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

Abstract

C omputed tomography (CT)-guided transthoracic needle biopsy (TTNB) is a well-established method for investigating pulmonary nodules and masses. It offers a better diagnostic yield than bronchoscopy for the assessment of lung nodules and peripheral lesions (1, 2). Referral for CT-guided TTNB is expected to increase in the coming years. One reason is the higher proportion of adenocarcinomas among current lung cancers, which are more likely to be peripheral and not reachable by bronchoscopy (3, 4). Another reason is the recommendation of re-biopsy for molecular analysis of non-small cell lung cancers that progress or recur (5-7). Although TTNB is considered a safe and efficient method for obtaining a definite pathologic diagnosis, complications are reported in up to two-thirds of procedures (8, 9). The three main complications of TTNB are pneumothorax, alveolar hemorrhage, and hemoptysis. These complications are rarely life threatening, and pulmonary bleeding is usually self-resolving. However, severe hemoptysis can necessitate endobronchial tamponade, arterial embolization, or surgery (8, 10).It is important for the operator to be aware of potentially modifiable risk factors. Several modifiable risk factors for pneumothorax have been reported in the literature, including angle between needle and pleural surface (11), transpulmonary needle-path length (12, 13), patient position during the procedure (11), and operator's level of experience (12). A large pleural angle, a long needle path, the prone position, and limited expertise are all reported to increase the risk of pneumothorax. By contrast, data on risk factors for hemoptysis in this setting are scarce, and most published studies of transthoracic biopsy have combined alveolar hemorrhage and hemoptysis under the term "pulmonary bleeding. " Chakrabarti et al. (14) 347 C H E S T I MAG I N G O R I G I N A L A R T I C L E PURPOSEWe aimed to identify modifiable and nonmodifiable risk factors for hemoptysis complicating computed tomography (CT)-guided transthoracic needle biopsy. METHODSAll procedures performed in our institution from November 2013 to May 2015 were reviewed. Hemoptysis was classified as mild if limited to hemoptoic sputum and abundant otherwise. Presence of intra-alveolar hemorrhage on postbiopsy CT images was also evaluated. Patient-and lesion-related variables were considered nonmodifiable, while procedure-related variables were considered modifiable. RESULTSA total of 249 procedures were evaluated. Hemoptysis and alveolar hemorrhage occurred in 18% and 58% of procedures, respectively, and were abundant or significant in 8% and 17% of procedures, respectively. Concordance between the occurrence of significant alveolar hemorrhage (grade ≥2) and hemoptysis was poor (κ=0.28; 95% CI [0.16-0.40]). In multivariate analysis, female gender (P = 0.008), a longer transpulmonary needle path (P = 0.014), and smaller lesion size (P = 0.044) were independent risk factors for hemoptysis. Transpulmonary needle-path length was the only risk factor for abundant ...

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

“…In agreement with previously published studies, this study showed that pneumothorax and pulmonary hemorrhage were the most frequent reported complications of CT-guided lung biopsy [ 12 , 18 – 20 , 6 ]. The rates of pneumothorax in the literature vary widely.…”

“…Pulmonary hemorrhage was less frequent with reported frequencies ranging from 4–27% [ 21 , 22 ].This is also in a line with our findings, 22% of biopsies in our study are complicated by pulmonary hemorrhage (grade 1 pulmonary hemorrhage in 14% and grade 2 in 8%); none of them shows progression to a major complication. Hemoptysis was reported to occur in up to 20% of procedures [ 12 ], however, no documented cases of hemoptysis after biopsy in our data base is recorded. This can be explained as suggested by Tai et al [ 13 ]: hemoptysis limited to hemorrhagic sputum may have been underreported.…”

“…The association between trans-pulmonary needle path length and complication severity is in keeping with previous reports; the longer is the needle path from the pleural surface to the lesion, the more difficult accurate targeting of the needle with increased chances of pleural and lung parenchymal damage [ 4 , 24 , 9 , 25 , 26 , 11 , 7 ]. In comparison, biopsies of subpleural lesions in our study are not associated with occurrence of major complications, however, they may be associated with minor complications, such as small pneumothorax due to pleural injury, and/or pulmonary hemorrhage may be due to extension of the cutting needle into the normal surrounding lung parenchyma [ 12 ]. In our study, fissure puncture is also an independent risk factor for major complications.…”

“…This can be explained as suggested by Tai et al [ 13 ]: hemoptysis limited to hemorrhagic sputum may have been underreported. Furthermore, the concordance between the occurrence of significant pulmonary hemorrhage (grade ≥2) and hemoptysis is poor [ 12 ].…”

“…Pulmonary hemorrhage was identified as new ground-glass opacity on post-biopsy CT, documented hemoptysis, or bleeding complications necessitating intervention. The severity of pulmonary hemorrhage on post-biopsy CT was graded into; grade 0 as no hemorrhage or needle tract hemorrhage <1cm (as the needle tract hemorrhage <1cm is often expected from our prior experience after CT-guided lung biopsies, was not considered as a complication), grade 1 as needle tract hemorrhage 1-2cm in width, grade 2 as hemorrhage >2cm in width but sublobar, grade 3 as lobar hemorrhage or greater [ 12 , 13 ]. Other complications were also assessed.…”