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• W2039785901 abstract "Percutaneous transthoracic biopsies are commonly performed for the diagnosis of thoracic lesions. Early reports of needle biopsies of the lung were published in the late 1800s.1Leyden OO Uber infektiose pneumonic.Dtsch Med Wochenschr. 1883; 9: 52-54Crossref Google Scholar2Menetrier P Cancer primitif du poumon.Bull Soc Anat Paris. 1886; 11: 643-647Google Scholar In 1883, Leyden1Leyden OO Uber infektiose pneumonic.Dtsch Med Wochenschr. 1883; 9: 52-54Crossref Google Scholar biopsied the consolidated right lower lobe of a moribund 48-year-old man. The specimen was stained, and bacteria and WBCs were identified. Pneumonia was diagnosed, unfortunately, the patient died 1 day later. Menetrier2Menetrier P Cancer primitif du poumon.Bull Soc Anat Paris. 1886; 11: 643-647Google Scholar described a 51-year-old man who presented on May 25, 1885, with a productive cough, fever, and physical examination findings positive at the left base. On July 14, 150 mL pus was extracted via a needle, and the organism was identified as Streptococcus pyogenes. The patient died on October 19 of that year. Autopsy showed an organized left pleural empyema with no malignancy. Since then, needle biopsy has gained wide acceptance for diagnosing malignant and benign lung lesions. The common modalities employed in the guidance of percutaneous lung biopsy are fluoroscopy and CT scanning. Since the advent of CT scanning, fluoroscopic guidance has been utilized less often, and CT scanning and CT scan-fluoroscopic guidance dominate the current literature. Ultrasound guidance can be used for the biopsy of subpleural lesions.3Savage C Zwischenberger JB Image-guided fine needle aspirate strategies for staging of lung cancer.Clin Lung Cancer. 2000; 2: 101-110Abstract Full Text PDF PubMed Scopus (17) Google Scholar However, the use of ultrasound as an imaging modality for guiding lung biopsies has not been widely adopted. Technologic advances in both needle design and imaging equipment have broadened the range of lesions that are accessible to needle biopsy. Lung biopsies can be performed by fine-needle aspiration (FNA), providing a specimen for cytologic examination, or using an automated core biopsy needle, providing a specimen for histologic examination. FNA was introduced by Nordenstrom4Nordenstrom B A new technique for transthoracic biopsy of lung changes.Br J Radiol. 1965; 38: 550-553Crossref Google Scholar in 1965. Numerous reports have advocated the use of FNA, since it is a reasonably simple and safe technique with an accuracy of about 95% for malignant lesions,5Tarver RD Conces DJ Interventional chest radiology.Radiol Clin North Am. 1994; 32: 689-709PubMed Google Scholar despite a lower yield for benign lesions.6Stanley JH Fish GD Andriole JG et al.Lung lesions: cytologic diagnosis by fine-needle biopsy.Radiology. 1987; 162: 389-391Crossref PubMed Scopus (155) Google Scholar Early reports7Klein JS Salomon G Stewart EA Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients.Radiology. 1996; 198: 715-720Crossref PubMed Scopus (279) Google Scholar cited cytology to be less reliable than histology in determining the cell type of malignant lesions. This disadvantage can be obviated by the presence of a cytopathologist during the biopsy, which has been shown to increase the diagnostic accuracy of FNA.8Austin JH Cohen MB Value of having a cytopathologist present during percutaneous fine-needle aspiration biopsy of lung: report of 55 cancer patients and metaanalysis of the literature.AJR Am J Roentgenol. 1993; 160: 175-177Crossref PubMed Scopus (175) Google Scholar9Stewart CJ Stewart IS Immediate assessment of fine needle aspiration cytology of lung.J Clin Pathol. 1996; 49: 839-843Crossref PubMed Scopus (61) Google Scholar However, at many centers, well-trained cytopathologists are not available to immediately interpret FNA specimens. To avoid this problem, several series7Klein JS Salomon G Stewart EA Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients.Radiology. 1996; 198: 715-720Crossref PubMed Scopus (279) Google Scholar have advocated the use of automated cutting needles to obtain core tissue for histologic evaluation. Complication rates for automated cutting needle biopsies are comparable to, or slightly higher than those for FNA.7Klein JS Salomon G Stewart EA Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients.Radiology. 1996; 198: 715-720Crossref PubMed Scopus (279) Google Scholar10Arakawa H Nakajima Y Kurihara Y et al.CT-guided transthoracic needle biopsy: a comparison between automated biopsy gun and fine needle aspiration.Clin Radiol. 1996; 51: 503-506Abstract Full Text PDF PubMed Scopus (62) Google Scholar The most common complications of percutaneous transthoracic lung biopsy are pneumothorax and bleeding. Pneumothorax has a broad frequency range of 8 to 64%.11Haramati LB Austin JH Complications after CT-guided needle biopsy through aerated versus nonaerated lung.Radiology. 1991; 181: 778Crossref PubMed Scopus (109) Google Scholar Bleeding occurs less often (range, 2 to 10%) but is more frequently fatal. Many reports have evaluated the relationship between specific variables and the complications of percutaneous lung biopsy. Complications are evaluated according to variables related to the patient, the lesion, and the biopsy procedure. In this issue of CHEST (see page 748), Yeow et al analyzed the risk factors for pneumothorax and bleeding for 660 consecutive CT scan-guided percutaneous coaxial cutting needle biopsies. They consistently performed coaxial cutting needle biopsies because an on-site cytopathologist was not available. The diagnostic accuracy of these biopsies has been previously reported.12Yeow KM Tsay PK Cheung YC et al.Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures.J Vasc Interv Radiol. 2003; 14: 581-588Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Multiple variables related to the patient, the lesion, the biopsy needle, and the radiologist were assessed using univariate and multivariate analysis to determine the influence of each specific variable on the rate of pneumothorax and bleeding. The analyzed variables included the presence of emphysema, chest wall thickness, lesion size and depth, lesion necrosis or cavitation, needle size, number of specimens obtained, needle-pleural angle, and the experience of the radiologist performing the biopsies. The results of multivariate analysis showed that patients with lesions ≤ 2 cm had a higher incidence of pneumothorax than did those with larger lesions. In fact, the risk of pneumothorax was 11 times greater for patients with lesions ≤ 2 cm compared with patients with lesions > 4 cm. Smaller lesion size has been reported previously12Yeow KM Tsay PK Cheung YC et al.Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures.J Vasc Interv Radiol. 2003; 14: 581-588Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar13Cox JE Chiles C McManus CM et al.Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax.Radiology. 1999; 212: 165-168Crossref PubMed Scopus (256) Google Scholar14Kazerooni EA Hartker III, FW Whyte RI et al.Transthoracic needle aspiration in patients with severe emphysema: a study of lung transplant candidates.Chest. 1996; 109: 616-619Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar to correlate with an increased risk of pneumothorax. This may be due to the difficulty in maneuvering the needle into the target lesion, thus extending the time required to biopsy smaller lesions. The pleura-to-lesion distance was the second factor influencing the risk of pneumothorax. Haramati and Austin11Haramati LB Austin JH Complications after CT-guided needle biopsy through aerated versus nonaerated lung.Radiology. 1991; 181: 778Crossref PubMed Scopus (109) Google Scholar reported a negligible risk of pneumothorax for lesions abutting the pleura and not requiring the traversal of the aerated lung. Interestingly, Yeow et al demonstrated a sevenfold increase in the rate of pneumothorax for the biopsy of subpleural lesions that were ≤ 2 cm from the pleural surface compared with lesions abutting the pleural surface. Patients with subpleural lesions also had a fourfold increase in the rate of pneumothorax compared with those with lesions that were > 2 cm from the pleural surface. In contrast, other authors who have analyzed the pleura-to-lesion distance,13Cox JE Chiles C McManus CM et al.Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax.Radiology. 1999; 212: 165-168Crossref PubMed Scopus (256) Google Scholar15Yeow KM See LC Lui KW et al.Risk factors for pneumothorax and bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung lesions.J Vasc Interv Radiol. 2001; 12: 1305-1312Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar16Tanaka J Sonomura T Shioyama Y et al.“Oblique path”: the optimal needle path for computed tomography-guided biopsy of small subpleural lesions.Cardiovasc Intervent Radiol. 1996; 19: 332-334PubMed Google Scholar17Moore EH Technical aspects of needle aspiration lung biopsy: a personal perspective.Radiology. 1998; 208: 303-318Crossref PubMed Scopus (122) Google Scholar18Miller KS Fish GB Stanley JH et al.Prediction of pneumothorax rate in percutaneous needle aspiration of the lung.Chest. 1988; 93: 742-745Crossref PubMed Scopus (88) Google Scholar have described an increasing rate of pneumothorax with greater lesion depth. Subpleural lesions are technically more difficult to biopsy,19Fish GD Stanley JH Miller KS et al.Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.AJR Am J Roentgenol. 1988; 150: 71-74Crossref PubMed Scopus (120) Google Scholar20Kazerooni EA Lim FT Mikhail A et al.Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung.Radiology. 1996; 198: 371-375Crossref PubMed Scopus (309) Google Scholar21Laurent F Michel P Latrabe V et al.Pneumothoraces and chest tube placement after CT-guided transthoracic lung biopsy using a coaxial technique: incidence and risk factors.AJR Am J Roentgenol. 1999; 172: 1049-1053Crossref PubMed Scopus (150) Google Scholar and the associated increase in the pneumothorax rate is likely due to small needle-pleural angles, multiple punctures, and a longer biopsy time. Furthermore, insufficient anchoring, which is accentuated in cutting biopsies by the heavier hub, may result in the tearing of the pleura and the laceration of the adjacent parenchyma. Based on the present study by Yeow et al and on data from previous studies,19Fish GD Stanley JH Miller KS et al.Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.AJR Am J Roentgenol. 1988; 150: 71-74Crossref PubMed Scopus (120) Google Scholar20Kazerooni EA Lim FT Mikhail A et al.Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung.Radiology. 1996; 198: 371-375Crossref PubMed Scopus (309) Google Scholar21Laurent F Michel P Latrabe V et al.Pneumothoraces and chest tube placement after CT-guided transthoracic lung biopsy using a coaxial technique: incidence and risk factors.AJR Am J Roentgenol. 1999; 172: 1049-1053Crossref PubMed Scopus (150) Google Scholar it would be reasonable to take a longer needle path for subpleural nodules in order to reduce the risk of pneumothorax. Yeow et al demonstrated a significant correlation between operator experience and the risk of developing a pneumothorax. This is in contrast to the conclusions of Cox et al,13Cox JE Chiles C McManus CM et al.Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax.Radiology. 1999; 212: 165-168Crossref PubMed Scopus (256) Google Scholar who reported an identical risk of pneumothorax when FNA was performed by operators with various levels of expertise. Although the complication rates for automated cutting needle biopsies and FNA are comparable, differences in the learning curve between the two biopsy techniques has not, to our knowledge, been studied and may explain the difference in the results. Negative findings in a large series are an important component of the results. Yeow et al showed no increase in the risk of pneumothorax for factors that intuitively, and in other series, have been suggested to increase the risk of pneumothorax. Emphysema, cavitation of the lesion, needle size, number of specimens, and postbiopsy patient positioning all showed no association with an increased risk of pneumothorax. Earlier studies14Kazerooni EA Hartker III, FW Whyte RI et al.Transthoracic needle aspiration in patients with severe emphysema: a study of lung transplant candidates.Chest. 1996; 109: 616-619Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar15Yeow KM See LC Lui KW et al.Risk factors for pneumothorax and bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung lesions.J Vasc Interv Radiol. 2001; 12: 1305-1312Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar16Tanaka J Sonomura T Shioyama Y et al.“Oblique path”: the optimal needle path for computed tomography-guided biopsy of small subpleural lesions.Cardiovasc Intervent Radiol. 1996; 19: 332-334PubMed Google Scholar22Garcia-Rio F Pino JM Casadevall J et al.Use of spirometry to predict risk of pneumothorax in CT-guided needle biopsy of the lung.J Comput Assist Tomogr. 1996; 20: 20-23Crossref PubMed Scopus (42) Google Scholar23Saji H Nakamura H Tsuchida T et al.The incidence and the risk of pneumothorax and chest tube placement after percutaneous CT-guided lung biopsy: the angle of the needle trajectory is a novel predictor.Chest. 2002; 121: 1521-1526Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar reported a higher risk of pneumothorax in patients with obstructive pulmonary disease. However, others,17Moore EH Technical aspects of needle aspiration lung biopsy: a personal perspective.Radiology. 1998; 208: 303-318Crossref PubMed Scopus (122) Google Scholar24Anderson CL Crespo JC Lie TH Risk of pneumothorax not increased by obstructive lung disease in percutaneous needle biopsy.Chest. 1994; 105: 1705-1708Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar in agreement with Yeow et al, have found no correlation among emphysema, abnormal pulmonary function test results, and pneumothorax. Bleeding is the second most common complication of percutaneous lung biopsy. Yeow et al reported a sixfold increase in bleeding complications for patients with lesions ≤ 2 cm in size compared with those having lesions > 4 cm in size. This increased risk has been attributed to the sampling of the adjacent aerated lung along with the decreased ability of the adjacent aerated lung to provide tamponade. Laurent et al25Laurent F Latrabe V Vergier B et al.CT-guided transthoracic needle biopsy of pulmonary nodules smaller than 20 mm: results with an automated 20-gauge coaxial cutting needle.Clin Radiol. 2000; 55: 281-287Abstract Full Text PDF PubMed Scopus (187) Google Scholar reported comparable rates of pneumothorax and bleeding for nodules < 2 cm and > 2 cm. However, a varied length of needle throw may have confounded their results. In that series, the needle throw was adjusted on a case-by-case basis, depending on the size and position of the lesion. In contrast, Yeow et al consistently used a needle throw of 1.3 cm. The depth of the lesion also correlated with the risk of bleeding. Lesions that were > 2 cm from the pleural surface had a 10-fold increased risk of bleeding compared with those that abutted the pleural surface. This is intuitive and has been previously observed.19Fish GD Stanley JH Miller KS et al.Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.AJR Am J Roentgenol. 1988; 150: 71-74Crossref PubMed Scopus (120) Google Scholar Pulmonary vessels are more crowded and are larger centrally. Therefore, during the biopsy of a peripheral lesion, the radiologist is less likely to traverse a pulmonary vessel, and if a vessel is traversed, it is likely to be a smaller one. Surprising to us, the presence of a pleural effusion correlated with a decreased risk of bleeding. To our knowledge, no previous study has described this correlation. Although the lesions associated with a pleural effusion were generally larger and closer to the pleural surface than those without effusions, this finding was an independent risk factor for bleeding in the multivariate analysis. The possible reasons for a decreased risk of bleeding in those with effusions may include diminution in the negative intrapleural pressure and tamponade by the effusion. Furthermore, the presence of a pleural effusion may hinder the detection of bleeding. In conclusion, the study by Yeow et al in this issue of CHEST describes a large consecutive series of patients who underwent transthoracic cutting needle biopsies of the lung. Although most of the results are in line with those of previous publications, the size of the series, and the meticulous statistical evaluation of the risk factors for pneumothorax and bleeding make this a definitive study." @default.
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• W2039785901 title "Complications of CT Scan-Guided Lung Biopsy" @default.
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