Pneumothorax Requiring Chest Tube Placement Research Articles

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Safety and Success of Repeat Lung Needle Biopsies in Patients with Epidermal Growth Factor Receptor-Mutant Lung Cancer.

Postprogression repeat biopsies are critical in caring for patients with lung cancer with epidermal growth factor receptor (EGFR) mutations. However, hesitation about invasive procedures persists. We assessed safety and tissue adequacy for molecular profiling among repeat postprogression percutaneous transthoracic needle aspirations and biopsies (rebiopsies). All lung biopsies performed at our hospital from 2009 to 2017 were reviewed. Complications were classified by Society of Interventional Radiology criteria. Complication rates between rebiopsies in EGFR-mutants and all other lung biopsies (controls) were compared using Fisher's exact test. Success of molecular profiling was recorded. During the study period, nine thoracic radiologists performed 107 rebiopsies in 75 EGFR-mutant patients and 2,635 lung biopsies in 2,347 patients for other indications. All biopsies were performed with computed tomography guidance, coaxial technique, and rapid on-site pathologic evaluation (ROSE). The default procedure was to take 22-gauge fine-needle aspirates (FNA) followed by 20-gauge tissue cores. Minor complications occurred in 9 (8.4%) rebiopsies and 503 (19.1%; p = .004) controls, including pneumothoraces not requiring chest tube placement (4 [3.7%] vs. 426 [16.2%] in rebiopsies and controls, respectively; p < .001). The only major complication was pneumothorax requiring chest tube placement, occurring in zero rebiopsies and 38 (1.4%; p = .4) controls. Molecular profiling was requested in 96 (90%) rebiopsies and successful in 92/96 (96%). At our center, repeat lung biopsies for postprogression molecular profiling of EGFR-mutant lung cancers result in fewer complications than typical lung biopsies. Coaxial technique, FNA, ROSE, and multiple 20-gauge tissue cores result in excellent specimen adequacy. Repeat percutaneous transthoracic needle aspirations and biopsies for postprogression molecular profiling of epidermal growth factor receptor (EGFR)-mutant lung cancer are safe in everday clinical practice. Coaxial technique, fine-needle aspirates, rapid on-site pathologic evaluation, and multiple 20-gauge tissue cores result in excellent specimen adequacy. Although liquid biopsies are increasingly used, their sensitivity for analysis of resistant EGFR-mutant lung cancers remains limited. Tissue biopsies remain important in this context, especially because osimertinib is now in the frontline setting and T790M is no longer the major finding of interest on molecular profiling.

DIPNECH: A UNIQUE PRESENTATION OF A RARE DISEASE

SESSION TITLE: Diffuse Lung Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a very rare disease that consists of a proliferation of scattered single cells, small nodules, or linear proliferations of pulmonary neuroendocrine cells (1). The entity has been described as a precursor to pulmonary carcinoid tumors (2), is thought to be more common in middle-aged women, and can be associated with slowly-progressive cough or shortness of breath with exertion (1,3). CASE PRESENTATION: We present a case of a 42-year-old female with a complicated pulmonary history including a childhood diagnosis of asthma, two spontaneous pneumothoraces, chronic daily cough, dyspnea on exertion, and a seven-year history of incidentally-noted pulmonary nodules. An initial workup for her nodules was negative for fungal or autoimmune etiologies. An interval CT scan was obtained and showed an increase in nodule size which was further evaluated with a PET-CT. While none of the lung nodules were PET-avid, a hypermetabolic thyroid nodule was incidentally noted, which was biopsied and found to be papillary thyroid cancer. Pulmonary function testing was obtained for her dyspnea and showed mild restriction with no evidence of obstruction and normal diffusion capacity. After a non-diagnostic CT-guided biopsy of a right middle lobe lung nodule led to an iatrogenic pneumothorax requiring chest tube placement, she eventually underwent video assisted thoracoscopic surgery and right middle and lower lobe wedge resections. Biopsy showed the presence of a typical carcinoid tumor as well as neuroendocrine hyperplasia consistent with DIPNECH. DISCUSSION: This case represents an atypical presentation of a rare disease. Though pulmonary nodules, shortness of breath, and cough are common findings in DIPNECH, the occurrence of spontaneous pneumothoraces is not. Few case reports have described spontaneous pneumothoraces in patients with large endobronchial carcinoid tumors; however, this patient had no evidence of endobronchial obstruction and thus represents a unique presentation of the disease (4,5). This case also demonstrates the importance of maintaining a broad differential in the approach to patients presenting with dyspnea, cough, and pulmonary nodules. While the DIPNECH is very rare, appropriate diagnosis and close follow-up is important given the association of DIPNECH with subsequent development of carcinoid tumors (6). CONCLUSIONS: The differential for diffuse pulmonary nodules in the setting of chronic cough or dyspnea is incredibly broad. After more common etiologies like metastatic disease, granulomatous disease, autoimmune, and infectious disorders are ruled out, one should consider the diagnosis of DIPNECH, particularly in a middle-aged female with chronic, otherwise-unexplained respiratory symptoms and especially with an associated diagnosis of a carcinoid tumor (2). Reference #1: Travis WD, Brambilla EW, Burke AP, et al. WHO Classification of Tumours of the Lung, Pleura, Thymus, and Heart, IARC Press, Lyon 2015. Reference #2: Gorshtein, A., Gross, D. J., Barak, D., Strenov, Y., Refaeli, Y., Shimon, I. and Grozinsky-Glasberg, S. (2012), Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia and the associated lung neuroendocrine tumors. Cancer, 118: 612–619. https://doi.org/10.1002/cncr.26200. Reference #3: Nassar A. A., Jaroszewski D. E., Helmers R. A., Colby T. V., Patel B. M., Mookadam F. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia—a systematic overview. American Journal of Respiratory and Critical Care Medicine. 2011;184(1):8–16. https://doi.org/10.1164/rccm.201010-1685pp. DISCLOSURES: No relevant relationships by Carleen Risaliti, source=Web Response No relevant relationships by Kyle Stinehart, source=Web Response

Autologous blood patch after CT-guided lung biopsy might reduce pneumothorax requiring chest tube placement

Autologous blood patch after CT-guided lung biopsy might reduce pneumothorax requiring chest tube placement

High power microwave ablation of normal swine lung: impact of duration of energy delivery on adverse event and heat sink effects

Purpose: The purpose of this study is to assess the impact of duration of energy delivery on adverse events (AEs) and heat sink effects during high power microwave ablation (MWA) of normal swine lung.Materials and methods: High power (100 W) MWA was performed with short (2 min, 18 ablations) or long (10 min, nine ablations) duration of energy delivery in unilateral lung of swine (n = 10). CT imaging was done prior to sacrifice at 2 or 28 d post-treatment, with additional imaging at 7 and 14 d for the latter cohort. Ablation zones were assessed with CT imaging and histopathology analysis. Differences in AEs and ablation characteristics between groups were compared with Fisher’s exact test and Student’s t-test, respectively.Results: There were no significant differences in formation of air-filled needle tract, cavitation, and pneumonia (p > 0.5) between the treatment groups. Intra-procedural pneumothorax requiring chest tube placement occurred in three animals. Substantial (>20%, p = 0.01) intra-procedural ablation zone distortion was observed in both groups. The presence of large airways or blood vessels did not result in heat sink effect within the ablation zones and was not indicative of reduced ablation size. Increased energy delivery yielded larger (8.9 ± 3.1 cm3 vs. 3.4 ± 1.7 cm3, p < 0.001) spherical ablations (sphericity: 0.70 ± 0.10 vs. 0.56 ± 0.13, p = 0.01).Conclusions: High power MWA of normal lung with longer duration of energy delivery can create larger spherical ablations, without significant differences in post-procedure AEs when compared with shorter energy delivery time.

Abstract No. 502 Increased rate of pneumothorax in underweight patient after CT-guided lung biopsy

Identify the influence of body mass index on rates of clinically significant pneumothorax after CT-guided lung nodule biopsy requiring additional management. Retrospective analysis of 98 CT-guided lung nodule biopsies was performed to evaluate for development of clinically significant pneumothorax requiring chest tube placement. The procedures were performed by two experienced interventional radiologists using standardized, outpatient protocol for CT-guided lung biopsy. The patients were categorized by body mass index (BMI) as follows = overweight. Statistical analysis was performed using Chi-square analysis, Fisher’s Exact test and linear regression analysis to determine significance. Based on the standard BMI scale, 75% of underweight patients suffered a pneumothorax requiring chest tube placement. Four out of 34 normal-weight patients and 4 out of 40 overweight patients experienced a pneumothorax. None of the twenty obese patients developed a pneumothorax. Significance was determined at a level <.05. The chi-square value was 21.011, df = 3 with a p-value of 0.0001407. The Fisher’s exact test was used to compare underweight patients to the remainder of the patient population. This also demonstrated a high-level of significance with the two-tailed p values = 0.0028. Underweight patients are at a higher risk of developing a clinically significant pneumothorax after CT-guided lung biopsy. This may be due to technical factors such as a lack of the stabilizing effect of the body habitus in heavier patients. Underweight patients may have more severe confounding disease processes such as COPD. Patient’s capacity to control respiration may also be altered in these populations adding to the complexity of the procedure and increasing the complication rate. Significant care and peri-procedural caution must be exercised in the under-weight patient. Perhaps use of pleural closure devices should be considered in high-risk patients.

Percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma under C-arm cone beam CT guidance.

The aim of this study was to assess the feasibility, safety and efficacy of percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma using C-arm cone beam computed tomography (CBCT) guidance. This single-center prospective observational study was performed from August 2013 to August 2016, and included consecutive patients referred for radiofrequency ablation of lung metastases from colorectal cancer. Radiofrequency ablation procedures were performed under C-arm CBCT guidance. Feasibility was assessed by probe accuracy placement, time to accurate placement and number of C-arm CBCT acquisitions to reach the target lesion. Safety was assessed by the report of adverse event graded using the common terminology criteria for adverse events (CTCAE-V4.0). Efficacy was assessed by metastases response rate using RECIST 1.1 and 18FDG-PET-CT tumor uptake at 6months. Fifty-four consecutive patients (32 men, 22 women) with a mean age of 63±8 (SD) years (range: 51-81years) with a total of 56 lung metastasis from colorectal metastases were treated in a single session. The mean tumor diameter was 25.6±4.5 (SD)mm (range: 17-31mm). Median time to insert the needle into the target lesion was 10min (range: 5-25min). Median number of needles repositioning and C-arm CBCT acquisition per patient was 1 (range: 0-3) and 4 (range: 3-6) respectively. The accuracy for radiofrequency ablation probe placement was 2±0.2 (SD)mm (range: 0-9mm). Pneumothorax requiring chest tube placement occurred in one patient (CTCAE-V4.0 grade 3). At 6months, all patients were alive with tumor response rate of -27% and had no significant activity on the 18FDG-PET CT follow-up. Percutaneous radiofrequency ablation of lung metastases from colorectal cancer under C-arm CBCT guidance is feasible and safe, with immediate and short-term results similar to those obtained using conventional CT guidance.

Preoperative Localization of Lung Nodules With Fiducial Markers: Feasibility and Technical Considerations

The purpose of this study was to determine whether computed tomography-guided fiducial placement is a feasible and safe localization procedure to aid resection of small pulmonary nodules. A retrospective review was performed of 20 nodules (mean size 11 mm; range, 6 to 19 mm) referred for preoperative computed tomography-guided fiducial placement in 19 patients (average age 64 ± 11 years; 13 women and 6 men). The technical success rate for the placement of fiducials was 95%, with deployment of fiducials into the pleural space in 1 case. Biopsy specimen was obtained at time of the fiducial placement in 4 cases, with sensitivity of 75% and specificity of 100% for malignancy. Two procedures (10%) were complicated by a pneumothorax requiring chest tube placement. The median time between fiducial placement and surgery was 7 days (range, 1 to 123). One to four fiducials were placed a median distance of 0 mm (range, 0 to 7 mm) from the edge of the nodule. Fiducials were identified by on-table fluoroscopy in all cases, and all nodules were completely excised with negative surgical margins. Mean fluoroscopy time was 46 seconds, and mean radiation dose was 12.97 mGy. The final diagnosis was primary lung cancer in 85% of cases, with organizing pneumonia and sarcoidosis accounting for the three benign nodules. Computed tomography-guided fiducial placement is a feasible and safe technique that allows biopsy at the time of the procedure and aids localization of small pulmonary nodules during video-assisted thoracic surgery.

Image-guided biopsy in primary lung cancer: Why, when and how.

Initial histopathological analysis of a pulmonary lesion is mandatory whenever a lung cancer is suspected in order to determine the optimal diagnostic strategy. Adequate material must be obtained for a definite histological diagnosis (preferable to a cytological one) and in some cases (mainly in adenocarcinoma) molecular analysis. The two main methods to obtain adequate biopsy samples are flexible bronchoscopy and computed tomography (CT)-guided lung biopsy. Flexible bronchoscopy is a valuable method for proximal tumors. On the other hand, CT-guided lung biopsy is more accurate for peripheral tumors. CT-guided lung biopsy is a reliable procedure that conveys a 90% sensitivity for the diagnosis of lung cancer. When performed in a secured environment after contraindications evaluation, its severe complications rate is low, mainly consisting of pneumothorax requiring chest tube placement and hemoptysis.

Utilization of the track embolization technique to improve the safety of percutaneous lung biopsy and/or fiducial marker placement

PurposeThe purpose of the study was to describe and present outcomes of the track embolization technique with absorbable hemostat gelatin powder during percutaneous computed tomography (CT)-guided lung biopsy and/or fiducial marker placement versus the standard of care (no track embolization) in an attempt to decrease rates of pneumothorax (PTX), chest tube placement, hemorrhage and/or complications, and average cost per patient. Materials and methodsAn institutional review board-approved, case–control, retrospective study was performed in which 125 consecutive patients who underwent track embolization were compared with 124 consecutive controls at one institution. For subjects in whom the track embolization technique was utilized, it was performed passively through a coaxial needle as it was removed. All procedures were performed by one of three attending interventional radiologists. For each group, medical records and procedure images were reviewed for PTX occurring postprocedure, PTX requiring chest tube placement, and occurrence of minor or major complication and/or hemorrhage. Comparison was made with published complication rates, and a cost-per-patient analysis was performed. Statistical analysis was performed utilizing Fisher's Exact Test. ResultsIn track embolization cases versus controls, there were statistically significant reduction in PTX (8.8% vs. 21%; P=.007) and reduction in PTX requiring chest tube placement (4% vs. 8.1%; P=.195). This compares favorably to previously published rates of PTX and chest tube placement of 8%–64% and 1.6%–17%, respectively. None of the pneumothoraces occurring at time of needle placement increased in size with use of the track embolization technique. There were no major complications (including neurological sequela) in the track embolization group. In track embolization cases versus controls, there was a statistically significant reduction in both the rate of major hemorrhage (0% vs. 4%; P=.029) and average cost per patient ($262.40 vs. $352.07; P=.044). ConclusionsCT-guided percutaneous lung biopsy and/or fiducial marker placement were safer utilizing the track embolization technique during trocar removal. In addition, this technique was cost effective in the study population.

Effects of a Multidisciplinary Approach to Improve Volume of Diagnostic Material in CT-Guided Lung Biopsies.

BackgroundRecent publications have emphasized the importance of a multidisciplinary strategy for maximum conservation and utilization of lung biopsy material for advanced testing, which may determine therapy. This paper quantifies the effect of a multidisciplinary strategy implemented to optimize and increase tissue volume in CT-guided transthoracic needle core lung biopsies. The strategy was three-pronged: (1) once there was confidence diagnostic tissue had been obtained and if safe for the patient, additional biopsy passes were performed to further increase volume of biopsy material, (2) biopsy material was placed in multiple cassettes for processing, and (3) all tissue ribbons were conserved when cutting blocks in the histology laboratory. This study quantifies the effects of strategies #1 and #2.DesignThis retrospective analysis comparing CT-guided lung biopsies from 2007 and 2012 (before and after multidisciplinary approach implementation) was performed at a single institution. Patient medical records were reviewed and main variables analyzed include biopsy sample size, radiologist, number of blocks submitted, diagnosis, and complications. The biopsy sample size measured was considered to be directly proportional to tissue volume in the block.ResultsBiopsy sample size increased 2.5 fold with the average total biopsy sample size increasing from 1.0 cm (0.9–1.1 cm) in 2007 to 2.5 cm (2.3–2.8 cm) in 2012 (P<0.0001). The improvement was statistically significant for each individual radiologist. During the same time, the rate of pneumothorax requiring chest tube placement decreased from 15% to 7% (P = 0.065). No other major complications were identified. The proportion of tumor within the biopsy material was similar at 28% (23%–33%) and 35% (30%–40%) for 2007 and 2012, respectively. The number of cases with at least two blocks available for testing increased from 10.7% to 96.4% (P<0.0001).ConclusionsThe effect of this multidisciplinary strategy to CT-guided lung biopsies was effective in significantly increasing tissue volume and number of blocks available for advanced diagnostic testing.

Usefulness of normal saline for sealing the needle track after CT-guided lung biopsy

To determine whether the use of normal saline for sealing the needle track can reduce the incidence of pneumothorax and chest tube placement after computed tomography (CT)-guided lung biopsy. A prospective, randomised, controlled trial enrolling 322 patients was conducted. All patients were randomly assigned to one of two groups: those in whom the needle track was not sealed with normal saline (n=161, Group A) and those who did receive normal saline (n=161, Group B). CT-guided biopsy was performed with coaxial technique. Normal saline, which ranged from 1-3ml, was injected while the trocar needle was being withdrawn. Patient characteristics, lesion, and procedure variables were analysed as potential risk variables for occurrence of pneumothorax and chest tube placement. The incidence of pneumothorax was 26.1% in Group A and 6.2% in Group B (p<0.001). Nine patients in Group A and one patient in Group B required chest tube placement (p=0.010). Using multiple logistic regression analysis, smaller lesion size, greater needle-pleural angle, longer lesion-pleural distance, presence of emphysema, and no sealing the needle track with normal saline were significantly associated with an increased risk of pneumothorax, and that the latter three factors were also associated with an increased risk of pneumothorax requiring chest tube placement. Normal saline for sealing the needle track significantly reduces the incidence of pneumothorax and prevents subsequent chest tube placement after CT-guided lung biopsy.

Radiofrequency Ablation of Lung Metastases from Adenoid Cystic Carcinoma of the Head and Neck: Retrospective Evaluation of Nine Patients

PurposeTo retrospectively evaluate the outcomes of radiofrequency (RF) ablation of lung metastases from head and neck adenoid cystic carcinoma (ACC). Materials and MethodsNine patients (two men and seven women; mean age, 61.6 y) with 45 lung metastases (mean diameter, 1.1 cm; range, 0.4–2.7 cm) from head and neck ACC underwent RF ablation in 30 sessions. Primary endpoints were technical success, technique effectiveness, and procedural complications. Secondary endpoints included overall survival (OS). ResultsRF ablation was technically successful for all 45 metastases. The median tumor follow-up period was 37.1 months (range, 12.9–128.3 mo). Local progression occurred in six tumors, two of which were treated again and subsequently showed complete response. Major complications (pneumothorax requiring chest tube placement) occurred in five sessions (16.7%). The median patient follow-up period was 61.6 months (range, 20.5–134.5 mo). Two patients died of disease progression at 38.9 and 61.6 months after RF ablation, respectively, whereas the other seven remained alive at the end of the study. OS rates from the initial RF ablation were 100% at 3 years and 83.3% at 5 years (mean survival time, 106.4 mo). OS rates from the treatment of the primary site were 100% at 5 years and 62.5% at 10 years (mean survival time, 210.1 mo). ConclusionsRadiofrequency ablation is an acceptable and effective local treatment for lung metastases from head and neck ACC. However, further study is needed to evaluate its effect on patient survival.

Abstract No. 446 - Diagnostic yield of CT-guided percutaneous core biopsy of groundglass pulmonary lesions

PurposeThe purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions.Materials and MethodsA retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage.Results51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy.ConclusionCT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate. PurposeThe purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions. The purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions. Materials and MethodsA retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage. A retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage. Results51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy. 51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy. ConclusionCT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate. CT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate.

Trends, Predictors, and Outcomes of Iatrogenic Pneumothorax Requiring Chest Tube Placement in United States

Trends, Predictors, and Outcomes of Iatrogenic Pneumothorax Requiring Chest Tube Placement in United States

Complications From Computed Tomography–Guided Core Needle Biopsy for Patients Receiving Stereotactic Body Radiation Therapy for Early-Stage Lesions of the Lung

BackgroundObtaining a tissue diagnosis has traditionally been standard practice before initiating therapy for early-stage non–small-cell lung cancer (NSCLC). In several recent studies from Europe and Asia, a substantial proportion of patients have received stereotactic body radiation therapy (SBRT) based only on the imaging characteristics of the suspicious lesion. The underlying assumption is that the risk of percutaneous needle biopsy may outweigh the benefits in a population that generally has underlying pulmonary dysfunction and other medical comorbidity. Nevertheless, there is limited information regarding biopsy-related complication rates in high-risk patients with early-stage NSCLC who are treated with SBRT. Materials and MethodsThis was a retrospective review of outcomes after biopsy in patients treated with SBRT. Complications of percutaneous core needle biopsy were analyzed in relation to patient and tumor characteristics. Each biopsy event was analyzed independently for patients with multiple biopsies. ResultsA total of 112 percutaneous biopsies were performed in 103 patients. Pneumothorax of any degree was observed in 40 patients (35%) (95% CI, 27%-45%), and 12 patients (10.7%) had a clinically significant pneumothorax requiring chest tube placement (95% CI, 6%-18%). The time to first fraction of SBRT was not different in patients who had a pneumothorax or placement of a chest tube. On multivariate analysis, age, performance status, smoking history, pack-years of smoking, chronic obstructive pulmonary disease history, and forced expiratory volume in the first second of expiration were not statistically significantly associated with chest tube placement. ConclusionComputed tomography–guided needle biopsy in a primarily medically inoperable patient population is safe, with an acceptable degree of complications.

8:18 AM Abstract No. 157 - Safety and feasibility of percutaneous microwave ablation (MVA) of lung tumors

Purpose: Percutaneous ablation of lung tumors is a minimally invasive therapy for patients with primary or metastatic cancer who are not surgical candidates or in whom standard therapy fails. We present our experience with percutaneous MWA of lung tumors. Materials and Methods: 14 consecutive patients (3 male, 11 female), aged 64-89, underwent 17 treatments of 17 target lesions. 9/17 tumors were primary non-small cell lung carcinomas and 8/17 were metastatic (Colon n1⁄42, Hepatobiliary n1⁄41, Neuroendocrine n1⁄41, Head and Neck n1⁄44). Clinical evaluation was performed at baseline, 2 weeks, 30 days and 6 months. Response was assessed using Modified Response Evaluation Criteria in Solid Tumors (n1⁄413) at 6 months and classified as: Complete Response (CR), Partial Response (PR), or Progressive Disease (PD). Complications were reported according to Society of Interventional Radiology Grading System [1,2]. Results: Baseline Eastern Cooperative Oncology Group performance status average was 0.9 (range 0-3). Mean tumor size for 2.4 cm (N1⁄417, 1.2 cm-5.8 cm); mean tumor size was 2.6 cm (Primary N1⁄49, 1.4 cm-4.5 cm) and 2.1cm (Metastatic n1⁄48, 1.2 cm-5.8 cm). 16/17 treatments were technically successful with one unsuccessful case secondary to inability to place the probe safely through the tumor. 30 day, 6 month and 1 year survival was: 100% (n1⁄414), 100% (n1⁄411) and 100%(n1⁄47). Response rates for primary and metastatic tumors were as follows: (Primary, n1⁄46) CR 83%, PR 17%, PD 0 %, (Metastatic, n1⁄47) CR 100%, PR 0.0%, PD 0%. One case of locally progressive disease was initially treated with palliative intent. Three major and 2 minor complications: pneumothorax requiring chest tube placement (3/17), pneumothorax without chest tube (1/17), self-resolved hemoptysis (1/17). Conclusion: Percutaneous microwave ablation is a feasible and potentially safe technique for lung tumor ablation with promising response rates.

Vanishing Lung Syndrome in a Patient with HIV Infection and Heavy Marijuana Use

Vanishing lung syndrome (VLS) is a rare and distinct clinical syndrome that usually affects young men. VLS leads to severe progressive dyspnea and is characterized by extensive, asymmetric, peripheral, and predominantly upper lobe giant lung bullae. Case reports have suggested an additive role of marijuana use in the development of this disease in young male tobacco smokers. We herein report a case of a 65-year-old Hispanic male previously diagnosed with severe emphysema and acquired immune deficiency syndrome (AIDS), with a history of intravenous heroin use and active marijuana smoking who presents to the emergency department with severe progressive shortness of breath he was found to have multiple large subpleural bullae occupying more than one-third of the hemithorax on chest computerized tomography (CT), characteristic of vanishing lung syndrome. The patient was mechanically ventilated and later developed a pneumothorax requiring chest tube placement and referral for surgical bullectomy. Surgical bullectomy has shown high success rates in alleviating the debilitating symptoms and preventing the life threatening complications of this rare syndrome. This case further emphasizes the importance of recognizing VLS in patients with severe emphysema and heavy marijuana smoking.

Tract Embolization With Gelatin Sponge Slurry for Prevention of Pneumothorax After Percutaneous Computed Tomography-Guided Lung Biopsy

To determine the effect of embolization with absorbable gelatin sponge slurry on the incidence of pneumothorax (PTX) and need for chest tube placement after percutaneous lung biopsy. Seven hundred fifty-two percutaneous lung biopsy procedures and fiducial seed placements were performed using computed tomography (CT)-guidance at a single institution. A retrospective review was performed including 145 patients with embolization (19.28%) of the tract with gelatin sponge slurry during needle withdrawal and 607 patients who did not undergo tract embolization. Patient- and lesion-related characteristics were collected through the electronic health record and PACS. Outcome measures included the occurrence of PTX during or after the biopsy procedure and the need for chest tube placement. Analysis was performed by multivariate logistic regression. Although tract embolization did not significantly decrease the chances of developing PTX (p = 0.06), it did decrease the likelihood of progressing to requiring chest tube insertion. Without tract embolization, 10.7% of cases required a chest tube, whereas only 6.9% of the patients whose tract was embolized needed a chest tube (p = 0.01). A history of emphysema was associated with 151% increased odds of PTX requiring chest tube placement after lung biopsy (p = 0.009). Tract length >24 mm was associated with a 262% increase in the odds of requiring chest tube placement (p = 0.003). Embolization of the needle tract during percutaneous lung biopsy with gelfoam slurry significantly decreased the odds of requiring a chest tube for PTX and should be considered for all patients, particularly those with emphysema and deep lesions.

Effect of Intraparenchymal Blood Patch on Rates of Pneumothorax and Pneumothorax Requiring Chest Tube Placement After Percutaneous Lung Biopsy

The purpose of this study was to determine whether an autologous intraparenchymal blood patch reduces the rate of pneumothorax and the rate of pneumothorax requiring chest tube placement after percutaneous lung biopsy. A prospective randomized controlled trial enrolling 242 patients was conducted. Adult patients undergoing percutaneous biopsy of lung or mediastinal lesions of undetermined cause were candidates. Patients were excluded if aerated lung tissue was not crossed during the biopsy. A standard biopsy procedure was followed for all patients until an adequate tissue sample was obtained. Patients were then randomized. For patients randomized to the treatment group, an intraparenchymal blood patch was administered through the guiding needle on removal. The same postbiopsy procedures were followed for both the treatment and control groups. Data collected included development of pneumothorax and placement of a chest tube. The rate of pneumothorax was reduced from 35% to 26% (p = 0.12) with the use of the blood patch, but the reduction was not significant. The rate of pneumothorax requiring chest tube placement was significantly reduced from 18% to 9% (p = 0.048). There was a greater benefit in the blood patch group when a 19-gauge guiding needle was used: Pneumothorax requiring chest tube placement was reduced from 19% to 3% whereas an increase from 16% to 20% was seen with a 17-gauge needle (p = 0.029). The use of an autologous intraparenchymal blood patch significantly reduces the rate of pneumothorax requiring chest tube placement. It seems to be more beneficial when a 19-gauge guiding needle is used.