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Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 695-701

Computed tomography-guided lung biopsy: A meta-analysis of low-dose and standard-dose protocols

1 Department of Oncology, Binzhou People's Hospital, Binzhou, China
2 Department of Radiology, Xuzhou Central Hospital, Xuzhou, China
3 Department of Interventional Vascular Surgery, Binzhou People's Hospital, Binzhou, China

Date of Submission31-Aug-2020
Date of Decision20-Jan-2021
Date of Acceptance04-May-2021
Date of Web Publication9-Jul-2021

Correspondence Address:
Rong Hua
Xuzhou Central Hospital, 199 South Jiefang Road, Xuzhou 221009
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1274_20

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 > Abstract 

Objectives: The aim of the study was to compare the relative diagnostic utility of low-dose computed tomography (LDCT) and standard-dose computed tomography (SDCT)-guided lung biopsy approaches.
Materials and Methods: The PubMed, Embase, and Cochrane Library databases were searched for relevant studies published through August 2020. Data pertaining to endpoints including technical success, diagnostic performance, operative time, radiation dose, and complications, were extracted, and meta-analysis was performed using RevMan v5.3.
Results: Three retrospective analyses and three randomized controlled trials, were included. The studies included 1977 lung lesions across 1927 patients who underwent LDCT-guided lung biopsy, and 887 lung lesions across 879 patients who underwent SDCT-guided lung biopsy. No significant differences were observed between these LDCT and SDCT groups with respect to the rates of technical success (99.0% vs. 99.5%, odds ratio [OR]: 1.82, P = 0.35,), diagnostic yield (79.6% vs. 76.2%, OR: 0.93, P = 0.47), diagnostic accuracy (96.1% vs. 96.1%, OR: 0.93, P = 0.69), operative time (mean difference [MD]: 1.04, P = 0.30), pneumothorax (19.9% vs. 21.3%, OR: 0.92, P = 0.43) or hemoptysis (4.6% vs. 5.8%, OR: 1.14, P = 0.54). Patients in the LDCT group received a significantly lower radiation dose (MD: ‒209.87, P < 0.00001) than patients in the SDCT group. Significant heterogeneity was observed with respect to the operative duration and radiation dose endpoints (I2 = 84% and 100%, respectively).
Conclusions: Relative to SDCT-guided lung biopsy, an LDCT-guided approach is equally safe and can achieve comparable diagnostic efficacy while exposing patients to lower doses of radiation.

Keywords: Biopsy, low-dose, lung, tomography

How to cite this article:
Zhang P, Liu JM, Zhang YY, Hua R, Xia FF, Shi YB. Computed tomography-guided lung biopsy: A meta-analysis of low-dose and standard-dose protocols. J Can Res Ther 2021;17:695-701

How to cite this URL:
Zhang P, Liu JM, Zhang YY, Hua R, Xia FF, Shi YB. Computed tomography-guided lung biopsy: A meta-analysis of low-dose and standard-dose protocols. J Can Res Ther [serial online] 2021 [cited 2021 Jul 29];17:695-701. Available from: https://www.cancerjournal.net/text.asp?2021/17/3/695/321008

 > Introduction Top

Computed tomography (CT)-guided lung biopsy is a standard approach for diagnosing lung nodules and masses that can achieve diagnostic accuracy rates exceeding 90%.[1],[2],[3],[4] However, CT analyses expose patients to radiation, which substantially increases their risk for cancer development at a rate proportional to the cumulative radiation dosage received.[5],[6],[7] Unlike most forms of diagnostic CT imaging, CT-guided biopsy approaches necessitate repeated CT imaging to facilitate lesion localization, needle tip adjustment, and evaluation of patients for potential procedure-related complications. CT-guided interventions may be associated with markedly elevated radiation doses relative to standard diagnostic CT imaging techniques.

To decrease intraoperative exposure to high levels of radiation, low-dose CT (LDCT) versions of many interventional procedures have been developed,[8],[9],[10],[11],[12],[13],[14],[15] particularly in LDCT-guided lung biopsy strategies.[10],[11],[12],[13],[14],[15] However, LDCT parameters have not been consistent across prior studies; as such, bias may exist in the reporting or interpretation of the relative safety and efficacy of this diagnostic approach. To definitively establish the safety and diagnostic utility of LDCT-guided lung biopsy, it is essential that large population studies comparing standard-dose CT (SDCT)-and LDCT-guided lung biopsy be conducted.

Therefore, we performed a meta-analysis to develop evidence-based guidelines that differentiate between LDCT- and SDCT-guided lung biopsy approaches with respect to diagnostic performance, radiation dose, and complication rates.

 > Materials and Methods Top

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and the PRISMA extension for network meta-analyses were used to guide the design and execution of the present meta-analysis.[16]

Study selection

The PubMed, Embase, and Cochrane Library databases were searched for all relevant studies published through August 2020 using the following search strategy: ((((computed tomography [Title/Abstract]) OR (CT [Title/Abstract])) AND (low dose [Title/Abstract])) AND ((lung [Title/Abstract]) OR (pulmonary [Title/Abstract]))) AND (biopsy [Title/Abstract]).

Studies eligible for inclusion in the present analysis were those meeting the following criteria: (a) randomized controlled trials (RCTs) or nonrandomized comparative studies pertaining to LDCT-guided and SDCT-guided lung biopsy, and (b) studies that had been published in English.

Studies were excluded from this analysis if they were: (a) noncomparative studies; (b) animal studies; or (c) reviews.

Data extraction

Two authors independently extracted all data from the included studies, with any discrepancies being resolved by the corresponding author. Data extracted from the included studies included baseline data (first author, year, country, study design, and quality scores) and patient baseline data (age, lesion size, and biopsy-related data).

Quality assessment

The quality of all included RCTs was evaluated using the 8-point Jadad composite score.[17] Scores ranged from 0 to 7, and a score of ≥4 points was indicative of a high-quality study with a low risk of bias. The quality of non-RCTs was evaluated using the Newcastle-Ottawa scale, with studies being awarded up to 9 points.[18] High-quality non-RCTs with a low risk of bias were those that achieved a score of ≥5 points.


The following endpoints were included in the present analysis: (a) technical success; (b) diagnostic performance; (c) operative time; (d) radiation dose; and (e) complications.

Lung biopsies were technically successful when sufficient samples were obtained to permit diagnostic analyses. The diagnostic performance included diagnostic yield and accuracy, which corresponded to biopsy-based definitive diagnoses as a fraction of total lesions and accurate diagnoses of malignancies or benign lesions as a fraction of all diagnostic determinations, respectively.[19] The radiation dose was presented with dose-length product (DLP).

Statistical analyses

RevMan v. 5.3 was used for all statistical testing. For dichotomous variables, pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, whereas continuous variables were analyzed using pooled estimates of mean difference (MD) values with corresponding 95% CIs. Study heterogeneity was assessed using X2 tests and I2 tests, with I2 >50% indicating significant heterogeneity. When significant heterogeneity among studies was detected with respect to a specific endpoint, a random-effects model was used for data analyses. Otherwise, fixed-effects models were used. The sources of heterogeneity were identified through subgroup and sensitivity analyses, and the risk of publication bias was assessed using funnel plots.

 > Results Top

Study characteristics

Our initial search strategy identified 549 potentially relevant studies, of which 6 were ultimately included in the final meta-analysis [Figure 1]. Hence, three RCTs[11],[14],[15] and 3 retrospective studies[10],[12],[13] were evaluated [Table 1]. Only one RCT was ranked asf high quality,[11] whereas all three retrospective studies were ranked as high quality.
Figure 1: The flowchart of this study

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Table 1: Baseline data of the 9 studies

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These studies included 1977 lung lesions across 1927 patients who had undergone LDCT-guided lung biopsy, and 887 lung lesions across 879 patients who had undergone SDCT-guided lung biopsy. Data pertaining to the patient baseline data, CT scanning parameters, and needle types are compiled in [Table 2].
Table 2: Characteristics of the included studies

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Technical success

Data pertaining to technical success were obtained from three studies.[11],[13],[14] Similar rates of technical success were observed in the SDCT and LDCT groups [99.0% vs. 99.5%, OR: 1.82, P = 0.35, [Figure 2]a]. No significant heterogeneity was detected among studies with respect to technical success (I2 = 0%; P = 0.91).
Figure 2: The pooled results of (a) technical success, (b) diagnostic yield, (c) diagnostic accuracy, (d) operative time, and (e) radiation dose between two groups, (f) pneumothorax rates, (g) hemoptysis rates

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Diagnostic yield

Data pertaining to diagnostic yield rates were obtained from four studies.[10],[11],[12],[13] Similar diagnostic yield rates were observed when comparing the SDCT and LDCT groups [79.6% vs. 76.2%, OR: 0.93, P = 0.47, [Figure 2]b]. No significant heterogeneity was detected among studies with respect to the diagnostic yield (I2 = 21%; P = 0.29).

Diagnostic accuracy

Data pertaining to diagnostic accuracy were obtained from 4 studies.[11],[13],[14],[15] Similar diagnostic accuracy was observed when comparing the SDCT and LDCT groups [96.1% vs. 96.1%, OR: 0.93, P = 0.69, [Figure 2]c]. No significant heterogeneity was detected among studies with respect to diagnostic accuracy (I2 = 0%; P = 0.76).

Operative time

Two of the included studies reported data pertaining to operative time.[10],[11] There were no significant differences in operative time between the LDCT and SDCT groups [MD: 1.04, P = 0.30, [Figure 2]d]. Significant heterogeneity was detected with respect to the operative time (I2 = 84%; P = 0.01). However, as only two studies reported data pertaining to this endpoint, sensitivity analyses were not conducted.

Radiation dose

All studies reported data pertaining to the DLP for analyzed patients. The DLP was significantly lower for patients in the LDCT group relative to patients in the SDCT group [MD: ‒209.87, P < 0.00001, [Figure 2]e]. Significant heterogeneity was detected among included studies with respect to the radiation dose (I2 = 100%; P < 0.00001). Sensitivity analyses suggested that removing individual studies had no impact on the detected heterogeneity.


Data pertaining to pneumothorax rates were obtained from 5 studies.[11],[12],[13],[14],[15] Similar rates of pneumothorax were observed between the SDCT and LDCT groups [19.9% vs. 21.3%, OR: 0.92, P = 0.43, [Figure 2]f]. No significant heterogeneity was detected among studies with respect to the pneumothorax (I2 = 0%; P = 0.81).


Data pertaining to hemoptysis rates were obtained from 4 studies.[11],[13],[14],[15] Similar rates of hemoptysis were observed between the SDCT and LDCT groups [4.6% vs. 5.8%, OR: 1.14, P = 0.54, [Figure 2]g]. No significant heterogeneity was detected among studies with respect to hemoptysis (I2 = 0%; P = 0.87).

Subgroup analyses

We conducted the subgroup analyses based on the CT-guided biopsy for lung nodules [Table 3]. Two studies reported the data of CT-guided biopsy for lung nodules.[11],[14]
Table 3: Meta-analytic pooled results based on the computed tomography-guided biopsy for lung nodules

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Four endpoints could be pooled based on the subgroup analyses. Similar rates of diagnostic accuracy, pneumothorax, and hemoptysis were observed between the SDCT and LDCT groups (P = 0.66, 0.52, and 0.85, respectively). The DLP was significantly lower for patients in the LDCT group relative to the SDCT group (P < 0.00001). Significant heterogeneity was only detected with respect to the endpoint of radiation dose (I2 = 100%).

Publication bias

Funnel plots did not reveal any evidence of potential publication bias with respect to these analyzed study endpoints.

 > Discussion Top

In the present meta-analysis, the relative utility, diagnostic performance, safety, and radiation dosages of LDCT- and SDCT-guided lung biopsy were compared. In pooled analyses, technical success rates were high (>99%) and comparable for both of these diagnostic approaches, thus suggesting that the LDCT protocol did not adversely impact the lung biopsy procedure.

We were unable to analyze the image quality associated with these two diagnostic approaches, as image quality assessment strategies were inconsistent across the included studies. However, prior reports indicate that LDCT protocols can degrade image quality.[10],[11],[12],[13],[14],[15] Unlike conventional diagnostic imaging approaches, lung biopsy, however, does not require the assessment of specific lesion features in detail.

Diagnostic performance is a critical endpoint when evaluating lung biopsy procedures. Diagnostic yield can be used to assess the ability to make a definitive biopsy-based diagnosis,[19] whereas diagnostic accuracy refers to the reliability of the resultant biopsy results.[20],[21],[22],[23] We found that diagnostic yield and accuracy were comparable between the LDCT and SDCT groups. The pooled diagnostic accuracy rates in both groups were extremely high (up to 96.1%), which is in line with rates published in prior studies of CT-guided lung biopsy approaches (90%–96%).[1],[24] These data may be attributable to the following factors: (a) rates of technical success were high in both the LDCT and SDCT groups, and (b) core needle biopsy approaches were used in all included studies.

One of the included RCTs also indicated that the scanning protocol was not a risk factor associated with diagnostic failure.[11] When comparing LDCT and SDCT for spine biopsy procedures, Shpilberg et al.[25] similarly revealed comparable diagnostic yield rates between the two groups (P = 0.6017).

Radiation dose is a key endpoint in studies of LDCT procedures, and is generally presented in the form of DLP values. In the present meta-analysis, we found that LDCT approaches were associated with significantly lower radiation doses, although significant heterogeneity was observed among the included studies with respect to this endpoint. However, we were unable to identify sources of heterogeneity in subgroups or sensitivity analyses in the present study, which may be attributable to the different CT parameters that were used by the included studies.[10],[11],[12],[13],[14],[15]

Two of these three studies did not provide any details pertaining to the utilized scanning parameters.[10],[12] In the study conducted by Lee et al.,[13] the tube voltage only decreased from 120 kV to 100 kV for LDCT procedures, thus limiting the scope of radiation dose reduction. Despite these inconsistencies, we believe that LDCT procedures significantly reduce patient exposure to radiation during a lung biopsy.

Rates of biopsy-related complications were assessed by the pooling rates of hemoptysis and pneumothorax between groups in the present study. Rates of these complications were comparable between the LDCT and SDCT groups, which indicates that reducing the effective radiation dose was not associated with reduction in the safety of CT-guided lung biopsy procedures.

The subgroup analyses indicated that LDCT-guided lung biopsy could provide the similar diagnostic accuracy and safety with a significant lower radiation dose for lung nodules when compared to SDCT-guided. However, the data of CT-guided lung nodule biopsy could be only extracted from 2 studies.[11],[14] Further studies regarding to LDCT-guided biopsy for lung nodules are still required.

Kim et al.[26] previously reported the use of a CT fluoroscopy-guided lung biopsy approach as a means of decreasing the rates of procedure-associated complications. However, both patients and operators were exposed to significantly higher radiation doses than typically associated with conventional CT-guided lung biopsies.[26]

There are numerous limitations to the present meta-analysis. For one, several of the included studies were retrospective, which introduces selection bias. In addition, two of the three included RCTs were of low quality.[14],[15] As additional high-quality RCTs are published in the future, we will conduct updated meta-analyses to validate and expand upon these findings. We detected significant heterogeneity among studies with respect to some of the endpoints in this analysis. While sensitivity and subgroup analyses were conducted to identify the sources of heterogeneity, additional high-quality studies are required to fully elucidate them. It is also important to note that the included studies were focused on a range of lung lesion types. As such, future analyses of specific lesion types such as lung nodules are needed.

 > Conclusions Top

Relative to SDCT-guided lung biopsy, LDCT-guidance can achieve comparable diagnostic and safety outcomes while effectively lowering the amount of radiation to which patients are exposed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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