Novel Risk Factors of Pulmonary Hemorrhage Complicating CT-Guided Lung Biopsy in Coaxial Technique View PDF

Diagnostic lung biopsies using coaxial biopsy systems have become a standard procedure in most interventional radiology departments and are associated with comparable diagnostic accuracy to other biopsy systems [1]. Lower rates of pneumothoraces and time reduction have been described with coaxial cutting systems [1].

After pneumothorax, pulmonary hemorrhage is the second most the common complication of needle biopsy of the chest [2,3].

Previous studies have determined subsolid lesions as a risk factor for severe hemoptysis and higher-grade parenchymal hemorrhage [4,5].

Yeow KM, et al. (2004) [2], has stated that the needle size, number of biopsies, pleural puncture site position after a needle biopsy, location of the lung lesions, patient’s age, and emphysema were not associated with an increased risk of parenchymal hemorrhage. Lesion size, lesion depth and pleural effusion have been described as significantly associated with pulmonary hemorrhage [2].

Pneumothoraces and parenchymal hemorrhage have furthermore been described to significantly correlate with lesion sizes ≤ 2 cm and lesion depth [2]. Lesion depth ≥ 2.1 cm correlate to an elevated bleeding risk. Lesion size < 4 cm is strongly correlated with a higher occurrence of perifocal hemorrhage [3].

Considering these variables, the aim of this study was to determine whether the coaxial biopsy technology, patient positioning and lesion dignity are three new risk factors of parenchymal hemorrhage after coaxial biopsies of the lung (Figure 1 to Figure 3).

Regarding pneumothorax, the most common complication after transthoracic lung biopsies, several studies correlated the incidence and severity with patient positioning [6-8]. Other studies correlated inflammatory lesions with higher rates of systemic air embolism [9-11]. The aim of our study was to correlate these variables as potential risk factors for pulmonary parenchymal hemorrhage.

Data Collection

Three radiology physicians with five, six and eight years of experience respectively retrospectively analyzed acquired CT images during the biopsy procedure. The correlating pathological diagnosis of the biopsy specimens, as well as the patient history were acquired through the clinical data collecting system.

Pulmonary hemorrhage was classified according to a grading scheme, ranging from 0 to 3. The presence of parenchymal hemorrhage, consisting of the search for ground-glass opacity and more confluent hemorrhages after biopsy was assessed for each procedure.

The grading scheme was developed and modified according to existing literature [2,4].

Grade 0 was defined as no pulmonary hemorrhage, grade 1 as hemorrhage not overpassing the needle tract in length or width by more than 2.5 cm, grade 2 as hemorrhage more than 2.5 cm in width or length along the needle tract, grade 3 as lobar hemorrhage or greater, including hemothorax (Figure 4 and Figure 5).

A biopsy was registered as successful if enough tissue out of the target lesion was sampled by the biopsy procedure and only the diagnostic specimen was included, as this study did not evaluate the diagnostic accuracy.

Three patient, technique and lesion-related variables were evaluated as predictors of pulmonary hemorrhage. The patient-related variable consisted of patient positioning. The technique-related variable of the type of the coaxial system and the lesion-related variable of the lesion dignity.

Patients and Biopsy Technique

A retrospective analysis of 117 consecutive lung biopsy procedures with different coaxial cutting systems between January 2018 and April 2020, involving patients with a documented pulmonary nodule or mass lesion on previous CT scans has been performed.

The study population included 80 males (68.4 %) and 37 females (31.6 %) aged 28-89 years (mean age 67.6 years). Image-guided procedures with two different co-axial cutting systems (Temno^®, Merit Medical and Achieve^®, Merit Medical) have been performed in 75 (64.1%) patients (Figure 6).

The study includes 42 (35,9%) patients, who underwent a procedure with a co-axial cutting system with full core technology (CorVocet^®, Merit Medical) (Table 1).

Table 1: Patient, tumor, and biopsy system-related characteristics.

Only patients who underwent a biopsy with a 18G biopsy needle were included in this study.

Pathological Analysis of the Specimens

Detailed histological information on the subtype of the neoplasms and the differentiation into benign or malignant lesions were included in the pathology assessment, which was performed routinely in our pathology institute.

In the case, that sufficient material had been obtained for a histopathological analysis to yield a diagnosis of a malignant or benign lesion, the biopsy was defined as diagnostic.

Complications

We reported and classified all early complications during the biopsy procedure in the sense of immediate complications and complications after an observation time of two to four hours after the biopsy procedure using the international standardized and revised SIR (Society of Interventional Radiology) Classification System for Complications by Outcome to differentiate minor from major complications. In our present study we included patients with pulmonary hemorrhage on the interventional and post-interventional CT-scans.

On the other hand, for the registration of eventual other late complications, we reviewed the following hospital history in our electronic patient care software. Other complications, such as pneumothorax were not included in this study.

Our three novel factors related to the patient, target lesion and biopsy procedure were recorded (patient positioning, coaxial biopsy technology and dignity of the lesion).

The classification of hemorrhage degree consisted of two categories: no or small hemorrhage (included degree 0 and 1) and significant hemorrhage (included degree 2 and 3) respectively.

These factors were evaluated in univariate analysis. Considering the statistical outcome of the described previous studies, that showed no correlation between patient age, sex, needle size, number of biopsies, pleural puncture site, position of the needle, location of the lung lesions, patient’s age and emphysema, no further univariate or multivariate analyses including these parameters have been performed [2].

We also considered that it is of limited interest and effectiveness to rank our three variables in subgroups for a multivariate statistical analysis, due to the lack of pre-biopsy diagnosis of a benign or a malignant lesion, so that an adoption of the coaxial biopsy technology is not possible in advance of the intervention. Furthermore, a selective patient positioning is only possible and adaptable in limited cases, due to physical patient restrictions.

These data were recorded in the biopsy data reports by the interventional radiologists and have been retrospectively controlled and evaluated for our retrospective study.

Significant pulmonary hemorrhage, including grade 2 and 3 of our classification system occurred after 47 of the 117 lung biopsy procedures (40.2%). No (grade 0) and no significant hemorrhage (grade 1) occurred in 70 patients (59.8%). Four of the 117 TTLBs (3.4%) resulted in grade 3 hemorrhage, 43 (36.8%) in grade 2 hemorrhage, 39 (33.3%) in grade 1 hemorrhage, and 31 (26.5%) in grade 0 hemorrhage (Table 2).

Table 2: Distribution of significant vs no significant pulmonary hemorrhage.

18 (15.4%) patients who underwent a procedure with cutting coaxial biopsy technology showed a significant parenchymal hemorrhage, whereas 29 (24.8%) patients with full core coaxial technology showed significant hemorrhage on the post-biopsy control scans, versus 57 (48.7%) and 13 (11.1%) patients without significant hemorrhage, respectively. OR=0.1416 (CI: 0.0610-0.3285); p<0.0001.

36 (30.8%) patients with a malignant histological diagnosis showed significant pulmonary hemorrhage, versus 11 (9.4%) patients with a benign histological diagnosis on the post-biopsy specimen. 44 (37.6%) patients with a malignant process had no significant hemorrhage versus 26 (22.2%) patients with a benign diagnosis. OR=1.9339 (CI: 0.8422-4.4407); p=0.1199.

In the third evaluated category, 29 (24.8%) patients in prone or lateral position during the biopsy procedure showed significant post-biopsy pulmonary hemorrhage, versus 18 (15.4%) patients in supine position. No significant parenchymal hemorrhage was observed in 40 (34.1%) patients in prone/lateral position and 30 (25.7%) patients in supine position, respectively. OR=1.2083 (CI: 0.5679-2.5708); p= 0.6232.

One patient in the category of grade 3 hemorrhage required bronchoscopy. The remaining three patients with grade 3 hemorrhage did not require additional interventions.

The registration of late complications in our electronic patient care software and on the imaging performed in the week after the lung biopsy showed no worsening further parenchymal hemorrhage or major hemorrhage-related complication.

Widely established protocols for a safe and successful lung biopsy with coaxial biopsy systems have been described [12]. The choice between the different coaxial biopsy systems depends upon personal selection criteria, without a complete and exhaustive scientific-based availability of risk analysis. The rapidly evolving market of biopsy technologies offers a wide range of coaxial biopsy systems in particular.

Novel risk factors for pneumothoraces, including patient positioning and needle paths through atelectasis have been determined [13-15].

However, considering the second most common complication after lung biopsies, notably parenchymal hemorrhage, none of our three studied criteria (dignity of the lesion, coxial biopsy technology and patient positioning) has been paid closer attention to in literature.

The incidence of postprocedural pneumothoraces in our study correlates very well with other studies (24%) [2,3, and 16].

Pulmonary hemorrhage was described as having a potential preventive effect on the development of pneumothorax through a sealing effect in the biopsy path [17]. Other factors have been studied to reduce air leak after removal of the needle using blood-patches and injection of tissue adhesives through the needle tract [18-21].

Three novel risk factors of parenchymal pulmonary hemorrhage have been evaluated in patients following a coaxial lung biopsy and further studies with larger patient populations allowing an additional multivariate analysis are necessary to determine whether or not patient positioning and lesion dignity can be definitely excluded as a risk factor for pulmonary hemorrhage following percutaneous lung biopsies. However, the interest and consequences of such a study are limited, due to the fact that lesion dignity can only be conclusively evaluated after histological examination. Patient positioning may also be biased by the physical condition of the patients. The higher incidence and severity of pulmonary hemorrhage in lung biopsy, after the use of a coaxial technique with full core technology, could be explained by the more powerful and eventually more tissue damaging shot of these systems.

In conclusion, a statistically significant relation exists between the incidence, as well as the severity of pulmonary hemorrhage and the coaxial biopsy technology used. Coaxial biopsy techniques with full core technology seem to be more tissue damaging than conventional cutting systems. No significant correlation between parenchymal pulmonary hemorrhage and patient positioning or lesion dignity was established in this prognostic study.

Brönnimann MP and Schroeder C were involved in the conception of the study, diagnostic work-up, data collection and manuscript writing.

Loebelenz LI and Kim SY assisted with the data collection and manuscript writing.

Noeldge G reviewed the manuscript and was involved in the conception of the study.

The authors declare that they have no competing interests.

No.

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