AIM: Pneumothorax common after pulmonary nodule biopsy
Transthoracic needle lung biopsy (CT-guided biopsy) was complicated by pneumothorax in 15 percent of cases, according to a study published Aug. 1 in Annals of Internal Medicine. The findings of fairly common complications led the authors to call for physicians to present patients with more information about the risks and benefits of pulmonary nodule biopsy.

Every year, several 100,000 patients in the U.S. are diagnosed with a pulmonary nodule and must decide whether or not to have the nodule biopsied.

In some cases, the invasive biopsy leads to complications. However, estimates of complications are based on single-site case studies and highly variable.

To better gauge the risks, the authors devised a population-based risk estimate for complications after transthoracic needle biopsy. The study entailed a cross-sectional analysis of discharge records for four states: New York, Florida, California and Michigan in 2006, which comprised 15,865 patients.

Pneumothorax occurred in 15 percent of cases, pneumothorax severe enough to require a chest tube occurred in 6.6 percent and hemorrhage occurred in 1 percent, wrote Renda Soylemez Wiener, MD, MPH, of the Pulmonary Center at Boston University School of Medicine, and colleagues. Pneumothorax requires serial imaging and hospitalization for an average of two to five days, they noted.

Patients with complications were hospitalized more often (from the outpatient setting) or had longer lengths of stay (from the inpatient setting) than patients without complications, the authors said.

Factors significantly associated with hemorrhage were age 60 to 69 years, female sex and comorbid pulmonary disease. Similarly, age 60 to 69 years, tobacco use and chronic obstructive pulmonary disease were associated with higher rates of pneumothorax and pneumothorax requiring a chest tube.

The researchers acknowledged several shortcomings of the study. Specifically, data are de-identified in the administrative databases and do not provide information about the biopsy findings or the procedure risks and benefits. In addition, minor complications may be undercoded, said the researchers. The databases also omit clinical variables such as nodule size and location and physician characteristics.

Soylemez Wiener et al also noted variations in biopsy use rates among states, from a high of 36.2 per 100,000 adults in Florida to a low of 14.7 per 100,000 adults in New York. “The striking variation in rates of biopsy use between states suggests a lack of consensus on optimal management of pulmonary nodules, which reflects a lack of evidence in this area,” they wrote.

The researchers observed that more patients and physicians will need to make decisions about lung nodule management in the wake of the National Lung Screening Trial.

“For many patients, including those with a low risk for cancer, those who are too frail to undergo cancer treatment or those with a high risk for cancer who should proceed directly to surgery, this procedure may be unnecessary. Before exposing patients to potential harm from CT-guided biopsy, physicians must ensure that patients understand the risks,” said Soylemez Wiener and colleagues. The population-based estimates produced in the study may help inform such decisions.