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Vascular and Interventional Radiology |
1 From the Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC. Received June 17, 1998; revision requested July 30; revision received September 22; accepted December 16. Address reprint requests to J.E.C., 59 MDW/MTRD, 2200 Bergquist Dr, Suite 1, Lackland AFB, TX 78236-5300 (e-mail: joecox@aol.com).
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Abstract |
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MATERIALS AND METHODS: In 346 patients, 331 computed tomographically (CT) guided and 24 fluoroscopically guided lung biopsies were performed. Variables analyzed were lesion size, depth, and location; number of pleural passes; needle size; presence of emphysema; and training level of the person who performed the biopsy.
RESULTS: Pneumothorax occurred at 144 (40.4%) of 356 biopsies, including 139 (42.0%) CT-guided and five (21%) fluoroscopically guided biopsies. Chest tube placement was needed in 25 (17.4%) of 144 cases of pneumothorax (7% of all biopsies). An increased rate of pneumothorax was correlated with smaller lesion size (P = .001) and presence of emphysema (P = .01). Patients with emphysema were three times as likely to require chest tube placement. The pneumothorax rate was 15% (16 of 105) if no aerated lung was traversed and approximately 50% if aerated lung was penetrated. Lesion location, needle size, number of pleural passes, and level of training were not correlated with pneumothorax rate.
CONCLUSION: Smaller lesion size and emphysema are strongly correlated with occurrence of pneumothorax. Pneumothorax was more than three times less frequent if no aerated lung was traversed. After pneumothorax, chest tube placements were related to the presence of emphysema.
Index terms: Biopsies, complications, 60.411, 60.732 • Computed tomography (CT), guidance, 60.12111 • Lung, biopsy, 60.126, 60.732 • Pneumothorax, 60.411, 60.732
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Introduction |
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Fatal complications due to systemic air embolism, hemorrhage, or pericardial tamponade have been described (3,7–10), but these complications are rare. Other serious complications, such as seeding of malignant cells into the needle track (11), lung torsion (12), and empyema (7), also are rare and should not alter indications for TNAB.
Pneumothorax is, by far, the most frequent complication of the procedure: Reported (2,8,13–23) rates range widely, from 5% to 61%. Most of these data pertain to fluoroscopically guided TNAB. Overall, TNAB performed with computed tomographic (CT) guidance may be associated with a higher frequency of pneumothorax than fluoroscopically guided TNAB, probably because CT requires more time, and the average size of the lesion is smaller. The reported rate of pneumothorax with CT-guided biopsy may also be slightly higher because CT is more sensitive for the detection of pneumothorax. The authors of several investigations (1,13,24) have reported a 22%–45% risk of pneumothorax for CT-guided TNAB. The purpose of this study was to examine the influence of multiple variables on the frequency of pneumothorax and chest tube placement.
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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All procedures were performed by a staff radiologist (J.E.C., C.C., S.L.C., R.H.C.) or by a radiology resident (C.M.M.) with staff supervision, in accordance with the protocol followed by the thoracic radiology section at our institution (North Carolina Baptist Hospital, Winston-Salem). Biopsies were assigned randomly to the resident or staff radiologist who was covering the chest CT service. Informed consent was obtained before each biopsy.
The procedure was performed with the patient in a prone, supine, or lateral decubitus position, depending on the location of the lesion. Conscious sedation was used in anxious patients and on request. Local anesthesia was administered by means of a subcutaneous injection of 1% lidocaine. Coaxial procedures were performed with a 19-gauge outer needle (Greene needle; Cook, Bloomington, Ind) and a 22-gauge inner needle. Biopsy of a peripheral lesion often was performed directly with a 22-gauge needle. If CT guidance was used, axial images were acquired before needle aspiration to document the position of the 19- or 22-gauge needle in the lesion. Nine biopsies were performed with an 18-, 20-, or 21-gauge needle. Pleural effusions, fissures, and bullae were avoided during biopsy if possible. As a general rule, the radiologists would not refuse to perform a biopsy because of emphysema.
The frequency of pneumothorax and chest tube placement was analyzed in relationship to several variables, including lesion location (upper lobe, lower lobe, right middle lobe), lesion size, lesion depth, number of pleural passes, size of the needle used to traverse the pleura, presence of emphysema in lobe in which biopsy was performed, and level of training of person performing the biopsy.
For CT-guided biopsies, images were first acquired at 3- or 5-mm collimation through the lesion by using a CT HiSpeed Advantage scanner (GE Medical Systems, Milwaukee, Wis). Lesion size was determined on the basis of the average lesion diameter in two axial planes. CT scans were available for all fluoroscopically guided biopsies. (Fluoroscopically-guided biopsies generally were performed when the CT scanner was not immediately available.) Lesion depth was the amount of aerated lung traversed from the surface of the pleura to the edge of the lesion. The presence of any type of emphysema in the lobe in which biopsy was performed was determined on the basis of CT results alone. At our institution, thin-section (1-mm-collimation) CT images of the lung are routinely acquired and could be used to evaluate for emphysema in most cases. The level of training (11st- through 4th-year resident or staff physician) of each person performing the procedure was recorded.
A cytotechnologist and resident or staff cytopathologist were present at all biopsies. All specimens obtained were immediately smeared and then stained by the cytotechnologist. The adequacy of the specimen for diagnosis was assessed by the resident pathologist, the staff pathologist, or both. If possible, additional aspirates were obtained when specimens were not sufficient for diagnosis.
After the procedure, patients were placed on a stretcher for 1 hour in the puncture-side-down position, with the supervision of a nurse. Chest radiographs were obtained 1–2 hours after biopsy, with the patient in the erect position. The procedure was complicated by pneumothorax if pneumothorax was seen on either the follow-up CT scan obtained immediately after biopsy or on the chest radiograph obtained 1–2 hours after biopsy. An enlarging or symptomatic pneumothorax was treated with placement of a chest tube. The relationship between pneumothorax and quantitative variables was analyzed by using the Fisher exact test or the 
2 statistic.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Table 1 shows the comparison of the frequency of pneumothorax and the level of training of the physician who performed the procedure. No significant difference in pneumothorax rate was found when the procedure was performed by a junior resident (73 [41%] of 178), a senior resident (58 [40%] of 144), or a staff physician (12 [40%] of 30).
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Table 2 shows the comparison of the frequency of pneumothorax with the number of passes made across the pleural surface with the needle. No significant correlation between these two variables was found. Pneumothorax occurred in 103 (40.6%) of 254 biopsies performed with two or fewer pleural passes and in 41 (40.2%) of 102 biopsies performed with three or more pleural passes. In addition, no significant difference in the prevalence of pneumothorax was found when comparing one pass with multiple passes (2 = 1.71).
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Table 3 shows the comparison of the frequency of pneumothorax with the distance of the lesion from the pleural surface, that is, amount of aerated lung traversed by the needle. A measurement of 0 cm indicates that the lesion contacted the pleural surface, and no aerated lung was traversed during the TNAB. For these peripheral lesions, pneumothorax occurred at only 16 (15%) of 105 biopsies. If any amount of aerated lung was traversed during biopsy, the rate of pneumothorax approximated 50%. The pneumothorax rate did not increase with increasing distance of the lesion from the pleural surface (if peripheral lesions are excluded from consideration).
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2 = 6.9, P < .01) in patients who had CT evidence of emphysema (usually determined on the basis of thin-section CT findings) in the lobe in which biopsy was performed. In patients in whom biopsy was complicated due to pneumothorax, the frequency of chest tube placement was significantly greater (2 = 7.12, P < .01) in those with CT evidence of emphysema (18 [27%] of 66) than in those with no CT evidence of emphysema (seven [9%] of 78).
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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There is some debate in the literature about the correlation between abnormal pulmonary function test results and the risk of development of pneumothorax. Recently, Anderson et al (17) and Kazerooni et al (24) found that pulmonary function test results had no predictive value with regard to the frequency of pneumothorax in their studies of CT-guided TNAB in 93 and 121 patients, respectively. In contrast, both Fish et al (15) and Miller et al (16) found that obstructive lung disease was a factor that affected the pneumothorax rate. In those studies, pneumothorax developed in approximately 45% of patients with an obstructive pulmonary abnormality, as compared with about 20% of patients with normal pulmonary function. Poe et al (14) found a twofold increase in the prevalence of pneumothorax in patients who had greater than 120% of predicted total lung capacity.
In our study, thin-section CT (usually 1–3-mm collimation) was used to determine if emphysema was visible in the lobe in which biopsy was performed. We found a significantly higher (2 = 7.45, P < .01) risk of pneumothorax in patients with emphysema (49% vs 35% in those without emphysema) when evaluated as a single independent variable. Also, patients with emphysema in whom a pneumothorax developed required chest tube placement at three times the rate of those with pneumothorax but no CT evidence of emphysema (27% and 9%, respectively).
The increased likelihood of chest tube placement in patients who have obstructive lung disease has previously been demonstrated (15,24,25) and could be due to several factors. Patients with emphysema have decreased pulmonary reserve and are more likely to have a symptomatic pneumothorax. Also, disruption of dilated air spaces may prevent rapid sealing of the air leak (24). Pneumothorax resorbs more slowly in patients with an obstructive pulmonary abnormality (26).
The strong correlation between pneumothorax rate and lesion size is difficult to explain, although this correlation has previously been reported (15,24). It could be argued that larger lesions are more likely to contact the pleural surface and, hence, not require needle passage through aerated lung. However, the correlation of increasing frequency of pneumothorax with decreasing lesion size persists, even if lesions with pleural contact are eliminated from consideration. The pneumothorax rate was 64.2% (68 of 106) for lesions 2 cm or less in size, as compared with 41.4% (60 of 145) for lesions more than 2 cm in size (excluding the 105 lesions in contact with pleura). A possible explanation for this finding is that the up-and-down movement of the needle tip during aspiration biopsy results in more tearing of adjacent lung parenchyma when the lesion is relatively small.
No relationship was found between the number of pleural passes and the pneumothorax rate. Although this lack of association is surprising, other studies (14–16,24) have shown similar results. There also was no correlation between pneumothorax rate and needle size (19-gauge vs 22-gauge) or lesion location (upper lobe vs lower lobe). Of interest, the risk of pneumothorax was nearly identical when TNAB was performed by a junior resident, senior resident, or staff physician, possibly because the factors that influence the pneumothorax rate are not operator dependent.
In conclusion, the only factors that independently altered the risk of pneumothorax were size of the lesion and presence of emphysema. If no aerated lung was traversed during needle penetration, the pneumothorax rate was low. However, the rate of pneumothorax was approximately 50% if any amount of aerated lung was penetrated. The presence of emphysema increased the likelihood that chest tube placement would be necessary.
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Footnotes |
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Abbreviation: TNAB = transthoracic needle aspiration biopsy
Author contributions: Guarantors of integrity of entire study, J.E.C., C.C., C.M.M.; study concepts and design, J.E.C., C.C., C.M.M.; definition of intellectual content, J.E.C.; literature research, J.E.C., C.M.M.; clinical studies, all authors; data acquisition, all authors; data analysis, J.E.C.; statistical analysis, J.E.C.; manuscript preparation, J.E.C.; manuscript editing and review, J.E.C., C.C., R.H.C.
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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