Patient reported experiences of CT guided lung biopsy: a prospective cohort study

CT guided lung biopsy is a common radiological procedure performed throughout the world. It is frequently used to obtain tissue to confirm a suspected diagnosis of lung cancer to enable the histological analysis necessary for treatment planning. The procedure may also be performed for non-malignant disease, such as to obtain a specimen for microbial analysis in suspected infection. However, the majority of biopsies are for malignant disease.

Within the County Durham and Darlington Foundation Trust approximately 120 CT guided lung biopsies are performed per year across the three hospital sites. Complications of CT guided lung biopsy have been well documented and include pneumothorax (4-60%), pneumothorax requiring chest drain (5-10%), haemoptysis (10%), pain, air embolism, atrial fibrillation, tumour seeding of the biopsy tract and, on rare occasions, death (0.5%)[1‐13]. To our knowledge and after an extensive literature search, all studies and procedure audits performed to date have been retrospective analyses of hospital databases, PACS (Picture Archiving and Communication System) image databases and patient notes. There have been no prospective studies directly questioning patients regarding their experiences. We propose that the reported complication rates are under-representative and only include those patients who presented to the specific hospital in the study. Patients who represented post lung biopsy to a different hospital, who consulted or sought advice from primary care services or who had symptoms after the biopsy but did not seek medical treatment would be missed from the current literature. Any less severe complications (such as minor haemoptysis) not requiring physician input would also be missed. We believe that by consulting the patients directly a more accurate assessment of the true complication rates of CT guided lung biopsy will be possible.

This was a prospective cross sectional survey of 49 patients (40% recruitment rate) who underwent CT guided lung biopsy within County Durham and Darlington Foundation Trust. Ethical approval was granted by the County Durham and Tees Valley Ethics Committee and funding was provided by County Durham and Darlington Foundation Trust.

Adult patients with capacity were eligible for inclusion in the study if they had previously undergone a CT examination of the chest demonstrating an abnormality within the chest that was suspected to be malignant or indeterminate. Patients were excluded from the study if they were under 18 years of age, lacked capacity or were not contactable by telephone. Patients were invited to participate in the study during a clinic appointment with the referring physician and an information leaflet was supplied. Further information about the study was given by the research nurse prior to the procedure and written and informed consent was taken to participate in the study. The patients were re-assured that they could withdraw their consent at any time without detriment to their future care. Consent for the procedure was taken by the physician performing the biopsy, separately from the consent for involvement in the study.

The CT guided biopsy was performed to a standard technique by one of two Consultant Radiologists (JS, PO): the patient was placed within the CT scanner and a suitable position for biopsy was ascertained. Local anaesthetic was infiltrated into the sub-cutaneous tissues and an 18G core biopsy needle was placed within the lesion. Usually, one to three samples were taken, depending on radiologist preference and the subjective opinion of whether an adequate sample had been obtained. No pathology service was available to analyse the sample at the time of the biopsy to check for adequacy. Routine post-procedure care included observation within the hospital for four hours. Additionally, a post-procedure chest radiograph was obtained to determine whether the patient had sustained a pneumothorax. Patients who were well post biopsy were discharged home after four hours. If the patient was unwell, then local hospital admission was arranged.

Within two weeks following the procedure, the patients were telephoned by the study nurse and a structured telephone interview was undertaken. It was made clear to the patients at the time of the biopsy that the purpose of the telephone interview was to discuss the biopsy procedure and not the biopsy results. The patients were informed that the biopsy results would be obtained from the referring physician during their next clinic appointment and that the study nurse did not have any information about the biopsy results.

The questions asked during the telephone interview were standardised (Table 1).

On average, the interview lasted 20 minutes. All patients who agreed to participate in the study were contacted post-biopsy and no patients withdrew their consent. The qualitative information was initially recorded on paper and then collated into a database.

In total, 49 patients were recruited to the study over 15 months. There were 28 male and 21 female patients, with ages ranging from 34 to 87.

Our study confirms that the described procedure is safe to perform as a day-case and tolerated well by most patients. The majority of our patients felt adequately informed about the procedure. However, an area for development is to counsel about the potential for some patients to experience more prolonged post-procedural pain, with a strategy for managing this pain.

Our complication rates are commensurate with the reported rates in the literature and there is no significant difference between the patient reported rates and those obtained from retrospective review in our patient cohort. We now know the true complication rates for our institutions and can advise our patients accordingly.