Li et al.

Journal of Cardiothoracic Surgery (2023) 18:86 Journal of

https://doi.org/10.1186/s13019-023-02183-8
Cardiothoracic Surgery

RESEARCH Open Access

Low‑dose versus standard‑dose computed

tomography‑guided biopsy for pulmonary
nodules: a randomized controlled trial
Er‑Liang Li1†, Ai‑Li Ma1†, Tao Wang1, Yu‑Fei Fu1, Han‑Yang Liu2* and Guang‑Chao Li3*

Abstract
Background To assess relative safety and diagnostic performance of low- and standard-dose computed tomography
(CT)-guided biopsy for pulmonary nodules (PNs).
Materials and methods This was a single-center prospective randomized controlled trial (RCT). From June 2020
to December 2020, consecutive patients with PNs were randomly assigned into low- or standard-dose groups. The
primary outcome was diagnosis accuracy. The secondary outcomes included technical success, diagnostic yield,
operation time, radiation dose, and biopsy-related complications. This RCT was registered on 3 January 2020 and
listed within ClinicalTrials.gov (NCT04217655).
Results Two hundred patients were randomly assigned to low-dose (n = 100) and standard-dose (n = 100) groups.
All patients achieved the technical success of CT-guided biopsy and definite final diagnoses. No significant differ‑
ence was found in operation time (n = 0.231) between the two groups. The mean dose-length product was markedly
reduced within the low-dose group compared to the standard-dose group (31.5 vs. 333.5 mGy-cm, P < 0.001). The
diagnostic yield, sensitivity, specificity, and accuracy of the low-dose group were 68%, 91.5%, 100%, and 94%, respec‑
tively. The diagnostic yield, sensitivity, specificity, and accuracy were 65%, 88.6%, 100%, and 92% in the standard-dose
group. There was no significant difference observed in diagnostic yield (P = 0.653), diagnostic accuracy (P = 0.579),
rates of pneumothorax (P = 0.836), and lung hemorrhage (P = 0.744) between the two groups.
Conclusions Compared with standard-dose CT-guided biopsy for PNs, low-dose CT can significantly reduce the
radiation dose, while yielding comparable safety and diagnostic accuracy.
Keywords Low-dose, Computed tomography, Biopsy, Lung nodule

Background
In recent years, computed tomography (CT) screening
†
Er-Liang Li and Ai-Li Ma have contributed equally to this work. for lung cancer has become a routine examination [1–3].
*Correspondence: Therefore, the detection rate of pulmonary nodules (PNs)
Han‑Yang Liu has also increased. However, according to the guidelines
[email protected] for the management of incidental PNs on CT, no routine
Guang‑Chao Li
[email protected] follow-up or optional CT at 12 months is recommended
1
Department of Radiology, Xuzhou Central Hospital, Xuzhou, China for PNs ≤ 5 mm. This is because the chances of malig-
2
Department of Interventional Radiology, Xuzhou Central Hospital, nancy are very low in nodules ≤ 5 mm in size [4]. How-
Xuzhou, China
3
Department of Radiology, Shanghai Sixth People’s Hospital, Shanghai, ever, the malignancy rate ranges from 43 to 63% when
China the PNs > 5 mm [5, 6]. CT-guided biopsy is commonly
employed for differential diagnosis in PNs due to its

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 2 of 11

advantages, such as simplicity and minimal invasiveness, Table 1 Scanning parameters between 2 groups
with the diagnostic accuracy of 92.7–97.0% [6–8]. Low-dose group Standard-dose group
Compared to CT-guided biopsy for lung masses, biopsy
for PNs is a more difficult technique due to the smaller Tube voltage 120 kV 120 kV
lesion size. Therefore, when performing CT-guided Tube current 15 mA 150 mA
biopsy for PNs, prolonged CT scans are usually required Thickness 2 mm 2 mm
to adjust the needle position and angle [9–11]. Conse- Collimation 16 × 0.75 mm 16 × 0.75 mm
quently, exposing individual patients to additional radia- Pitch 1.063 1.063
tions. Therefore, low-dose CT procedures were employed Rotation time 0.5 s 0.5 s
to decrease unnecessary dosing during CT-guided inter- Field of view 350 mm 350 mm
ventions [11]. Previous investigations have also described
low-dose CT-guided biopsy for diagnosing PNs [9, 10].
However, these studies were retrospective with a high risk
Randomization and blinding
of selection, comparability, and outcome bias. A previous
The eligible patients were randomly assigned into 1:1
randomized controlled trial (RCT) has been conducted
low-dose and standard-dose groups through the block-
to assess the relative safety and diagnostic accuracy
randomization technique (block size: 8). The rand-
between low-dose and standard-dose CT-guided lung
omized computer-generated numbers were placed within
biopsy [12]. However, that RCT contained both lung
sequentially-numbered, opaque, sealed envelopes. Before
masses and LNs [12], and thus, the outcomes of low-dose
the biopsy, envelopes were opened by a member of the
CT-guided biopsy for PNs are still unclear. Therefore, a
Science and Education department without a defined role
well-designed RCT which only focuses on low-dose CT-
in the trial. This RCT was single-blinded for the patients.
guided biopsy for PNs should be conducted.
In this study, we conducted an RCT to evaluate the
relative safety and diagnostic performance of low- and
CT‑guided biopsy protocols
standard-dose CT-guided biopsy for PNs.
a 16-row CT (Philips™, Cleveland, OH, USA) operated
All procedures were performed under the guidance of

through a CT-guided interventional radiology expert

Methods
(10+ years). Only the spiral CT was used for guiding the
Study design
biopsy procedures, while the CT fluoroscopy was not
The study protocol of this single-center RCT was
used.
approved by our center’s Institutional Review Board.
The patient’s position was decided according to the
All participants gave written, informed-consent. In
sites of PNs. The needle-paths were chosen depend-
addition, this RCT was listed within ClinicalTrials.gov
ing upon preoperative CT outcomes. The co-axial tech-
(NCT04217655).
outer needle (DuoSmart™, Modena, Italy) was used to
nique was employed during the procedure. First, a 17G
From June 2020 to December 2020, consecutive eligible
patients with PNs were randomly assigned into low-dose
pierce the lung-parenchyma, followed by a second CT
and standard-dose groups. Table 1 showed the scanning
scan to establish a needle-tip to displace it accordingly.
parameters of the low-dose and standard-dose CT.
semi-automatic core-needle (Wego™, Weihai, China) was
Once the outer needle-tip touched the PN, an 18G inner
Inclusion criteria: (a) clinical cases with PNs, detected
on CT; (b) solid PNs; (c) PNs > 8 mm; (d) PNs having
inserted via the outer needle to obtain the samples from
intermediate-high risk for lung cancer, depending upon
the PNs. A total of 3–4 samples were obtained from each
clinical/radiology-based characteristics [4].
PN and consequently submerged into 10% formaldehyde
Exclusion criteria: (a) patients who underwent CT-
until pathology assessment was done.
guided biopsy previously; (b) PNs which were stable in
After biopsy, another CT intervention was conducted
size for at least 1 year; (c) PNs that decreased in size dur-
to assess the procedure-associated complications.
ing follow-up; (d) clinical cases having a history of intense
cardiac, pulmonary, renal or coagulation dysfunctional
conditions; and (e) patients who refused to join this RCT.
Image reconstruction
The primary endpoint of this RCT was diagnostic accu-
CT raw data were reconstructed by a third-generation
racy. The secondary endpoints included technical suc-
image reconstruction technique (iDose, Philips, Hybrid
cess, diagnostic yield, operation time, radiation dose, and
Model Based Iterative Reconstruction) with strength
biopsy-related complications.
level of 5, slice thickness of 2 mm, and an increment of

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 3 of 11

1 mm. Reconstructions using a sharp reconstruction fil- size-reduction (without anticancer treatments), or main-
ter (Y-sharp) for lung structures and a standard recon- tained dimensions (no change or decreased < 20%) for a
struction filter (B) for soft tissue structures. 12 month-minimum period (with no anti-cancer treat-
ments), the final benign diagnosis could be accepted [6,
Imaging subjectivity 14].
Two radiologists (T.W. and E-L.L.) evaluated imaging True-positive was postulated when biopsy-based
standards independently. One radiologist (T.W.) had malignancy/suspicious was confirmed as malignant at
15 years of experience in CT-guided intervention and finalized-diagnosis. The true-negative was postulated
the other (E-L.L.) had 8 years of experience in CT-guided when biopsy-based benignities confirmed benignities at
intervention. Imaging-quality was evaluated across four finalized-diagnosis.
categories according to the previous study for low-dose Diagnosis yield = (biopsy-based malignancy + biopsy-
CT-guided lung biopsy [12]: category A: needle/PN based specific benignity)/all cases. Diagnostic accu-
were distinctly observable; category B: needle/PN were racy = (true positive + true negative)/all cases with the
adequately observable; category C: needle/PN were only final diagnosis. Pneumothorax and lung hemorrhage
somewhat observable; and category D: needle/PN could were assessed by chest CT. Lung hemorrhage was con-
not be seen. Therefore, only category A and B could be sidered as a novel consolidating/ground-glass opacity
used for CT-guided biopsy procedures. In the case of cat- around the needle tract [15]. High-grade hemorrhage was
egory C or D images, tube voltage and/or current were defined as the width of needle tract hemorrhage > 2 cm
adjusted to obtain higher quality images. However, the [15].
procedures should be considered a technical failure.
Statistical analyses
Evaluation of radiation dose The sample size was calculated based on diagnostic accu-
The radiation dose was assessed by the dose-length prod- racy with the non-inferiority analysis. Based upon past
uct (DLP) value. DLP was measured in mGy*cm and it investigations linked to CT-guided biopsy for PNs, we
was a measure of CT tube radiation output/exposure. estimated that the diagnostic accuracy was 94% [6, 8, 12].
DLP accounts for the length of the radiation output along Based on the − 10% of non-inferiority margin with the
the z-axis. one-sided significance category of 0.025, we estimated
that 200 patients (100 patients per group) were needed
Definitions and diagnoses after considering the 10% dropout rate.
PN was defined as a spherical/oval image of non-trans- Intention-to-treat (ITT) evaluations were performed
parent lesions ≤ 3 cm in diameter with neighboring depending on the total patient group quantity enrolled
pulmonary parenchyma/non-linked to atelectasis, medi- in this study. In contrast, per-protocol (PP) evalua-
astinal lymphadenopathy, or pleural effusion [4]. Tech- tions were performed depending on the total number
nical success for CT-guided biopsy was confirmed once of patients who achieved technical success and definite
pathologists finalised their diagnosis from extracted final-diagnoses.
specimens [12, 13]. Biopsy-based diagnoses could be The continuous data were compared through the inde-
classified into four categories: (a) malignancy; (b) sus- pendent sample t test when the distribution was normal,
pected malignancy; (c) specific benignity; and (d) non- while Mann–Whitney U test was used if the distribution
specific benignity. Suspected malignancy was defined was not normal. Categorical data were compared through
as atypical cells suspected of indicated malignancy [14]. Pearson χ2/Fisher exact test. Univariate and multivariate
Specific benignity was defined as dataset outcomes sug- logistic regression tests were used for predictive indica-
gested defined benign-diagnosis, including hamartomas tors of diagnosis accuracy and complications. Kappa
and tuberculosis [14]. Finally, non-specific benignity was analysis was conducted to assess inter-observer agree-

were conducted through SPSS® v.16.0 (SPSS Inc™, Chi-

defined as benign pathology characteristics that existed ment regarding imaging-quality. All statistical analyses
through and did not suffice for a formal diagnosis [14].
Resection was used to make the final diagnoses for both cago, Illinois, USA). The significance level was P < 0.05.
malignant and benign PNs. biopsy-based malignancy
and specific benignity could be accepted as the final Results
diagnosis [8–13]. Biopsy-based suspected malignancy Patients
and non-specific benignity could not be accepted as the A total of 200 patients who fulfilled the inclusion criteria
final diagnoses, if they were not confirmed by resection, were randomly assigned to low-dose (n = 100) and stand-
the CT medical observation would be useful for attain- ard-dose (n = 100) groups (Fig. 1). All patients achieved
ing a finalized diagnostic outcome. For an PN with ≥ 20% the technical success of CT-guided biopsy and the

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 4 of 11

Fig. 1 The flowchart of this study

definite final diagnoses. Therefore, ITT and PP analyses inter-observer agreements were very good across both
were conducted based on the same population (Table 2). groups (kappa value = 0.926 and 1.000, respectively). The
category A images occurred more frequently within the
Procedure details standard-dose group (P < 0.001).
Table 2 shows the procedure details of low-/standard-
dose CT-guided biopsy. There were no significant dif- Diagnosis
ferences in the number of needle pathways (n = 0.694), In low-dose group (Fig. 2), biopsy-based diagnoses
number of samples (P = 0.880), and duration of proce- included malignancy (n = 64), suspicious malignancy
dures (n = 0.231) between the two groups. The median (n = 1), specific benignity (n = 4), and non-specific benig-
DLP was significantly reduced within the low-dose group nity (n = 31). Among them, malignancy/specific benig-
in comparison to the standard-dose group (P < 0.001). nity results could be approved as finalized-diagnoses.
Suspicious malignancy was further validated as lung
Imaging‑quality adenocarcinoma through surgical resection. Twenty-five
Within the low-dose group, 72 images (72%) were con- non-specific benignities were confirmed as true benig-
sidered as category A and 28 images (28%) were con- nities by CT medical observation (n = 23) or surgical
sidered as category B. Within the standard-dose group, resection (n = 2). In contrast, 6 non-specific benignities
all imaging scans were considered as category A. The were confirmed as false benignities by surgical resection.

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 5 of 11

Table 2 Baseline data and procedure details between 2 groups

Low-dose group (n = 100) Standard-dose group (n = 100) P value

Normal data
Age (y) 63.7 ± 10.5 61.1 ± 13.0 0.144
Gender (male/female) 68/32 62/38 0.374
Smoking history 49 40 0.200
Tumor history 7 10 0.447
BMI (kg/m2) 23.1 ± 3.6 22.8 ± 3.2 0.590
Imaging findings
Emphysema 28 33 0.229
Lesion size (mm) 24.8 ± 4.2 23.5 ± 5.0 0.045
Lung (left/right) 42/58 45/55 0.669
Lobe (upper/non-upper) 45/55 42/58 0.669
Biopsy procedure
Lesion-pleura distance (< / ≥ 30 mm) 85/15 75/25 0.077
Needle-pleura angle (< / ≥ 50 degrees) 13/87 11/89 0.663
Prone/Supine/Decubitus 67/30/3 54/44/2 0.120
Number of needle pathways 1.3 ± 0.7 1.3 ± 0.7 0.694
Number of samples 3.3 ± 0.5 3.3 ± 0.5 0.880
Duration of procedure (min) 10.8 ± 4.1 11.6 ± 5.3 0.231
Complications
Pneumothorax (chest tube insertion) 14 (4) 13 (3) 0.836
Lung hemorrhage (high-grade hemorrhage) 24 (14) 26 (14) 0.744
Radiation dose
DLP (mGy-cm) 31.5 (Q1: 27.3; Q3: 38.2) 333.5 (Q1: 273.6; Q3: 407.9) < 0.001*
BMI body mass index, DLP dose-length product
*Mann–Whitney U test results

Therefore, the diagnostic yield, sensitivity, specificity, and The risk factors of diagnostic failure were detected by
diagnostic accuracy were 68%, 91.5%, 100%, and 94%, multivariate logistic regression test based on all patients.
respectively. In the univariate logistic regression test, non-prone posi-
Within the standard-dose group (Fig. 3), biopsy-based tion (P = 0.059) and upper lobe (P = 0.038) were found
diagnoses included malignancy (n = 61), suspicious to be associated with diagnostic failure. However, when
malignancy (n = 1), specific benignity (n = 4), and non- these 2 factors were put into the multivariate logis-
specific benignity (n = 34). Among them, the malig- tic regression test, no risk factor (P = 0.323 and 0.165,
nancy and specific benignity results could be approved respectively) was associated with the diagnostic failure
as finalized- diagnoses. Suspicious malignancy was fur- (Table 4).
ther validated as lung adenocarcinoma through surgi-
cal resection. Twenty-six non-specific benignities were Complications
confirmed as true benignities by CT medical observa- Pneumothorax was observed in 14 (14%) and 13 (13%)
tion (n = 22) or surgical resection (n = 4). Furthermore, 8 cases for low-dose and standard-dose groups, respec-
non-specific benignities were confirmed as false benigni- tively (P = 0.836). Among them, 4 (28.6%) and 3 (23.1%)
ties by surgical resection. Therefore, the diagnostic yield, patients required chest tube insertion (P = 0.745). In
sensitivity, specificity, and diagnostic accuracy were 65%, the univariate logistic regression test, lesion-pleura
88.6%, 100%, and 92%, respectively. distance ≥ 30 mm (P = 0.021), more needle path-
There were no significant differences observed in ways (P = 0.006) and longer duration of the procedure
diagnostic yield (P = 0.653), sensitivity (P = 0.554), and (P = 0.033) were found to be associated with pneumo-
diagnostic accuracy (P = 0.579) between the two groups thorax. However, when these 3 factors were put into the
(Table 3). The number of true positive, true negative multivariate logistic regression test, more needle path-
(Fig. 4), false positive, and false negative was shown in ways (P = 0.012) was the only risk factor of pneumotho-
Table 3. rax (Table 5).

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 6 of 11

Fig. 3 The images for standard-dose CT-guided biopsy for PN.

Fig. 2 The images for low-dose CT-guided biopsy for PN. a a Preoperative CT for the PN; b the procedure of standard-dose
Preoperative CT for the PN; b the procedure of low-dose CT-guided CT-guided biopsy
biopsy

Lung hemorrhage was observed in 24 (24%) and 26 were found to be associated with high-grade hemorrhage.
(26%) patients in low-dose and standard-dose groups, When these 8 factors were assessed in the multivariate
accordingly (P = 0.744) in low-dose and standard-dose logistic regression test, lesion-pleura distance ≥ 30 mm
groups, respectively. Among them, 14 (28.6%) and 14 (P = 0.031) was the only risk factor for high-grade hemor-
(23.1%) patients experienced high-grade hemorrhage rhage (Table 5).
(P = 0.749). All patients with lung hemorrhage were man-
aged with hemostasis. In the univariate logistic regression Discussion
test, smoking history (P = 0.03), higher BMI (P = 0.05), This RCT assessed the feasibility, safety, and diagnos-
smaller lesion size (P = 0.002), upper lobe (P = 0.052), tic ability between low- and standard-dose CT-guided
lesion-pleura distance ≥ 30 mm (P < 0.001), and needle- biopsy in PNs. Although the quality of images under
pleura angle ≥ 50 degrees (P = 0.012), more needle path- the standard-dose CT was significantly better, low-
ways (P = 0.068), longer duration of procedure (P = 0.011) dose CT resulted in similar technical success rates, the

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 7 of 11

Table 3 Diagnostic performance between 2 groups Diagnostic yield usually indicates the ability to make a
Low-dose Standard-dose P value
definite diagnosis by biopsy [16–18]. We found that the
group group (n = 100) low-dose CT did not reduce the diagnostic yield of CT-
(n = 100) guided biopsy. Furthermore, the diagnostic yield rates
Technical success rate 100% 100% –
in both groups (68% and 65%) were similar to previous
Biopsy pathological diagnosis 0.976
reports regarding CT-guided biopsy for PNs [9, 17]. Simi-
Malignancy 64 61
larly, Shpilberg et al. [16] revealed that low-dose CT did
Suspected malignancy 1 1
not reduce diagnostic yield for spine biopsies (low-dose
Specific benign 4 4
group: 69%; standard-dose: 60%, P = 0.60).
Diagnostic accuracy was the primary endpoint for
Non-specific benign 31 34
this RCT. The low-dose group’s sensitivity and diagnos-
Final diagnosis 0.877
tic accuracy rates were comparable to the standard-dose
Malignancy 71 70
group. This finding was similar to that in previous studies
Benign 29 30
which compared the effectiveness of low-dose and stand-
Diagnostic performance 0.830
ard-dose CT-guided lung biopsy [9, 10, 12–14]. Addition-
True positive 65 62
ally, in concurrence with previous studies, the diagnostic
False positive 0 0
accuracy rates in both groups (94% and 92%) were simi-
True negative 29 30
lar (90%-96%) for CT-guided biopsy for PNs [17, 19,
False negative 6 8
20]. However, we did not find any risk factors associated
Diagnostic yield 68/100 (68%) 65/100 (65%) 0.653
with the diagnostic failure. In past investigations on CT-
Sensitivity 65/71 (91.5%) 62/70 (88.6%) 0.554
guided biopsy, the risk factors of diagnostic failure usu-
Specificity 29/29 (100%) 30/30 (100%) –
ally encompassed fewer sample tissues and larger lesion
Overall accuracy 94/100 (94%) 92/100 (92%) 0.579
size [9, 12, 21, 22]. We used the co-axial technique in this
study and obtained 3–4 samples from each PN. There-
fore, the number of sample tissues did not interfere with
number of needle pathways, and the duration of pro- the diagnostic accuracy. With a larger lesion size, espe-
cedures compared to standard-dose CT. Furthermore, cially more than 5 cm, the diagnostic failure occurs due
unlike the conventional diagnostic images, the images to the higher rates of obtained necrosis tissue [21]. Our
for biopsy procedures do not require meticulous details RCT focused on the PNs, and we also found that lesion
of the lesion, but adequately observable locations of the size was not associated with diagnostic failure at univari-
needle tip and lesion are needed [12]. These findings ate logistic analysis (P = 0.580).
may indicate that low-dose CT images made by our Biopsy-related complications were also the impor-
parameters can also fulfill the biopsy criteria for PNs. tant endpoints in this RCT. The comparative results of
pneumothorax and lung hemorrhage indicated that the

a b c
Fig. 4 A group of images showed a case of true negative. a A PN (arrow) located at the right upper lobe; b The CT-guided biopsy indicated the
benign result; c The PN (arrow) decreased 3 months later

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 8 of 11

Table 4 Predictors of diagnostic accuracy

Variables Univariate analysis Multivariate analysis
Odds ratio 95% CI P value Odds ratio 95% CI P value

Age 1.033 0.981–1.089 0.218

Gender
Male 1
Female 0.727 0.220–2.409 0.602
Smoking history 1.728 0.577–5.179 0.328
BMI 0.991 0.845–1.162 0.909
Emphysema 1.786 0.592–5.390 0.303
Body position
Prone 1 1
Non-prone 2.983 0.961–9.259 0.059 1.906 0.531–6.839 0.323
Lesion size 1.036 0.914–1.176 0.580
Lung sides
Right 1
Left 0.705 0.227–2.183 0.544
Lobe
Non-upper 1 1
Upper 3.539 1.071–11.699 0.038 2.592 0.675–9.947 0.165
Lesion-pleura distance
< 30 mm 1
≥ 30 mm 0.649 0.139–3.024 0.582
Needle-pleura angle
< 50 degrees 1
≥ 50 degrees 1.834 0.229–14.687 0.568
Number of samples 2.321 0.778–6.929 0.131
Duration of procedure 1.007 0.900–1.125 0.908
CT protocol
Low-dose 1
Standard-dose 1.362 0.455–4.080 0.581
BMI body mass index, CI confidential interval, CT computed tomography

low-dose protocol did not decrease the safety of biopsy. may be attributed to the use of iterative reconstruction
Furthermore, the chest tube requirement rates were only technique [25]. The reconstruction technique can signifi-
4% and 3% in low-dose and standard-group. Risk factors cantly reduce the image noise and provide better overall
for pneumothorax and high-grade hemorrhage included image quality [25].
a greater number of needle pathways, smaller lesion size, This study had some limitations. First, we only used
and lesion-pleura distance ≥ 30 mm. These risk factors the block randomization method, but the randomiza-
were consistent with past investigations regarding CT- tion was not performed by the stratification of the lesion
guided lung biopsy [10, 20]. size. Therefore, the unbalanced data of lesion size was
The low-dose CT protocol could be achieved by reduc- observed, which may cause selective bias. However, this
ing the tube voltage and/or current [12, 23, 24]. In our study included PNs only. The difference in mean lesion
study, we adjusted the tube current to 10% of the nor- size between the two groups was not large (24.8 mm vs.
mal tube current (150 mA) and achieved a significant 23.5 mm). These findings may reduce the risk of bias.
reduction in radiation exposure. This result was largely Second, this investigation did not find the risk factor of
consistent with past investigations regarding low-dose diagnostic failure. This finding could be due to the lim-
CT-guided lung biopsy [12, 23, 24]. Although major dose ited sample size. Third, we did not collected the C­ TDIvol
reductions exacerbated noise and decreased image qual- value. Although many previous studies also did not pro-
ity, low-dose CT at 120 kV and 15 mA produced an image vide the ­CTDIvol value [9, 10, 12, 16], DLP with ­CTDIvol
quality adequate for the biopsy procedure. This result may have a better convincingness on the reduction of

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 9 of 11

Table 5 Predictors of biopsy-related complications

Variables Univariate analysis Multivariate analysis
Odds ratio 95% CI P value Odds ratio 95% CI P value

Pneumothorax
Age 0.997 0.964–1.032 0.884
Gender
Male 1
Female 1.328 0.580–3.045 0.502
Smoking history 1.185 0.526–2.671 0.682
BMI 0.920 0.810–1.044 0.196
Emphysema 1.163 0.491–2.759 0.731
Body position
Prone 1
Non-prone 0.491 0.197–1.223 0.126
Lesion size 0.996 0.914–1.085 0.926
Lung sides
Right 1
Left 0.733 0.318–1.693 0.468
Lobe
Non-upper 1
Upper 1.475 0.654–3.326 0.349
Lesion-pleura distance
< 30 mm 1 1
≥ 30 mm 2.804 1.169–6.724 0.021 2.350 0.905–6.102 0.079
Needle-pleura angle
< 50 degrees 1
≥ 50 degrees 1.821 0.403–8.229 0.436
Number of needle pathways 2.322 1.280–4.214 0.006 1.954 1.156–3.302 0.012
Duration of procedure 1.151 1.011–1.310 0.033 1.048 0.956–1.150 0.315
CT protocol
Low-dose 1
Standard-dose 0.918 0.408–2.067 0.836
High-grade lung hemorrhage
Age 0.982 0.951–1.014 0.261
Gender
Male 1
Female 1.239 0.545–2.817 0.609
Smoking history 0.366 0.148–0.905 0.030 0.425 0.156–1.159 0.095
BMI 1.117 1.000–1.248 0.050 1.111 0.979–1.260 0.103
Emphysema 0.728 0.292–1.817 0.497
Body position
Prone 1
Non-prone 1.947 0.871–4.353 0.104
Lesion size 0.802 0.701–0.927 0.002 0.931 0.850–1.020 0.123
Lung sides
Right 1
Left 0.817 0.361–1.848 0.628
Lobe
Non-upper 1 1
Upper 2.252 0.995–5.098 0.052 2.085 0.812–5.351 0.127

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Li et al. Journal of Cardiothoracic Surgery (2023) 18:86 Page 10 of 11

Table 5 (continued)
Variables Univariate analysis Multivariate analysis
Odds ratio 95% CI P value Odds ratio 95% CI P value

Lesion-pleura distance
< 30 mm 1 1
≥ 30 mm 10.147 2.835–36.321 < 0.001 3.058 1.106–8.461 0.031
Needle-pleura angle
< 50 degrees 1 1
≥ 50 degrees 0.185 0.050–0.686 0.012 0.419 0.130–1.350 0.145
Number of needle pathways 1.532 0.969–2.422 0.068 1.352 0.726–2.517 0.341
Duration of procedure 1.187 1.041–1.355 0.011 0.993 0.896–1.101 0.896
CT protocol
Low-dose 1
Standard-dose 1.000 0.450–2.223 1.000
BMI body mass index, CI confidential interval, CT computed tomography

radiation dose. Fourth, the patients were from a single- Competing interests
The authors declare that they have no competing interests.
center and further multi-center studies should be con-
ducted to validate the results.
Received: 15 April 2022 Accepted: 12 March 2023

Conclusions
In conclusion, compared to the standard-dose CT-guided
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