2nd Eurasian Respiratory and Allergy Summit Eyüp Şenol, MD Atatürk Chest Disease and Thoracic Surgery Training and Research Hospital, Department of Radiology, Ankara, TURKEY 2nd Eurasian Respiratory and Allergy Summit Budva, MONTENEGRO 21-24 September 2017

2nd Eurasian Respiratory and Allergy Summit Factors Affecting the Accuracy of Diagnosis and Complications in Computed Tomography Guided Transthoracic Percutaneous Lung Biopsy 2nd Eurasian Respiratory and Allergy Summit Budva, MONTENEGRO 21-24 September 2017

Introduction Computed Tomography (CT) guided transthoracic lung biopsy (NLB) has been known as a gold standard for diagnosis of lung lesions. Being less invasive, safer, more affordable and quicker than thoracotomy and having accurate diagnosis for the most lesions are the main advantages of this procedure. Besides its advantages NLB has some life-threating complications like pneumothorax and hemothorax.

Introduction Efforts are introduced to increase the patient compliance, comfort and performance of biopsy in order to reduce the complications of NLB and increase the accuracy of diagnosis. We aimed to examine the factors affecting the complications and the accuracy of diagnosis by the CT-guided lung biopsy.

Materials and Methods Within one year period 200 transthoracic co-axial needle biopsy were analyzed retrospectively. Patients who were over 18 years old and eligible with respect to lung capacity, coagulation parameters and vital signs and who had parenhcymal lung lesions were included in this study. 17/18 Gauge co-axial needles were used for one hundred patients and 19/20 Gauge were used for the rest of the other one hundred patients.

Measures Age Gender Co-morbidities Medications Coagulation parameters FEV1/FVC rate Cigarette pack year Used needle type Patient position Chest wall thickness Presence of pleural effusion Lesion size Lesion location Lesion distance from pleura FDG uptake of lesion in PET-CT Entrance angle of needle to pleura Length of intrapulmonal biopsy path Number of pleural needle passes Number of manipulations in needle passages Complications seen due to procedure Length of procedure Histopathologic diagnosis

Results Mean age of the patients was 61,9±10,95 (25-86) 164 (82%) of patients were male, 36 (18%) of patients were female Mean cigarette package year was 42,3 ± 32,4 (0-150) Frequency of co-morbidities; DM n=42 (21%) HT n=65 (33%) CAD n=26 (13%) COLD n=32 (16%) Hypothyroidism n=7 (4%) Psychiatric disease n=6 (3%) BPH n=3 (1,5%) Tuberculosis n=2 (1%) Buerger disease n=3 (1,5%) Non-lung malignancy n=4 (2%)

Results Variables Mean Standard Deviation FEV1/FVC rate 77,7 8,1 Lesion size (mm) 4,8 4,2 Lesion distance from pleura (cm) 1,5 1,8 FDG uptake of lesion in PET-CT 9,5 5,8 Number of pleural needle passes 1,1 0,4 Number of manipluations in needle passages 0,8 Length of procedure (min) 6,7 2,8

Results

Results

Results Factors effecting accuracy of diagnosis U-FDG Mean Standard Deviation Median Min Max p value Malignant* 11.8 5.07 11 3 26 Non-diagnostic 7.5 6.3 6 33 p<0.001 Inflammation 4.2 5 2 17 According to Kruskal-Wallis test; as shown the details in table, FDG uptake of lesion in PET-CT could able to differantiate the diagnosis of malignancy group from inflammation and undiagnosed groups significantly. There was no significant relationship between accuracy of diagnosis and other variables except U-FDG.

Results Complications Pneumothorax occured in 31 of 200 patients (15,5%). Perilesional hemorrhage occured in 83 of 200 patients (41,5%). Hemoptysis occured in 8 of 200 patients (4%). Hypotension occured in 5 of 200 patients (2.5%) and hypertension occured in 1 of 200 patients (0.5%).

Results Pneumothorax Hemorrhage Age p=0.008 p=0,809 Gender p=0,470 Co-morbidities p>0,05 Coagulation parameters FEV1/FVC rate p=0,817 p=0,156 Cigarette pack year p=0,874 p=0,119 Used needle type p=0,171 p=0,952 Patient position p=0,825 p=0,185 Chest Wall thickness p=0,844 p=0,552 Pleural effusion p=0,896 p=0,225

Results Pneumothorax Hemorrhage Lesion size p=0.032 p<0,001 Lesion location p=0,977 p=0,840 Lesion distance from pleura p=0,05 FDG uptake of lesion in PET-CT p=0,404 p=0,011 Entrance angle of needdle to pleura p=0,444 p=0,680 Length of intrapulmonal biopy path p=0,543 p=0,012 Number of pleural needle passes p<0.001 p=0,132 Number of manipulations in needle passages p=0.008 Length of procedure p=0.002 Histopathologic diagnosis p>0.05 p>0,05

Results There were positive correlations between age, lesion distance from pleura, number of pleural needle passes, length of procedure and risk of penumothorax. There was negative correlation between lesion size and risk of pneumothorax. There were positive correlations between lesion distance from pleura, length of intrapulmonal biopsy path, length of procedure, number of manipulations in needle passages and risk of perilesional hemorrhage. There were negative correlations between lesion size, FDG uptake of lesion in PET-CT and risk of hemorrhage.

Results Logistic regression analysis for pneumothorax   One Variable Multiple variables Variables p Exp(B) %95 CI Age 0,016 0,029 1.049 1.005 1.094 Number of pleural needle passes 0,002 0,051 2.893 0.996 8.402 Length of procedure <0.001 0,05 1.142 1 1.305 Our logistic regression model as shown in table found that the age, confers a 1 fold increase risk for the development of pneumothorax complication. Number of pleural needle passes, confers a 2,9 fold increase risk for the development of pneumothorax complication. Length of procedure, confers a 1,1 fold increase risk for the development of pneumothorax complication.

Results Logistic regression analysis for hemorrhage   One Variable Multiple variables Variables p Exp(B) %95 CI Lesion distance from pleura p<0,001 0,009 1.295 1.067 1.570 Lesion size 0,625 0,507 0,772 Length of procedure Number of manipulations in needle passages 0,029 2,484 1,098 5,619 Our logistic regression model as shown in table found that the lesion distance from pleura, confers a 1,3 fold increase risk for the development of hemorrhage complication. Lesion size confers a 1,6 fold decrease risk for the development of hemorrhage complication. Number of manipulations in needle passages, confers a 2,5 fold increase risk for the development of hemorrhage complication.

Conclusion Patient’s age, number of pleural needle passes and length of procedure were posing greatest risks for pneumothorax complication during transthoracic lung biopsy. Lesion distance from pleura, lesion size, number of manipulations in the needle passages were posing greatest risks for hemorrhage. FDG uptake of lesion in PET-CT was the most important factor for accuracy of diagnosis.

Conclusion According to our study results, in order to reduce complications due to transthoracic lung biopsy procedure, we should minimalise the number of pleural needle passes, manipulations in the needle trace and the length of procedure especially for older patients with small lesions which are far from pleura. For detecting the accuracy of the histopathological tissue diagnosis, our study results showed that the malignant lesions can be differantiated from undiagnosed and the inflamation groups by the FDG uptake of lesion in PET-CT.

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