Elsevier

Clinical Radiology

Volume 70, Issue 12, December 2015, Pages 1382-1387
Clinical Radiology

Predictors of pneumothorax after CT-guided transthoracic needle lung biopsy: the role of quantitative CT

https://doi.org/10.1016/j.crad.2015.08.003Get rights and content

Highlights

  • Examine the association between quantitative emphysema measures & post NLB pneumothorax.

  • The risk of post-NLB pneumothorax increases with every unit increase in percent emphysema.

  • Percent emphysema is a significant predictor of pneumothorax post transthoracic NLB.

  • Quantitative analysis of chest CT offers clinicians' objective measures to assess pneumothorax risk.

Aim

To evaluate the association of quantitative computed tomography (CT) measures of emphysema with the occurrence of pneumothorax after CT-guided needle lung biopsy (NLB) accounting for other risk factors.

Materials and methods

One hundred and sixty-three CT-guided NLBs performed between 2008 and 2013 with available complete chest CT within 30 days were reviewed for the occurrence of post-procedure pneumothorax. Percent emphysema was determined quantitatively as the percentage of lung voxels below −950 HU on chest CT images using automated software. Multivariable regression was used to assess the association of percent emphysema volume with the occurrence of post-procedure pneumothorax. The association of percent emphysema volume with the pneumothorax size and need for chest tube placement after NLB was also explored.

Results

Percent emphysema was significantly associated with the incidence of post-NLB pneumothorax (OR=1.10 95% confidence interval: 1.01–1.15; p=0.03) adjusting for lower-lobe lesion location, needle path length, lesion size, number of passes, and pleural needle trajectory angle. Percent emphysema was not associated with the size of the pneumothorax, nor the need for chest tube placement after NLB.

Conclusion

Percent emphysema determined quantitatively from chest CT is a significant predictor of post-NLB pneumothorax.

Introduction

Computed tomography (CT)-guided transthoracic needle lung biopsy (NLB) is a well-established procedure for diagnosing lung lesions.1 NLB has significantly reduced the need for diagnostic thoracotomy,2 but despite being less invasive than thoracotomy, it is associated with complications ranging from mild to life threatening. Pneumothorax is the most frequently reported complication in the literature, with an estimated incidence between 12 and 45% following NLB.3, 4, 5, 6 Up to 53% of post-NLB pneumothorax require chest tube placement and, therefore, hospitalisation.7, 8, 9, 10, 11, 12, 13

Multiple studies have evaluated the risk factors of these complications.7, 8, 9, 10, 11, 12, 13 Emphysema, which is an abnormal and permanent enlargement of the air spaces distal to the terminal bronchioles caused by the destruction of bronchial walls, is a well-accepted independent risk factor of post-NLB-pneumothorax proven in multiple studies.11, 13, 14 The presence of emphysema on chest CT also predicts the need for chest tube placement for post-NLB pneumothorax.9, 12, 13 In these studies emphysema was determined qualitatively by visual inspection of the chest CT images. CT volumetric lung analysis and quantification of emphysema, is an emerging technique for the detection of early lung diseases. Emphysema quantified by CT was correlated with the extent of emphysema at autopsy15, 16 and was associated with lung function decline,17, 18 small airways disease,19 chronic obstructive pulmonary disease (COPD) symptoms such as the level of dyspnoea20 and mortality in COPD patients21; however, to the authors' knowledge the association between quantitative CT measures of emphysema and post-NLB pneumothorax has not been evaluated. The main objective of the present study was to evaluate the association of quantitative CT measures of emphysema with the occurrence of pneumothorax after CT-guided NLB accounting for other risk factors. It was hypothesised that percent emphysema is an independent predictor of post-NLB pneumothorax. The association of quantitative CT lung volume with the occurrence of post-NLB pneumothorax and the association of quantitative emphysema with the pneumothorax size, and the need for chest tube placement after CT-guided NLB was also explored.

Section snippets

Study design and sample size

This cross-sectional designed study was conducted in 2014. Participants were identified using the Radiology Department electronic database after the institutional review board's approval with waiver of informed consent. Of 283 patients who underwent CT-guided NLB at the American University of Beirut Medical Center (AUBMC) between October 2008 and July 2013, 187 patients had a CT chest examination performed within 30 days from the biopsy with adequate images for quantitative analysis. Seven

Results

The incidence of post-NLB pneumothorax was 36.2% (n=59), of which 20% (n=12) were large sized and 15.3% (n=9) required aspiration, using chest tube placement. The characteristics of the patients, lesions, and procedures are presented for the whole sample and stratified by presence of post-NLB pneumothorax in Table 1. The mean age of participants was 61 years, 68% were men, and 72% reported ever smoking. The median emphysema volume was 36.3 ml (range 0–1493.5 ml) and the median percent emphysema

Discussion

Quantitative CT determined percent emphysema was found to be a significant predictor of incident post-procedure pneumothorax after adjustment for other potential risk factors in this sample. The risk of post-NLB pneumothorax increased by 7.4% with every unit increase in percent emphysema. Although prior studies have reported an increased risk of pneumothorax with visually assessed emphysema on chest CT,11, 13, 14 to the authors' knowledge, this is the first study to evaluate pneumothorax risk

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