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ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 5  |  Page : 1186-1191

Risk of pneumothorax caused by computerized tomography-guided percutaneous core needle biopsy of the lung in elderly and young patients


1 Department of Radiation Oncology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, China
2 Department of Oncology, Liaocheng Tumor Hospital, Liaocheng, Shandong, China
3 Shandong Medicinal Biotechnology Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
4 Department of Radiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, China
5 Department of Pulmonary and Critical Care Medicine, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, China

Date of Submission03-Nov-2021
Date of Acceptance29-Jul-2021
Date of Web Publication27-Nov-2021

Correspondence Address:
Dexiang Wang
Department of Pulmonary and Critical Care Medicine, Cheeloo College of Medicine, Qilu Hospital, Shandong University, 107 Wenhuaxi Street, Jinan, Shandong Province, 250012
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.jcrt_1058_21

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 > Abstract 


Context: The incidences and risk factors caused by computed tomography (CT)-guided percutaneous computed tomography-guided needle biopsies (PCNBs) in elderly and young patients were not very clear.
Aims: This study explored the different incidences of pneumothorax caused by PCNBs and related risk factors in elderly and young patients.
Settings and Design: The medical records of 1100 patients who underwent CT-guided PCNBs in a hospital from January 2018 to December 2019 were retrospectively reviewed.
Subjects and Methods: Data relating to the patients, lesions, techniques, and diagnoses were collected according to the ethical standards of the institutional research committee (registration number: KYLL-202008-145).
Statistical Analysis Used: The variables were significant by univariate analysis and further analyzed by multivariate logistic regression analysis.
Results: In the 1100 patients with PCNBs, the incidence of pneumothorax in groups ≥65 years old and <65 years old was 15.2% and 12.9%, respectively. There was no significant difference in the incidence of pneumothorax between the young and elderly patients. In elderly and young patients, emphysema along the needle path and dwell time was independent predictors. However, in young patients, lesion-abutting pleura was an independent risk factor for pneumothorax, but not in elderly patients.
Conclusions: The risk of pneumothorax caused by CT-guided percutaneous core needle biopsy of the lung does not increase in elderly patients. Emphysema along the needle path and dwell time is independent predictors of pneumothorax in elderly and young patients.

Keywords: Elderly, percutaneous computed tomography-guided needle biopsies, pneumothorax, risk, young


How to cite this article:
Zhou W, Yu X, Song Y, Yang F, Li C, Liu B, Jia H, Wang D. Risk of pneumothorax caused by computerized tomography-guided percutaneous core needle biopsy of the lung in elderly and young patients. J Can Res Ther 2021;17:1186-91

How to cite this URL:
Zhou W, Yu X, Song Y, Yang F, Li C, Liu B, Jia H, Wang D. Risk of pneumothorax caused by computerized tomography-guided percutaneous core needle biopsy of the lung in elderly and young patients. J Can Res Ther [serial online] 2021 [cited 2022 Jan 24];17:1186-91. Available from: https://www.cancerjournal.net/text.asp?2021/17/5/1186/331301




 > Introduction Top


Percutaneous computed tomography-guided needle biopsy (PCNB) can effectively avoid large blood vessels and bronchi and reduce the number of pleural passes, with a diagnostic sensitivity of more than 90%.[1] However, there are also certain related complications. Pneumothorax is considered the most common. Studies have identified many possible risk factors for pneumothorax.[2],[3],[4],[5] Nowadays, with the improvement in puncture technology, more older adults undergo PCNB. The incidence and risk factors in elder patients were unknown. This study analyzed the incidences and risk factors of pneumothorax in 1100 patients with coaxial PCNB, including 39.5% of those older than 65 years.


 > Subjects and Methods Top


Study population and data collection

The medical records of 1100 consecutive patients who underwent computed tomography (CT)-guided PCNBs at our hospital from January 2018 to December 2019 were retrospectively reviewed. Collected data relating to the patients, lesions, techniques, and diagnoses were anonymized before analysis and complied with the Declaration of Helsinki and the ethical standards of the Institutional Research Committee (registration number: KYLL-202008-145) of Qilu Hospital, Cheeloo College of Medicine, Shandong University. The patient's data included age, sex, smoking, prior surgery, radiotherapy, or chemotherapy. Lesion data included the location, size of the sampled lesion (maximum axial diameter), and whether the lesion abutted the pleural and emphysema. Lower locations included middle lobe, lingular, and lower lobe lesions. Technique-related data included patient position, needle puncture site, depth from the pleura along the biopsy track, dwell time, needle-pleural angle (minimum angle formed at the puncture point between the needle and the line tangent to the pleura), needle redirection, and number of pleural punctures and cores. In addition, histopathological results were obtained.

Computed tomography-guided percutaneous computed tomography-guided needle biopsies procedure

All procedures were performed percutaneously under CT guidance by an intervention team. Informed consent was obtained in all cases. An enhanced prebiopsy CT scan was reviewed to avoid larger vessels. Local anesthesia was given with 10–20 ml of 1% lidocaine along the projected path of the biopsy needle into the soft tissues. Only 18-gage cutting needles on 17-gage coaxial needle-guide systems (Biopince, Argon Medical Devices, Frisco, Texas) were used in all cases. Needle biopsies were performed in a stable position, considering the shortest track to the targeted lesion, averting critical structures, such as visible bronchi, vessels, interlobar fissures, emphysema, or bulla. When the needle position needs to be adjusted, real-time multiplanar reconstruction is performed. During and after the biopsy, patients were instructed to breathe calmly and abstain from talking and coughing. In addition, the patients were instructed to hold their breath during CT scanning, needle insertion, exchange, and withdrawal. The presence of pneumothorax was assessed by postbiopsy CT scan. Representative images of the CT-guided PCNB are shown in [Figure 1]. Patients then fasted with a routine 4-h observation; then, complications, such as pneumothorax, were recorded. Patients with severe pneumothorax or other complications were hospitalized until it was resolved. After biopsy, a CT scan assessed pneumothorax as the largest separation between the visceral and parietal pleura.
Figure 1: Computed tomography-guided core needle biopsy (a and b) a solitary suspected lesion in the right lower lobe in a 98-year-old male patient (no-smoking) without pneumothorax; (c and d) a solitary suspected lesion in the left lower lobe in a 64-year-old male patient (40 pack-years smoking) with pneumothorax

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Statistical analysis

Descriptive statistics were shown as number (percentage) for categorical variables or median (lower to upper quartile) for numerical variables with nonnormal distribution. The descriptive data were compared between the two groups with or without pneumothorax after lung biopsy, using Chi-square and the Mann–Whitney U-test for categorical and numerical values, respectively. The variables found significant by univariate analysis were further analyzed by multivariate logistic regression analysis. Odds ratios with 95% confidence intervals identified the relative risk of each significant factor for pneumothorax. All analyses were performed using SPSS software, v. 25.0 (SPSS Inc., Chicago, IL, USA). P value was considered as statistically significant. All P values were two-sided, and the significance level was less than 0.05.


 > Results Top


Risk factors for pneumothorax in all patients evaluated by univariate analysis

The baseline characteristics of total PCNB cases are summarized in [Table 1]. The mean patient age was 62.0 (18–98) years; 58.9% were male. All numerical variables showed nonnormal distribution, so the median and lower quartile to the upper quartile were given here. Thirty-three cases (3.0%) were nondiagnostic. The initial diagnostic rate of CT-guided PCNB was 97.0%, with 755 (68.6%) diagnosed with malignancy.
Table 1: Patients' baseline characteristic

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Six hundred and twenty-nine patients had lesions located in the upper lobes, and 471 had lesions in the lower lobes [Table 2]. The median lesion size was 30.6 mm. Thus, pneumothorax occurred in 152 (13.8%) of the 1100 biopsy procedures. In the univariate analyses of numerical and categorical variables, the location of the lesion (upper or lower; P = 0.035), lesion-abutting pleura (P = 0.003), emphysema along the needle path (P = 2.563 × 10−18), and dwell time (P = 1.471 × 10−36) were significant risk factors for pneumothorax [Tables 2 and 3]. No other factor showed statistical significance.
Table 2: Lesion variables of percutaneous spot

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Risk factors for pneumothorax in young and elderly patients evaluated by univariate analysis

Of the 1100 patients with PCNBs, 435 (39.5%) patients were older than 65 years. The total incidence of pneumothorax in groups ≥65 years and <65 years old was 15.2% (66/435) and 12.9% (86/665), respectively. There was no significant difference in the incidence of pneumothorax between the young and elderly patients (P = 0.292). The lesion and technique in the young and elderly patients are separately summarized in [Table 2] and [Table 3]. From initial univariate analyses in these elderly patients, significant risk factors affecting the incidence of pneumothorax were emphysema along the needle path (P = 7.909 × 10−7) and dwell time (P = 8.319 × 10−21). In the 665 young patients, lesion-abutting pleura (P = 0.014), emphysema along the needle path (P = 1.760 × 10−12), and longer dwell time (P = 7.295 × 10−18) were related to a higher risk of pneumothorax. Furthermore, possible risk factors for pneumothorax were obtained from univariate analysis in [Table 2] and [Table 3].
Table 3: Techniques variables related to percutaneous CT-guided needle biopsy

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Multivariable logistic regression model for predictors of pneumothorax in all patients and in young and elderly patients

The results of further multivariate analyses are shown in [Table 4]. Multivariate logistic regression analysis revealed emphysema along the needle path, lesion-abutting pleura, and dwell time as significant independent risk factors in all patients for pneumothorax. In 435 elderly patients, emphysema along the needle path and dwell time were independent predictors of pneumothorax. In addition, in the 665 young patients, lesion-abutting pleura, emphysema along the needle path, and dwell time were independent risk factors for pneumothorax.
Table 4: Multivariable logistic regression model for predictors of pneumothorax

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 > Discussion Top


Elderly patients undergoing pulmonary biopsy were previously assessed to have a high risk, were listed as contraindications for puncture, and were excluded from treatment. However, in the event of PCNB complications, such as pneumothorax and pulmonary hemorrhage, the tolerance of elderly patients was worse than that of young patients, and the risk of poor prognosis was higher than that of young patients. The high risk and low tolerance made radiologists feel anxious and stressed before performing a biopsy for elderly patients. However, with population aging, older age was a challenge that radiologists could not avoid. As a result, elderly patients account for an increasing proportion of biopsy patients. In this study, 39.5% had been achieved; here, we explored the different risk factors for pneumothorax in elderly and young patients.

In this study, the incidence of pneumothorax was 13.8%, similar to other reports.[6],[7],[8],[9] The independent risk factors affecting pneumothorax occurrence were emphysema along the needle path, lesion-abutting pleura, and dwell time. The location of the lesion (upper or lower) significantly correlated with pneumothorax in univariate analysis but was not an independent predictor of pneumothorax. Similar results have also been reported in other studies.[8],[9],[10] However, other procedure-related factors, such as needle-pleural angle, needle depth to the lesion, and number of needle passes, considered by previous studies, did not influence the incidence of pneumothorax here. The characteristics of the lesions were more decisive than the procedure itself, which also reflected the technique's improvement. Similarly, for smaller lesions, the technical success rate of fine-needle aspiration biopsy was significantly lower (74% for ≤1.5 cm vs. 96% for >1.5 cm).[11] Taleb et al. believed that achieving sufficient tissue from smaller lesions is technically more demanding,[12] which may increase the number of punctures and risk of pneumothorax. At present, CT-guided PCNB has been improved to biopsy pulmonary nodules <1 cm and rarely more than twice.

This study focused on whether the risk of lung biopsy in elderly patients was different from that in young patients. The incidence of pneumothorax in the elderly and young groups was 15.2% and 12.9%, respectively, and there was no statistical difference. This showed that pneumothorax caused by PCNB of the lung does not increase in elderly patients, somewhat dispelling the concerns of radiologists.

The results revealed that in elderly and young patients, emphysema along the needle path and dwell time were independent predictors. Similarly, Lee et al. found that perilesional emphysema was significantly related to pneumothorax,[13] but the severity of visual and quantitative emphysema was not a significant risk factor for pneumothorax. The median (lower–upper quartile) dwell time in the elderly and young patients was 4.33 (3.50–5.00) min and 4.33 (3.33–5.00) min, respectively. It could be explained that the longer the needle stayed in the lung, the more likely breathing movement will cause the lung to tear. In contrast, Ko et al. reported that longer dwell times did not increase the risk of pneumothorax.[5] The study was about aspiration biopsy, and dwell times were as long as 12–66 min.

However, in young patients, lesion-abutting pleura was an independent risk factor for pneumothorax, but not in elderly patients. Interestingly, Capalbo et al. showed that the incidence of pulmonary hemorrhage was high in the elderly patients (31 vs. 10%),[14] whereas pneumothorax was more common in the young patients (30 vs. 17%). According to Ko et al.,[5] focal or diffuse pleural thickening, chest wall invasion, or previous surgery could protect from the occurrence of pneumothorax and reduce the incidence of pneumothorax. Hence, we speculate that the elderly had a high incidence of pleural thickening and adhesion, which were protective mechanisms for pneumothorax. Asymptomatic elderly individuals had an increased prevalence of bronchial wall thickening than younger individuals.[15] In addition, respiratory mobility decreased in elderly patients; the movement amplitude of the lung and damage to the pleura were reduced.

The advantage of the study is the large number of cases included in this study. In addition, the age spectrum of the population covered is broad; however, there were limitations in the study. First, this is a retrospective study. Second, the data of this study were from a single center.


 > Conclusions Top


Conclusively, the results of this study suggested that the risk of pneumothorax caused by CT-guided percutaneous core needle biopsy of the lung does not increase in elderly patients. Furthermore, emphysema along the needle path and dwell time are independent predictors of pneumothorax in elderly and young patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Chakrabarti B, Earis JE, Pandey R, Jones Y, Slaven K, Amin S, et al. Risk assessment of pneumothorax and pulmonary haemorrhage complicating percutaneous coaxial cutting needle lung biopsy. Respir Med 2009;103:449-55.  Back to cited text no. 1
    
2.
Laurent F, Montaudon M, Latrabe V, Bégueret H. Percutaneous biopsy in lung cancer. Eur J Radiol 2003;45:60-8.  Back to cited text no. 2
    
3.
Heerink WJ, De Bock GH, De Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: Meta-analysis. Eur Radiol 2017;27:138-48.  Back to cited text no. 3
    
4.
Saji H, Nakamura H, Tsuchida T, Tsuboi M, Kawate N, Konaka C, 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;121:1521-6.  Back to cited text no. 4
    
5.
Ko JP, Shepard JO, Drucker EA, Aquino SL, Sharma A, Sabloff B, et al. Factors influencing pneumothorax rate at lung biopsy: Are dwell time and angle of pleural puncture contributing factors? Radiology 2001;218:491-6.  Back to cited text no. 5
    
6.
Jang H, Rho JY, Suh YJ, Jeong YJ. Asymptomatic systemic air embolism after CT-guided percutaneous transthoracic needle biopsy. Clin Imaging 2019;53:49-57.  Back to cited text no. 6
    
7.
Yin Z, Liang Z, Li P, Wang Q. CT-guided core needle biopsy of mediastinal nodes through a transpulmonary approach: Retrospective analysis of the procedures conducted over six years. Eur Radiol 2017;27:3401-7.  Back to cited text no. 7
    
8.
Yildirim E, Kirbas I, Harman A, Ozyer U, Tore HG, Aytekin C, et al. CT-guided cutting needle lung biopsy using modified coaxial technique: Factors effecting risk of complications. Eur J Radiol 2009;70:57-60.  Back to cited text no. 8
    
9.
Yoon SH, Park CM, Lee KH, Lim KY, Suh YJ, Im DJ, et al. Analysis of complications of percutaneous transthoracic needle biopsy using CT-guidance modalities in a multicenter cohort of 10568 biopsies. Korean J Radiol 2019;20:323-31.  Back to cited text no. 9
    
10.
Yeow KM, Su IH, Pan KT, Tsay PK, Lui KW, Cheung YC, et al. Risk factors of pneumothorax and bleeding: Multivariate analysis of 660 CT-guided coaxial cutting needle lung biopsies. Chest 2004;126:748-54.  Back to cited text no. 10
    
11.
Li H, Boiselle PM, Shepard JO, Trotman-Dickenson B, Mcloud TC. Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: Comparison of small and large pulmonary nodules. Ajr Am J Roentgenol 1996;167:105-9.  Back to cited text no. 11
    
12.
Taleb S, Jalaeian H, Frank N, Golzarian J, D'souza D. Is a routine chest X-ray necessary in every patient after percutaneous CT-guided lung biopsy? A retrospective review of 278 cases. Cardiovasc Intervent Radiol 2017;40:1415-20.  Back to cited text no. 12
    
13.
Lee DS, Bak SH, Jeon YH, Kwon SO, Kim WJ. Perilesional emphysema as a predictor of risk of complications from computed tomography-guided transthoracic lung biopsy. Jpn J Radiol 2019;37:808-16.  Back to cited text no. 13
    
14.
Capalbo E, Peli M, Lovisatti M, Cosentino M, Mariani P, Berti E, et al. Trans-thoracic biopsy of lung lesions: FNAB or CNB? Our experience and review of the literature. Radiol Med 2014;119:572-94.  Back to cited text no. 14
    
15.
Copley SJ. Morphology of the aging lung on computed tomography. J Thorac Imaging 2016;31:140-50.  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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