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Population-Based Risk for Complications After Transthoracic Needle Lung Biopsy of a Pulmonary Nodule: An Analysis of Discharge Records

Renda Soylemez Wiener, MD, MPH; Lisa M. Schwartz, MD, MS; Steven Woloshin, MD, MS; and H. Gilbert Welch, MD, MPH
[+] Article, Author, and Disclosure Information

From Boston University School of Medicine, Boston, Massachusetts; Center for Health Quality, Outcomes, & Economic Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts; Veterans Affairs Outcomes Group, Department of Veterans Affairs, White River Junction, Vermont; and Dartmouth Medical School, Hanover, New Hampshire.

Disclaimer: The views expressed herein do not necessarily represent the views of the funding agencies, the Department of Veterans Affairs, or the U.S. government.

Acknowledgment: The authors thank Janice Weinberg, PhD, Boston University School of Medicine, for her voluntary statistical assistance and recognize the contribution of our colleagues in the Veterans Affairs Outcomes Group and the Center for Health Quality, Outcomes, and Economic Research, whose voluntary feedback enhanced both our thinking and the presentation of our results.

Grant Support: By career development award K07 CA138772 from the National Cancer Institute (Dr. Wiener) and by the Department of Veterans Affairs.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2560.

Reproducible Research Statement:Study protocol and data set: Available from Dr. Wiener (e-mail, rwiener@bu.edu). Statistical code: Not available.

Requests for Single Reprints: Renda Soylemez Wiener, MD, MPH, The Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R-304, Boston, MA 02118; e-mail, rwiener@bu.edu.

Current Author Addresses: Dr. Wiener: The Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R-304, Boston, MA 02118.

Drs. Schwartz, Woloshin, and Welch: Veterans Affairs Outcomes Group 111 B, Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT 05009.

Author Contributions: Conception and design: R.S. Wiener, L.M. Schwartz, S. Woloshin, H.G. Welch.

Analysis and interpretation of the data: R.S. Wiener, L.M. Schwartz, S. Woloshin, H.G. Welch.

Drafting of the article: R.S. Wiener.

Critical revision for important intellectual content: R.S. Wiener, L.M. Schwartz, S. Woloshin, H.G. Welch.

Final approval of the article: R.S. Wiener, L.M. Schwartz, S. Woloshin, H.G. Welch.

Statistical expertise: L.M. Schwartz, S. Woloshin, H.G. Welch.

Obtaining of funding: R.S. Wiener.

Ann Intern Med. 2011;155(3):137-144. doi:10.7326/0003-4819-155-3-201108020-00003
Text Size: A A A

Background: Because pulmonary nodules are found in up to 25% of patients undergoing computed tomography of the chest, the question of whether to perform biopsy is becoming increasingly common. Data on complications after transthoracic needle lung biopsy are limited to case series from selected institutions.

Objective: To determine population-based estimates of risks for complications after transthoracic needle biopsy of a pulmonary nodule.

Design: Cross-sectional analysis.

Setting: The 2006 State Ambulatory Surgery Databases and State Inpatient Databases for California, Florida, Michigan, and New York from the Healthcare Cost and Utilization Project.

Patients: 15 865 adults who had transthoracic needle biopsy of a pulmonary nodule.

Measurements: Percentage of biopsies complicated by hemorrhage, any pneumothorax, or pneumothorax requiring a chest tube, and adjusted odds ratios for these complications associated with various biopsy characteristics, calculated by using multivariate, population-averaged generalized estimating equations.

Results: Although hemorrhage was rare, complicating 1.0% (95% CI, 0.9% to 1.2%) of biopsies, 17.8% (CI, 11.8% to 23.8%) of patients with hemorrhage required a blood transfusion. In contrast, the risk for any pneumothorax was 15.0% (CI, 14.0% to 16.0%), and 6.6% (CI, 6.0% to 7.2%) of all biopsies resulted in pneumothorax requiring a chest tube. Compared with patients without complications, those who experienced hemorrhage or pneumothorax requiring a chest tube had longer lengths of stay (P < 0.001) and were more likely to develop respiratory failure requiring mechanical ventilation (P = 0.020). Patients aged 60 to 69 years (as opposed to younger or older patients), smokers, and those with chronic obstructive pulmonary disease had higher risk for complications.

Limitations: Estimated risks may be inaccurate if coding of complications is incomplete. The analyzed databases contain little clinical detail (such as information on nodule characteristics or biopsy pathology) and cannot indicate whether performing the biopsy produced useful information.

Conclusion: Whereas hemorrhage is an infrequent complication of transthoracic needle lung biopsy, pneumothorax is common and often necessitates chest tube placement. These population-based data should help patients and physicians make more informed choices about whether to perform biopsy of a pulmonary nodule.

Primary Funding Source: Department of Veterans Affairs and National Cancer Institute.


Grahic Jump Location
Figure 1.
Study flow diagram.

* Includes open or video-assisted thoracoscopic surgical biopsy, excision, wedge resection, segmentectomy, lobectomy, or pneumonectomy.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Adjusted risk for complications after transthoracic needle biopsy of a pulmonary nodule.

Adjusted for all variables in Table 3 by using generalized estimating equation models.

Grahic Jump Location




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Transthoracic Needle Aspiration Biopsy and Pneumothorax Risk
Posted on August 18, 2011
Steven C Leong
The Prince Charles Hospital
Conflict of Interest: None Declared

We read with interest the important findings by Soylemez-Wiener et al. highlighting the 15% (CI 14-16%) risk of pneumothorax as a complication of transthoracic needle aspiration (TTNA) biopsy for pulmonary nodules.

We agree that there is an increasing need for the clinician to consider TTNA for the evaluation of pulmonary nodules which are frequently identified in this era of modern imaging (intentionally through screening studies and unintentionally through CT pulmonary angiography1 and CT coronary angiography2).

This high quality population based study provides a reliable population level risk estimate. However, like with all good clinical decisions, this population risk level must be tempered by a careful consideration of the individualised risk:benefit ratio since the risk of TTNA associated pneumothorax is well known to be associated with lesion depth and size3 as well as underlying lung disease such as emphysema4. Alternative diagnostic procedures such as radial probe endobronchial ultrasound guided transbronchial biopsies or electromagnetic navigation bronchoscopy are associated with much lower pneumothorax rates and should be considered in patients with poor lung function or non-pleural based lesions5.

Moreover, the pretest probability of any one nodule being malignant, the method of case finding (symptomatic vs screening) and the likelihood of successful clinical intervention/treatment must be considered in the decision making process. A multidisciplinary approach together with knowledge of local complication rates is imperative to ensure the most appropriate diagnostic test is chosen.

We congratulate and thank the authors for a significant study that provides a robust baseline on which astute physicians and informed patients can start to personalise decision making in the assessment of pulmonary nodules based on available evidence.


1. Foley P, Hamaad A, El-Gendi H, Leyva F. Incidental cardiac findings on computed tomography imaging of the thorax. . BMC Res Notes 2010;3(3):326.

2. George A, Movahed A. Recognition of noncardiac findings on cardiac computed tomography examination. . Rev Cardiovasc Med 2010;11(2):84-91.

3. Kazerooni E, Lim F, Mikhail A, Martinez F. Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung. Radiology 1996;198(2):371-5.

4. Cox J, Chiles C, McManus C, Aquino S, Choplin R. Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax. Radiology 1999;212(1):165-8.

5. Steinfort D, Khor Y, Manser R, Irving L. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. European Respiratory Journal 2011;37:902-10.

Conflict of Interest:

None declared

Primum non nocere
Posted on August 25, 2011
Helmy Haja Mydin
Department of Respiratory Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen. AB25 2ZN. Unit
Conflict of Interest: None Declared

We read with great interest the paper by Wiener, et al (1) whereby the risks associated with radiologically-guided percutaneous lung biopsy were highlighted. However, it is important to point out that the authors failed to discuss the use and benefits of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in their discussion which, in comparison, confers many advantages as a tool in diagnosing underlying malignancy. Moreover, there was no mention of the proportion of patients studied who had enlarged hilar and mediastinal lymphadenopathy in whom EBUS-TBNA could have made the diagnosis and facilitated staging in a single procedure.

Sampling mediastinal and hilar lymph nodes using this technique in patients with peripheral lung masses is safe, quick (approximately 10-20 minutes) and fairly non-invasive (2). EBUS-TBNA is usually performed as a day case under sedation and in many large studies, it has been demonstrated that complications are almost non-existent (3)(4).

In summary, EBUS-TBNA should be considered a first-line diagnostic and staging procedure (5) for patients with a peripheral lung mass with mediastinal and/or hilar lymphadenopathy. As a consequence, this is highly likely to reduce the number of radiologically-guided lung biopsies and follow the well established principle in medicine of primum non nocere.


1. Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155:137-44.

2. Currie GP, McKean ME, Kerr KM, Denison AR, Chetty M. Endobronchial ultrasound-transbronchial needle aspiration and its practical application. QJM. 2011; 104:653-62.

3. Herth FJF, Eberhardt R, Vilmann P, Krasnik M, A Ernst. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006;61:795-98.

4. Vincent BD, El-Bayoumi E, Hoffman B, Doelken P, DeRosimo J,Reed C, et al. Real-Time Endobronchial Ultrasound-Guided Transbronchial Lymph Node Aspiration. Ann Thorac Surg. 2008;85:224-30.

5. Lim E, Baldwin D, Beckles M, Duffy J, Entwisle J, Faivre-Finn C, et al. Guidelines on the radical management of patients with lung cancer.Thorax. 2010;65(Supp lII):iii1-iii27.

Conflict of Interest:

None declared

Authors' Letter in Response
Posted on September 27, 2011
Renda Soylemez Wiener
Boston University School of Medicine
Conflict of Interest: None Declared

We appreciate the interest in our study expressed by Leong and colleagues and Mydin and colleagues. We recognize that newer bronchoscopic techniques guided by endobronchial ultrasound or electromagnetic navigation may be considered, if available, when deciding how to evaluate a patient with a pulmonary nodule. However, we were unable to include these procedures in our analysis because they do not have dedicated ICD-9 procedure codes assigned to them. We therefore cannot comment on either the utilization or complication rates of these procedures.

We fully agree with Leong and colleagues that individual characteristics must be considered when estimating the risk of complications from transthoracic needle biopsy. Unfortunately, the administrative databases we used for this analysis lacked clinical detail, such that we could not assess the impact of important individual characteristics such as nodule size and location on risk of complications. Our goal in this study was to provide an estimate of the risk of complications following transthoracic needle biopsy (CT-guided biopsy) when all patients undergoing the procedure were considered; for individuals, the pre-test probability of a complication may of course be higher or lower based on their personal risk factors.

We believe that population-level data on complications, as reported in our study, can be useful to provide patients with a general sense of risks of a procedure, but that it is equally important to indicate to individual patients whether (and why) their risk of complications might be higher or lower than average. To minimize harm to patients while maximizing benefit, doctors and patients should weigh the individualized pre-test probability both of malignancy and of complications from testing before deciding whether to proceed with biopsy of a pulmonary nodule.

Conflict of Interest:

None declared

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