Japanese Journal of Radiology

, Volume 37, Issue 12, pp 808–816 | Cite as

Perilesional emphysema as a predictor of risk of complications from computed tomography-guided transthoracic lung biopsy

  • Doo Sik Lee
  • So Hyeon BakEmail author
  • Yong Hwan Jeon
  • Sung Ok Kwon
  • Woo Jin Kim
Original Article



This study evaluated whether or not patterns of emphysema and their qualitative and quantitative severity can predict the risk of complications with post-computed tomography (CT)-guided transthoracic lung biopsy (TTLB).

Materials and methods

Three hundred and ninety-seven patients who underwent CT-guided TTLB in 2010–2018 were retrospectively reviewed. The severity of emphysema and presence of perilesional emphysema were assessed visually using the Fleischner Society classification. Ninety seven of the 397 patients underwent quantitative analysis of emphysema. Complications, including pneumothorax, chest tube insertion, and hemorrhage, were assessed by post-TTLB CT and radiographic imaging. The grade of hemorrhage was categorized into three groups. Independent risk factors for pneumothorax and hemorrhage were assessed by univariate and multivariate logistic regression analyses.


Pneumothorax occurred in 48.6% of cases and hemorrhage in 70.5%. Perilesional emphysema was significantly associated with pneumothorax (odds ratio 6.720; 95% confidence interval 3.265–13.831, p < 0.001) and hemorrhage (odds ratio 3.877; 95% confidence interval 1.796–8.367; p = 0.001). The severity of visual and quantitative emphysema was not a significant risk factor for pneumothorax or hemorrhage (p > 0.05). Perilesional emphysema was significantly associated with the grade of hemorrhage (p < 0.001).


Perilesional emphysema can estimate the risk of iatrogenic complications from CT-guided TTLB.


Emphysema Biopsy Pneumothorax Hemorrhage 



This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF 2018R1D1A1B07049670).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics statement

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

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11604_2019_880_MOESM5_ESM.docx (19 kb)
Supplementary material 5(DOCX 20 kb)


  1. 1.
    Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395–409.CrossRefGoogle Scholar
  2. 2.
    Young RP, Hopkins RJ. Chronic obstructive pulmonary disease (COPD) and lung cancer screening. Transl Lung Cancer Res. 2018;7:347–60.CrossRefGoogle Scholar
  3. 3.
    Wiener RS, Wiener DC, Gould MK. Risks of transthoracic needle biopsy: how high? Clin Pulm Med. 2013;20:29–35.CrossRefGoogle Scholar
  4. 4.
    Jo Y, Han DH, Beck KS, Park JS, Kim TJ. Practice pattern of transthoracic needle biopsy: 2016 survey in the members of korean society of thoracic radiology. Korean J Radiol. 2017;18:1005–111.CrossRefGoogle Scholar
  5. 5.
    Tai R, Dunne RM, Trotman-Dickenson B, Jacobson FL, Madan R, Kumamaru KK, et al. Frequency and severity of pulmonary hemorrhage in patients undergoing percutaneous CT-guided transthoracic lung biopsy: single-institution experience of 1175 cases. Radiology. 2015;279:287–96.CrossRefGoogle Scholar
  6. 6.
    Sharma A, Shepard JO. Lung cancer biopsies. Radiol Clin North Am. 2018;56:377–90.CrossRefGoogle Scholar
  7. 7.
    Young RP, Hopkins RJ, Christmas T, Black PN, Metcalf P, Gamble GD. COPD prevalence is increased in lung cancer, independent of age, sex and smoking history. Eur Respir J. 2009;34:380–6.CrossRefGoogle Scholar
  8. 8.
    Cho YH, Seo JB, Lee SM, Choe J, Lee D, Kim N. Quantitative CT imaging in chronic obstructive pulmonary disease: review of current status and future challenges. J Korean Soc Radiol. 2018;78:1–12.CrossRefGoogle Scholar
  9. 9.
    Mouronte-Roibas C, Leiro-Fernandez V, Fernandez-Villar A, Botana-Rial M, Ramos-Hernandez C, Ruano-Ravina A. COPD, emphysema and the onset of lung cancer. A systematic review. Cancer Lett. 2016;382:240–4.CrossRefGoogle Scholar
  10. 10.
    Gohari A, Haramati LB. Complications of CT scan-guided lung biopsy: lesion size and depth matter. Chest. 2004;126:666–8.CrossRefGoogle Scholar
  11. 11.
    Anzidei M, Porfiri A, Andrani F, Di Martino M, Saba L, Catalano C, et al. Imaging-guided chest biopsies: techniques and clinical results. Insights Imaging. 2017;8:419–28.CrossRefGoogle Scholar
  12. 12.
    Gevenois PA, de Maertelaer V, De Vuyst P, Zanen J, Yernault JC. Comparison of computed density and macroscopic morphometry in pulmonary emphysema. Am J Respir Crit Care Med. 1995;152:653–7.CrossRefGoogle Scholar
  13. 13.
    Madani A, De Maertelaer V, Zanen J, Gevenois PA. Pulmonary emphysema: radiation dose and section thickness at multidetector CT quantification—comparison with macroscopic and microscopic morphometry. Radiology. 2007;243:250–7.CrossRefGoogle Scholar
  14. 14.
    Martinez CH, Chen YH, Westgate PM, Liu LX, Murray S, Curtis JL, et al. Relationship between quantitative CT metrics and health status and BODE in chronic obstructive pulmonary disease. Thorax. 2012;67:399–406.CrossRefGoogle Scholar
  15. 15.
    Schroeder JD, McKenzie AS, Zach JA, Wilson CG, Curran-Everett D, Stinson DS, et al. Relationships between airflow obstruction and quantitative CT measurements of emphysema, air trapping, and airways in subjects with and without chronic obstructive pulmonary disease. AJR Am J Roentgenol. 2013;201:W460–70.CrossRefGoogle Scholar
  16. 16.
    Lynch DA, Austin JH, Hogg JC, Grenier PA, Kauczor HU, Bankier AA, et al. CT-definable subtypes of chronic obstructive pulmonary disease: a statement of the fleischner society. Radiology. 2015;277:192–205.CrossRefGoogle Scholar
  17. 17.
    Lynch DA, Moore CM, Wilson C, Nevrekar D, Jennermann T, Humphries SM, et al. CT-based visual classification of emphysema: association with mortality in the COPDGene study. Radiology. 2018;288:859–66.CrossRefGoogle Scholar
  18. 18.
    Hsu JS, Han IT, Tsai TH, Lin SF, Jaw TS, Liu GC, et al. Pleural tags on CT scans to predict visceral pleural invasion of non-small cell lung cancer that does not abut the pleura. Radiology. 2016;279:590–6.CrossRefGoogle Scholar
  19. 19.
    Lee SM, Park CM, Lee KH, Bahn YE, Kim JI, Goo JM. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of lung nodules: clinical experience in 1108 patients. Radiology. 2014;271:291–300.CrossRefGoogle Scholar
  20. 20.
    Bhatt SP, Washko GR, Hoffman EA, Newell JD Jr, Bodduluri S, Diaz AA, et al. Imaging advances in chronic obstructive pulmonary disease. Insights from the genetic epidemiology of chronic obstructive pulmonary disease (COPDGene) study. Am J Respir Crit Care Med. 2019;199:286–301.CrossRefGoogle Scholar
  21. 21.
    Zhang HF, Liao MY, Zhu DY, Chen J, Wang YF. Lung radiodensity along the needle passage is a quantitative predictor of pneumothorax after CT-guided percutaneous core needle biopsy. Clin Radiol. 2018;73(319):e1–7.Google Scholar
  22. 22.
    Rivera MP, Detterbeck F, Mehta AC. Diagnosis of lung cancer: the guidelines. Chest. 2003;123:s129–36.CrossRefGoogle Scholar
  23. 23.
    Kazerooni EA, Lim FT, Mikhail A, Martinez FJ. Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung. Radiology. 1996;198:371–5.CrossRefGoogle Scholar
  24. 24.
    Topal U, Ediz B. Transthoracic needle biopsy: factors effecting risk of pneumothorax. Eur J Radiol. 2003;48:263–7.CrossRefGoogle Scholar
  25. 25.
    Cox JE, Chiles C, McManus CM, Aquino SL, Choplin RH. Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax. Radiology. 1999;212:165–8.CrossRefGoogle Scholar
  26. 26.
    Chami HA, Faraj W, Yehia ZA, Badour SA, Sawan P, Rebeiz K, et al. Predictors of pneumothorax after CT-guided transthoracic needle lung biopsy: the role of quantitative CT. Clin Radiol. 2015;70:1382–7.CrossRefGoogle Scholar
  27. 27.
    Lendeckel D, Kromrey ML, Ittermann T, Schafer S, Mensel B, Kuhn JP. Pulmonary emphysema is a predictor of pneumothorax after CT-guided transthoracic pulmonary biopsies of pulmonary nodules. PLoS ONE. 2017;12:e0178078.CrossRefGoogle Scholar
  28. 28.
    Anderson CL, Crespo JC, Lie TH. Risk of pneumothorax not increased by obstructive lung disease in percutaneous needle biopsy. Chest. 1994;105:1705–8.CrossRefGoogle Scholar
  29. 29.
    Asai N, Kawamura Y, Yamazaki I, Sogawa K, Ohkuni Y, O'Uchi T, et al. Is emphysema a risk factor for pneumothorax in CT-guided lung biopsy? Springerplus. 2013;2:196.CrossRefGoogle Scholar
  30. 30.
    Yeow KM, Su IH, Pan KT, Tsay PK, Lui KW, Cheung YC, et al. Risk factors of pneumothorax and bleeding: multivariate analysis of 660 CT-guided coaxial cutting needle lung biopsies. Chest. 2004;126:748–54.CrossRefGoogle Scholar
  31. 31.
    Heyer CM, Reichelt S, Peters SA, Walther JW, Muller KM, Nicolas V. Computed tomography-navigated transthoracic core biopsy of pulmonary lesions: which factors affect diagnostic yield and complication rates? Acad Radiol. 2008;15:1017–26.CrossRefGoogle Scholar
  32. 32.
    Wu CC, Maher MM, Shepard JA. Complications of CT-guided percutaneous needle biopsy of the chest: prevention and management. AJR Am J Roentgenol. 2011;196:W678–82.CrossRefGoogle Scholar
  33. 33.
    Winokur RS, Pua BB, Sullivan BW, Madoff DC. Percutaneous lung biopsy: technique, efficacy, and complications. Semin Intervent Radiol. 2013;30:121–7.CrossRefGoogle Scholar
  34. 34.
    Khan MF, Straub R, Moghaddam SR, Maataoui A, Gurung J, Wagner TOF, et al. Variables affecting the risk of pneumothorax and intrapulmonal hemorrhage in CT-guided transthoracic biopsy. Eur Radiol. 2008;18:1356–63.CrossRefGoogle Scholar
  35. 35.
    Ko JP, Shepard JO, Drucker EA, Aquino SL, Sharma A, Sabloff B, et al. Factors influencing pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture contributing factors? Radiology. 2001;218:491–6.CrossRefGoogle Scholar

Copyright information

© Japan Radiological Society 2019

Authors and Affiliations

  1. 1.Department of Radiology, Kangwon National University HospitalKangwon National University School of MedicineChuncheonRepublic of Korea
  2. 2.Biomedical Research InstituteKangwon National University HospitalChuncheonRepublic of Korea
  3. 3.Department of Internal Medicine and Environmental Health Center, School of MedicineKangwon National UniversityChuncheonRepublic of Korea

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