Transthoracic Needle Lung Biopsy Research Articles

Robotics in the diagnosis and staging of lung cancer.

The diagnosis of peripheral small lung lesions by electromagnetic navigational bronchoscopy is still inferior to computed tomography(CT) guided percutaneous transthoracic needle lung biopsy. Robotic bronchoscopy is a new technology that may be a potential breakthrough in the diagnosis of small lung lesions. Real-time tools such as electromagnetic navigation, radial-endobronchial ultrasound, and cone beam CT may further improve the diagnostic yield rate may further improve the diagnostic yield rate. In this article, we reviewed early experience of robotic bronchoscopy for diagnosis and staging of lung cancer.

Pneumothorax and Intrapulmonary Hemorrhage in CT-Guided Transthoracic Biopsy

Objective: To study the frequency of pneumothorax and intrapulmonary haemorrhage in computed tomography (CT) guided transthoracic needle lung biopsy (NLB) and the factors that affect the development of these complications in Pakistan through a representative limited data obtained from a tertiary care centre.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Armed Forces Institute of Radiology and Imaging, Rawalpindi, from Jan 2018 to Feb 2019.
 Methodology: A total of 68 patients who underwent CT-guided transthoracic biopsy were evaluated for intra- and immediate (within 04 hours) post-procedural pneumothorax and pulmonary haemorrhage. The factors affecting the development of these complications were evaluated.
 Results: Complications developed in 30 patients with the frequency of pneumothorax at 26.5 % and frequency of pulmonary haemorrhage at 19.1%. Significant risk factors for the development of pneumothorax were small lesions less than 2.5 cm in diameter (p-value <0.05), increased needle track path within the lung tissue of more than 21 mm (p-value = 0.05), and presence of emphysema in the surrounding lung tissue (p-value <0.05). In addition, smaller lesion size (p-value <0.05) and increased traversed lung parenchyma (p-value <0.05) were also significant factors in the development of intrapulmonary haemorrhage.
 Conclusion: Significant risk factors for pneumothorax and intrapulmonary haemorrhage are smaller lesion size and length of puncture path. The presence of emphysema is related to the development of pneumothorax.

Systemic air embolism following computed-tomography-guided transthoracic needle biopsy of lung lesion - a systematic search of case reports and case series.

BackgroundSystemic air embolism is a rare, however potentially fatal, low incidence, complication to CT-guided transthoracic needle biopsy of lung lesions.PurposeThe purpose of this review of case reports and series was to pool data about this rare complication and glance for a pattern or similarities in the patients’ initial symptoms and course, as well as the management of the patients in relation to current guidelines.Material and methodsPubMed was searched for case reports and case series about systemic air embolisms following CT-guided transthoracic needle biopsy of lung lesions from inception to November 2021. A reviewer screened the results for eligibility and included studies which reported at least two outcomes of interest. Data was extracted by one author and a descriptive analysis was conducted.ResultsOf 1,136 studies screened, 83 were eligible for inclusion involving 97 patients. The mean age was 64.8±11.7 years and ≈60% of the patients were men. In 15 cases the outcome was fatal, and most of the fatal cases (n = 12) had cardiac arrest as the primary initial symptom. In addition to conventional oxygen therapy, 34 patients received hyperbaric oxygen therapy, and in 30 cases the physician in charge chose to change the patient from standard supine position to – most often – Trendelenburg position.ConclusionNo similarities were found that could lead to more rapid diagnosis or more correct management. The staff should keep systemic air embolisms in mind, when more common complications are ruled out, and consider hyperbaric oxygen therapy in case of suspicion.

Early detection of delayed pneumothorax using lung ultrasound after transthoracic needle lung biopsy: A prospective pilot study.

ObjectivesDelayed pneumothorax can cause an emergency room visit and be life‐threatening in case of tension pneumothorax after transthoracic needle biopsy. We hypothesized that most delayed pneumothoraces are diagnosed by later enlargement of occult pneumothorax due to the low diagnostic accuracy of a chest X‐ray. Lung ultrasound is a highly accurate tool for detection of pneumothorax. The aim of this study is to evaluate the diagnostic accuracy of lung ultrasound for prediction of delayed pneumothorax on chest X‐ray.MethodsThis prospective pilot study was performed between April 2020 and July 2020 in Chungnam National University Hospital. The participants underwent chest X‐rays and lung ultrasound before, immediately after, and 3 h after transthoracic needle biopsy, respectively. The presence or absence of lung sliding at each anterior BLUE‐point on an ultrasound and pneumothorax on a chest X‐ray was recorded.ResultsPneumothorax occurred in 17 (35.4%) participants, and three of them underwent chest tube replacement. Of the 17 (35.4%) cases of pneumothorax, five participants (10.4%) were diagnosed with delayed pneumothorax. Three out of five participants showed loss of lung sliding on lung ultrasound before the diagnosis of delayed pneumothorax. Therefore, the sensitivity of lung sliding on lung ultrasound for early detection of delayed pneumothorax was 60%. Two undetected cases were asymptomatic, and the pneumothoraces were exceedingly small and recovered spontaneously. Thus, sensitivity for detection of clinically meaningful delayed pneumothorax requiring chest tube replacement was 100% (2/2).ConclusionLung ultrasound can probably predict clinically meaningful delayed pneumothorax after transthoracic needle lung biopsy.

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

Amiodarone-Induced Multi-Systemic Toxicity Involving the Liver, Lungs, Thyroid, and Eyes: A Case Report

ObjectivesAmiodarone is widely used to treat arrhythmia. However, amiodarone is known for its severe toxicity to the liver, lungs, and thyroid. Amiodarone causes liver damage ranging from asymptomatic serum aminotransferase elevation to hepatic failure requiring liver transplantation. Although amiodarone toxicity has been reported, its simultaneous multi-organ toxicity is not well-known. Here, we introduce a novel case of multi-systemic amiodarone toxicity involving the liver, lungs, thyroid, and eyes.Case PresentationA 61-year-old woman visited the emergency room due to general weakness, nausea, visual disturbance, heat intolerance, and a non-productive cough. The patient had been using clopidogrel and amiodarone due to underlying atrial fibrillation. The total level of bilirubin was 0.71 mg/dL, aspartate aminotransferase was 358 U/L, alanine aminotransferase was 177 U/L, and prothrombin time was 27.1 s. Computed tomography showed diffuse increased liver intensity and scattered hyperattenuated nodular consolidations in both lungs. Transthoracic needle lung biopsy revealed fibrinoid interstitial inflammation with atypical change of type II pneumocytes and intra-alveolar foamy macrophages. In addition, the thyroid-stimulating hormone level was <0.008 μIU/mL, and free thyroxine was 4.67 ng/dL. The thyroid scan showed diffuse homogenous intake of technetium-99 m pertechnetate in both thyroid lobes. The ophthalmologic exam detected bilateral symmetrical corneal deposits in a vortex pattern. With these findings, we could diagnose amiodarone-induced hepatic, pulmonary, thyroid, and ophthalmologic toxicity. Liver function was restored after cessation of amiodarone, and thyroid function was normalized with methimazole administration. However, due to aggravated lung consolidations, systemic steroid treatment was administered, and improvement was seen 1 week after, at the follow-up exam. As her symptoms improved, she was discharged with a plan of steroid administration for 3 to 6 months.ConclusionsThis case implies the possibility of multi-systemic amiodarone toxicity. Thus, the toxicity of amiodarone to multiple organs must be monitored. Prompt cessation of the drug should be considered upon diagnosis.

Preoperative percutaneous needle lung biopsy techniques and ipsilateral pleural recurrence in stage I lung cancer.

A recent meta-analysis of individual patient data revealed that preoperative percutaneous transthoracic needle lung biopsy (PTNB) was associated with an increased risk of ipsilateral pleural recurrence in stage I lung cancer. This study aimed to examine whether particular PTNB techniques reduced the risk of pleural recurrence. We retrospectively included 415 consecutive patients with stage I lung cancer who underwent preoperative PTNB and curative resection from 2009 through 2016. Detailed information was collected, including clinical, PTNB technique, radiologic, and pathologic characteristics of lung cancer. Cox regression analyses were performed to identify risk factors for pleural recurrence before and after propensity score matching. The overall follow-up period after PTNB was 62.1 ± 23.0months, and ipsilateral pleural recurrence occurred in 40 patients. Before propensity score matching, age (p = 0.063), microscopic pleural invasion (p = 0.065), and pathologic tumor size (p = 0.016) tended to be associated with pleural recurrence in univariate analyses and subsequently were matched using a propensity score. After propensity score matching, multivariate analysis revealed that ipsilateral pleural recurrence was associated with a larger target size on computed tomography (hazard ratio [HR] = 1.498; 95% CI, 1.506-2.125; p = 0.023) and microscopic lymphatic invasion (HR = 3.526; 95% CI, 1.491-8.341; p = 0.004). However, no PTNB techniques such as needle gauge, biopsy, or pleural passage numbers were associated with a reduced risk of recurrence. No particular PTNB techniques were associated with reduced pleural seeding after PTNB in stage I lung cancer. Regardless of the technique, PTNB needs to be cautiously applied when early lung cancer is suspected, followed by curative treatment. • Age, microscopic pleural invasion, and pathologic tumor size tended to be associated with pleural recurrence in stage I lung cancer before propensity matching. • After propensity matching, pre-biopsy CT target size and microscopic lymphatic invasion were associated with pleural recurrence. • No particular PTNB techniques were associated with reduced pleural seeding in stage I lung cancer before and after propensity matching.

Diagnostic accuracy and complication rate of image-guided percutaneous transthoracic needle lung biopsy for subsolid pulmonary nodules: a systematic review and meta-analysis.

To determine the diagnostic accuracy and complication rate of percutaneous transthoracic needle biopsy (PTNB) for subsolid pulmonary nodules and sources of heterogeneity among reported results. We searched PubMed, EMBASE, and Cochrane libraries (until November 7, 2020) for studies measuring the diagnostic accuracy of PTNB for subsolid pulmonary nodules. Pooled sensitivity and specificity of PTNB were calculated using a bivariate random-effects model. Bivariate meta-regression analyses were performed to identify sources of heterogeneity. Pooled overall and major complication rates were calculated. We included 744 biopsies from 685 patients (12 studies). The pooled sensitivity and specificity of PTNB for subsolid nodules were 90% (95% confidence interval [CI]: 85-94%) and 99% (95% CI: 92-100%), respectively. Mean age above 65 years was the only covariate significantly associated with higher sensitivity (93% vs 85%, p = 0.04). Core needle biopsy showed marginally higher sensitivity than fine-needle aspiration (93% vs 83%, p = 0.07). Pooled overall and major complication rate of PTNB were 43% (95% CI: 25-62%) and 0.1% (95% CI: 0-0.4%), respectively. Major complication rate was not different between fine-needle aspiration and core needle biopsy groups (p = 0.25). PTNB had acceptable performance and a low major complication rate in diagnosing subsolid pulmonary nodules. The only significant source of heterogeneity in reported sensitivities was a mean age above 65 years. This is the first meta-analysis attempting to systemically determine the cause of heterogeneity in the diagnostic accuracy and complication rate of PTNB for subsolid pulmonary nodules.

Accuracy and complications of percutaneous transthoracic needle lung biopsy for the diagnosis of malignancy in patients with idiopathic pulmonary fibrosis.

To determine the accuracy of CT-guided percutaneous transthoracic needle lung biopsy (PTNB) for the diagnosis of malignancy and the associated complication rates in patients with idiopathic pulmonary fibrosis (IPF). This retrospective study included 91 CT-guided PTNBs performed in 80 patients with IPF from April 2003 through December 2016. Data regarding patients, target lesions, procedures, complications, and pathological reports were collected, and the final diagnosis was made. The diagnostic accuracy, sensitivity, specificity, percentage of nondiagnostic results, and complication rates were determined. Multivariable logistic regression analyses were performed to identify risk factors for nondiagnostic results and major complications. Three biopsies (technical failure [n = 2] and undetermined final diagnosis [n = 1]) were excluded from the diagnostic accuracy calculation. The diagnostic accuracy, sensitivity, and specificity were 89% (78/88), 90% (62/69), and 84% (16/19), respectively. The percentage of nondiagnostic results was 34% (30/88). Lesion size ≤ 3 cm (odds ratio [OR], 8.8; 95% confidence interval [CI], 2.5-31.2; p = 0.001) and needle tip placement outside the target lesion (OR, 13.7; 95% CI, 1.4-132.2; p = 0.02) were risk factors for nondiagnostic results. The overall and major complication rates were 51% (46/91) and 12% (11/91), respectively. The presence of honeycombing along the path of the needle (OR, 11.2; 95% CI, 1.4-89.1; p = 0.02) was an independent risk factor for major complications. CT-guided PTNB shows a relatively reasonable accuracy in diagnosing malignancy in patients with IPF. The complication rate may be high, especially when the needle passes through honeycomb lesions. • In patients with idiopathic pulmonary fibrosis (IPF), CT-guided percutaneous transthoracic needle lung biopsy (PTNB) showed a relativelyreasonable accuracy for the diagnosis of malignancy. • Target lesion size ≤ 3 cm and biopsy needle tip placement outside the target lesion were risk factors for nondiagnostic results of CT-guided PTNB. • The complication rate may be high, especially in cases where the biopsy needle passes through honeycomb lesions.

Development of a risk prediction model of pneumothorax in percutaneous computed tomography guided transthoracic needle lung biopsy

To retrospectively evaluate the incidence of and the risk factors for pneumothorax and intercostal catheter insertion (ICC) after CT-guided lung biopsy and to generate a risk prediction model for developing a pneumothorax and requiring an ICC. 255 CT-guided lung biopsies performed for 249 lesions in 249 patients from August 2014 to August 2019 were retrospectively analysed using multivariate logistic regression analysis. Risk prediction models were established using backward stepwise variable selection and likelihood ratio tests and were internally validated using split-sample methods. The overall incidence of pneumothorax was 30.2% (77/255). ICC insertion was required for 8.32% (21/255) of all procedures. The significant independent risk factors for pneumothorax were lesions not in contact with pleura (P<0.001), a shorter skin-to-pleura distance (P=0.01), the needle crossing a fissure (P=0.004) and emphysema (P=0.01); those for ICC insertion for pneumothorax were a needle through emphysema (P<0.001) and lesions in the upper lobe (P=0.017). AUC of the predictive models for pneumothorax and ICC insertion were 0.800 (95% CI: 0.745-0.856) and 0.859 (95% CI: 0.779-0.939) respectively. Upon internal validation, AUC of the testing sets of pneumothorax and ICC insertion were 0.769 and 0.822 on average respectively. The complication rates of pneumothorax and ICC insertion after CT-guided lung biopsy at our institution are comparable to results from previously reported studies. This study provides highly accurate risk prediction models of pneumothorax and ICC insertion for patients undergoing CT-guided lung biopsies.

Pleural recurrence after transthoracic needle lung biopsy in stage I lung cancer: a systematic review and individual patient-level meta-analysis

IntroductionConflicting results exist regarding whether preoperative transthoracic biopsy increases the risk of pleural recurrence in early lung cancer. We conducted a systematic, patient-level meta-analysis to evaluate the risk of pleural...

Cone-Beam CT-Guided Percutaneous Transthoracic Needle Lung Biopsy of Juxtaphrenic Lesions: Diagnostic Accuracy and Complications.

ObjectiveTo investigate the diagnostic accuracy and complications of cone-beam CT-guided percutaneous transthoracic needle biopsy (PTNB) of juxtaphrenic lesions and identify the risk factors for diagnostic failure and complications.Materials and MethodsIn total, 336 PTNB procedures for lung lesions (mean size ± standard deviation [SD], 4.3 ± 2.3 cm) abutting the diaphragm in 326 patients (189 male and 137 female; mean age ± SD, 65.2 ± 11.4 years) performed between January 2010 and December 2014 were included. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the PTNB procedures for the diagnosis of malignancy were measured based on the intention-to-diagnose principle. The risk factors for diagnostic failures and complications were evaluated using logistic regression analysis.ResultsThe accuracy, sensitivity, specificity, PPV, and NPV were 92.7% (293/316), 91.3% (219/240), 91.4% (74/81), 96.9% (219/226), and 77.9% (74/95), respectively. There were 23 diagnostic failures (7.3%), and lesion sizes ≤ 2 cm (p = 0.045) were the only significant risk factors for diagnostic failure. Complications occurred in 98 cases (29.2%), including 89 cases of pneumothorax (26.5%) and 7 cases of hemoptysis (2.1%). The multivariable analysis showed that old age (> 65 years) (p = 0.002), lesion size of ≤ 2 cm (p = 0.003), emphysema (p = 0.006), and distance from the pleura to the target lesion (> 2 cm) (p = 0.010) were significant risk factors for complications.ConclusionThe diagnostic accuracy of cone-beam CT-guided PTNB of juxtaphrenic lesions for malignancy was fairly high, and the target lesion size was the only significant predictor of diagnostic failure. Complications of cone-beam CT-guided PTNB of juxtaphrenic lesions occurred at a reasonable rate.

Hemoptysis complicating ultrasound-guided transthoracic needle lung biopsy: air bronchial sign is a risk predictor.

BackgroundHemoptysis is the most frequently reported complication of ultrasound-guided transthoracic needle lung biopsy (US-TTLB). However, factors influencing the occurrence of hemoptysis as a result of US-TTLB remain uncertain. Therefore, the aim of this study was to evaluate the incidence of hemoptysis as a complication of US-TTLB and to identify the related risk factors.MethodsWe retrospectively analyzed all data of patients who underwent US-TTLB from February 2013 through December 2016. The incidence, severity, and treatment of hemoptysis in each case were carefully recorded. Study variables were classified into patient-related factors (age, sex, smoking history, pulse oxygen saturation, laboratory tests and emphysema), biopsy-related factors (use of contrast agent, number of punctures and operators), and lesion-related factors (lesion location, size, pathology, length of puncture path and the grade of air bronchial sign). Univariate and multivariate logistic regression analyses were performed to analyze the risk factors of hemoptysis. We investigated whether incidence of hemoptysis increased according to increased grade of air bronchial sign by Mantel-Haenszel test.ResultsA total of 209 patients were evaluated. Hemoptysis occurred in 20 of the 209 patients (9.6%). In univariate analysis, the lesion pathology (P=0.037) and grade of air bronchial sign (P<0.001) were statistically significant factors between the hemoptysis group and the non-hemoptysis group. In multivariate analysis, the presence of multi-air bronchogram in sonographic image (odds ratio =8.946; 95% confidence interval: 2.873–27.863; P<0.001) was a statistically significant predictive risk factor for hemoptysis complicating US-TTLB. There was a significant tendency for incidence of hemoptysis with the grade of air bronchial sign (P<0.001).ConclusionsWe found that the rate of hemoptysis complicating US-TTLB was 9.6% and the severity of hemoptysis was not serious. Target lesion without air bronchogram is a safety sign, minor bronchogram means relatively low-risk, while multiple bronchogram is a highly dangerous ultrasound sign of hemoptysis.

CT-guided transthoracic core needle lung biopsy: diagnostic efficacy and complication rates

Amaç: Bu çalışmanın amacı bilgisayarlı tomografi (BT) kılavuzluğunda transtorasik akciğer kesici iğne biyopsilerinin tanısal etkinliğini ve komplikasyon oranlarını göstermektir.Materyal ve metod: Çalışmaya BT kılavuzluğunda transtorasik kesici iğne akciğer biyopsisi yapılan 50 hastanın 50 akciğer lezyonu dahil edildi. Hastaların 31̍ i erkek 19̍ u kadın ve yaş ortalaması 58,16 idi. Akciğer lezyonlarının yerleşimi, boyutu, morfolojik yapısı ve geçilen akciğer parankim uzunluğu, histopatolojik sonuçlar ve komplikasyon oranları elde edildi.Bulgular: Biyopsi sonucu 50 lezyonun 46 tanesinde tanısal sonuç elde edildi. Dört hastada alınan biyopsi materyali yetersiz bulundu. Tanısal sonuç elde edilen 46 lezyonun 30 ̍ unda malign bulgular, 16̍ sında benign bulgular elde edildi. İşlem sırasında ve sonrasında üç hastada pnömotoraks, dört hastada hemoraji ve üç hastada pnömotoraks ve hemoraji birlikte gelişti.Sonuç: BT kılavuzluğunda transtorasik kesici iğne akciğer biyopsisi güvenli ve akciğer lezyonlarının tanısında etkin bir yöntemdir. Anahtar Kelimeler: Bilgisayarlı tomografi, akciğer lezyonu, akciğer biyopsisiAmaç: Bu çalışmanın amacı bilgisayarlı tomografi (BT) kılavuzluğunda transtorasik akciğer kesici iğne biyopsilerinin tanısal etkinliğini ve komplikasyon oranlarını göstermektir. Materyal ve metod: Çalışmaya BT kılavuzluğunda transtorasik kesici iğne akciğer biyopsisi yapılan 50 hastanın 50 akciğer lezyonu dahil edildi. Hastaların 31̍ i erkek 19̍ u kadın ve yaş ortalaması 58,16 idi. Akciğer lezyonlarının yerleşimi, boyutu, morfolojik yapısı ve geçilen akciğer parankim uzunluğu, histopatolojik sonuçlar ve komplikasyon oranları elde edildi. Bulgular: Biyopsi sonucu 50 lezyonun 46 tanesinde tanısal sonuç elde edildi. Dört hastada alınan biyopsi materyali yetersiz bulundu. Tanısal sonuç elde edilen 46 lezyonun 30 ̍ unda malign bulgular, 16̍ sında benign bulgular elde edildi. İşlem sırasında ve sonrasında üç hastada pnömotoraks, dört hastada hemoraji ve üç hastada pnömotoraks ve hemoraji birlikte gelişti. Sonuç: BT kılavuzluğunda transtorasik kesici iğne akciğer biyopsisi güvenli ve akciğer lezyonlarının tanısında etkin bir yöntemdir. Anahtar Kelimeler: Bilgisayarlı tomografi, akciğer lezyonu, akciğer biyopsisi

Stroke after lung biopsy

A 69-year-old man presented with a reduced level of consciousness and left hemiparesis immediately after a percutaneous CT-guided transthoracic needle lung biopsy, performed to investigate an interstitial pulmonary disease. CT...

SC13.03 Limitation by COPD for Diagnostic Procedures

Limitation by COPD for Diagnostic Procedures Ostoros, Gy. Varga, J. and Kerpel-Fronius A. National “Korányi” Institute for Pulmonology Hungary, Budapest Lung cancer and COPD are smoking dependent diseases. Smoking cessation is crucial before and during the diagnostic procedures because of the consequences of smoking (e.g. sputum retention, mucociliary dysfunction and potential other more serious complications after the procedures). Severe obstructive or restrictive pulmonary disorders limit the diagnostic possibilities in patients with malignant pulmonary diseases. The screening of lung cancer with low-dose CT has become the gold standard in the past decade. The two imaging-based phenotypes of COPD can be well distinguished by this technique. CT screening can also help to identify non-diagnosed emphysema patients and may lead to early treatment of the disease. It has been showed that non-smoker emphysema patients have a similar risk of lung cancer as smokers with emphysema. Thus, patients with emphysema may be an eligible subgroup for a more intensive lung cancer screening program. However, once a suspicious lesion is found severe COPD, it can limit the choices available for differential diagnosis seriously - CT guided lung biopsies in COPD patients carry a higher risk of hemorrhage and pneumothorax. Patients with severe COPD and respiratory failure with decreased oxygen saturation limit the indication of diagnostic bronchoscopic procedures as well. The examination of exhaled breath condensate (EBC) is a noninvasive process. There are efforts to discriminate lung cancer and COPD with EBC. Lung tumors have influence on lung function. Besides the severity of COPD, the result of the lung function test (LFT) depends on the size and position of the pulmonary tumor as well. In the case of a big central tumor or a huge amount of pleural fluid, the LFT will show rather restrictive than obstructive character. A small peripheral malignancy will not change the shape and volume of the LFT. If the tumor is in the trachea or compresses it's wall, the inspiratory phase of the flow-volume chart could be flat. Sometimes the lung tumors could lead a misdiagnosis of COPD. A centrally located small tumor which is not visible on the chest X-ray but compresses the trachea or any of the pulmonary vessels can cause breathlessness, fatigue and decreased oxygen saturation. A mediastinal conglomerate of lymph nodes can cause similar symptoms. Low physical activity, obesity, smoking and comorbidities are significant negative factors for risk stratification before any pulmonary diagnostic procedure as well. Pulmonary rehabilitation can improve functional reserves if functional capacity is at borderline. Pulmonary rehabilitation has positive effect on cardiovascular function, metabolism, muscle-function and lung mechanics. As for lung function parameters, we need to focus on forced expiratory volume in one second (FEV1) and diffusion capacity (DLCO). We can follow the common agreement of minimum criteria of the European Society of Chest Surgeon and European Respiratory Society for risk stratification before a diagnostic pleuroscopy. Based on this protocol, FEV1 and DLCO need to be >35%pred. In the case of 35%pred< FEV1 and DLCO<75%pred, we need to consider VO2/kg during a cardiopulmonary exercise test. If VO2 is <10 ml/kg/min, the patient need a pulmonary rehabilitation program to improve functional reserves. Regarding lung function, we need to focus on lung mechanics and lung kinematics as well. Lung mechanics can be monitored by resting functional reserve capacity (FRC) and residual volume (RV). Lung kinematics can be monitored by chest expansion. Improved resting or dynamic hyperinflation and lung kinematics of the patients with chest physiotherapy and complex pulmonary rehabilitation is also suggested. As a general effect of rehabilitation, training programs can improve the cardiovascular response, oxygen uptake and the metabolism. We may also focus on physical activity, which is a general prognostics marker. Physical activity can be monitored by pedometer. Obesity can influence the complications of the surgical procedure and it has some effect on lung mechanics as well. If we have time, in case of an obese patient we may also consider improving their body composition before the invasive procedure. To sum up, comorbidities have to be considered before an invasive diagnostic procedure of lung cancer. Patients with impaired pulmonary hemodynamics, ischemic heart disease, diabetes or obesity have to be carefully evaluated. de Torres JP. Casanova C. et al.: Exploring the impact of screening with low-dose CT on lung cancer mortality in mild to moderate COPD patients: A pilot study. Respiratory Medicine, 107, 5, 702-707. 2013. Wiener RS. Schwarcz LM. et al. Population-Based Risk of Complications Following Transthoracic Needle Lung Biopsy of a Pulmonary Nodule. Annals of Internal Medicine, 155, 3, 137-144. 2011. GOLD-www.goldcopd.org Brunelli, A. Charloux, A. et al.: ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients Eur. Resp. J., 34, 1, 2009. diagnosis, copd, lung cancer

Efficacy of a Dehydrated Hydrogel Plug to Reduce Complications Associated With Computed Tomography-guided Percutaneous Transthoracic Needle Biopsy.

The aim of the study was to determine whether a hydrogel plug, when placed in the needle tract after a computed tomography-guided percutaneous transthoracic needle lung biopsy, reduces the rate of complications. This retrospective analysis included biopsies of lung lesions from 200 consecutive patients. The first 100 consecutive biopsies made up the control group, in which no plug intervention was used. The next 100 consecutive biopsies made up the treatment group, in which a hydrogel plug was deployed through a 19-G coaxial needle system after 20-G core samples were obtained. The overall mean age was 64.92 years. No statistically significant differences in patient characteristics and procedure parameters were found between the control and treatment groups except for age (mean age, 62.92 vs. 66.92 y, P=0.022) and procedure duration (mean minutes, 7.81 vs. 6.47 min, P=0.021). The rate of pneumothorax in the control versus treatment group was 31% vs. 29% (P=0.498) and the rate of hemoptysis was 6% vs. 3% (P=0.354). The rate of chest tube insertion after pneumothorax was significantly higher in the control group than in the treatment group (10% vs. 2%, P=0.032) and the average length of hospital stay was longer in the control group (0.44 vs. 0.07 d, P=0.041). The difference was still statistically significant for the chest tube insertion rate (P=0.030) and close to statistically significant for the length of hospital stay (P=0.063), after adjusting for the confounding effect of age and procedure duration. These data show that the deployment of a hydrogel plug after a computed tomography-guided lung biopsy significantly reduced the rate of chest tube insertion along with a reduced length of hospital stay.

Acute Pulmonary Coccidioidomycosis and Review of Published Cases with Lung Involvement in Korea

Coccidioidomycosis is a fungal infection caused by Coccidioides immitis. The endemic area is mostly south-western United States. As increasing in overseas travel to endemic areas, the incidence rate has been recently increased in non-endemic areas. The diagnosis may be delayed in non-endemic area. It is important to elicit traveling histories and to differentiate lung consolidation with eosinophilia, for timely diagnosis of coccidioidomycosis. Recently, we experienced a case with pulmonary coccidioidomycosis in a Korean American who visited Korea showed consolidation in right lower lobe on chest X-ray and prolonged eosinophilia. In the case, a confirmatory diagnostic method was percutaneous transthoracic needle biopsy of lung. We report acute pulomonary coccidioidomycosis case and review previous published reports with pulmonary manifestation in Korea.

Frequency and Severity of Pulmonary Hemorrhage in Patients Undergoing Percutaneous CT-guided Transthoracic Lung Biopsy: Single-Institution Experience of 1175 Cases.

To evaluate the frequency and severity of pulmonary hemorrhage after transthoracic needle lung biopsy (TTLB) and assess possible factors associated with pulmonary hemorrhage. This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Records from 1113 patients who underwent 1175 TTLBs between January 2008 and April 2013 were retrospectively reviewed. Primary outcomes were pulmonary hemorrhage, documented hemoptysis, and bleeding complications necessitating intervention. Pulmonary hemorrhage was graded as follows: 0, none; 1, less than or equal to 2 cm around the needle; 2, more than 2 cm and sublobar; 3, at least lobar; and 4, hemothorax. Patient, technique, and lesion-related variables were evaluated as predictors of pulmonary hemorrhage. Patient-related variables included main pulmonary artery diameter (mPAD) at computed tomography (CT), pulmonary artery pressures at echocardiography and right-sided heart catheterization, medications, chronic lung disease, bleeding diathesis, and immunodeficiency. Technique- and lesion-related variables included needle gauge, number of passes, pleura-needle angle, lesion size and morphologic characteristics, and distance to pleura. Univariate analysis was performed with χ(2), Fisher exact, and Student t tests. Pulmonary hemorrhage occurred in 483 of the 1175 TTLBs (41.1%); hemoptysis was documented in 21 of the 1175 TTLBs (1.8%). Higher-grade hemorrhage (grade 2 or higher) occurred in 201 of the 1175 TTLBs (17.1%); five of the 1175 TTLBs (0.4%) necessitated hemorrhage-related admission. Higher-grade hemorrhage was more likely to occur with female sex (P = .001), older age (P = .003), emphysema (P = .004), coaxial technique (P = .025), nonsubpleural location (P < .001), lesion size of 3 cm or smaller (P < .001), and subsolid lesions (P = .028). Enlarged mPAD at CT (≥2.95 cm) was not significantly associated with higher-grade hemorrhage (P = .430). Pulmonary hemorrhage after TTLB is common but rarely requires intervention. An enlarged mPAD at CT may not be a risk factor for higher-grade hemorrhage.

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

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. 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 -950HU 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. 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. Percent emphysema determined quantitatively from chest CT is a significant predictor of post-NLB pneumothorax.