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Percutaneous lung biopsies: a survey of UK practice based on 5444 biopsies

¹ Department of Respiratory Medicine, Medical Research Centre Building and ² Department of Radiology, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK

Correspondence: Dr J T Macfarlane

	Abstract

Top Abstract Introduction Methods Results Discussion Conclusion References

 
Percutaneous transthoracic lung biopsies are commonly performed for the investigation of lung masses. We describe current practice and complication rates in the UK. A postal questionnaire was sent to all centres in the British Thoracic Society directory. 157 replies (61% response rate) were received, providing data on 5444 biopsies. Mean number of biopsies performed per annum was 30.5 per centre; 8% of centres did not perform biopsies, 36% performed <25 biopsies per annum, 34% <50, 16% <100 and 6% >100. Consultant radiologists perform 91% of biopsies. Written consent was obtained at all centres. The operator obtained consent at 50% of centres. Written information for patients was provided at 35 (24%) centres. Biopsies are performed on a day case basis at 103 (71%) centres. Prior to biopsy the following were obtained routinely: CT scan (73% of centres), platelet count (73%), full clotting screen (70%), lung function (55%). Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring chest drain (3.1%), haemoptysis (5.3%) and death (0.15%). The timing of post-procedure chest radiography was variable. Those centres that performed predominantly cutting needle biopsies had similar pneumothorax rates to centres performing mainly fine needle biopsies (18.9% vs 18.3%). There is great variation in practice throughout the UK. Most procedures are performed on a daycase basis. Small pneumothoraces are common but infrequently require treatment. National guidelines are needed to ensure consistency of standards.

	Introduction

Top Abstract Introduction Methods Results Discussion Conclusion References

 
Percutaneous transthoracic lung biopsy is a common procedure used mainly to elucidate the nature of pulmonary masses [1–3]. It is generally regarded as a safe procedure, although there are occasional reports of deaths following lung biopsies [4, 5]. Published complication rates vary widely, and technique and practice differs according to the centre. With the advent of clinical governance, it was felt to be important to describe national practice as a first step in establishing guidelines for this procedure.

	Methods

Top Abstract Introduction Methods Results Discussion Conclusion References

 
Postal questionnaires were sent out in January 2000 to a named respiratory physician at every one of the 257 UK respiratory centres listed in the British Thoracic Society directory of services. A duplicate questionnaire was sent out to those centres that had not responded after 6 weeks. Physicians were asked to pass the questionnaire on to their radiology colleagues if they were unable to provide data themselves. A copy of the questionnaire is available from the authors.

	Results

Top Abstract Introduction Methods Results Discussion Conclusion References

 
Replies were received from 157 centres (61% response rate) providing data on 5444 biopsies. These included 39 centres that had collected complication audit data prospectively on 1860 biopsies. Audited data was collected over a 12-month period. The other 118 centres provided an estimate of their complication rates.

Number of biopsies performed per annum
The mean number of biopsies performed per centre was 30.5 per annum. 12 centres (8%) did not perform any biopsies, 57 (36%) performed less than 25 biopsies per annum, 53 (34%) performed between 25 and 49 biopsies, 25 (16%) performed between 50 and 100 biopsies and 10 centres (6%) performed more than 100 biopsies.

Written information
Only 35 (24%) centres provided written information for patients prior to the procedure.

Consent
Written consent was obtained at all centres. The operator obtained consent at 73 centres (51%). Many centres stated that they warned patients of the following complications as part of the consent: pneumothorax (98% of centres), haemoptysis (92%), pneumothorax requiring a chest drain (88%) and death (4%).

Pre-biopsy investigations
Prior to the procedure, the following investigations were routinely obtained: CT scan (73% of centres), platelet count (73%), clotting studies (70%) and spirometry (55%).

Procedure performed as day case or on in-patient basis
Biopsies were performed as day cases at 103 centres (71%). The remaining centres (34%) usually admitted patients overnight following the procedure.

Patient clerking
At 87 centres (55%), patients were re-clerked by a junior doctor on the day of the procedure.

Operator
Consultant radiologists performed 4975 (91%) of the biopsies. Specialist registrars training in radiology performed 415 (8%) biopsies. In only six centres were biopsies performed by consultant respiratory physicians, comprising only 54 (1%) of all biopsies.

Cutting needle biopsy vs aspiration
By selecting audited data it was possible to examine which centres performed cutting needle biopsies in comparison to fine needle biopsies from the prospective audited data provided from 39 centres. These could be subdivided into those that performed two thirds or more of their biopsies using fine needle aspiration (19 centres, 49%), those that performed two thirds or more using cutting needles (12 centres, 31%) and those that performed an approximately even mixture of cutting needle and fine needle aspiration.

Cytology services
A cytologist or cytology technician was present in the procedure room at the time of the biopsy to prepare, and in some cases examine, slides in 8 of 19 (42%) centres that performed mostly fine needle biopsies.

Timing of post-biopsy follow-up chest radiography
Wide variation exists in the timing of post-biopsy follow-up chest radiography. Eight centres (6%) reported that they performed chest radiography following biopsy only if the patient reported symptoms. 40 centres (28%) performed chest radiography within 4 h of biopsy, 58 centres (40%) at 4 h post-biopsy and 20 centres (14%) the following day.

Complication rate
Overall complications reported by centres, including both audited data on 1860 biopsies and estimated data on 3684 cases were recorded (Table 1). Reported complications included pneumothorax, pneumothorax requiring chest drain, and haemoptysis. Major haemoptysis requiring transfusion (8 cases), death following biopsy (8 cases), air embolism (1 case) and tumour seeding in the biopsy tract (1 case) were infrequently reported.

	Discussion

Top Abstract Introduction Methods Results Discussion Conclusion References

 
This is the first national study to show differences in practice throughout the UK with respect to percutaneous lung biopsies. We have estimated that approximately 8000 percutaneous lung biopsies are undertaken each year in the UK. The procedure is undertaken in a wide range of hospitals and with varying protocols. Only 8% of UK respiratory centres that responded to our survey did not perform biopsies. The reasons for not undertaking biopsies included lack of CT facilities or lack of cardiothoracic surgical support on site. These centres usually referred cases to a larger centre nearby.

The number of biopsies performed at each centre varied greatly. Although the average centre in the UK performed approximately 30 biopsies per year, some smaller centres performed just 3 biopsies per year, with one centre performing over 250 biopsies. The reasons for such large differences in the number of biopsies performed are varied. Decisions to proceed to biopsy may be influenced by access to thoracic surgeons. In some centres, solitary pulmonary nodules may be referred directly to surgeons for excision rather than biopsy. Some hospitals prefer to establish a diagnosis by other means, such as bronchoscopy, requesting percutaneous lung biopsy only when other methods have failed. The advent of positron emission tomography scanning may also reduce the need for biopsy in centres that have access to this facility [6]. We were unable to determine to what extent these individual factors have influenced biopsy rates in the UK.

Admission for the procedure
We found that just over two thirds of centres perform percutaneous lung biopsies as a day case procedure, the remainder admitting their patients for an overnight stay following biopsy. Historically, patients have been admitted after percutaneous transthoracic lung biopsies because of concerns regarding delayed complications. Out-patient percutaneous lung biopsies are now common practice in the USA and seem to be accepted practice in most UK centres. Several studies, both in the USA [7–9] and the UK [10] have shown that percutaneous lung biopsies can be carried out safely as day case procedures. Delayed pneumothoraces have been reported infrequently. Patients can be warned of this rare occurrence and instructed to seek help if chest pain or breathlessness develops [11]. No death has been reported in the published series where patients have been sent home after the procedure. Given the increasing pressure on beds and the additional cost and inconvenience for the patient of an overnight stay, it would seem desirable to perform as many biopsies as possible on a day case basis, as long as there is adequate support at home.

Consent
In this study all patients gave consent prior to the procedure. The person performing the biopsy obtained consent in only 50% of cases. The General Medical Council (GMC) states in Seeking Patients' Consent: The Ethical Considerations, that it is the responsibility of the clinician who performs the procedure to ensure that adequate consent has been obtained, although the actual task of obtaining the consent may be delegated to a another suitably trained and qualified health professional [12]. That half the patients were re-clerked on the day of biopsy by a trainee doctor suggests not only that a potentially unnecessary task is commonly being performed, but also that that doctor may well have been obtaining consent inappropriately, as part of the admission procedure. Many radiologists may feel uneasy about obtaining consent with the patient "on the table" and are unlikely to have met the patient prior to that time. Provision of adequate information regarding the procedure and its place in the individual's overall management is essential before the patient attends the radiology department for biopsy. Patient information sheets will help to overcome these problems and have been advocated by the GMC and the Department of Health [13]. We found that only one quarter of centres gave written information to patients prior to the procedure.

Almost all patients were informed of the risk of pneumothorax pre-biopsy, but fewer were informed that some pneumothoraces require treatment with a chest drain. The risk of pneumothorax requiring a chest drain was 3%. This is a significant risk, of which all patients should be informed in order to take adequate consent.

Pre-biopsy investigations
The range and frequency of tests performed before percutaneous transthoracic lung biopsy varied widely. The reason why only 73% of respondents routinely checked CT scans prior to biopsy is unclear. Where stated, the majority of biopsies were performed under CT screening. Ultrasound or fluoroscopic screening is used at some centres although detailed information regarding imaging is not available.

Surprisingly, only half the centres checked lung function tests prior to biopsy. In those centres that did measure spirometry prior to biopsy, there was no information on spirometry values below which biopsy would be contraindicated. The literature is conflicting as to whether or not spirometry is helpful in predicting complication rate, and it may be that the presence or absence of bullous disease is more important than the presence of airways obstruction itself [14–17]. Low respiratory reserve, however, reduces the ability of a patient to tolerate either pneumothorax or significant pulmonary haemorrhage. For this reason spirometry should be checked prior to biopsy as part of the overall risk assessment.

Abnormal clotting studies with a prothrombin ratio above 1.3 are quoted as being a relative contraindication to lung biopsy [18], although only 70% of centres requested a clotting screen prior to the procedure.

Cutting needles/fine needle
Most centres in the UK expressed a preference for predominantly using either fine needle aspiration or cutting needles to make a diagnosis, with only one quarter of centres usually employing a combination of the two methods. The decision about whether or not to use cutting needle or fine needle aspiration appears to be largely related to the personal preference of the operator, rather than being adapted to the individual patient, as demonstrated by the centre preference for one or other method. Much has been written in the literature regarding the safety and efficacy of each method. Historically, it has been suggested that cutting needles are associated with a higher complication rate. We found no difference in complication rate between the two methods, a conclusion supported by other studies [18–20].

Another factor that may influence the decision to use cutting needles is the non-availability of a cytopathologist at the time of biopsy. Of those centres predominantly performing fine needle biopsies, over half always have a cytologist present during biopsy. The reported diagnostic accuracy of fine needle biopsy varies in the literature, but access to a cytologist at the time of biopsy has been shown to improve diagnostic yield [21–23]. Cutting needles have been shown to increase diagnostic yield when compared with fine needle biopsies in the absence of a cytopathologist, specifically with respect to benign diagnoses [24–26].

Timing of post-biopsy follow-up chest radiography
There is great variation in the timing of follow-up chest radiography. Perlmutt et al [27] studied 673 transthoracic needle biopsies to determine optimum timing of chest radiography after the procedure to detect pneumothorax. Of the total number of pneumothoraces, 89% were detected immediately, a further 9% were seen after 1 h and only 2% were first seen at 4 h. Of the pneumothoraces requiring intervention, 88% were detected immediately and the rest detected after 1 h [27]. This finding is supported by a number of other studies [7, 28].

Pneumothoraces developing after 24 h occur, but are extremely uncommon. Two cases of delayed pneumothorax, both requiring treatment, were reported in 1997 [11]. There are no reports in the literature of deaths attributed to delayed pneumothoraces. We recommend that a chest radiograph should therefore be performed at 1 h post-procedure. If there is no pneumothorax at that time, patients can be discharged safely as long as there is adequate support at home.

Complication rates
This is the largest series to date to report on complication rates. Of the 5444 biopsies we obtained information on, 1860 were audited and therefore provide accurate information. The complication rates in this study are in keeping with previously published figures, which quote pneumothorax occurrence rates in the range of 3.1–41.7%, and 0–16.6% for pneumothorax requiring chest drain [29]. It is interesting that the complication rate from audited data is higher than the estimated complication rate, suggesting a degree of under reporting when complication rate depends upon memory. The pneumothorax complication rate from audited data ranged from 5% to 50%. The reason for such variability may be related to the method of screening for pneumothorax. CT scanning has been shown to have greater sensitivity in the diagnosis of pneumothoraces [30]. Where the biopsy was performed with CT guidance, many centres performed a final check scan following the procedure and were therefore able to detect even the smallest pneumothorax.

There were eight reported deaths (0.15%) in our study as a complication of biopsy. Reports of death in the literature are very rare. Greene [31] estimated mortality associated with fine needle aspiration to be 0.02%. Most deaths were attributed to fatal air embolism [31]. Sinner [32] reports an incidence of 0.07% for air embolism, although fewer than 10 cases are documented in the world literature [4, 5]. The manifestations of air embolism are variable and include arrhythmias, seizures, cardiac ischaemia and stroke. Deaths may occur for other reasons, including bleeding. The reason for such wide variation in mortality rates is unclear. It may be that whilst deaths occur rarely, they are remembered long after the event, possibly leading to over reporting in this study. As deaths following biopsy are so infrequent, a prospective study would be required to provide definitive mortality data.

	Conclusion

Top Abstract Introduction Methods Results Discussion Conclusion References

 
This is the first comprehensive study to document current practice with respect to percutaneous lung biopsies in the UK. It shows great variation in the number of biopsies performed in different centres, the pre-biopsy tests requested and timing of follow-up chest radiography. Almost a third of patients are being admitted overnight for the procedure, which in light of published evidence seems to be unnecessary for most patients. Nationally there is a need to improve the availability of written information for patients prior to the procedure. The complication rate in the UK is comparable to published figures internationally.

Now that the wide variation in national practice has been described, guidelines are needed to ensure consistency of care and to improve standards throughout the UK.

	Acknowledgments

 
We are grateful to those specialists who completed the questionnaire.

Received for publication January 29, 2002. Revision received May 15, 2002. Accepted for publication May 21, 2002.

	References

Top Abstract Introduction Methods Results Discussion Conclusion References

 

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This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Richardson, C M Articles by Macfarlane, J T Search for Related Content PubMed PubMed Citation Articles by Richardson, C M Articles by Macfarlane, J T