Pre-surgical lung biopsy in management of solitary pulmonary nodules: a cost effectiveness analysis

A look ahead to promote the early detection of lung cancer: technical and cost implications of a confirmed diagnosis before surgery

OBJECTIVE

To compare the costs and length of hospital stay among patients with a confirmed diagnosis of lung cancer (LC) prior to surgery versus those without confirmation.

METHODS

This retrospective, single-center study was conducted in patients who underwent a surgical procedure for LC, with or without a pathologically confirmed LC diagnosis prior to surgery, between March 2017 and December 2019. The main outcomes were costs and length of hospital stay (LOS).

RESULTS

Among the 269 patients who underwent surgery for lung cancer between March 2017 and December 2019, 203 (75.5%) patients underwent surgery due to a histopathological diagnosis, and 66 (24.5%) because of a Multidisciplinary Cancer Committee indication. The unadjusted mean cost was significantly lower in Group II (patients with surgery based on Multidisciplinary Cancer Committee criteria) (Є2,581.80 ± Є1,002.50) than in Group I (patients with histopathological diagnosis) (Є4,244.60 ± Є2,008.80), P < 0.0001. Once adjusted for covariables, there was a mean difference of -Є1,437.20 in the costs of Group II, P < 0.0001. Unadjusted mean hospital stay was significantly longer in Group I (5.6 days) than in Group II (3.5 days).

CONCLUSIONS

The results suggest that indicating surgical resection of lung cancer based on Multidisciplinary Cancer Committee criteria, rather than performing CT-guided percutaneous lung biopsy, may result in a significant decrease in cost and length of hospital stay.

Application of three-dimensional reconstruction combined with dial positioning in small pulmonary nodules surgery

Background

With the popularization of HRCT and VATS, the incidence of early stage lung cancer is increasing recent years. About 63% of small pulmonary nodules can not be accurately identified in VATS. We use 3-D reconstruction combined with dial positioning to analyze its accuracy and impact on patients undergoing VATS in our hospital.

Method

All patients underwent HRCT scanning and 3-D reconstruction preoperatively to determine the scope of surgery. The precise positional relationship between the nodule and the nearest rib must be recorded. Locate the plane of pulmonary nodule on CT, rotate the plane to make the affected side upwards, take the highest point of pleura as 12 o'clock on the dial, record the corresponding point of the nodule meticulously, mark the pulmonary nodule on the skin of the patient. A 18G indwelling needle was used to puncture through the marker into the visceral pleura. Electrocautery mark was made on the bleeding point of the lung surface. Then wedge resection or segmental resection was made.

Materials and result

From September 2019 to December 2020, 74 patients underwent VATS pulmonary nodule resection in our institute, with an average age of (56.4 ± 11.7) years old. A total of 83 nodules were resected in 74 patients, 23 nodules received segmentectomy and 60 nodules received wedge resection with 16 benign nodules and 67 malignant nodules. The distance between the nodules and pleura was (0–25) mm, with an average of (8.0 ± 3.9) mm. The target nodules were found in all patients, the positioning accuracy was 97.6%. All patients were satisfied with the positioning method, and there was no scar left at the skin puncture point after operation.

Conclusion

3-D reconstruction combined with dial positioning method can reduce patients' anxiety preoperatively, avoid various complications, reduce hospitalization expenses, and has an acceptable accuracy and short learning curve, which can be further promoted and applied in clinic.

A Retrospective Multi-Site Academic Center Analysis of Pneumothorax and Associated Risk Factors after CT-Guided Percutaneous Lung Biopsy

PURPOSE

To assess the risk factors, incidence and significance of pneumothorax in patients undergoing CT-guided lung biopsy.

METHODS

Patients who underwent a CT-guided lung biopsy between August 10, 2010 and September 19, 2016 were retrospectively identified. Imaging was assessed for immediate and delayed pneumothorax. Records were reviewed for presence of risk factors and the frequency of complications requiring chest tube placement. 604 patients were identified. Patients who underwent chest wall biopsy (39) or had incomplete data (9) were excluded.

RESULTS

Of 556 patients (average age 66 years, 50.2% women) 26.3% (146/556) had an immediate pneumothorax and 2.7% (15/556) required chest tube placement. 297/410 patients without pneumothorax had a delayed chest X-ray. Pneumothorax developed in 1% (3/297); one patient required chest tube placement. Pneumothorax risk was associated with smaller lesion sizes (OR 0.998; 95% CI (0.997, 0.999); [p = 0.002]) and longer intrapulmonary needle traversal (OR 1.055; 95% CI (1.033, 1.077); [p < 0.001]). Previous ipsilateral lung surgery (OR 0.12; 95% CI (0.031, 0.468); [p = 0.002]) and longer needle traversal through subcutaneous tissue (OR 0.976; 95% CI (0.96, 0.992); [p = 0.0034]) were protective of pneumothorax. History of lung cancer, biopsy technique, and smoking history were not significantly associated with pneumothorax risk.

CONCLUSION

Delayed pneumothorax after CT-guided lung biopsy is rare, developing in 1% of our cohort. Pneumothorax is associated with smaller lesion size and longer intrapulmonary needle traversal. Previous ipsilateral lung surgery and longer needle traversal through subcutaneous tissues are protective of pneumothorax. Stratifying patients based on pneumothorax risk may safely obviate standard post-biopsy delayed chest radiographs.

[CT-guided Percutaneous Lung Puncture for the Diagnosis of Solid Pulmonary Nodules: A Single-center Experience Summary]

背景与目的

探究经皮肺穿刺对于实性肺小结节（直径≤15 mm）的诊断价值。

方法

本研究回顾性地纳入了2014年1月-2018年12月于本中心行经皮肺穿刺的20例实性肺小结节患者，其中男性11例，女性9例。病灶最大直径介于0.5 cm-1.5 cm之间，排除严重脏器功能不全，有凝血障碍患者。

结果

20例患者全部取材成功，19例患者均获得明确的病理诊断，其中11例患者找到恶性肿瘤细胞，明确为肺恶性肿瘤，5例为肺慢性炎，2例纤维组织增生，1例找到肺软骨组织，1例未见肿瘤细胞。穿刺后少量气胸1例，穿刺侧少量胸腔积液患者1例。

结论

经皮肺穿刺对于实性肺小结节的诊断具有较高的有效性以及安全性。

Financial implications of CT-guided lung biopsy in a tertiary centre: a radiologists' perspective

AIM

To evaluate the financial costs of performing computed tomography (CT)-guided lung biopsies in a large tertiary centre to help guide service development.

MATERIALS AND METHODS

Local financial data were collected to create a balance sheet, considering all expenses as well as revenue sources associated with the procedure. Data were based on accurate pricing and income data and evaluated on a per-procedure basis, with consideration of additional costs arising from post-procedural complications. Revenue data were estimated based on reimbursement information. A small coding quality audit was also performed to check if reimbursement claims were filed correctly.

RESULTS

This study demonstrated a healthy income generated from CT-guided lung biopsy procedures with a profit margin of 50%. Notably different financial impact was observed when comparing the same procedure undertaken on an outpatient as opposed to inpatient basis with inpatient procedures generating a net loss of - £2,146.79 a year. Overall, the activity generated a profit of £157,015.25, after accounting for loss generated by inpatient activity.

CONCLUSION

This analysis furthered understanding of the financial impact from performing CT-guided lung biopsy and will enable better planning and expansion of the service in the future, with emphasis around day-case and ambulatory service development, the positive intended consequence being an improved patient pathway.

Endobronchial Ultrasound Combined with Clinical Data for Predicting Malignant Peripheral Pulmonary Lesions

Introduction

This study was to develop a simple model for predicting malignancy of peripheral pulmonary lesions (PPLs) based on endobronchial ultrasonography (EBUS) and clinical findings.

Methods

Patients who had EBUS for PPLs were analyzed and compared on the EBUS imaging characteristics and clinical data. The malignancy prediction model was established by the logistic equation of probability of malignant PPL based on the data of 135 patients. The model was tested on an additional 50 patients for efficiency.

Results

Among 135 prospectively enrolled patients, 77 (57%) patients had malignant and 58 (43%) had benign lesions with the size of 36.5±19.9 mm. Univariate analysis demonstrated a significant (P<0.05) difference in the serum CEA (borderline 15 µg/mL) and smoking history between malignant and benign lesions but a non-significant (P>0.05) difference in age (50 years as the cutoff value) and history of extra-thoracic malignancies. Logistic analysis of multiple factors showed that smoking history, serum CEA, borderline, air bronchogram, heterogeneous echo, and anechoic areas were significant (P<0.02) risk factors for malignant lesions. The malignancy prediction model was established by the logistic equation of probability of malignant PPL (P) = l/[l+e^–Z], where Z=−2.986+1.993X₁+2.293X₂+l.552X₃+1.616X₄–2.011X₅+1.718X₆, e is the base of the natural logarithm, X₁ is the smoking history, X₂ is the serum CEA, X₃ is the borderline, X₄ is the heterogenicity, X₅ is the air bronchogram, and X₆ is the anechoic area. The receiver operating characteristic curve had an area under the curve (AUC) of 0.926 (95% confidence interval: 0.883–0.969). The sensitivity, specificity, and accuracy were 88.2% (30/34), 75.0% (12/16), and 92.0% (46/50), respectively, for the logistic equation to predict the malignancy.

Conclusion

Endobronchial ultrasonography is a safe and practical method, and the model combining EBUS and clinical data can accurately predict the malignancy of peripheral pulmonary lesions.

Biopsy of lung lesions under CT control

OBJECTIVES

With the increasing number of detected lung nodules and the need for morphological verification, the number of CT- controlled biopsies is increasing. The aim of this study was to assess the risks and benefits of these biopsies.

METHODS

This is a prospective and observational study. We evaluated 101 punctures performed on a group of 90 consecutive patients in the Department of Radiology.

RESULTS

In patients with a mean age of 66 years, with mostly accidentally detected lung nodules, we observed complications 38 times. The most common were minor pneumothoraxes or insignificant bleedings. In 6 patients, the complications were more serious, 5 times the pneumothoraxes required chest drainage, once massive hemoptysis was recorded. The lesions were successfully biopsied 78 times, the target was missed 23 times. The diagnosis of lung cancer (LC) was confirmed in 60 patients, 49 LCs were verified by puncture under CT control. 42% (25/60) of patients with LC were diagnosed in TNM stages I and II. 23% (14/60) of patients with LC were treated surgically. The remaining 30 patients most often suffered from lung metastazes (13/30), in 8 of them an inflammatory lung disease was diagnosed. 69 patients underwent bronchoscopy, in only 19% (13/69) it contributed to the diagnosis. In a model "screening like" group of 49 patients with only randomly detected lung deposits, we diagnosed LC in 76% (37/49). 49% (18/37) were in TNM stage I and II, 11 were treated surgically.

CONCLUSIONS

CT-controlled biopsy of lung lesions is an effective and safe diagnostic method.