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BACKGROUND. CT-guided percutaneous transthoracic needle biopsy (PTNB) is widely used for evaluation of indeterminate pulmonary lesions, although guidelines are lacking regarding the experience need...

BACKGROUND: A percutaneous transthoracic needle biopsy (PTNB) is performed to obtain tissue for a pathologic diagnosis. A PTNB is necessary prior to the initiation of many cancer treatments. There is a risk of hemoptysis, the expectoration of blood, with the possibility for adverse, life-threatening outcomes. A critical event checklist is a cognitive aid used in an emergency to ensure critical steps are followed. To date, there are no known checklists published for management of PTNB-related, life-threatening hemoptysis. The purpose of this report is to describe the development and implementation of a critical event checklist and the adoption of the checklist into hemoptysis management. METHODS: In March 2017, a process improvement team convened to evaluate the hemoptysis response using the Plan-Do-Study-Act (PDSA) methodology. The checklist was evaluated and updated through September 2019. The team educated Interventional Radiology (IR) clinicians on the new checklist and conducted simulations on its use. A retrospective chart review was performed on hemoptysis events between the ten-year period of October 1, 2008 and September 30, 2018 to evaluate the adoption of the checklist into practice. RESULTS: There were 231 hemoptysis events occurring in 229 patients (2 with repeat biopsies). Prior to implementing the protocol and checklist, there were 166 (71.9%) hemoptysis events. After implementation there were 65 (28.1%) events. The median amount of documented blood expectorated with hemoptysis was 100 mL (IQR 20.0–300.0). Twenty-six patients were admitted after PTNB for reasons related to the hemoptysis event (11.3%). During the procedure, four (1.7%) patients with hemoptysis suffered a cardiac arrest. Prior to implementation of the protocol and critical events checklist, nurses positioned patients in the lateral decubitus (LD) position in 40 out of 162 (24.7%) cases. After implementation of the critical events checklist, nurses positioned patients in the LD position 42 out of 65 cases (64.6%) (OR=5.57(95% CI 2.99–10.367), p

Objective To investigate the value of application of low-dose and optimized length CT scan on puncture results, complications and patients’ radiation dosage during CT-guided percutaneous biopsy of pulmonary nodules (PTNB). Methods A total of 231 patients with PTNB under CT guidance were collected. Low dose scanning utilized tube current of 20 mA as compared with 40 mA in conventional dosage. Optimized length in CT is defined as intentionally narrowing the range of CT scanning just to cover 25 mm (5 layers) around the target layer during needle adjustment. According to whether low-dose scans and optimized length scans techniques were utilized, patients were divided into three groups: conventional group (conventional sequence + no optimization), optimized length group (conventional sequence + optimized length), and low-dose optimized length group (low dose sequence + optimized length). The ED (effective dose), the DLP (dose length product), the average CTDIvol (Volume CT dose index), total milliampere second between subgroups were compared. Results Compared with the conventional group, ED, intraoperative guidance DLP, total milliseconds and operation time in the optimized length group were reduced by 18.2% (P=0.01), 37% (P=0.003), 17.5% (P=0.013) and 13.3% (P=0.021) respectively. Compared with the optimized length group, the ED was reduced by 87%, preoperative positioning, intraoperative guidance and postoperative review DLP were also reduced by 88%, total milliampere second was reduced by 79%, with an average CTDIvol was reduced by 86%, in the low-dose optimized length group (P Conclusion Optimizing the length during CT scanning can effectively reduce the intraoperative radiation dose and reduce the operation time compared with conventional plan; low-dose and optimized length CT scan can further reduce the total radiation dose compared with optimized length group with no differences on intraoperative complications, biopsy results and operation time.

BACKGROUND:Although transthoracic needle biopsy (TTNB) is an effective method for diagnosis of lung tumors, it has some complications. It is crucial to know the frequency and severity of the complications of TTNB and its risk factors in order to avoid them.OBJECTIVES:Evaluate the complications and risk factors of computed tomography guided core needle lung biopsies (CT-CNLB).DESIGN:Prospective evaluation of complications.SETTING:Single center in Turkey.PATIENTS AND METHODS:For CT-CNLBs performed between October 2017 and March 2018, the complications of biopsies were noted and classified as major and minor based on guidelines of the Society of Interventional Radiology.MAIN OUTCOME MEASURES:The complications and risk factors for complications were evaluated.SAMPLE SIZE:123 adult patients.RESULTS:The most common complications were pulmonary hemorrhage (30.9%) and pneumothorax (22%). Increased overall pulmonary hemorrhage was observed with underlying emphysema (P=.022), non-peripheral location of the lesion (PPP=.011), increased number of pleura penetrations (P=.024), prolonged needle time across pleura (P=.037), and decreased lesion size (P=.033). The pneumothorax rate increased with non-peripheral location of the lesion (PP=.021), prolonged needle time across the pleura (P=.013), and decreased lesion size (P=.002). In the logistic regression analyses for he two most common complications, the only risk factor for both alveolar hemorrhage and pneumothorax was a non-peripheral location of the lesion (PP=.001, OR=156.2, 95% CI =7.34–3324.7 for pneumothorax).CONCLUSION:Most common complications of CT-CNLB were pneumothorax and pulmonary alveolar hemorrhage with a 5.7% major complication rate. Choosing the shortest possible trans-pulmonary needle pathway minimizes the risk of complications.LIMITATIONS:Limited number of patients, absence of rare complications as death, air embolism, and needle tract seeding.CONFLICT OF INTEREST:None.

Percutaneous computed tomography (CT)-guided transthoracic needle biopsy (TTNB) is a valuable procedure for obtaining tissue or cells for diagnosis, which is especially indispensable in thoracic oncology. Pneumothorax and hemoptysis are the most common complications of percutaneous needle biopsy of the lung. According to reports published over the past decades, pneumothorax incidence in patients who underwent TTNB greatly varies. The morbidity of pneumothorax after CT-guided TTNB depends on several factors, including size and depth of lesions, emphysema, the number of pleural surfaces and fissure crossed, etc. Attention to biopsy planning and technique and post-biopsy precautions help to prevent or minimize potential complications. Many measures can be taken to help prevent the progression of a pneumothorax, which in turn might reduce the number of pneumothoraces requiring chest tube placement. A multitude of therapeutic options is available for the treatment of pneumothorax, varying from observation and oxygen treatment, simple manual aspiration, to chest tube placement. When a pneumothorax develops during the biopsy procedure, it can be manually aspirated after the needle is retracted back into the pleural space or by inserting a separate needle into the pleural space. Biopsy side down positioning of the patient after biopsy significantly reduces the incidence of pneumothorax and the requirement of chest tube placement. Aspiration in biopsy side down position is also recommended for treating pneumothorax when simple manual aspiration is unsuccessful or delayed pneumothorax occurred. Chest tube placement is an important treatment strategy for patients with a large or symptomatic pneumothorax. Clinicians are encouraged to understand the development, prevention, and treatment of pneumothorax. Efforts should be made to reduce the incidence of pneumothorax in biopsy planning and post-biopsy precautions. When pneumothorax occurs, appropriate treatment should be adopted to reduce the risk of worsening pneumothorax.

Pulmonary epithelioid hemangioendothelioma is a rare vascular tumor and infrequently described in medical literature as case reports and case series. Diagnosis is often incidental with high index of histopathological suspicion from clinical pathologist. The pathological pattern is quite unique with distinct immunohistochemical stains. Up to this day, there is no established standard treatment owing to the scarcity of this tumor. In this case report, we describe a case of pulmonary epithelioid hemangioendothelioma unexpectedly diagnosed with transthoracic needle biopsy, along with a review of the current literature.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: does percutaneous transthoracic needle biopsy (PTNB) increase the risk of pleural recurrence in patients with stage I lung cancer? Altogether, 298 papers were found using the reported search, of which 7 cohort studies and 1 meta-analysis represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Four cohort studies suggested an association between PTNB and pleural recurrence in patients with stage I lung cancer, while the other 3 cohort studies found that PTNB had no impact. One meta-analysis (the largest study) including 5 of the cohort studies above concluded that PTNB increased the risk of pleural recurrence among patients with stage I lung cancer with subpleural lesions. Based on the available evidence, it was suggested that there may be an association between PTNB and pleural recurrence in patients with stage I lung cancer, especially for patients with subpleural lesion.

Background Transthoracic needle biopsy is a well-established technique for diagnosing pulmonary lesions. Computed tomography (CT) is usually used as guidance. Ultrasound (US)-guided biopsy is a relatively affordable modality for diagnosis of peripheral lung lesions (PLLs; also known as peripheral pulmonary lesions [PPLs]) and peripheral pleural lesions. Objectives The purpose of this study was to study the diagnostic yield of US guidance sampling a consecutive series of peripheral lung and pleural lesions and potential factors influencing the diagnostic yield with recording the occurrence of any complications. Patients and Methods This was a prospective study that was conducted at Ain Shams University Hospitals upon a population of 60 patients, during the period from September 2018 to August 2019. A special puncture transducer is used to perform US-guided biopsy with visualization of the biopsy needle and the lesion; facilitating the sampling procedure. Results The use of US-guided transthoracic needle biopsies across 60 patients was shown to have a yield of 75% which found the occurrence of 45 conclusive and 15 non-conclusive results From this study population, 70% (n = 42/45) were found to have malignant manifestations, of which 26 were undifferentiated high grade adenocarcinoma, and 9 were moderately differentiated adenocarcinoma. As for complications arising from the biopsy procedure, twenty percent 20% (n = 12) of patients suffered from complications in the form of hemoptysis in 8 which was controlled by hemostatic measures and 4 patients acquired pneumothorax, three (¾) of them received high flow oxygen and conservative treatment and only one (1/4) patient had intercostal tube placement. Diagnostic yield was significantly increased with the presence of Wedge shaped hypoechoic lesions(p Conclusion US-guided biopsy is a robust and accurate procedure to effectively diagnose peripheral lung lesions, with a low incidence of complications and gradually improving results with the mastery of the procedure.

BACKGROUND Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) is an effective means for diagnosing various thoracic diseases. Pneumothorax is the most common complication, and when it becomes life-threatening, urgent medical intervention is required. The purpose of this study was to develop and validate a model that can be used to predict postoperative pneumothorax following CT-guided PTNB. MATERIAL AND METHODS We enrolled 245 patients who completed CT-guided PTNB to develop the model. A random forest (RF) model was built using 15 risk factors (15-RFs). The 7 most critical risk factors (7-RFs) were extracted by feature selection and used to build a new model. The independent external validation data contained 97 patients. Logistic regression (LR), support vector machine (SVM), and decision tree (DT) models were also developed using both 15-RFs and 7-RFs, and their performance was compared with the RF models. RESULTS The length of the aerated lung traversed was identified as the most important risk factor for developing pneumothorax, followed by angle of pleural puncture, lesion depth, lesion size, age, procedure time, and sex. The RF model demonstrated better performance in the development and validation datasets when compared with the LR, SVM, and DT based on 15-RFs and 7-RFs. According to DeLong's test for difference in ROC curves, the RF models based on the 15-RFs and 7-RFs achieved similar classification performance (P0.05). CONCLUSIONS This study demonstrated the feasibility of using the 7-RFs RF model for predicting postoperative pneumothorax before patients undergo CT-guided PTNB.

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

Purpose To evaluate the safety and diagnostic performance of pulmonary nodule biopsies using cone-beam computed tomography (CBCT) guidance compared with conventional CT (CCT) guidance. Material and methods Patients who had pulmonary nodules and underwent a transthoracic needle biopsy at the interventional unit from January 1, 2013 to June 30, 2018 were enrolled. CBCT with XperGuide software was used to biopsy 100 nodules, and CCT guidance was used to biopsy 266 nodules. The two techniques were compared in terms of radiation exposure, complications, and diagnostic accuracy. The p values of less than 0.05 were considered statistically significant. Results The characteristics of the nodules were similar between CBCT and CCT guidance. The median radiation doses were not significantly different between the two groups (5.6 mGy vs. 5.4 mGy; p = 0.78). All minor, major, and overall complications were insignificant (25% vs. 24.4%, 3% vs. 4.9% and 28% vs. 29.3%, respectively). Although CBCT guidance showed higher sensitivity and accuracy than CCT guidance (93.3% vs. 84.1% and 95.0% vs. 89.9%), both techniques had similar specificity (100% vs. 100%) in the diagnosis of malignancy. Conclusions CBCT guidance in pulmonary nodule biopsy provided higher diagnostic sensitivity and accuracy than CCT guidance. However, the complication rates and effective radiation doses did not differ between both techniques.

Non-diagnostic results can affect the diagnostic performance of percutaneous transthoracic needle biopsy (PTNB) but have not been critically meta-analyzed yet. To meta-analyze the incidence and malignancy rate of non-diagnostic results, 3-by-2 table approaches rather than the conventional 2-by-2 approaches are needed to know its impact on the diagnostic performance of PTNB. A systematic literature search identified studies evaluating the diagnostic performance of PTNB with extractable outcomes. A total of 143 studies with 35,059 biopsies were included. The pooled incidence of non-diagnostic results was 6.8% (95% CI, 6.0–7.6%; I2 = 0.91). The pooled malignancy rate of non-diagnostic results was 59.3% (95% CI, 51.7–66.8%; I2 = 0.80), and was correlated with the prevalence of malignancy (correlation coefficient, 0.66; 95% CI, 0.42–0.91). Pooled percentage decrease of sensitivity and specificity due to non-diagnostic results were 4.5% (95% CI, 3.2–5.7%; I2 = 0.64) and 10.7% (95% CI, 7.7–13.7%; I2 = 0.70), respectively, and the pooled incidence of non-diagnostic results was 4.4% (95% CI, 3.2–5.8%; I2 = 0.83) in lesions ultimately diagnosed as malignancies and 10.4% (95% CI, 7.5–13.8%; I2 = 0.74) in benign disease. In conclusion, non-diagnostic results averagely occurred in 6.8% of PTNB and more than half of the results were malignancies. The non-diagnostic results decreased specificity and sensitivity by 10.7% and 4.5%, respectively, demanding efforts to minimize the non-diagnostic results in PTNB.

Background Although there have been several studies on concordance of different assays testing programmed cell death ligand‐1 (PD‐L1) expression using surgical specimens, studies using real‐world biopsy specimens are scarce. However, many of the non‐small cell lung cancer (NSCLC) cases requiring immunotherapy and thus PD‐L1 testing are unresectable having to rely on small biopsy results. Therefore, we sought to assess the concordance of two diagnostic assays (22C3 and SP263) in evaluating PD‐L1 expression using specimens from CT‐guided transthoracic needle biopsy (TNB) specimens in a routine clinical setting. Methods A total of 202 NSCLC cases that underwent CT‐guided TNB from April 2017 to February 2018 were retrospectively reviewed. Biopsy specimens tested with both 22C3 and SP263 assays were included. Concordance of PD‐L1 expression levels determined by two assays was assessed using intraclass correlation coefficient, and the agreement of dichotomized values at various cutoffs (1%, 25%, and 50%) were assessed using Cohen's κ coefficient of agreement. Results A total of 80 patients (M:F = 47:33, mean age: 68.0 years) were included in the study. Concordance of PD‐L1 expression levels was high (intraclass coefficient: 0.892) between 22C3 and SP263 assays. Agreements at cutoff levels of 1%, 25%, and 50% were also good, with κ values of 0.878, 0.698, and 0.790, respectively. Positive percent agreement was 93.2%, 100.0%, and 95.2% for agreements at 1%, 25%, and 50%. Conclusion There is a high concordance of PD‐L1 expression evaluated with 22C3 and SP263 assays using CT‐guided TNB specimens.

Mycobacterial infection(MI) is sometimes diagnosed using CT-guided transthoracic needle biopsy (TNB). However, the exact role of CT-guided TNB in this diagnostic process is not clearly known. The purpose of this study is to analyze the role of CT-guided TNB in patients with MI who present with a focal lung lesion. Of 1233 patients who underwent CT-guided TNB from January 2010 through February 2016 at our institution, patients with a final diagnosis of MI were included for analysis. Clinical characteristics and biopsy-related factors were compared between patients whose diagnosis could be established using TNB samples alone (group 1) and those whose samples from additional tests were necessary for diagnosis (group 2). We also analyzed the possible benefit of CT-guided TNB as compared with bronchoscopy in a subgroup who underwent both procedures. 47 patients with MI were included in the study, with 37 patients (78.7%) in group 1 and 10 patients (21.2%) in group 2. There was no statistically significant difference in clinical characteristics or biopsy-related factors between the two groups. Of 41 patients with MI who underwent both bronchoscopy and TNB, success in diagnosis was solely attributable to TNB in 16 (39.0%) patients; in 19 (46.0%) patients, diagnosis could be made based on bronchoscopy results alone. MI can be successfully diagnosed by CT-guided TNB in about 80% of patients with MI who underwent TNB, but 46% of the patients could have been diagnosed with bronchoscopy results alone. CT-guided TNB is inferior to bronchoscopy in the differentiation of Mycobacterium species even in peripheral lung lesions.

Objective We conducted a systematic review and meta-analysis of the tissue adequacy and complication rates of percutaneous transthoracic needle biopsy (PTNB) for molecular analysis in patients with non-small cell lung cancer (NSCLC). Materials and methods We performed a literature search of the OVID-MEDLINE and Embase databases to identify original studies on the tissue adequacy and complication rates of PTNB for molecular analysis in patients with NSCLC published between January 2005 and January 2020. Inverse variance and random-effects models were used to evaluate and acquire meta-analytic estimates of the outcomes. To explore heterogeneity across the studies, univariable and multivariable meta-regression analyses were performed. Results A total of 21 studies with 2232 biopsies (initial biopsy, 8 studies; rebiopsy after therapy, 13 studies) were included. The pooled rates of tissue adequacy and complications were 89.3% (95% confidence interval [CI]: 85.6%-92.6%; I² = 0.81) and 17.3% (95% CI: 12.1%-23.1%; I² = 0.89), respectively. These rates were 93.5% and 22.2% for the initial biopsies and 86.2% and 16.8% for the rebiopsies, respectively. Severe complications, including pneumothorax requiring chest tube placement and massive hemoptysis, occurred in 0.7% of the cases (95% CI: 0%-2.2%; I² = 0.67). Multivariable meta-regression analysis showed that the tissue adequacy rate was not significantly lower in studies on rebiopsies (p = 0.058). The complication rate was significantly higher in studies that preferentially included older adults (p = 0.001). Conclusion PTNB demonstrated an average tissue adequacy rate of 89.3% for molecular analysis in patients with NSCLC, with a complication rate of 17.3%. PTNB is a generally safe and effective diagnostic procedure for obtaining tissue samples for molecular analysis in NSCLC. Rebiopsy may be performed actively with an acceptable risk of complications if clinically required.

Background: Adequate and representative tissue from lung tumor is important in the era of precision medicine. The aim of this study is to identify detailed procedure-related variables and factors influencing diagnostic success and tissue adequacy for molecular testing in CT-guided TTNB.Methods: Consecutive patients undergoing CT-guided TTNB were retrospectively enrolled between January 2013 and May 2020. Multivariate analysis was performed for predictors for diagnostic accuracy and tissue adequacy for molecular testing. Logistic regression was used to identify risk factors for procedure-related complications.Results: A total of 2,556 patients undergoing CT-guided TTNB were enrolled and overall success rate was 91.5% (2,338/2,556). For lung nodules ≤3 cm, predictors for diagnostic success included coaxial needle use [OR = 0.34 (0.16–0.71), p = 0.004], CT scan slice thickness of 2.5 mm [OR = 0.42 (0.15–0.82), p = 0.011] and additional prefire imaging [OR = 0.31 (0.14–0.68), p = 0.004]. For lung tumor >3 cm, ground glass opacity part more than 50% [OR = 7.53 (2.81–20.23), p < 0.001] or presence of obstructive pneumonitis [OR = 2.31 (1.53–3.48), p < 0.001] had higher risk of diagnostic failure. For tissue adequacy, tissue submitted in two cassettes (98.9 vs. 94.9%, p = 0.027) was a positive predictor; while male (5.7 vs. 2.5%, p = 0.032), younger age (56.61 ± 11.64 vs. 65.82 ± 11.98, p < 0.001), and screening for clinical trial (18.5 vs. 0.7%, p < 0.001) were negative predictors.Conclusions: Using a coaxial needle, with thin CT slice thickness (2.5 mm), and obtaining additional prefire imaging improved diagnostic success, while obtaining more than two tissue cores and submitting in two cassettes improved tissue adequacy for molecular testing.

Testicular microlithiasis (TM) is a condition in which punctate calcifications are present in the testicle. A case of a 29-year-old Saudi male who developed a cough, hemoptysis, and shortness of breath is presented in this report. A computed tomography (CT) scan of the chest revealed a large mediastinal mass. CT scans of the abdomen and pelvis were normal. Testicular ultrasonography (US) showed multiple, bilateral punctate echoes that are characteristic of TM. No primary testicular tumor was detected. Transthoracic needle biopsy of the mediastinal tumor was consistent with a mixed germ cell tumor. This is the seventh case of extragonadal germ cell tumor with TM.

Background To systematically evaluate the correlation between percutaneous transthoracic needle biopsy (PTNB) and recurrence in stage I lung cancer. Methods The databases of PubMed, EMbase, The Cochrane Library, CNKI, WanFang Data and China Biology Medicine disc were retrieved to collect relevant literatures about the correlation between PTNB and recurrence in stage I lung cancer. The retrieval time was limited from the time of their database establishment to April 30/2020.Screened the literature, extracted the data and assessed the quality of studies included. Then the meta-analysis was performed by using Stata l6.0 software. Results A total of 8 cohort studies involving 2760 lung cancer patients were included. The results of meta-analysis showed that PTNB did not increase the risk of total recurrence and pleural recurrence in the patients with stage I lung cancer. The result of subgroup analysis is according to the tumor location. For stage I lung cancer, PTNB will increase the risk of pleural recurrence in patients with sub-pleural lesions but not in those without sub-pleural lesions. Conclusions To stage I lung cancer, PTNB is not associated with the total recurrence and pleural recurrence but PTNB will increase the risk of pleural recurrence in patients with sub-pleural lesions.

BACKGROUND: Prior studies in pulmonology have examined the validity of procedural training tools, however, translation of simulation skill acquisition into real world competency remains understudied. We examine an assessment process with a simulation training course for electromagnetic navigational (EMN) bronchoscopy and percutaneous transthoracic needle aspiration (PTTNA). METHODS: A cohort study was conducted by subjects using EMN bronchoscopy and PTTNA. A procedural assessment tool was developed to measure basic competency for EMN bronchoscopy and PTTNA at three different time points: first simulation case, final simulation case upon reaching a competent score, and at their first live case. The assessment tool was divided into four domains (total score 4–16, competency ≥ 12) with each domain requiring a passing score (1–4, competency ≥ 3.0). Complication, and procedural time were collected during their first live case. RESULTS: Twenty-two serial procedures (12 EMN bronchoscopies, 10 EMN PTTNA) were observed by fourteen subjects. The mean first simulation score for EMN bronchoscopy (4.66 ±0.89) improved after cadaver simulation (12.67 ±0.89, median 3 simulations attempts). The subjects’ mean score for their first live case was 13.0 ±0.85 (self-reported score 12.5 ±1.07). For EMN PTTNA, the mean first simulation score (4.3 ±2.40) improved after cadaver simulation (12.6 ±1.51, median 3 simulation attempts). The subjects’ mean score for their first live PTTNA case was 12.5 ±2.87 (self-reported score 12.1 ±1.05). There was only one minor complication. CONCLUSION: Learning EMN bronchoscopy/PTTNA is feasible using a structured simulation course with an assessment tool.

Primary pulmonary lymphoma (PPL) is a rare neoplasm. We report a case of 45-year-old men who was admitted to hospital for multiple nodules and masses in both lungs. The contrast enhanced chest CT scans revealed multiple nodules and masses of varying sizes in right upper and middle lobes and both lower lobes. CT-guided percutaneous transthoracic needle biopsy was performed. The diagnosis of PPL was confirmed by histopathological examination and Immunohistochemical staining. PPL should be included in the differential diagnoses in symptomless patients with multiple pulmonary nodules and masses.

Biopsy has been used to diagnose thoracic diseases for more than a century. Percutaneous needle biopsy plays a crucial role in the diagnosis, staging, and treatment planning for tumors in the lungs, thoracic wall, hilum, and mediastinum. With the continuous improvement in imaging techniques, the range of clinical applications for percutaneous needle biopsy is also expanding. It has become important to improve Chinese professionals' and technicians' understanding of percutaneous transthoracic needle biopsy (PTNB) in order to standardize operating procedures and to strengthen perioperative management. However, there is currently no Chinese expert consensus that provides systematic standardization and guidance for PTNB in clinical practice. The Committee of Chinese Society of Interventional Oncology (CSIO) of the Chinese Anti-Cancer Association (CACA) initiated a Chinese multidisciplinary expert consensus on PTNB. The consensus includes image-guided methods, indications, contraindications, multidisciplinary team recommendations, biopsy procedures, daytime/outpatient biopsy, complications, pathological examination, and management of negative results.

In 1883, Leyden successfully performed percutaneous transthoracic needle biopsy (PTNB) of the lung in three patients with pneumonia according the records (1); three years later, Menetrier was the first recorded to employ this technique for the diagnosis of lung cancer (2).

Objectives: Traumatic iatrogenic pneumothorax occurs most often after a transthoracic needle biopsy. Since this procedure has become a common outpatient intervention, emergency department admissions of post-biopsy pneumothorax patients have increased. The aim of this study was to determine the factors that predict the need for tube thoracostomy in patients with post-biopsy pneumothorax in the emergency department. Methods: A retrospective cross-sectional study was conducted on 191 patients with post-biopsy pneumothorax who were admitted to the emergency department between 2010 and 2017. Patient characteristics, clinical findings at the emergency department presentation, and procedural and radiological features were reviewed. A multivariate logistic regression model was constructed using the variables from univariate comparisons to determine the need for tube thoracostomy in patients with iatrogenic pneumothorax, and the effect sizes were demonstrated with odds ratios. Results: Tube thoracostomies were performed on 69 out of 191 patients (36.1%). A total of 122 patients (63.9%) were treated with supplemental oxygen therapy without any other intervention, and 126 patients (66.0%) were hospitalized. In the multivariate model, the variables predicting the need for a tube thoracostomy were decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation and increased pleura–lesion distance. A distance of 19.7 mm predicted the need with a sensitivity of 69.6% and a specificity of 62.3%. Conclusion: Decreased breath sounds, dyspnea, decreased systolic blood pressure, decreased oxygen saturation, and increased pleura-lesion distance may predict the need for a tube thoracostomy in patients with post-biopsy pneumothorax. Keywords: Pneumothorax, Iatrogenic disease, Needle biopsy, Chest tubes, Tube thoracostomy

Introduction Thymoma is an epithelial tumor that commonly lies in the anterior mediastinum. It rarely extends to the pleural cavities. There is no standard approach for resecting similar giant thymomas. Case presentation An eighteen-year-old woman presented with a six-month history of progressive exertional dyspnea, weight loss, and loss of appetite. Radiological imaging demonstrated a giant mediastinal mass extending to both pleural cavities, a transthoracic needle biopsy was then performed, which indicated thymic hyperplasia. Clinical discussion The tumor was completely resected using a two-step approach, starting with a median sternotomy then extending it to a hemiclamshell incision, which provided better exposure of the tumor and caused less morbidity. The left part of the thymoma was resected using a median sternotomy, which took a relatively long time and caused significant blood loss. Then the incision was extended to a hemiclamshell incision through the pleural cavity to remove the right part of the tumor. This approach helped us to visualize the tumor better and did not cause any significant blood loss. The removed mass measured 36 × 29 × 10 cm and weighed 4500 g. Pathologic diagnosis indicated a type B1 tumor with no capsular invasion according to the World Health Organization classification. Conclusion The hemiclamshell approach is superior to the median sternotomy incision in resecting giant thymomas extending to the pleural cavity, as it saves time and causes less morbidity., Highlights • Giant Thymoma is an extremely rare clinical entity. • It is very uncommon for a thymoma to reach both pleural cavities. • Comparing the median sternotomy to the hemiclamshell approach in resecting giant thymomas extending to the mediastinum. • The hemiclamshell approach caused less morbidity and no significant blood loss compared to the median sternotomy.

A mediastinal germ cell tumor with a sarcomatous component is extremely rare and is accompanied by a poor prognosis. Clinical and radiologic diagnosis is very difficult. Herein, we report a rare case of anterior mediastinal malignant teratoma containing a growing liposarcomatous component and detail the diagnostic process. The case was diagnosed by repeated transthoracic needle biopsy and correlated with changes in follow-up chest computed tomography and serum tumor markers. We also provide a review of the literature.

Objective To assess the current practice patterns of radiologists who perform transthoracic needle biopsy (TNB). Materials and methods An email survey of 71 questions on TNB was sent to 240 members of the Korean Society of Thoracic Radiology. The answers to multiple-choice questions (n = 56) were analyzed. Results Of 60 respondents, 45% had 10 or more years of experience in chest radiology, and 70% had 5 or more years of experience in TNB. For the question on the most frequently used diagnostic method for lesions with high probability of being resectable-stage lung cancer, 70% of respondents answered that TNB is initially used, with or without bronchoscopy. In patients at high-risk of TNB-related complications, the proportion of the respondents who consistently declined TNB was only 5%. The number of rebiopsies was said to be increased; molecular analysis for an established target therapy (43.6%) and clinical trial of a new drug (28.2%) were the two most common reasons for it. The most popular needle type was the coaxial cutting needle (55%), and the popular guiding modality was conventional computed tomography (CT) (56.7%). In addition, 15% of respondents have encountered air embolism. Conclusion Despite high variation in how TNB is being performed in Korea, some patterns were noted. It is common for patients with resectable-stage lung cancer to undergo TNB prior to surgery. Rebiopsy is now more common than before, with personalized medicine as the most important reason for it. The most popular type of needle is the coaxial system; the most popular modality for guidance is still CT.

Objective This study was performed to assess the complication and diagnostic rates of computed tomography (CT)-guided transthoracic needle biopsy of pulmonary parenchymal and mediastinal lesions. Methods Patients who were suspected to have a malignancy based on chest imaging and CT and could not be otherwise diagnosed were evaluated. Results Sixty-five patients were included; 48 (73.8%) were male and 17 (26.2%) were female. Their average age was 58 years. The lesion size ranged from 11 to 105 mm. The most common specific histologic subtype was adenocarcinoma, and the least common was lymphoma. The diagnostic rate was 90.8%. The mean complication rate was 15.4%. Statistically significant associations were found between the complication rate and needle size and between the needle path length and lesion size. Conclusion CT-guided needle biopsy is an effective diagnostic method for patients with mediastinal and parenchymal lesions before thoracotomy. This method can also reliably differentiate benign and malignant tumors.

Objectives: To compare CT-guided transthoracic cutting needle biopsy (TCNB) with transthoracic aspiration needle biopsy (TANB) for pulmonary lesions with respect to the diagnostic accuracy and complication rate. Methods: Of the 859 cases that underwent consecutive CT-guided biopsy of pulmonary lesions, 713 cases confirmed by surgical pathology or clinical follow-up were enrolled. Of these, the first consecutive 275 cases underwent TANB, and the remaining 438 received TCNB. The final diagnosis determined the accuracy of biopsy. Based on the post-biopsy CT and clinical medical records, the presence or absence of biopsy-related complications was determined. The χ2 test was used to compare the differences between TCNB and TANB in terms of diagnostic accuracy and complication rate. Results: Among the 713 biopsy lesions, the final diagnosis was malignant in 411 cases and benign in 302 cases. As compared to TANB, the diagnostic accuracy of TCNB (98.9% vs 93.8%, χ2 = 14.35, p < 0.01), sensitivity to malignant lesions (97.8% vs 90.6%, χ2 = 10.58, p < 0.01), negative predictive value (97.6% vs 84.8%, χ2 = 19.03, p < 0.01), and specific diagnostic rate for benign lesions (73.4% vs 57.9%, χ2 = 7.29, p < 0.01) were improved. On the other hand, a statistical difference was detected between TCNB and TANB with respect to the incidence of pneumothorax (20.6% vs 13.1%, χ2 = 6.46, p = 0.01), hemorrhage (32.2% vs 13.1%, χ2 = 33.03, p < 0.01), and hemoptysis (8.2% vs 3.3%, χ2 = 6.87, p < 0.01). One patient died just several minutes after TCNB due to severe hemorrhage with hemoptysis. Conclusions: Compared to TANB, CT-guided TCNB improves the diagnostic accuracy of pulmonary lesions, but complication rate increases significantly. Advances in knowledge: In general, TCNB should be recommended, especially for highly suspicious benign lesions. For patients with small lesions adjacent to vessels or vessels within the lesion, TANB should be considered.