CT-guided Lung Biopsy Research Articles

44 CT guided lung biopsy: complications and positive histological diagnosis

44 CT guided lung biopsy: complications and positive histological diagnosis

Risk Factors for Systemic Air Embolism as a Complication of Percutaneous CT-guided Lung Biopsy: Multicenter Case-control Study

To determine risk factors for systemic air embolism by percutaneous computed tomography (CT)-guided lung biopsy. This case-control study used data from 2216 percutaneous lung biopsy procedures performed over 11 years at 12 institutions in Japan. Systemic air embolism was identified by retrospective review of CT images obtained during and immediately after the procedures. To fulfill our objective, multiple variables were compared between cases and controls with univariate analyses by using Student's t test and Fisher's exact test for numerical and categorical values, respectively. Multivariate logistic regression analysis was then performed using selected variables. Ten cases of systemic air embolism and 2,206 controls were identified. Univariate analyses showed that the lesions in the lower lobe (P = 0.025) and occurrence of parenchymal hemorrhage (P = 0.019) were significant risk factors. Multivariate analysis showed that the use of a larger biopsy needle was a significant risk factor (P = 0.014). Parenchymal hemorrhage during the procedure, lesions in the lower lobe, and the use of larger biopsy needles may be risk factors for systemic air embolism by percutaneous CT-guided lung biopsy. Our findings may provide clues toward minimizing the risk of this complication.

CT-guided needle lung biopsy is possible during apneic oxygenation: a case series

Background: It can be difficult to perform CT guided biopsy of small pulmonary nodules especially if the position is behind a costa or close to the diaphragm and respiratory movements may hamper the procedure. During apneic oxygenation with a pulmonary standstill these movements can be hindered. Methods: Six patients with decreased lung function and suspicious lung nodules are presented. Under general anesthesia including a muscle relaxant and a cuffed tube in the trachea CT guided biopsy was prepared. Just before the biopsy the ventilation mode was switched to a continuous positive airway pressure of 5–10 cm H2O, maintaining 100% oxygen delivery without ventilation. If the position of the lung nodule was inconvenient for biopsy the pressure was increased to up to 17 cm H2O to expand the lungs to a better biopsy position. After retrieving the biopsy controlled ventilation was re-established and a finishing control CT-scan was performed. Blood gas analyses were performed with few minutes interval. Results: All biopsies were diagnostic. All patients survived the procedure with no major complications, but 3 patients developed pneumothorax. The length of apneic oxygenation was median 10 minutes (8–10 minutes). No major changes in vital parameters were observed, and in all patients the peripheral oxygen saturation was 100% throughout the procedure. The arterial oxygen tension rose to very high values and the lowest pH was 7.18. Conclusions: It is possible to perform lung biopsies in selected patients with decreased lung function during apneic oxygenation in at least 10 minutes in a safe way.

CT-guided needle lung biopsy is possible during apneic oxygenation: a case series

BackgroundIt can be difficult to perform CT guided biopsy of small pulmonary nodules especially if the position is behind a costa or close to the diaphragm and respiratory movements may hamper the procedure. During apneic oxygenation with a pulmonary standstill these movements can be hindered.MethodsSix patients with decreased lung function and suspicious lung nodules are presented. Under general anesthesia including a muscle relaxant and a cuffed tube in the trachea CT guided biopsy was prepared. Just before the biopsy the ventilation mode was switched to a continuous positive airway pressure of 5–10 cm H2O, maintaining 100% oxygen delivery without ventilation. If the position of the lung nodule was inconvenient for biopsy the pressure was increased to up to 17 cm H2O to expand the lungs to a better biopsy position. After retrieving the biopsy controlled ventilation was re-established and a finishing control CT-scan was performed. Blood gas analyses were performed with few minutes interval.ResultsAll biopsies were diagnostic. All patients survived the procedure with no major complications, but 3 patients developed pneumothorax. The length of apneic oxygenation was median 10 minutes (8–10 minutes). No major changes in vital parameters were observed, and in all patients the peripheral oxygen saturation was 100% throughout the procedure. The arterial oxygen tension rose to very high values and the lowest pH was 7.18.ConclusionsIt is possible to perform lung biopsies in selected patients with decreased lung function during apneic oxygenation in at least 10 minutes in a safe way.

Clinical and pathological features of adult pulmonary tuberculosis with reversed halo sign

To understand the pathological correlation of the reversed halo sign (RHS) in adult pulmonary tuberculosis (PTB) patients, and to compare the clinical characteristics of PTB patients with RHS with those without RHS. The study included 80 patients consecutively diagnosed with PTB by pathology or smear-positive sputum or bronchoalveolar lavage fluid from 1 January to 31 August 2012. All patients underwent high-resolution computed tomography (HRCT) scan, and were divided into two groups based on HRCT findings: RHS and non-RHS. All patients in the RHS group underwent CT-guided transthoracic lung biopsy to evaluate histopathological abnormalities. Clinical features such as smoking history, TB-related symptoms and comorbidities were compared. The 'ring' in the RHS corresponded to granulomata, with or without acid-fast stain positivity, and with or without caseating necrosis. Compared with the non-RHS group, patients in the RHS group were significantly younger, were less likely to have a smoking history and had fewer TB-related symptoms and comorbidities. Our study shows that younger PTB patients with relatively better baseline status tended to present with RHS on HRCT, have fewer TB-related symptoms and present atypically.

Ameloblastoma with varied sites of metastasis: Report of two cases and literature review

ObjectiveWe report two rare cases of lung metastasis from maxillary ameloblastoma, in order to review its risk and analyse the types of metastases that can present with this disease. MethodsA 40-year-old male with multiple recurrences and a 46-year-old female, who had undergone successful surgical treatment of a maxillary ameloblastoma, presented with metastatic lesions. The primary tumour and metastases were benign in both patients. We reviewed and analysed 20 cases of the same condition reported in recent years. ResultsOur initial treatment for the primary maxillary lesion was performed more than 10 years before the pulmonary lesions presented. Due to the aggressive nature of this tumour, metastases in the lungs and cervical lymph nodes (male patient) were confirmed. ConclusionThese cases presented a diagnostic challenge due to the multiple and varied sites of recurrence, which indicate the natural behaviour of this tumour. Different routes of metastasis can occur, including implanting, haematogenous, and lymphatic spread. CT-guided percutaneous transthoracic lung biopsy is an important method to confirm metastatic ameloblastoma.

Diagnostic value of computed tomography-guided percutaneous lung biopsy for malignant lung tumors

To explore the diagnostic efficiency of percutaneous lung biopsy for malignant lung tumors under the guidance of computed tomography (CT). The clinical data of 623 patients undergoing CT-guided percutaneous lung biopsy at Department of Respiratory Medicine, Xinqiao Hospital, Third Military Medical University from January 2010 to November 2012 were analyzed to examine the influencing factors for the occurrences of pneumothorax and hemoptysis, including patient age, gender, site of puncture, tumor location and size, depth and number of puncture, chronic obstructive pulmonary disease (COPD) and doctor's clinical experience. A total of 623 cases were recruited. There were 410 male and 213 female with an average age of 60 ± 11 (15-87) years. Among them, 618 were diagnosed as malignant lung tumors with a positive rate of 99.2%. Pathological classifications were adenocarcinoma (n = 387, 62.1%), squamous carcinoma (n = 166, 26.6%), small cell lung cancer (n = 30, 4.8%), undifferentiated cancer (n = 18, 2.9%) adenosquamous carcinoma (n = 2, 0.3%), sarcomatoid carcinoma (n = 6, 0.9%), leiomyosarcoma (n = 3, 0.5%), neuroendocrine carcinoma (n = 2, 0.3%), low differentiated carcinoid (n = 1, 0.2%), cribriform carcinoma (n = 1, 0.2%), malignant lymphoma (n = 1, 0.2%) and metastatic renal cell carcinoma (n = 1, 0.2%) respectively. Another 5 patients (0.8%) had an initial diagnosis of chronic inflammation according to their pathological features of lung punctures. Their definite diagnoses were lung squamous cell carcinoma (n = 3), adenocarcinoma (n = 1) and small cell carcinoma (n = 1) respectively. The major complications were pneumothorax and hemoptysis. Among 73 cases of pneumothorax (n = 73, 11.7%), 65 cases (n = 65, 10.4%) of mild pneumothorax (lung compression < 20%) were cured by sufficient oxygen inhalation and repose while 8 cases (1.3%) suffered lung compression ≥ 75% recovered via closed thoracic drainage. Eighty-four patients (13.5%) suffered from the complications of slight or self-limited hemoptysis with blood-tinged sputum. The symptoms of hemoptysis disappeared after oral hemostatic or other treatments. Another 5 patients (0.8%) suffered from moderate hemoptysis (100-500 ml) and their symptoms disappeared after rest or an intravenous infusion of haemostatic. None of them died of massive hemoptysis or biopsy. The occurrence of pneumothorax was significantly correlated with the diameter of lesions ( ≤ 2 cm) (P = 0.006), depth of needle (>3 cm) (P = 0.044), number of puncture needles ( ≥ 3 needles) (P = 0.025), inadequate clinical experience of puncturing doctors (P = 0.003) and COPD (P = 0.036); the occurrence of hemoptysis was obviously correlated with the diameter of lesions ( ≤ 2 cm) (P = 0.031), depth of needle (>3 cm) (P = 0.018), number of puncture needles ( ≥ 3 needles) (P = 0.015) and inadequate clinical experience of puncturing doctors (P = 0.014). However, the relationship was unremarkable between the occurrences of pneumothorax and hemoptysis and patient gender, age, sites of puncture and tumor location. With a high diagnostic value, CT-guided percutaneous lung biopsy is both safe and effective for malignant lung tumors.

Feasibility and outcome of CT-guided lung biopsy in patients with hematological diseases and suspected fungal pneumonia

Fungal pneumonia is a major cause of morbidity and mortality in immunocompromised patients with hematological diseases. This study is aimed to evaluate the feasibility and outcome of computed tomography (CT) guided lung biopsy or fine needle aspiration cytology (FNAC) in the diagnosis of fungal pneumonia in patients with hematological diseases. Seven hundred and seventy six consecutive patients with febrile neutropenia were evaluated prospectively over the period of three years. Patients with suspected fungal pneumonia, based on typical CT scan findings, were considered for lung biopsy. Of the 776 patients evaluated for fever, 235 (30.3%) showed CT scan findings consistent with fungal pneumonia. Of the 235 patients, CT-guided lung biopsy/FNAC was recommended for 178 patients but could be performed in only 34 (19.1%) patients. Fungal pneumonia was proven in 15 (44%) out of 34 patients (aspergillus in 12; mucormycosis in 3 patients). Lung biopsies could not be performed for a number of reasons. These included thrombocytopenia, nodules being too small, infection improving with empiric treatment and patient recovering clinically, and the patient being too sick to undergo intervention. The median absolute neutrophil count (ANC) of patients at the time of lung biopsy was 0.41 x 10⁹/l in patients whose lung biopsy/FNAC showed fungal pneumonia, compared to 2.10 x 10⁹/l in patients whose biopsy/FNAC showed necrotizing pneumonitis. CT-guided lung biopsy/FNAC can allow the definitive diagnosis of fungal pneumonia in selected patients with various hematological diseases and should be attempted whenever clinically indicated and radiologically feasible.

Suitability of Computed Tomography-Guided Biopsy Specimens for Subtyping and Genotyping of Non–Small-Cell Lung Cancer

IntroductionRecent advances in the treatment of NSCLC highlight the importance of distinguishing NSCLC subtypes and genotypes. We aimed to determine whether histological specimens obtained from computed tomography (CT)-guided biopsy are suitable for specific subtyping and epidermal growth factor receptor (EGFR) analyses of NSCLC. Patients and MethodsThe clinicohistological data of 332 consecutive patients undergoing 352 CT-guided biopsies for lung lesions between January 2007 and December 2011 were retrospectively analyzed. Additionally, NSCLC specimens were examined for the suitability of EGFR mutational testing. ResultsOf 209 specimens diagnosed as NSCLC, 197 (94.3%) were specifically subtyped into adenocarcinoma (n = 164; 78.5%), squamous cell carcinoma (n = 27; 12.9%) and other subtypes (n = 6; 2.9%). The rate of NSCLC not otherwise specified (NOS) was 5.7%, and the diagnosis of NSCLC-NOS was significantly associated with the poor differentiation of cancer (adjusted odds ratio, 6.17; 95% confidence interval, 1.62-23.55; P = .008). Of 134 histological tumor specimens submitted for EGFR molecular testing, 132 (98.5%) were suitable for analyses, and 130 of them (98.5%) showed conclusive results, revealing 59.8% (n = 79) with EGFR exon mutation(s). The sensitivity, specificity, and positive and negative predictive values of CT-guided biopsy in patients with malignancy were 92.2%, 100%, 100%, and 74.1%, respectively. Six percent (n = 21) of total lung biopsies led to pneumothorax requiring chest drainage, and no procedure-related fatality was observed. ConclusionSmall tumor specimens obtained with CT-guided needle lung biopsy are suitable for specific subtyping and EGFR analyses of NSCLC, thus providing critical information for personalized therapy.

Computed tomography-guided needle aspiration and biopsy of pulmonary lesions: a single-center experience in 1000 patients

Computed tomography (CT)-guided fine needle aspiration (FNA) and biopsies are well-established, minimally invasive diagnostic tools for pulmonary lesions. To analyze retrospectively the results of 1000 consecutive lung CT-guided FNA and/or core needle biopsies (CNB), the main outcome measures being diagnostic yield, and complication rates. Patients considered eligible were those referred to our department for lung lesions. The choice of FNA, CNB, or both was based upon the radiologist's judgment. Diagnostic yield was defined as the probability of having a definite result by cytology/histology. The study included 733 male patients and 267 female patients, with a mean (SD) age of 66.4 (11.4) years. The mean (SD) lesion size was 3.7 (2.4) cm in maximal diameter. Six hundred and forty-one (64%) patients underwent an FNA procedure, 245 (25%) a CNB, and 114 (11%) had been subjected to both. The diagnostic yield was 960/994 (96.6%); this decreased significantly with the use of CNB only (odds ratio [OR] 0.32; 95% CI 0.12-0.88; P = 0.03), while it increased with lesion size (OR 1.35; 95% CI 1.03-1.79; P = 0.03 per cm increase). In 506 patients (52.7%), a malignant process was diagnosed by cytopathology/histology. The complication rate reached 97/1000 (9.7%); complications included: hemorrhage, 62 (6.2%); pneumothorax, 28 (2.8%); hemorrhage and pneumothorax, 5 (0.5%); and hemoptysis, 2 (0.2%). It was not significantly affected by the type of procedure or localization of the lesion. The overall risk for complications was three times higher for lesions <4 cm (OR 3.26; 95% CI 1.96-5.42; P < 0.001). CT-guided lung biopsy has a high diagnostic yield using FNA, CNB, or both. The CNB procedure alone will not suffice. Complication rates were acceptable and correlated inversely with lesion size, not localization or type of procedure.

Is emphysema a risk factor for pneumothorax in CT-guided lung biopsy?

IntroductionComputed tomography (CT)-guided lung biopsy is commonly used to make a histological diagnosis for pulmonary lesions. Its most common complication is pneumothorax. While it is thought that CT-guided lung biopsy should be avoided in patients with emphysema, however, there is no scientific report documenting the relationship the occurrence of pneumothorax and the severity of emphysema.Purpose and methodsTo investigate the relationship between the severity of emphysema and the frequency of pneumothorax, we retrospectively reviewed all the patients who received CT-guided lung biopsy. Severity of emphysema is evaluated by Goddard classification, a visual scale by which areas of vascular disruption and low attenuation value were scored for each lung field of high resolution CT.Patients’ characteristics, prognostic accuracy of this method, size and location of the lesion, length of intrapulmonary biopsy paths, and frequency of complications such as pneumothorax or intrapulmonary hemorrhage were evaluated.ResultsOne hundred-two patients (69 males and 33 females) received 102 procedures. Diagnostic accuracy was 90.2%. Pneumothorax occurred in 41 of 102 biopsies (40.2%). Chest tube placement was required in 3 out of the 41 cases (7.3%) complicated by pneumothorax (2.9% of all the biopsies). The longer lesion depths from pleura were, the more frequently pneumothorax occurred (6.67 vs 3.66 mm, p=0.019). No correlation was found between location of lesions and frequency of pneumothorax. No significant differences of COPD staging or LAA score were seen between the patients with and without pneumothorax (5.73 vs 4.32 points, p=0.339).ConclusionWe suggest that severity of emphysema such as stage I or II COPD may not be related to the frequency of pneumothorax.

Abstract No. 423 - Ultra-low–dose radiation protocol for CT-guided lung biopsies: initial experience

Purpose CT-guided percutaneous needle biopsy (PNB) is an established and effective procedure for tissue diagnosis in suspected pathologic processes. Computed tomography (CT) scans are a significant source of radiation to both patients and staff. A retrospective analysis of ultra-lower–dose (ULD) CT-guided PNB for lung lesions was undertaken to determine safety, efficacy, and complication rates following biopsy. Materials and Methods The use of ULD protocol for CT-guided lung biopsy was initiated as part of a quality initiative. The standard dose (120kV localizing/120kV subsequent guiding scans with auto-mA) was changed to a ULD protocol (100kV, 7.5mAs). The total dose and complications of the procedure were tabulated. The technical success rate in obtaining a representative sample for diagnosis was evaluated. The rates of complication were compared to the 2010 guidelines published in a joint document by the American College of Radiology and the Society of Interventional Radiology. Results A total of 52 consecutive patients (27 males and 25 females; average age 71) who underwent lung lesion biopsies were evaluated. The average size of lesion was 4.1cm. The overall biopsy success rate was 100%. The rate of pneumothorax was 19%, well within suggested guidelines of 12-45%. Pneumothoraces requiring tube insertion occurred in 6% of cases, compared to guidelines of 2-15%. There is a strong inverse correlation between the size of the lesion (≤3 cm; >3 cm) and the rate of complications (p = .00020). Nonetheless, the size of the lesion did not influence the total dose of radiation required for the biopsy procedure (p = .48). Conclusion Radiation dose to the chest during CT-guided lung PNB is reduced significantly through the use of a ULD protocol. Our findings suggest that reducing the CT radiation dose does not negatively impact patient safety or biopsy diagnostic rates in PNB.

CT-guided biopsies in lung infections in patients with haematological malignancies

CT-guided transparietal lung biopsy in imaging makes it possible to find the pathogenic agent in half of all fungal infections and most bacterial infections (sensitivity=55%, specificity=100%). Performance is decreased in consolidations (50% of infections) compared to masses. Complications, pneumothorax, alveolar bleeding and hemoptysis are generally benign and rarely (<5%) require specific treatment. On the other hand, the diagnostic performance increases significantly with the calibre of 18G co-axial systems compared to 20G. The risk is not related to the number of samples or platelet levels.

Bulky Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma Treated with Yttrium-90 Ibritumomab Tiuxetan

An 84-year-old woman was admitted to our hospital with nonproductive cough and dyspnea on exertion. Computed tomography (CT) scan revealed extensive consolidation in the right lung. She was diagnosed with pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma using CT-guided lung biopsy. Her pulmonary images and respiratory symptoms did not improve two months after receiving 4 cycles of rituximab weekly; therefore, yttrium-90 ibritumomab tiuxetan was chosen as salvage therapy. The abnormal shadow on her pulmonary images was significantly reduced two months later, and she had no symptoms without nonhematological toxicities. She has had no progression for 18 months. Furthermore, radiation pneumonitis has not also been observed. We herein reported bulky pulmonary MALT lymphoma treated with yttrium-90 ibritumomab tiuxetan.

CT-guided percutaneous transthoracic lung biopsy: First experience in Ibadan, Nigeria

Percutaneous lung biopsy had been described in the nineteenth century by Leyden, but image- guided needle chest biopsy only gained widespread acceptance in the 1970s. Currently, tissue sampling of a thoracic lesion is indicated when the diagnosis cannot be obtained by the non-invasive techniques and cytological diagnosis will modify the stage of the disease or influence the therapeutic strategy. Cytology obtained by small-gauge needle aspiration biopsy confirms the nature of the lesion in 80 - 95% of cases and carry a low incidence of major complications. The purpose of this report was to provide information on our first experience with CT-guided biopsy and show that with some innovativeness much can be achieve with limited resources and good team work. We performed a CT of the thorax using appropriately placed improvised metal markers, which determined the optimal cutaneous entry point. We then re-checked the location of the lesion scanning intermittently at 5mm slice thickness; we marked the entry point with a pen and cleaned the surface with methylated spirit. A local anaesthetic was subcutaneously injected around marked area. We used a 21G aspiration needle to obtain cytology sample then 18G Trucut biopsy needle to obtain histology specimen. The length of the needle was chosen based on predetermined distance of the target lesion from the skin estimated from the CT images. Our patient was a 51-year-old Nigerian female with a peripherally located nodule in the posterior aspect of the right lung. She had CT-guided biopsy of the nodule. The procedure was well tolerated with no complication of pneumothorax. The histology report provided the basis for treatment regimen. Our experience indicates that percutaneous transthoracic CT-guided needle biopsy is feasible and a safe procedure in our hospital for evaluation of undetermined lung lesions.

56 CT guided lung biopsy: A comparison of specialist registrar and consultant performed biopsies

56 CT guided lung biopsy: A comparison of specialist registrar and consultant performed biopsies

P28 A Successful Ambulatory Pathway For Elective CT Guided Lung Biopsy Which Reduces Bed Days is Co-Dependant on Adequate Discharge Planning Including a Pathway For Managing Patients with Small Pneumothoraces: Abstract P28 Table 1

Introduction and Objectives CT guided lung biopsy is a cost effective and reliable method to diagnose lung malignancy. The procedure has a low morbidity and mortality although pneumothorax complicates up to 61% of all lung biopsies. 1 Patients were previously admitted for this procedure but the lack of beds and the resources prompted the conversion to an out-patient service. 2 The aim of this study was to look at how a new policy for day-case CT guided biopsy of the lung affected bed-days, in particular those patients with a post biopsy pneumothorax. Methods We collected data on CT guided lung biopsies, its complications and bed days per biopsy during 2008 when procedure was performed as inpatient and compared it with the findings when procedure was performed as day case between 2009 and 2011. Results During 2008 we performed 35 CT guided lung biopsies as inpatients. Total bed days per biopsy were 2.31(81/35). With the introduction of a day case procedure in 2009 total bed days per biopsy were remarkably reduced to 0.12 (9/73). Post biopsy pneumothorax rate was 18.8% (13/73) over 3 years, but only one patient required treatment with a chest drain 7.7% (1/13). However 9/13 patients were admitted for observation irrespective of the symptoms and size of the pneumothorax. Conclusion We present evidence that the implementation of a successful day-case CT biopsy pathway has dramatically reduced bed days per successful biopsy. We have demonstrated that a further pathway for the ambulatory management of post-biopsy complications would further reduce this figure by a factor of 10 from 0.12 to 0.014 days (1/73)[see table). We recommend discharging suitably selected patients with small asymptomatic pneumothorax with an appropriate information leaflet. A CXR to confirm resolution of the pneumothorax could be done when the patient returns to clinic for their biopsy results. References MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010; 65. CT-guided cutting needle biopsy of lung lesions–safety and efficacy of an out-patient service. Charig MJ, Phillips AJ. Clin Radiol. 2000 Dec; 55(12):964–9.

Percutaneous Computed Tomography-Guided Lung Biopsies: Preliminary Results using an Augmented Reality Navigation System

"Augmented reality" is a technique to create a composite view by augmenting the real intervention field, visualized by the doctor, with additional information coming from a virtual volume generated using computed tomography (CT), magnetic resonance or ultrasound images previously acquired from the same patient. In the present study we verified the accuracy and validated the clinical use of an augmented reality navigation system produced to perform percutaneous CT-guided lung biopsies. One hundred and eighty consecutive patients with solitary parenchymal lung lesions, enrolled using a nonrandom enrollment system, underwent percutaneous CT-guided aspiration and core biopsy using a traditional technique (group C, 90 patients) and navigation system assistance (group S, 90 patients). For each patient we recorded the largest lesion diameter, procedure time, overall number of CT scans, radiation dose, and complications. The entire experimental project was evaluated and approved by the local institutional review board (ethics committee). Each procedure was concluded successfully and a pathological diagnosis was reached in 96% of cases in group S and 90% of cases in group C. Procedure time, overall number of CT scans and incident x-ray radiation dose (CTDIvol) were significantly reduced in navigation system-assisted procedures (P <0.001; z = 5.64) compared with traditional CT-guided procedures. The percentage of procedural complications was 14% in group S and 17% in group C. The augmented reality navigation system used in this study was a highly safe, technically reliable and effective support tool in percutaneous CT-guided lung biopsy, allowing to shorten the procedure time and reduce the incident x-ray radiation dose to patients and the rate of insufficient specimens. Furthermore, it has the potential to increase the number of procedures executed in the allocated time without increasing the number of complications.

Breath-hold after forced expiration before removal of the biopsy needle decreased the rate of pneumothorax in CT-guided transthoracic lung biopsy

PurposeTo assess the effect of a breath-hold after forced expiration on the rate of pneumothorax after computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions. Materials and methodsBetween January 2008 and December 2011, percutaneous CT-guided lung biopsy was performed in 440 patients. Two hundred and twenty-one biopsies were performed without (control group) and two hundred and nineteen biopsies were performed with (study group) the study maneuver – a breath-hold after forced expiratory approach. Multivariate analysis was performed between groups for risk factors for pneumothorax, including patient demographics, lesion characteristics, and biopsy technique. ResultsA reduced number of pneumothoraces (18 [8.2%] vs 35 [15.8%]; P=0.014) but no significant difference in rate of drainage catheter insertions (2 [0.9%] vs (4 [1.8%]; P=0.418) were noted in the study group as compared with the control group. By logistic regression analysis, three factors significantly and independently affected the risk for pneumothorax including lesion size (transverse and longitudinal diameter), distance from pleura and utilizing or avoiding the breath-hold after deep expiration maneuver. ConclusionBreath-holding after forced expiration before removal of the biopsy needle during the percutaneous CT-guided transthoracic lung biopsy almost halved the rate of overall pneumothorax. Small lesion size (longitudinal diameter) and the distance from pleura were also predictors of pneumothorax in our study.

Hemorrhagic Colitis as a Manifestation of Wegenerʼs Granulomatosis: Think Outside the Box

Case Report: A 37-year-old African American male presented to our institution with a 2 week history of diffuse crampy abdominal pain associated with frequent watery bowel movements and low grade fever. On presentation he was tachycardic, febrile and abdominal exam was unremarkable. Blood work revealed normocytic anemia, leucocytosis, coagulopathy, elevated ESR, CRP and hypokalemia and was started on intravenous antibiotics. Chest X-ray at admission revealed multiple cavitary lesions. Echocardiogram, stool studies, pancultures, serum Quantiferon, HIV test and urinalysis were unrevealing. CT chest showed lung opacities suspicious for septic emboli or neoplastic process and was started on anticoagulation that precipitated rectal bleeding while awaiting lung biopsy. Colonoscopy revealed large, deep, skipped, exudative ulcerations throughout the colon, pathology significant for chronic inflammation with crypt distortion. Due to the persistence of fever on antibiotics, steroids were started for possible autoimmune etiology. CT guided lung biopsy revealed suppurative granulomas with small vassel vasculitis, highly suspicious for Wegener's granulomatosis (WG) in the setting of elevated C-ANCA. Repeat colonoscopy for rectal bleeding revealed improvement in ulcerations with antibiotic and steroid use. Thoracoscopic lung biopsy revealed thrombotic arteriopathy, vascular intimal thickening indicative of vasculitis. He was discharged home on steroids having refused cyclophosphamide. He was asymptomatic at 6 months follow-up. Discussion: We present a unique case of a patient with pulmonary nodules and hemorrhagic colitis consistent with WG. Intestinal manifestations as an initial presentation of WG are rarely reported. As intestinal involvement is rare in WG, an important differential is inflammatory bowel disease (IBD), though lung manifestations are rare in IBD. Although our initial suspicion was Crohn's disease based on colonoscopic findings and pathology results, further investigation of the patient's lung pathology confirmed a systemic vasculitic process consistent with WG. Conclusion: Combined pulmonary and intestinal findings carry a small list of differentials, of which vasculitis including WG should be high on the differential.