RESEARCH ARTICLE

Diagnostic Accuracy of CT-Guided

Transthoracic Needle Biopsy for Solitary
Pulmonary Nodules
Wen Yang1☯, Wenkui Sun1☯, Qian Li1, Yanwen Yao1, Tangfeng Lv1, Junli Zeng1,
Wenjun Liang1, Xiaojun Zhou2, Yong Song1*
1 Department of Respiratory Medicine, Jinling Hospital, Nanjing University, School of Medicine, Nanjing,
China, 2 Department of pathology, Jinling Hospital, Nanjing University, School of Medicine, Nanjing, China

☯ These authors contributed equally to this work.

* [email protected]

Abstract
To evaluate the diagnostic accuracy of computed tomography (CT)-guided percutaneous
lung biopsy for solitary pulmonary nodules. Three hundred and eleven patients (211 males
and 100 females), with a mean age of 59.6 years (range, 19–87 years), who were diag-
OPEN ACCESS
nosed with solitary pulmonary nodules and underwent CT-guided percutaneous transtho-
Citation: Yang W, Sun W, Li Q, Yao Y, Lv T, Zeng J,
racic needle biopsy between January 2008 and January 2014 were reviewed. All patients
et al. (2015) Diagnostic Accuracy of CT-Guided
Transthoracic Needle Biopsy for Solitary Pulmonary were confirmed by surgery or the clinical course. The overall diagnostic accuracy and inci-
Nodules. PLoS ONE 10(6): e0131373. doi:10.1371/ dence of complications were calculated, and the factors influencing these were statistically
journal.pone.0131373 evaluated and compared. Specimens were successfully obtained from all 311 patients. A
Editor: Robert L Schmidt, University of Utah Health total of 217 and 94 cases were found to be malignant and benign lesions, respectively, by
Sciences Center, UNITED STATES biopsy. Two hundred and twenty-five (72.3%) carcinomas, 78 (25.1%) benign lesions, and
Received: March 3, 2015 8 (2.6%) inconclusive lesions were confirmed by surgery and the clinical course. The diag-
Accepted: May 31, 2015 nostic accuracy, sensitivity, and specificity of CT-guided percutaneous transthoracic needle
biopsy were 92.9%, 95.3%, and 95.7%, respectively. The incidences of pneumothorax and
Published: June 25, 2015
self-limiting bleeding were 17.7% and 11.6%, respectively. Taking account of all evidence,
Copyright: © 2015 Yang et al. This is an open
CT-guided percutaneous lung biopsy for solitary pulmonary nodules is an efficient, and safe
access article distributed under the terms of the
Creative Commons Attribution License, which permits diagnostic method associated with few complications.
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.

Data Availability Statement: Data are available from

Figshare at http://dx.doi.org/10.6084/m9.figshare.
Introduction
1430020.
With improved awareness of public health and the recent advances of various imaging technol-
Funding: The present study was supported by the
National Natural Scientific Foundation of 257 China
ogies, the detection rate of solitary pulmonary nodules (SPNs) is continuously increasing, with
(no. 81302032). The funders had no role in study the reported detection rate currently being 8–51% [1]. An SPN is classically defined as a single,
design, data collection and analysis, decision to discrete, round or oval opacity, less than or equal to 3 cm in diameter that is completely sur-
publish, or preparation of the manuscript. rounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated
Competing Interests: The authors have declared with adenopathy, atelectasis, or other lung lesions [2]. Accurate diagnosis of SPNs has always
that no competing interests exist. been difficult, and represents a substantial problem in chest imaging diagnoses. Preoperative

PLOS ONE | DOI:10.1371/journal.pone.0131373 June 25, 2015 1/9

 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

differentiation of benign and malignant SPNs is critical to reducing the rate of unnecessary
operations on benign SPNs, and is hence of utmost importance. For years, computed tomogra-
phy-guided percutaneous transthoracic needle biopsy (CT-PTNB) has represented a major
approach for the diagnosis and differential diagnosis of pulmonary masses, owing to its sim-
plicity and minimal invasiveness. However, recently, CT-PTNB has been challenged by new
technologies with outstanding safety results, such as electromagnetic navigation bronchoscopy
(ENB) and endobronchial ultrasonography (EBUS). Thus, we cannot help but wonder if, with
the constant development of new technologies, CT-guided PTNB will ultimately be replaced?
To evaluate the diagnostic accuracy of CT-guided PTNB for SPN, we conducted 311 SPN
patients and analysed the associated complications, and discuss the diagnostic value and safety
issues of CT-PTNB in the present study.

Methods
Patients
Between January 2004 and January 2014, 3383 patients underwent percutaneous CT-guided
lung biopsy at our hospital. Of these, 311 (9.2%) consecutive cases identified as SPNs were
enrolled. The diameters of all nodules were measured using lung window settings. All patients
had undergone diagnostic chest CT, either in our hospital or at another hospital, before the
biopsy (Fig 1).

Ethics Statement
This study was carried out in accordance with the Declaration of Helsinki and local institu-
tional ethical and legal requirements. The study was approved by the Medical Ethics

Fig 1. Flow diagram of the eligible patients and the enrolling process of the study.
doi:10.1371/journal.pone.0131373.g001

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

Committee of Jinling Hospital, Nanjing, China. The written informed consent was received
from all participants or statutory guardians before study enrollment.

Procedure
All biopsies were performed by three physicians experienced in pneumology and radiology. A
commercially available CT scanner was used for the biopsy. The patients underwent CT in the
prone, supine, or lateral position based on the shortest distance from the lesion to the body sur-
face. Images were obtained from the region of interest by using a section thickness of 5 mm and
were viewed by using lung window settings. One experienced physician performed all biopsies.
After local anaesthesia with 2% lidocaine from the skin to pleura, a coaxial 18-gauge needle
(Lot Number, REXK0682; Bard Peripheral Vascular, Inc., Tempe, AZ), (15 cm or 9 cm in
length) was inserted under intermittent CT guidance with its trajectory pointing toward the
lung lesion. The initial puncture was performed without penetrating the pleura. CT images
were obtained to assess the position of the biopsy needle. If the nodule was on the extended
path of the needle track, the biopsy procedure was continued. When the nodule was pene-
trated, the needle tip was checked and a specimen was obtained. This procedure was typically
performed once, and occasionally performed twice. The patients were instructed to hold their
breath during the CT scanning and the biopsy process. The resected specimen was placed in
10% formaldehyde for pathological examination.
The needle path length was defined as the length between the skin surface and the centre of
the solitary pulmonary nodule. In the lung, the needle path length was defined as the length
between the pleura and the centre of the solitary pulmonary nodule. The distance to the pleura
was defined as the distance from the pleura of the puncture to the centre of the solitary pulmo-
nary nodule. The needle-pleural angle was defined as the angle formed between the biopsy nee-
dle and the tangent to the pleura.
After removal of the biopsy needle, completion images were obtained to detect any post-
biopsy complication, such as pneumothorax and haemorrhage. The patients were requested to
stay supine for at least 6 hours and were only allowed to get off the bed 24 hours later. The
placement of a chest tube was considered in the event a patient became symptomatic or a large
(>30%) pneumothorax was found.

Diagnostic criteria
Ture positive: I)Patients whose biopsy histopathological findings showed malignancy and who
received surgical resection were considered as malignant. II) Positive findings at biopsy histo-
pathology were considered to be true-positive when biopsy of another site revealed cancer with
the same histologic characteristics, or when the lesion increased in size and other proven
metastases were found, or when the tumour size was reduced after radiotherapy, chemother-
apy, or targeted therapy.
Ture negative: I)Patients whose biopsy histopathological findings showed a benign lesion
and received surgical resection were considered as benign. II)Patients whose biopsy histopath-
ological findings showed a benign lesion that had shrunk, disappeared, or remained unchanged
after at least 1 year follow-up.
False positive: I)Patients whose biopsy histopathological findings showed malignancy and
surgical resection yielded a benign diagnosis. II) The lesions subsequently disappeared or
decreased in size or remained stable on the follow-up CT for at least 1year.
False negative: I)Patients whose biopsy histopathological findings showed benign and surgi-
cal resection yielded a malignancy diagnosis. II) The lesions increased in size or other proven
metastases were diagnosed.

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

Inconclusive diagnose: patients who lost of follow-up or the follow-up time being less than
1 year were defined.

Statistical analysis
Statistical analyses of the data were performed using SPSS version 21 (SPSS Inc., Chicago, IL).
The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of
CT-guided PTNB were calculated using the standard definitions. True-positive and true-nega-
tive cases were considered diagnosed cases. Falsepositive, false-negative and inconclusive diag-
nose cases were considered nondiagnosed cases. The diagnostic accuracy, and pneumothorax
rate were statistically compared for each influencing factor using bivariate logistic regression
analyses and the Chi-Square test, with P values <0.05 considered statistically significant.

Results
Diagnostic accuracy
Three hundred and eleven consecutive patients fulfilled the diagnostic criteria of SPN and were
enrolled in this study. The patient characteristics are shown in Table 1. Specimen samples were
successfully obtained from 311 SPNs (Table 2).
Of the 311 SPNs, 217 and 94 cases were found to be malignant and benign lesions, respec-
tively, by biopsy. Of these, 215 cases diagnosed as malignant and 74 diagnosed as benign were
found to be true-positive and true-negative cases, respectively. Two malignant and 12 benign

Table 1. Patient demographics and nodule characteristics (N = 311).

Characteristic N %
Age (years)
Range 19–87
Mean 59.6
Sex
Male 211 67.8
Female 100 32.2
Size of Pulmonary Nodule
>10 mm 3 1
>10 mm and 20 mm 152 48.8
>20 mm and 20 mm 156 50.2
Location of Pulmonary Nodule
Peripheral 221 71.1
Central 90 28.9
Left upper lobe 76 24.4
Left lower lobe 65 20.9
Right upper lobe 99 31.8
Right middle lobe 14 45
Right lower lobe 57 18.3
Smoker
Yes 153 49.2
No 158 50.8
History of cancer
Yes 19 6.1
No 292 93.9
doi:10.1371/journal.pone.0131373.t001

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

Table 2. Percutaneous lung biopsy details.

Characteristic N
Needle path length in lung (mm)
10 3
11–20 93
21–30 81
31–40 55
41–50 39
51–60 19
>60 21
Position of patients
Prone 155
Supine 129
Lateral 27
No. of punctures
1 274
2 35
3 2
doi:10.1371/journal.pone.0131373.t002

SPNs were false-positive and false-negative cases, respectively. The revising diagnoses were
established at surgery (n = 9), by sputum cytology (n = 1), or by follow-up examination (n = 2).
The remaining 8 patients were diagnosed as ‘inconclusive’, owing to being lost to follow-up
(n = 4) or the follow-up time being less than 1 year (n = 4).
The final diagnoses were established as follows: 225 (72.3%) lesions were malignant (158
adenocarcinoma, 34 squamous cell carcinoma, 4 undifferentiated non-small cell carcinomas,
6 small cell carcinomas, 4 large cell carcinomas, 1 pulmonary sarcoma, 2 adenosquamous
carcinomas, 2 adenocarcinoma in situ, and 14 metastatic carcinomas), 78 (25.1%) lesions
were benign (2 sclerosing haemangiomas, 24 tuberculosis, 45 organised pneumonia, 2 pul-
monary hamartoma, 2 pulmonary aspergillosis, and 1 vasculitide), and 8 lesions (2.6%) were
inconclusive (Table 3).
The overall diagnostic yield of CT-PTNB for SPN was 92.9%. The sensitivity, specificity,
and negative and positive predicted values for malignancy were 95.3%, 95.7%, 78.6%, and
99.2%, respectively.
The results of the logistic regression analyses of factors associated with the diagnostic accu-
racy of CT-PTNB are shown in Table 4. The diagnostic accuracy was significantly affected by
the lesion size (P = 0.003) and the number of punctures (P = 0.006).
Further analysis of the 200 non-small cell lung cancer patients showed that stage IA, IIIA,
IIIB, and IV tumours accounted for 100 (50%), 27 (13.5%), 9 (4.5%) and 64 (32%) cases,
respectively.

Complications of CT-PTNB biopsy

Pneumothorax occurred in 55 (17.7%) patients, with 3 cases (0.9% of all patients and 5.5% of
the pneumothorax patients) requiring thoracotomy tube placement. The remaining 52 patients
improved without any treatment. Higher rates of pneumothorax were encountered in patients
older (P = 0.006), in cases where a long needle path length in the lung was used (P = 0.007), in
patients who underwent CT-PTNB in the lateral position (P = 0.034), and in patients who
underwent repeated puncture (P = 0.001) (Table 4).

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

Table 3. Final diagnoses (N = 311).

Final Diagnosis N %
Malignant 225 72.3
Lung adenocarcinoma 158 50.9
Lung squamous cell carcinoma 34 11
Lung large cell carcinoma 4 1.3
Small cell lung carcinoma 6 1.9
Undifferentiated lung carcinoma 4 1.3
Metastatic carcinomas 14 4.5
Pulmonary sarcoma 1 0.3
Lung adenosquamous carcinoma 2 0.6
Lung adenocarcinoma in situ 2 0.6
Benign 78 25.1
Sclerosing haemangioma 2 0.6
Tuberculosis 24 7.7
Organised pneumonia 45 14.5
Pulmonary hamartoma 2 0.6
Pulmonary aspergillosis 4 1.3
Vasculitides 1 0.3
Inconclusive 8 2.6
Total 311 100.0

* Inconclusive diagnose cases were considered nondiagnosed cases in calculation of diagnostic accuracy.

doi:10.1371/journal.pone.0131373.t003

Pulmonary haemorrhage was found in 36 (11.6%) patients, and haemoptysis occurred in 11

(3.5%) patients. In all patients, the bleeding stopped when treated with hematischesis drugs.
Twenty-five (8%) patients showed some blood in the sputum after CT-PTNB.

Discussion
SPN is a relatively common clinical disease. With the recent advances in imaging technologies,
the incidence of SPN has been steadily increasing each year, and the diagnosis of SPN has
become an important task for clinicians and radiologists. The malignant rate of SPN in clinical
cases has been reported to range 10–68% [3]. Previously, the diagnosis of benign or malignant
SPN was determined mainly by the imaging features. The majority of previous studies have
suggested that lobulation, spiculation, and adjacent pleural indentation of the nodule were risk
factors of malignancy, whereas partial calcification was indicative of benign nodules. In

Table 4. Diagnostic accuracy and pneumothorax rates according to clinicodemographic characteristics.

Characteristic Diagnostic accuracy Pneumothorax rate

OR (95%CI) P vaule OR (95%CI) P vaule

Age (years) 1.859 (0.666~5.193) 0.237 2.401 (1.278~4.479) 0.006
Sex 1.675 (0.574~4.889) 0.345 0.922 (0.463~1.837) 0.818
Size of Nodule 1.161 (1.051~1.283) 0.003 1 (0.936~1.068) 0.988
Needle path length 0.986 (0.959~1.014) 0.317 1.031 (1.011~1.051) 0.007
No. of punctures 0.267 (0.105~0.681) 0.006 4.166 (1.955~8.7) 0.001

OR: odds ratio.

doi:10.1371/journal.pone.0131373.t004

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

addition, more studies later reported that the risk of malignancy may also be closely related to
the patients’ gender, age, smoking history, and history of malignant tumours [4, 5].
In our study, 303 cases of SPN were diagnosed, and 74.3% of these were found to be malig-
nant. Further analysis showed that among 200 cases of non-small cell lung cancer, 63.5% of
stage IA and IIIA patients showed indication for operation, suggesting that timely diagnosis of
SPN is critical to ensure early diagnosis and prompt treatment of lung cancer.
Obtaining a tissue biopsy for pathological examination is key to ensuring prompt and
appropriate diagnosis and treatment of SPNs. Haaga and Alfidi reported the first case of
CT-PTNB in 1976 [6], and, since then, CT-PTNB has been constantly developed and is cur-
rently widely employed as a routine diagnostic technique for SPN due to its several advantages,
such as a high true-positive rate, minimal invasiveness, and low cost. Out of the 311 SPN
patients in our study, there were 2 false positive cases, 12 false negative cases, and 8 undiag-
nosed cases, resulting in a diagnostic accuracy of CT-PTNB of 92.9%. Logistic regression analy-
ses revealed that nodule size and the number of needle punctures could affect the diagnostic
accuracy, whereas the depth of needle puncture and the patients’ body position did not. To a
certain degree, the number of needle punctures depended on the size and location of the nod-
ule. For most of the nodules, we could obtain a sufficient specimen by only one biopsy. How-
ever, when the nodule was too small or difficult to access, and if the first specimen was not
sufficient for pathological examination, a second biopsy was needed in some cases.
In the past decade, new techniques have emerged that offer guidance through the tracheo-
bronchial tree during bronchoscopy, which help reach and biopsy the nodule, such as ENB and
EBUS [7, 8]. Owing to the development and advantages of these new technologies, we cannot
help but wonder whether CT-PTNB will ultimately be replaced?
The diagnostic accuracy of peripheral pulmonary nodules by EBUS and ENB has been
reported as 46–86.2% [9–11] and 62.5–76.9%, respectively [12, 13]. Steinfort et al.[14] compre-
hensively analysed 1420 EBUS biopsies of peripheral pulmonary tumours from 16 studies, and
reported a sensitivity of 0.73 (95% confidence interval [CI], 0.70–0.76). In addition, a meta-
analysis of 15 studies involving 1033 patients with SPN by Gex et al.[15] showed that the diag-
nostic accuracy of pulmonary nodules with ENB was 73.9% (95% CI, 68.0–79.2). Accordingly,
our results show that, in some instances, CT-PTNB can be at least as accurate as ENB and
EBUS. Although it should be noted that some, more central lung lesions, are more amenable to
EBUS-directed sampling.
Regarding the safety of PTNB, the major complications are known to be pneumothorax and
pulmonary haemorrhage, with reported incidence rates of 10–40% and 26–33%, respectively
[16]. In our study, out of all 311 SPN patients, there were 55 cases of pneumothorax (17.7%), 2
cases for whom thoracentesis was performed and one case for whom tube drainage was per-
formed, while the rest were mild pneumothorax cases that recovered after self-absorption.
Moreover, there were 36 cases of self-limiting pulmonary haemorrhage (11.6%) without fatal
adverse reactions. Correlation analysis revealed that the incidence of pneumothorax was closely
related to age (P = 0.006), number of needle punctures (P = 0.001), the patients’ body position
during CT-PTNB (P = 0.034), and the depth of needle puncture inside the lung (P = 0.007),
with older age, multiple needle punctures, and deeper needle punctures being major risk factors
for pneumothorax. In addition, as mentioned above, we noticed that the patients’ position dur-
ing needle puncture also greatly correlated with the risk of pneumothorax. The incidence of
pneumothorax was higher when the patients were biopsied in the lateral position, as compared
to in the supine and prone positions. We speculate that this is likely owing to the fact that it
was more difficult for the patient to hold still for a long time in the lateral position during the
CT scanning and puncture, and that any movement/change of body position might lead to
pneumothorax. Although the incidence rates of pneumothorax and pulmonary haemorrhage

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 CT-PTNB Is Necessary for Solitary Pulmonary Nodules

of CT-PTNB in this study were higher than that of bronchoscopic biopsy, the 55 cases of pneu-
mothorax and 36 cases of haemorrhage were all relatively mild, and the patients recovered
after treatment without any fatal complications.
In terms of cost, CT-PTNB at a 3 armour hospital in China costs approximately 1,500 RMB
($241), whereas EBUS costs about 3,500 RMB ($563), and ENB costs around 8,000 RMB
($1287). Therefore, CT-PTNB has a significant price advantage.
In the last decade, we carried out more than three thousand CT-PTNB procedures, which
yielded a high diagnostic accuracy and no fatal adverse complications. Having strict selection
criteria of the appropriate patients is one of the most important factors for achieving this high
diagnostic accuracy and low rate of adverse reactions. For CT-PTNB, the risk of pneumothorax
increases if the nodule is near the hilum or away from the surface, if the puncture path passes
the pulmonary bulla, or if the patient’s lung function is compromised. On the other hand, the
risk of haemorrhage is high if the nodule is located near large blood vessels, and other diagnos-
tic methods should be considered in these cases.
In conclusion, CT-PTNB has several advantages, including a high diagnostic accuracy, low
cost, and manageable adverse reactions. With proficient operating skills and precise position-
ing of the puncture, the diagnostic accuracy of CT-PTNB can be greatly improved, and its com-
plications can be minimised. Thus, this conventional method is still useful for most SPN cases,
as determined based on the SPN features; and development of new complementary technolo-
gies will likely enhance the usefulness of this diagnostic procedure even further.

Supporting Information
S1 Checklist. STARD Checklist.
(PDF)

Author Contributions
Conceived and designed the experiments: YS XZ TL. Performed the experiments: WY WS.
Analyzed the data: WY YY JZ WL. Contributed reagents/materials/analysis tools: WY WS.
Wrote the paper: WY WS QL.

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