Risk factors for hemoptysis complicating 17-18 gauge CT-guided transthoracic needle core biopsy: multivariate analysis of 249 procedures

Development and validation of a predictive model for pulmonary hemorrhage in computed tomography-guided percutaneous lung biopsy

PURPOSE

This study aimed to identify risk factors for pulmonary hemorrhage (PH) and higher-grade PH that complicate computed tomography (CT)-guided percutaneous lung biopsy (CT-PNLB) and establish predictive models to quantify the risk.

METHODS

A total of 2653 cases of CT-PNLB were enrolled. Multivariate logistic regression was used to identify independent risk factors to develop a nomogram prediction model. The model was assessed using the area under the curve (AUC) of the receiver operator characteristic (ROC) and calibration curves and validated in the validation group.

RESULTS

PH occurred in 23.52% (624/2653) of cases, and higher-grade PH occurred in 7.09% (188/2653) of cases. The parameters of lesion size, puncture depth, and contact to pleura were identified as risk factors of PH and higher-grade PH in the logistic regression model, besides the position as a risk factor for PH. The AUC of the PH prediction model was 0.776 [95% confidence interval (CI): 0.752-0.800], whereas that of the validation group was 0.743 (95% CI: 0.706-0.780). The AUC of the higher-grade PH prediction model was 0.782 (95% CI: 0.742-0.832), whereas that of the validation group was 0.769 (95% CI: 0.716-0.822). The calibration curves of the model showed good agreement between the predicted and actual probability in the development and validation groups.

CONCLUSION

We identified risk factors associated with PH and higher-grade PH after PNLBs. Furthermore, we developed and validated two risk prediction models for PNLB-related PH and higher-grade PH risk prediction and clinical decision support. Key messages What is already known on this topic Pulmonary hemorrhage (PH) and other hemorrhagic complications are the most common complication in CT-guided percutaneous lung biopsy (CT-PNLB), except pneumothorax. However, the risk factors associated with PH remain controversial, and research on models of PH and higher-grade PH is also limited. What this study adds The parameters of lesion size, puncture depth, and contact to pleura were identified as risk factors of PH and higher-grade PH in the logistic regression model, besides the position as a risk factor for PH. In addition, we developed and validated two risk prediction models for PNLB-related PH and higher-grade PH risk prediction and clinical decision support. How this study might affect research, practice, or policy Of all the predictors, the position is the key factor to be considered by the operator. Moreover, two risk prediction models show good discrimination and calibration characteristics to identify patients at high risk of hemorrhage and higher-grade PH after PNLB, so these could assist clinicians in avoiding risk factors in advance.

Comparison of CT-Guided Core Needle Biopsy in Pulmonary Ground-Glass and Solid Nodules Based on Propensity Score Matching Analysis

Purpose: To compare the diagnostic accuracy and safety of computed tomography (CT)-guided core needle biopsy (CNB) between pulmonary ground-glass and solid nodules using propensity score matching (PSM) method and determine the relevant risk factors. Methods: This was a single-center retrospective cohort study using data from 665 patients who underwent CT-guided CNB of pulmonary nodules in our hospital between May 2019 and May 2021, including 39 ground-glass nodules (GGNs) and 626 solid nodules. We used a 1:4 PSM analysis to compared the diagnostic yields and complications rates of CT-guided CNB between 2 groups. Results: After PSM, 170 cases involved in the comparison (34 GGNs vs 136 solid nodules) were randomly matched (1:4) by patient demographics, clinical history, lesion characteristics, and procedure-related factors. There was no statistically significant difference in the diagnostic yields and complications rates between 2 groups. Significant pneumothorax incidence increase was noted at small lesion size, deep lesion location, and traversing interlobar fissure (P < .05). Post-biopsy hemorrhage was a protective factor for pneumothorax (P < .05). The size/proportion of consolidation of GGN did not influence the diagnostic accuracy and complication incidence (P > .05). Conclusions: The accuracy and safety of CT-guided CNB were comparable for ground-glass and solid nodules and the size/proportion of consolidation of GGN may be not a relevant risk factor. The biopsy should avoid traversing interlobar fissure as far as possible. Smaller lesion size and deeper lesion location may lead to higher pneumothorax rate and post-biopsy hemorrhage may be a protective factor for pneumothorax.

Frequency of complications and risk factors associated with computed tomography guided core needle lung biopsies

BACKGROUND

Although transthoracic needle biopsy (TTNB) is an effective method for diagnosis of lung tumors, it has some complications. It is crucial to know the frequency and severity of the complications of TTNB and its risk factors in order to avoid them.

OBJECTIVES

Evaluate the complications and risk factors of computed tomography guided core needle lung biopsies (CT-CNLB).

DESIGN

Prospective evaluation of complications.

SETTING

Single center in Turkey.

PATIENTS AND METHODS

For CT-CNLBs performed between October 2017 and March 2018, the complications of biopsies were noted and classified as major and minor based on guidelines of the Society of Interventional Radiology.

MAIN OUTCOME MEASURES

The complications and risk factors for complications were evaluated.

SAMPLE SIZE

123 adult patients.

RESULTS

The most common complications were pulmonary hemorrhage (30.9%) and pneumothorax (22%). Increased overall pulmonary hemorrhage was observed with underlying emphysema (P=.022), non-peripheral location of the lesion (P<.001), increased needle pathway (P<.001), fissure penetration (P=.011), increased number of pleura penetrations (P=.024), prolonged needle time across pleura (P=.037), and decreased lesion size (P=.033). The pneumothorax rate increased with non-peripheral location of the lesion (P<.007), fissure penetration (P=.021), prolonged needle time across the pleura (P=.013), and decreased lesion size (P=.002). In the logistic regression analyses for he two most common complications, the only risk factor for both alveolar hemorrhage and pneumothorax was a non-peripheral location of the lesion (P<.001, OR=14.7, 95% CI=3.9-55.4 for alveolar hemorrhage) and (P=.001, OR=156.2, 95% CI =7.34-3324.7 for pneumothorax).

CONCLUSION

Most common complications of CT-CNLB were pneumothorax and pulmonary alveolar hemorrhage with a 5.7% major complication rate. Choosing the shortest possible trans-pulmonary needle pathway minimizes the risk of complications.

LIMITATIONS

Limited number of patients, absence of rare complications as death, air embolism, and needle tract seeding.

CONFLICT OF INTEREST

None.

A paravertebral approach for CT-guided percutaneous biopsy of presumably inaccessible, posterior and centrally located pulmonary nodules

Introduction: To present 3 cases were a paravertebral approach had to be used for the biopsy of posterior and centrally located pulmonary nodules. Case presentation: Three patients underwent percutaneous CT-guided transthoracic biopsy of pulmonary nodules that were initially thought to be inaccessible because of their central, posterior location by a paravertebral approach. The first 2 patients had a history of extra thoracic malignancy and the third patient presented with a bone metastasis and an isolated pulmonary nodule in the right lower lobe, corresponding to potential stage IV lung cancer. Biopsy was feasible in all 3 patients using the paravertebral approach. Pulmonary metastases were confirmed in the first 2 patients, while a TTF-1 positive pulmonary adenocarcinoma was diagnosed in the last patient. No complications occurred. Conclusion: A paravertebral approach is feasible for posterior and centrally located pulmonary nodules.

Synchronous core-needle biopsy and microwave ablation for highly suspicious malignant pulmonary nodule via a coaxial cannula

Aims

This study aimed to evaluate the safety and feasibility of computed tomography (CT)-guided synchronous percutaneous core-needle biopsy and microwave ablation (MWA) for highly suspicious malignant pulmonary nodules.

Materials and Methods

This retrospective study evaluated medical records of 54 consecutive patients (mean age, 65.5 ± 11.2 years) with 62 highly suspicious malignant pulmonary nodules who synchronously underwent percutaneous core-needle biopsy and MWA via a coaxial cannula (Group A) or sequentially underwent these procedures (Group B) from September 2016 to November 2017. All patients were followed up for at least 6 months after MWA. The safety and feasibility of synchronous core-needle biopsy and MWA were analyzed by comparing clinical data, technical success rate, complication, and curative effect per nodule with those of sequential procedures.

Results

Technical success rates were 100% in both groups. The pneumothorax rate was 29.6% (8/27) in Group A and 57.1% (20/35) in Group B, which was statistically different (P = 0.031). In Group A, hemoptysis and pleural effusion rates were 22.2% (6/27), and in Group B, the corresponding rates were 28.6% (10/35) and 20.0% (7/35), respectively. No postprocedural pulmonary artery pseudoaneurysm, bronchopleural fistula, or needle-tract tumor seeding developed in both groups. After 6 months' follow-up, the effective rates (complete + partial response) in both groups were 100%.

Conclusions

Synchronous core-needle biopsy and MWA via a coaxial cannula is technically safe and feasible in the management of highly suspicious malignant pulmonary nodules, and this procedure has lesser complications and similar effects (both 100% effective treatment) compared with sequential procedures.

Hemoptysis complicating ultrasound-guided transthoracic needle lung biopsy: air bronchial sign is a risk predictor

Background

Hemoptysis is the most frequently reported complication of ultrasound-guided transthoracic needle lung biopsy (US-TTLB). However, factors influencing the occurrence of hemoptysis as a result of US-TTLB remain uncertain. Therefore, the aim of this study was to evaluate the incidence of hemoptysis as a complication of US-TTLB and to identify the related risk factors.

Methods

We retrospectively analyzed all data of patients who underwent US-TTLB from February 2013 through December 2016. The incidence, severity, and treatment of hemoptysis in each case were carefully recorded. Study variables were classified into patient-related factors (age, sex, smoking history, pulse oxygen saturation, laboratory tests and emphysema), biopsy-related factors (use of contrast agent, number of punctures and operators), and lesion-related factors (lesion location, size, pathology, length of puncture path and the grade of air bronchial sign). Univariate and multivariate logistic regression analyses were performed to analyze the risk factors of hemoptysis. We investigated whether incidence of hemoptysis increased according to increased grade of air bronchial sign by Mantel-Haenszel test.

Results

A total of 209 patients were evaluated. Hemoptysis occurred in 20 of the 209 patients (9.6%). In univariate analysis, the lesion pathology (P=0.037) and grade of air bronchial sign (P<0.001) were statistically significant factors between the hemoptysis group and the non-hemoptysis group. In multivariate analysis, the presence of multi-air bronchogram in sonographic image (odds ratio =8.946; 95% confidence interval: 2.873–27.863; P<0.001) was a statistically significant predictive risk factor for hemoptysis complicating US-TTLB. There was a significant tendency for incidence of hemoptysis with the grade of air bronchial sign (P<0.001).

Conclusions

We found that the rate of hemoptysis complicating US-TTLB was 9.6% and the severity of hemoptysis was not serious. Target lesion without air bronchogram is a safety sign, minor bronchogram means relatively low-risk, while multiple bronchogram is a highly dangerous ultrasound sign of hemoptysis.

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.

Complications of CT-guided lung biopsy with a non-coaxial semi-automated 18 gauge biopsy system: Frequency, severity and risk factors

Objectives

To evaluate frequency and severity of complications after CT-guided lung biopsy using the Society of Interventional Radiology (SIR) classification, and to assess risk factors for overall and major complications.

Materials and methods

311 consecutive biopsies with a non-coaxial semi-automated 18 gauge biopsy system were retrospectively evaluated. Complications after biopsy were classified into minor SIR1-2 and major SIR3-6. Studied risk factors for complications were patient-related (age, sex and underlying emphysema), lesion-related (size, location, morphologic characteristic, depth from the pleura and histopathology), and technique-related (patient position during procedure, thoracic wall thickness at needle path, procedure time length and number of procedural CT images, number of pleural passes, fissure penetration and needle-to-blood vessel angle). Data were analyzed using logistic and ordinal regression.

Results

Complications were pneumothorax and pulmonary hemorrhage. The complications were minor SIR1-2 in 142 patients (45.6%), and major SIR3-4 in 25 patients (8%). SIR5-6 complications were not present. Emphysema, smaller deeply located lesion, increased puncture time length and number of procedural CT images, multiple pleural passes and fissure puncture were significant risk factors for complication severity in univariate analysis. Emphysema (OR = 8.8, p<0.001), lesion depth from the pleura (OR = 1.9 per cm, p<0.001), and fissure puncture (OR = 9.4, p = 0.01) were the independent factors for major complications in a multiple logistic regression model. No statistical difference of complication rates between the radiologists performing biopsies was observed.

Conclusions

Knowledge about risk factors influencing complication severity is important for planning and performing CT-guided lung biopsies.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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