Efficacy of Percutaneous Direct Puncture Biopsy of Malignant Lung Tumors Contacting to the Pleura

Background/Aim: This is a retrospective evaluation of whether percutaneous direct puncture biopsy of lung lesions contacting to the pleura is justified. Patients and Methods: Between August 2016 and July 2021, 163 consecutive patients (100 males, 63 females with a median age of 73 years) who had malignant lung tumors measuring 0.6-12.4 cm (median, 2.9 cm) that contacted to the pleura and underwent percutaneous lung biopsy under computed tomography fluoroscopic guidance using an 18-gauge end -cut needle were examined. The trajectory was direct puncture in 80 patients (49.1%, 80/163), and trans-lung in 83 patients (50.9%, 83/163). Diagnostic yield and major adverse event rates of direct and trans-lung puncture biopsies were compared. Results: No difference was found in diagnostic yield between direct puncture and trans-lung biopsies (93.8% vs. 98.8%, p=0.11). Major adverse events were major pneumothorax (n=13/163, 8.0%), pleural dissemination (n=18/163, 11.0%), and hemothorax requiring arterial embolization (n=1/163, 1.0%). Direct puncture caused major pneumothorax significantly less than trans -lung puncture did (0%, 0/80 vs. 15.7%, 13/83, p<0.001). No significant difference was found between the two biopsy methods regarding the incidence of pleural dissemination (11.0%, 11/80 vs. 8.4%, 7/83, p=0.32). Conclusion: Direct puncture biopsy of malignant lung tumors contacting to the pleura is justified. As a reliable and safe procedure for the diagnosis of lung lesions, computed tomography (CT)-guided lung biopsy is widely accepted. The most frequent adverse event (AE) is pneumothorax. Pneumothorax requiring chest tube placement develops in approximately 7% of patients (1-3). Although rare, severe AEs including hemothorax, air embolism and tumor seeding might occur (2). Several reported risk factors related to major pneumothorax are the presence of emphysema, no pleural contact of the target tumor, and longer needle passage within the aerated lung tissue (1, 4, 5). Therefore, direct puncture through the pleura without passing the lung might mitigate the risk of pneumothorax. Direct puncture of malignant tumors might increase the risk of pleural tumor dissemination because subcapsular location has been reported as a risk factor of tumor dissemination when radiofrequency ablation is applied to liver tumors (6). Nevertheless, no consensus has been reached on whether direct puncture of malignant tumors contacting the pleura decreases the risk of pneumothorax and increases the risk of tumor dissemination.This retrospective study was conducted to evaluate whether percutaneous direct puncture biopsy is justified in malignant lung tumors contacting to the pleura.