scans in the differentiation of lung nodules, with significant implications for clinical decision-making, especially for indeterminate nodules, and the enhancement of diagnostic and predictive accuracy in this clinical context.

High risk lung nodule: A multidisciplinary approach to diagnosis and management

Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.

Circulating cell-free DNA sequencing for early detection of lung cancer

INTRODUCTION

Lung cancer is a leading cause of death in patients with cancer. Early diagnosis is crucial to improve the prognosis of patients with lung cancer. Plasma circulating cell-free DNA (cfDNA) contains comprehensive genetic and epigenetic information from tissues throughout the body, suggesting that early detection of lung cancer can be done non-invasively, conveniently, and cost-effectively using high-sensitivity techniques such as sequencing.

AREAS COVERED

In this review, we summarize the latest technological innovations, coupled with next-generation sequencing (NGS), regarding genomic alterations, methylation, and fragmentomic features of cfDNA for the early detection of lung cancer, as well as their clinical advances. Additionally, we discuss the suitability of study designs for diagnostic accuracy evaluation for different target populations and clinical questions.

EXPERT OPINION

Currently, cfDNA-based early screening and diagnosis of lung cancer faces many challenges, such as unsatisfactory performance, lack of quality control standards, and poor repeatability. However, the progress of several large prospective studies employing epigenetic features has shown promising predictive performance, which has inspired cfDNA sequencing for future clinical applications. Furthermore, the development of multi-omics markers for lung cancer, including genome-wide methylation and fragmentomics, is expected to play an increasingly important role in the future.

Risk factors for air embolism following computed tomography-guided percutaneous transthoracic needle biopsy: a systematic review and meta-analysis

To quantitatively analyze the risk factors for air embolism following computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and qualitatively review their characteristics. The databases of PubMed, Embase, Web of Science, Wanfang Data, VIP information, and China National Knowledge Infrastructure were searched on January 4, 2021, for studies reporting the occurrence of air embolisms following CT-guided PTNB. After study selection, data extraction, and quality assessment, the characteristics of the included cases were qualitatively and quantitatively analyzed. A total of 154 cases of air embolism following CT-guided PTNB were reported. The reported incidence was 0.06% to 4.80%, and 35 (22.73%) patients were asymptomatic. An unconscious or unresponsive state was the most common symptom (29.87%). Air was most commonly found in the left ventricle (44.81%), and 104 (67.53%) patients recovered without sequelae. Air location (P < 0.001), emphysema (P = 0.061), and cough (P = 0.076) were associated with clinical symptoms. Air location (P = 0.015) and symptoms (P < 0.001) were significantly associated with prognosis. Lesion location [odds ratio (OR): 1.85, P = 0.017], lesion subtype (OR: 3.78, P = 0.01), pneumothorax (OR: 2.16, P = 0.003), hemorrhage (OR: 3.20, P < 0.001), and lesions located above the left atrium (OR: 4.35, P = 0.042) were significant risk factors for air embolism. Based on the current evidence, a subsolid lesion, being located in the lower lobe, the presence of pneumothorax or hemorrhage, and lesions located above the left atrium were significant risk factors for air embolism.

FDG-PET/CT tumor to liver SUV ratio (TLR), tumor SUVmax, and tumor size: can this help in differentiating squamous cell carcinoma from adenocarcinoma of the lung?

Background

PET/CT plays an essential role in the diagnosis, staging, and follow-up of lung cancer. We aimed to assess the ability of PET/CT to differentiate between adenocarcinomas (AC) and squamous cell carcinomas (SCC) of the lung using tumor size, tumor maximum standardized uptake value (SUVmax), lymph nodes SUVmax, and tumor to liver SUV ratio (TLR).

Results

A total of 60 patients pathologically proved to have non-small cell lung cancer either AC or SCC were retrospectively evaluated. The mean tumor size, SUVmax of the tumor, and TLR were significantly higher in SCC lesions compared to AC lesions. The mean SCC tumoral size was 7.96 ± 2.18 cm compared to 5.66 ± 2.57 cm in AC lesions (P = 0.008). The mean tumor SUVmax in SCC lesions was 18.95 ± 8.3 compared to 12.4 ± 7.55 in AC lesions (P = 0.04). While the mean TLR of SCC lesions was 10.32 ± 4.03 compared to 7.36 ± 4.61 in AC lesions (P = 0.028). All three parameters showed the same sensitivity (75%), while TLR showed the highest specificity (77.78%) followed by tumor size (76.47%) and then SUVmax of the tumor (72.22%).

Conclusions

SCC of the lung has a higher mean tumor size, SUVmax of the tumor, and TLR as compared to AC which can be helpful tools in differentiation between them using PET/CT.

Efficacy and Safety Analysis of Multislice Spiral CT-Guided Transthoracic Lung Biopsy in the Diagnosis of Pulmonary Nodules of Different Sizes

Objective

This study is aimed at investigating the efficacy and safety of multislice spiral CT-guided transthoracic lung biopsy in the diagnosis of pulmonary nodules of different sizes.

Methods

Data of 78 patients with pulmonary nodules who underwent CT-guided transthoracic lung biopsy in our hospital from January 2020 to December 2021 were retrospectively analyzed, and they were divided into the small nodules group (n = 12), medium nodules group (n = 35), and large nodules group (n = 31) according to the diameter of pulmonary nodules. The results of puncture biopsy and final diagnosis of pulmonary nodules of different sizes were compared. The incidence of complications in patients with pulmonary nodules of different sizes was compared. Univariate analysis was used to compare the incidence of complications in 78 patients. Logistic multiple regression analysis was used to analyze the independent risk factors of pneumothorax in patients with pulmonary nodule puncture. Logistic multiple regression analysis was used to analyze the independent risk factors of pulmonary hemorrhage in patients with pulmonary nodule puncture.

Results

The diagnostic accuracy, sensitivity, and specificity were 83.33%, 100.00%, and 77.78% in small nodules group. The diagnostic accuracy, sensitivity, and specificity of medium nodules group were 85.71%, 100.00%, and 73.68%, respectively. The diagnostic accuracy, sensitivity, and specificity of large nodules group were 93.55%, 100.00%, and 33.33%, respectively. There was no significant difference in the incidence of pneumothorax among the three groups (P > 0.05). The incidence of pulmonary hemorrhage in small nodule group was higher than that in the medium nodule group and large nodule group, and the difference was statistically significant (P < 0.05). There was no significant difference in the incidence of total complications among the three groups (P > 0.05). There were statistically significant differences in clinical data such as the needle tract length, the puncture position, and the distance of the puncture needle passing through the lung tissue in patients with or without pneumothorax (P < 0.05). There were statistically significant differences in needle tract length, distance of puncture needle passing through lung tissue, and size of pulmonary nodules in patients with or without pulmonary hemorrhage (P > 0.05). Logistic multivariate analysis showed that needle tract length ≤ 50 mm, lateral decubitus position, and the distance of puncture needle passing through lung tissue ≥ 14 mm were independent risk factors for pneumothorax after puncture in patients with pulmonary nodules (P < 0.05). The needle tract length > 50 mm, the distance of puncture needle passing through lung tissue ≥ 14 mm, and small nodules (pulmonary nodules diameter ≤ 10 mm) were independent risk factors for pulmonary hemorrhage after puncture in patients with pulmonary nodules (P < 0.05).

Conclusion

Multislice spiral CT-guided transthoracic lung biopsy is effective in diagnosing pulmonary nodules of different sizes.

Systemic air embolism following computed-tomography-guided transthoracic needle biopsy of lung lesion – a systematic search of case reports and case series

Background

Systemic air embolism is a rare, however potentially fatal, low incidence, complication to CT-guided transthoracic needle biopsy of lung lesions.

Purpose

The purpose of this review of case reports and series was to pool data about this rare complication and glance for a pattern or similarities in the patients’ initial symptoms and course, as well as the management of the patients in relation to current guidelines.

Material and methods

PubMed was searched for case reports and case series about systemic air embolisms following CT-guided transthoracic needle biopsy of lung lesions from inception to November 2021. A reviewer screened the results for eligibility and included studies which reported at least two outcomes of interest. Data was extracted by one author and a descriptive analysis was conducted.

Results

Of 1,136 studies screened, 83 were eligible for inclusion involving 97 patients. The mean age was 64.8±11.7 years and ≈60% of the patients were men. In 15 cases the outcome was fatal, and most of the fatal cases ( n = 12) had cardiac arrest as the primary initial symptom. In addition to conventional oxygen therapy, 34 patients received hyperbaric oxygen therapy, and in 30 cases the physician in charge chose to change the patient from standard supine position to – most often – Trendelenburg position.

Conclusion

No similarities were found that could lead to more rapid diagnosis or more correct management. The staff should keep systemic air embolisms in mind, when more common complications are ruled out, and consider hyperbaric oxygen therapy in case of suspicion.

Effectiveness of Endobronchial Ultrasound-Guided Transbronchial Biopsy Combined With Tissue Culture for the Diagnosis of Sputum Smear-Negative Pulmonary Tuberculosis

Background

Microorganisms of tuberculosis (TB) are frequently difficult to identify from the airway specimen; therefore, lung biopsy for further histologic and microbiologic study is required. Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of pulmonary malignancy, but is rarely in the TB population. The purpose of this study was to verify the effectiveness and safety of EBUS-TBB with histologic study and tissue culture in the diagnosis of sputum smear-negative pulmonary TB.

Methods

Patients who underwent EBUS-TBB with histologic study and TB tissue culture for clinically suspected, but sputum smear-negative pulmonary TB from January 2016 to December 2018, were included. The accuracy of each diagnostic modality was calculated, respectively. Factors that might influence the positive rate of TB culture (washing fluid and tissue specimen) were also evaluated.

Results

One hundred sixty-one patients who underwent EBUS-TBB for clinically suspected, but sputum smear-negative pulmonary TB, were enrolled, and 43 of them were finally diagnosed as having pulmonary TB. The sensitivity of washing fluid (a combination of smear, culture, and polymerase chain reaction for TB) and tissue specimen (a combination of pathology and tissue culture) via EBUS-TBB for TB diagnosis were 48.8 and 55.8%, respectively. The sensitivity for TB diagnosis would be elevated to 67.4% when both washing fluid and tissue specimens are used. The positive TB culture rate would not statistically increase with a combination of tissue specimens and washing fluid. Univariate analysis revealed that TB microorganisms would be more easily cultivated when lesions had an abscess or cavity on the computed tomography (CT) image (presence vs. absence; 62.5 vs. 26.3%, p = 0.022), heterogeneous echogenicity on the EBUS finding (heterogeneous vs. homogeneous; 93.3 vs. 21.4%, p = 0.001), or a necrotic pattern via histologic study (presence vs. absence; 70.6 vs. 30.8%, p = 0.013). Heterogeneous echogenicity in the EBUS finding was the independent predictor according to the results of multivariate analysis. None of our patients encountered major adverse events or received further intensive care after EBUS-TBB.

Conclusion

Endobronchial ultrasound-guided transbronchial biopsy is safe and effective for use in diagnosing sputum smear-negative pulmonary TB. EBUS echoic feature is also a predictor of the positive TB culture rate in pulmonary TB. However, tissue culture via EBUS-TBB has little effect in improving the positive TB culture rate.

Full core technology versus notch sampling technology: evaluation of the diagnostic accuracy and the risk of a pneumothorax after transthoracic needle biopsy of suspicious lung lesions

BACKGROUND

Percutaneous needle biopsy of the lung (PCBL) under image guidance has become a safe and effective minimal invasive method to obtain a specimen related histological diagnosis of pulmonary lesions.

PURPOSE

To evaluate the diagnostic yield and safety of two different coaxial biopsy technologies: full core and notch sampling technology. The former allowing the removal of full punch cylinders and the latter using a cutting-edge mechanism.

MATERIAL AND METHODS

A retrospective analysis of 48 consecutive PCBL procedures has been carried out for this prognostic study, involving patients with a documented pulmonary nodule or mass lesion on previous computed tomography (CT) scans. The study population included 38 men and 10 women (mean age = 67 years). Of these 48 patients who underwent a procedure with a co-axial cutting system, 24 have been performed with notch sampling technology and 24 with full core technology.

RESULTS

Out of the 48 biopsy procedures, 46 yielded specimens were adequate for histopathological evaluation, consistent with a technical success rate of 96%. The most common induced image-guided biopsy complication was a pneumothorax, occurring in 14 patients (35%). Seven patients with a pneumothorax were attributed to the full core technology and seven to the notch sampling technology (odds ratio = 1, 95% confidence interval = 0.28-3.51, P = 1).

CONCLUSION

In the setting of full core versus notch sampling percutaneous CT-guided coaxial needle biopsy of the lung, no significant difference in the diagnostic accuracy and the incidence of pneumothoraces could be shown, while both technologies have an excellent diagnostic performance.

Computed tomography radiomic features hold prognostic utility for canine lung tumors: An analytical study

Quantitative analysis of computed tomography (CT) radiomic features is an indirect measure of tumor heterogeneity, which has been associated with prognosis in human lung carcinoma. Canine lung tumors share similar features to human lung tumors and serve as a model in which to investigate the utility of radiomic features in differentiating tumor type and prognostication. The purpose of this study was to correlate first-order radiomic features from canine pulmonary tumors to histopathologic characteristics and outcome. Disease-free survival, overall survival time and tumor-specific survival were calculated as days from the date of CT scan. Sixty-seven tumors from 65 dogs were evaluated. Fifty-six tumors were classified as primary pulmonary adenocarcinomas and 11 were non-adenocarcinomas. All dogs were treated with surgical resection; 14 dogs received adjuvant chemotherapy. Second opinion histopathology in 63 tumors confirmed the histologic diagnosis in all dogs and further characterized 53 adenocarcinomas. The median overall survival time was longer (p = 0.004) for adenocarcinomas (339d) compared to non-adenocarcinomas (55d). There was wide variation in first-order radiomic statistics across tumors. Mean Hounsfield units (HU) ratio (p = 0.042) and median mean HU ratio (p = 0.042) were higher in adenocarcinomas than in non-adenocarcinomas. For dogs with adenocarcinoma, completeness of excision was associated with overall survival (p<0.001) while higher mitotic index (p = 0.007) and histologic score (p = 0.037) were associated with shorter disease-free survival. CT-derived tumor variables prognostic for outcome included volume, maximum axial diameter, and four radiomic features: integral total, integral total mean ratio, total HU, and max mean HU ratio. Tumor volume was also significantly associated with tumor invasion (p = 0.044). Further study of radiomic features in canine lung tumors is warranted as a method to non-invasively interrogate CT images for potential predictive and prognostic utility.

Complications and Risk Factors of Patients Undergoing Computed Tomography-Guided Core Needle Lung Biopsy: A Single-Center Experience

Objectives To determine the risk factors and complications of transthoracic computed tomography (CT)-guided core needle lung biopsy. Methods This is a retrospective study of 124 patients who underwent CT-guided core lung biopsy in King Khalid University Hospital (KKUH), Riyadh. This retrospective study was conducted between January 2016 and January 2020. Patient data were collected using a standardized data form that was entered into an Excel sheet in accordance with the variables. The Statistical Package for the Social Sciences software (SPSS, version 24.0 [SPSS Inc., Chicago, IL, USA]) was used to compute for the risk of complications after CT-guided core lung biopsy and perform all statistical comparisons, and the results were reported. Results The overall complication rate due to CT-guided core needle biopsy was 34.7% (43) (P<0.001) of the total sample. Of the total complications, 69.76% (n = 30) had pneumothorax, 20.94% (n = 9) had hemorrhage, 6.98% (n = 3) had both pneumothorax and hemorrhage, and 2.32% (n = 1) had both air embolism and pneumothorax. Of all patients who developed pneumothorax, 20% (n = 6) required chest tube insertion. Patients with secondary chronic obstructive pulmonary disease (COPD) had a complication rate of 80% among the whole sample. Lung lesions less than 3 cm had a complication rate of 48.8% (P<0.034). The needle size showed a higher rate of complications between 20 and 18 gauge with 47.4% (n = 9) and 32.4% (n = 34), respectively. Conclusions We conclude that CT-guided lung biopsy is a well-established low-risk procedure that is less invasive. However, it still carries a risk of complications with some risk factors, such as small lung lesion size and secondary COPD.

Application of a treatment planning system-assisted large-aperture computed tomography simulator to percutaneous biopsy: initial experience of a radiation therapist

Objective

To evaluate the application of treatment planning system (TPS)-assisted large-aperture computed tomography (CT) simulator to percutaneous biopsy.

Methods

This retrospective study enrolled patients that underwent TPS-assisted large-aperture CT simulator-guided percutaneous biopsy from November 2018 to December 2019. Retrospective analyses of puncture accuracy were compared using paired t-test and a Wilcoxon rank sum test. The risk factors for puncture accuracy and complications were identified.

Results

A total of 38 patients were included in this study. There were no significant differences between the planned and actual puncture depth and angle. Pulmonary puncture was significantly associated with the accuracy of the puncture angle. The diagnostic rate of malignancy was 76% (29 of 38), of which 20 of 25 patients were in the group initially diagnosed with unconfirmed lesions and nine of 13 patients were in the group of treated patients that needed additional pathological analyses. For patients that underwent a pulmonary biopsy, 12 had minor pneumothorax and three suffered needle track bleeding. No other complications were observed. Regression analyses indicated a significant correlation between puncture angle and the incidence of pneumothorax.

Conclusion

TPS-assisted large-aperture CT simulator may improve the percutaneous biopsy procedure by combining the advantages of radiotherapy specialties with computer targeting.

Systemic vascular air embolus following CT-guided transthoracic needle biopsy: a potentially fatal complication

Following an uncomplicated CT-guided transthoracic biopsy, a patient becomes unconscious and subsequently dies despite immediate cardiac resuscitation. The patient felt well during the procedure but started complaining about dizziness and chest pain when he sat up. When he again was put in a supine position, cardiac arrest was noted. A CT scan performed when the symptoms initiated was afterwards rigorously reviewed by the team and revealed air located in the left ventricle, aorta and right coronary artery.We present a rare but potentially lethal complication following CT-guided transthoracic needle biopsy-systemic vascular air embolus. Knowledge and evidence about the complication are sparse because of low incidence and varying presentation. However, immediate initiation of treatment can save a life, and awareness of the complication is therefore crucial.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Emerging Lab-on-a-Chip Approaches for Liquid Biopsy in Lung Cancer: Status in CTCs and ctDNA Research and Clinical Validation

Simple Summary

Lung cancer (LCa) remains the leading cause of cancer-related mortality worldwide, with late diagnosis and limited therapeutic approaches still constraining patient’s outcome. In recent years, liquid biopsies have significantly improved the disease characterization and brought new insights into LCa diagnosis and management. The integration of microfluidic devices in liquid biopsies have shown promising results regarding circulating biomarkers isolation and analysis and these tools are expected to establish automatized and standardized results for liquid biopsies in the near future. Herein, we review the status of lab-on-a-chip approaches for liquid biopsies in LCa and highlight their current applications for circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) research and clinical validation studies.

Abstract

Despite the intensive efforts dedicated to cancer diagnosis and treatment, lung cancer (LCa) remains the leading cause of cancer-related mortality, worldwide. The poor survival rate among lung cancer patients commonly results from diagnosis at late-stage, limitations in characterizing tumor heterogeneity and the lack of non-invasive tools for detection of residual disease and early recurrence. Henceforth, research on liquid biopsies has been increasingly devoted to overcoming these major limitations and improving management of LCa patients. Liquid biopsy is an emerging field that has evolved significantly in recent years due its minimally invasive nature and potential to assess various disease biomarkers. Several strategies for characterization of circulating tumor cells (CTCs) and circulating tumor DNA (ctDNA) have been developed. With the aim of standardizing diagnostic and follow-up practices, microfluidic devices have been introduced to improve biomarkers isolation efficiency and specificity. Nonetheless, implementation of lab-on-a-chip platforms in clinical practice may face some challenges, considering its recent application to liquid biopsies. In this review, recent advances and strategies for the use of liquid biopsies in LCa management are discussed, focusing on high-throughput microfluidic devices applied for CTCs and ctDNA isolation and detection, current clinical validation studies and potential clinical utility.

miRNAs in lung cancer. A systematic review identifies predictive and prognostic miRNA candidates for precision medicine in lung cancer

Lung cancer (LC) is the leading cause of cancer-related death worldwide and miRNAs play a key role in LC development. To better diagnose LC and to predict drug treatment responses we evaluated 228 articles encompassing 16,697 patients and 12,582 healthy controls. Based on the criteria of ≥3 independent studies and a sensitivity and specificity of >0.8 we found blood-borne miR-20a, miR-10b, miR-150, and miR-223 to be excellent diagnostic biomarkers for non-small cell LC whereas miR-205 is specific for squamous cell carcinoma. The systematic review also revealed 38 commonly regulated miRNAs in tumor tissue and the circulation, thus enabling the prediction of histological subtypes of LC. Moreover, theranostic biomarker candidates with proven responsiveness to checkpoint inhibitor treatments were identified, notably miR-34a, miR-93, miR-106b, miR-181a, miR-193a-3p, and miR-375. Conversely, miR-103a-3p, miR-152, miR-152-3p, miR-15b, miR-16, miR-194, miR-34b, and miR-506 influence programmed cell death-ligand 1 and programmed cell death-1 receptor expression, therefore providing a rationale for the development of molecularly targeted therapies. Furthermore, miR-21, miR-25, miR-27b, miR-19b, miR-125b, miR-146a, and miR-210 predicted response to platinum-based treatments. We also highlight controversial reports on specific miRNAs. In conclusion, we report diagnostic miRNA biomarkers for in-depth clinical evaluation. Furthermore, in an effort to avoid unnecessary toxicity we propose predictive biomarkers. The biomarker candidates support personalized treatment decisions of LC patients and await their confirmation in randomized clinical trials.

Evaluation of circulating tumor cell clusters for pan-cancer noninvasive diagnostic triaging

BACKGROUND

Histopathologic examination (HPE) of tumor tissue obtained by invasive biopsy is the standard for cancer diagnosis but is resource-intensive and has been associated with procedural risks. The authors demonstrate that immunocytochemistry (ICC) profiling of circulating ensembles of tumor-associated cells (C-ETACs) can noninvasively provide diagnostic guidance in solid organ cancers.

METHODS

The clinical performance of this approach was tested on blood samples from 30,060 individuals, including 9416 individuals with known cancer; 6725 symptomatic individuals with suspected cancer; and 13,919 asymptomatic individuals with no prior diagnosis of cancer. C-ETACs were harvested from peripheral blood and profiled by ICC for organ-specific and subtype-specific markers relevant to the cancer type. ICC profiles were compared with HPE diagnoses to determine concordance.

RESULTS

The presence of malignancy was confirmed by the detection of C-ETACs in 91.8% of the 9416 individuals with previously known cancer. Of the 6725 symptomatic individuals, 6025 were diagnosed with cancer, and 700 were diagnosed with benign conditions; C-ETACs were detected in 92.6% of samples from the 6025 individuals with cancer. In a subset of 3509 samples, ICC profiling of C-ETACs for organ-specific and subtype-specific markers was concordant with HPE findings in 93.1% of cases. C-ETACs were undetectable in 95% of samples from the 700 symptomatic individuals who had benign conditions and in 96.3% of samples from the 13,919 asymptomatic individuals.

CONCLUSIONS

C-ETACs were ubiquitous (>90%) in various cancers and provided diagnostically relevant information in the majority (>90%) of cases. This is the first comprehensive report on the feasibility of ICC profiling of C-ETACs to provide pan-cancer diagnostic guidance with accuracy comparable to that of HPE.

Incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy: a systematic review and pooled analysis

Objectives

To determine the incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy (PTLB) by conducting a systematic review and pooled analysis.

Methods

We searched the EMBASE and OVID-MEDLINE databases to identify studies that dealt with air embolism after PTLB and had extractable outcomes. The incidence of air embolism was pooled using a random effects model, and the causes of heterogeneity were investigated. To analyze risk factors for symptomatic embolism and unfavorable outcomes, multivariate logistic regression analysis was performed.

Results

The pooled incidence of symptomatic air embolism after PTLB was 0.08% (95% confidence interval [CI], 0.048–0.128%; I² = 45%). In the subgroup analysis and meta-regression, guidance modality and study size were found to explain the heterogeneity. Of the patients with symptomatic air embolism, 32.7% had unfavorable outcomes. The presence of an underlying disease (odds ratio [OR], 5.939; 95% CI, 1.029–34.279; p = 0.046), the use of a ≥ 19-gauge needle (OR, 10.046; 95% CI, 1.103–91.469; p = 0.041), and coronary or intracranial air embolism (OR, 19.871; 95% CI, 2.725–14.925; p = 0.003) were independent risk factors for symptomatic embolism. Unfavorable outcomes were independently associated with the use of aspiration biopsy rather than core biopsy (OR, 3.302; 95% CI, 1.149–9.492; p = 0.027) and location of the air embolism in the coronary arteries or intracranial spaces (OR = 5.173; 95% CI = 1.309–20.447; p = 0.019).

Conclusion

The pooled incidence of symptomatic air embolism after PTLB was 0.08%, and one-third of cases had sequelae or died. Identifying whether coronary or intracranial emboli exist is crucial in suspected cases of air embolism after PTLB.

Key Points

• The pooled incidence of symptomatic air embolism after percutaneous transthoracic lung biopsy was 0.08%, and one-third of patients with symptomatic air embolism had sequelae or died.

• The risk factors for symptomatic air embolism were the presence of an underlying disease, the use of a ≥ 19-gauge needle, and coronary or intracranial air embolism.

• Sequelae and death in patients with symptomatic air embolism were associated with the use of aspiration biopsy and coronary or intracranial locations of the air embolism.

Iodine-125 seed implantation treatment of lung metastases < 2.5 cm using 5-ml syringe as a guide

PURPOSE

Small lung metastases change their location with respiration, making difficult to localize, therefore, increasing the number of punctures. Accurate puncture can reduce trauma to lung tissue and accelerate patient's recovery. The aim of the study was to present our experience with the technique of using local anesthesia 5-ml syringe as a guide for computerized tomography-guided iodine-125 seed implantation (CT-ISI).

MATERIAL AND METHODS

This was a retrospective study, including patients with small metastatic tumors in the lung, treated with CT-ISI between December 2013 and March 2018 at the Affiliated Hospital of the University. The patients were divided according to whether a 5-ml syringe was used as a guide during CT-ISI or not. The final follow-up was on March 31st, 2018. Implantation success and complications were examined.

RESULTS

Nineteen patients were included. A total of 840 seeds were used, with 44.2 ±33.6 (range, 10-160) seeds per patient. The mean D90 for CT-ISI was 134.5 ±7.5 Gy. Treatment intervention for eleven patients was performed using a 5-ml syringe as a guide during CT-ISI. There were no differences in total dose and number of implanted seeds between the two groups, but the number of punctures per lesion was lower in the syringe group than in the no-syringe group (1.9 ±0.5 vs. 2.9 ±0.6, p < 0.001), suggesting a higher puncture accuracy. The total number of SMTIL was 50 (median, 2; range, 1-10), and the median size was 1.9 cm (range, 0.8-2.4 cm). All SMTIL were well-controlled at 6-months follow-up (response rate [RR] = 100%). One patient in the no-syringe group experienced grade 2 chest tightness, chest pain, intraoperative needle tract bleeding, and post-operative blood in sputum.

CONCLUSIONS

Puncture with a 5-ml syringe as a guide during CT-ISI seems to be a more accurate option for patients with small (< 2.5 cm) lung metastasis.

Peripheral pulmonary nodule diagnosed as mycobacterium chelonae using electromagnetic navigation bronchoscopy combined with next generation sequencing: a case report

We report the case of a 29-year-old female with a 1.1 cm × 1.1 cm solitary nodule adjacent to the pleura in the upper lobe of the right lung that was diagnosed as Mycobacterium chelonae using electromagnetic navigation bronchoscopy combined with next generation sequencing. This diagnostics technology shows great promise in identifying peripheral pulmonary nodules, especially infectious lesions.

Pericardial fluid levels of growth differentiation factor 15 in patients with or without coronary artery disease: a prospective study

BACKGROUND

Growth differentiation factor 15 (GDF15) has already been reported as a novel efficient biomarker in patients with coronary artery diseases (CAD). However, very little is demonstrated about the potential impact of pericardial fluid GDF-15 accumulation on CAD. The aim of this study was to evaluate pericardial fluid and plasma GDF15 levels in patients with ischemic heart disease.

METHODS

In this study, 42 consecutive patients (21 patients with significant CAD; 21 patients without CAD) undergoing open heart surgery were recruited in this study. Pericardial fluid were obtained at the time of surgery, and GDF15 levels in the samples were measured by enzyme-linked immunosorbent assay. Plasma glucose, creatinine, CK-MB, cTnI and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements were performed.

RESULTS

The plasma GDF15 levels were markedly higher than the pericardial fluid levels both in the CAD group and non-CAD group (1,174.0±148.7 vs. 677.8±77.2 pg/mL, P<0.01; 925.8±127.4 vs. 617.4±76.2 pg/mL, P<0.01). The levels of pericardial fluid GDF15, was not statistically different between the CAD and non-CAD groups (P>0.05). An obvious correlation was observed between plasma and pericardial fluid GDF15 concentration both in the CAD group and non-CAD group (R=0.53, P<0.01; R=0.54, P<0.01). An obvious positive correlation was found between pericardial fluid GDF15 and plasma creatinine levels in CAD patients but not in non-CAD patients (R=0.65, P<0.01). In the CAD group, an obvious correlation was also observed between pericardial fluid GDF15 levels and NT-ProBNP (R=0.63, P<0.01), while no relationship was found in non-CAD group. There was a positive correlation between pericardial fluid GDF15 and LVEF in non-CAD group but not in CAD group patients (R=-0.44, P<0.05).

CONCLUSIONS

Our study first revealed an association between pericardial fluid GDF15 and baseline characteristics. Pericardial fluid GDF15 levels are associated with cardiac and kidney function in patients with coronary artery disease and may be a valuable marker for assessing CAD severity and predicting its complications.

A life-threatening condition: The pulmonary artery air embolism

Introduction

Air embolism is a very rare condition which occurs when air or gas enter into the vascular system in either the venous or arterial route. It can occur following a variety of circumstances ranging from invasive procedures to either blunt or penetrating trauma conditions.

Case presentation

We present a case of a 39-year-old male who had an air embolism in the pulmonary artery as a consequence of the injection of a contrast agent. He had dyspnea and chest pain following a contrast-enhanced chest computed tomography imaging. He was successfully treated and discharged from our hospital.

Conclusion

Air embolism is rare, but can be fatal. The critical care providers should be familiar with the signs indicating air embolism and be ready to perform the main therapeutic maneuvers. Early detection of this clinical condition is essential to prevent morbidity and mortality.

Solitary pulmonary nodules caused by Mycobacterium avium complex

BACKGROUND

The prevalence of Mycobacterium avium complex (MAC) pulmonary disease (PD) is increasing significantly in Japan. Among the patterns of MAC-PD, a solitary pulmonary nodule (SPN) is less common and often resembles lung cancer. The aim of this study was to identify the clinical features of MAC-SPN.

METHODS

SPNs culture-positive for MAC (definite cases) and culture-negative SPNs showing nucleic acid amplification test (NAAT)-positive status (probable cases) that presented between January 2007 and December 2017 were enrolled. The patients' clinical, laboratory, radiological, and microbiological findings and outcomes were investigated.

RESULTS

This study included 28 patients (median age, 66 years; 16 men, 12 women). All patients were asymptomatic when the disease was detected. Median SPN size was 23.5 mm. Twenty-six patients underwent video-assisted thoracoscopic surgery, while the others underwent percutaneous needle biopsy for diagnosis. Granulomatous inflammation was confirmed in all cases. Microbiologically, the 28 cases were divided into 17 in the definite group and 11 in the probable group. In both groups, M. avium was predominant. There were no significant differences in clinical and radiological findings and follow-up periods between the 2 groups. After diagnosis, 6 patients received medical treatment, while the others did not. The median follow-up period was 42 months, and no recurrence was observed in both groups.

CONCLUSIONS

MAC should be considered in the differential diagnosis of SPNs in asymptomatic patients. To overcome the difficulties in diagnosing MAC-SPN, this study underscores the importance of diagnostic interventions and identification of MAC by culture and/or NAAT in biopsied specimens.

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

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

[Analysis of Percutaneous Biopsy of 41 Small Lung Lesions]

BACKGROUND

When lung cancer screening work extensively developed in recent years, more and more small lung lesions were found in clinic. The aim of this study is to analysis computed tomography (CT) guided percutaneous biopsy for lung small lesions (diameter<2 cm) on results, complications and prognosis.

METHODS

Choose CT guided percutaneous lung biopsy were performed in 41 cases of pulmonary peripheral lesions, single lesion in 39 cases, multiple lesions in 2 cases, 5-20 (13.1±5.2) mm in maximum diameter, depth from lung surface 1-45 (16.5±13.7) mm, ground-glass opacity (GGO) components 0%-100% (66.8%±35.2%).

RESULTS

41 patients and 43 biopsies successfully obtained pathological tissue. Atypical adenomatous hyperplasia in 3 cases, squamous carcinoma in 1 case, adenocarcinoma in 37 cases( carcinoma in situ in 7 cases, micro-invasive carcinoma in 5 cases, invasive adenocarcinoma in 25 cases, double primary lung cancer in 2 cases), inflammatory lesions in 2 cases. Except 2 cases of inflammatory lesions are in follow-up, biopsy and surgical pathology alignment (specificity) was 100%. 41 patients occurred complications related to percutaneous biopsy. Pneumothorax were in 22 cases, drainage required in 2 cases. There were 17 cases with hemoptysis, accounting for 39.5% incidence are self-limited. Intracranial air embolism occurred in 2 cases by 4.6% incidence. They were fully recovered.

CONCLUSIONS

For small lung lesions, CT guided percutaneous biopsy is technically feasible. However, for small lung lesions especially pure GGO biopsy, it is still need to be cautious.

Image-guided tumour biopsies in a prospective molecular triage study (MOSCATO-01): What are the real risks?

PURPOSE

To evaluate efficacy, complications and preprocedural risk factors for percutaneous image-guided core needle biopsy of malignant tumours for genomic tumour analysis.

MATERIALS AND METHODS

Procedural data for core biopsies performed at a single centre for the MOSCATO-01 clinical trial were prospectively recorded between December 2011 and March 2016. Data assessed included patient demographics, tumour characteristics, procedural outcomes and complications.

RESULTS

A total of 877 biopsies were performed under computed tomography (38.4%) or ultrasound guidance (61.6%) for tumours in the liver (n = 363), lungs (n = 229), lymph nodes (n = 138), bones (n = 15) and other miscellaneous sites (n = 124). Each biopsy harvested a mean 4.4 samples [1-15], with adequate tumour yield for genomic analysis in 95.3% of cases. Procedural complications occurred in 89 cases (10.1%), with minor grade I complications in 59 (66.3%); grade II in 16 (18%) and grade III in 14 (15.7%). No grade IV complications and no procedure-related death occurred. The most common complications were pneumothorax (51/89, 57.3%), haemorrhage (24/89, 27%) and pain (8/89, 8.9%). Predictive factors for complications by univariate analysis included biopsied organ (lung vs other), sample number, prone position, lesion size, lesion depth and biopsy approach. By multivariate analysis, only pulmonary biopsy was a significant risk factor (odds ratio = 27.23 [4.93-242.76], p < 0.01).

CONCLUSION

Percutaneous image-guided core needle biopsy in cancer patients provides an effective method to obtain molecular screening samples, with an overall low complication rate. Lung mass biopsies present a higher risk of complication, although complications are manageable by minimally invasive techniques without prolonged sequelae.

Cardiac Arrest Due to Air Embolism: Complicating Image-guided Lung Biopsy

Cardiac arrest due to air embolism is an infrequent complication. Air embolism can be associated with procedures like endoscopic retrograde cholangiopancreatography, endoscopic variceal ligation, operative hysteroscopy, laparoscopic surgery, pacemaker placement, cardiac ablation, fiberoptic bronchoscopy, and decompression sickness. In rare cases, air embolus can be a catastrophic complication of computed tomography (CT) guided lung biopsy, which can lead to cardiac arrest. We present a case of a 67-year-old male chronic smoker with a left lower lobe pulmonary nodule who had a cardiac arrest due to air embolism as a consequence of CT guided biopsy of the pulmonary nodule found on a CT scan of the chest. He was successfully resuscitated and intubated for mechanical ventilation. He was managed conservatively and discharged home in a stable condition.