Table 2. Summary of the Recommendations for the Key Questions.
| Recommendations | Recommendation Grade | Evidence Level |
|---|---|---|
| Key Question 1. What are the indications for PTNB for lung lesions? | ||
| 1-1) What are the conventional indications and general factors for considering PTNB? | ||
| - We recommend assessing the risk of malignancy of pulmonary lesions before performing a biopsy | A | III |
| - We suggest performing a biopsy of pulmonary lesions that show definite growth | B | III |
| - We suggest performing a biopsy of multiple nodular lesions of unknown etiology | B | III |
| - We suggest performing a biopsy of persistent focal infiltrates of unknown etiology | B | III |
| - We recommend assessing the risks and benefits of a biopsy procedure before performing the biopsy | A | II |
| - We recommend evaluating the persistence of subsolid lesions by performing a follow-up CT scan 6–12 months later for pure ground-glass lesions, and 3–6 months later for part-solid lesions | A | II |
| - We suggest that biopsy may be considered for persistent or growing part-solid lesions larger than 15 mm overall and for those with a solid portion that is 8 mm or larger in diameter (remark: if a persistent or growing part-solid lesion is strongly suspected to be lung cancer, it is recommended to proceed directly to surgical resection without PTNB) | B | II |
| 1-2) What are the upcoming indications for PTNB in the era of personalized medicine? | ||
| - We recommend performing a biopsy to acquire a tumor specimen for molecular profiling of lung cancer or intrathoracic metastasis | A | I |
| - We recommend performing a biopsy according to the patient’s desire or clinical situation | A | III |
| - We recommend a multidisciplinary discussion to determine the necessity and site of the biopsy | A | III |
| 1-3) What are the contraindications for PTNB? | ||
| - We recommend not performing a biopsy in the following circumstances, which are absolute contraindications | A | III |
| 1) Patients who do not provide informed consent | ||
| 2) Pulmonary vascular lesions | ||
| - We suggest that PTNB should be carefully considered in the following circumstances based on a multidisciplinary risk-benefit assessment | B | III |
| 1) Patients with respiratory failure or with a predicted forced expiratory volume in 1 second of less than 35% | ||
| 2) Patients on mechanical ventilation | ||
| 3) Patients with bleeding tendency or coagulopathy | ||
| 4) Patients with pulmonary arterial or venous hypertension | ||
| 5) Patients who underwent pneumonectomy or functionally have a single lung | ||
| 6) Uncooperative patients | ||
| Key Question 2. Which laboratory and imaging evaluations are appropriate for patients before PTNB? | ||
| 2-1) Which laboratory tests are required prior to PTNB? | ||
| - We recommend checking hematocrit, prothrombin time, activated partial thromboplastin time, and platelet count before performing the biopsy | A | II |
| - We recommend withholding anticoagulants before performing the biopsy | A | II |
| 2-2) Should a pulmonary function test be performed prior to PTNB? | ||
| - We suggest performing a pre-procedural pulmonary function test in patients suspected of having severe chronic obstructive pulmonary disease | B | III |
| - We recommend a multidisciplinary discussion before performing PTNB in patients suspected of having severe chronic obstructive pulmonary disease | A | III |
| 2-3) Which imaging examinations should be performed prior to PTNB procedures? | ||
| - We recommend obtaining chest CT images of sufficient quality for planning the biopsy, possibly with contrast enhancement | A | II |
| - We suggest using an 18F-fluoro-deoxyglucose PET scan to determine the biopsy site for a pulmonary lesion suspected of having necrosis | B | III |
| Key Question 3. What are the appropriate techniques for PTNB of lung lesions? | ||
| 3-1) How accurate should PTNB be? | ||
| - We recommend that the sensitivity and specificity of the biopsy for malignancy should be higher than 85% and 90%, respectively | A | II |
| - We recommend minimizing non-diagnostic results and maintaining the proportion of insufficient biopsy specimens as less than 10% of biopsies | A | II |
| 3-2) How should interventionists choose the guidance modality for PTNB? | ||
| - We recommend primary utilization of fluoroscopic or CT-based guidance modalities for the biopsy, including cone-beam CT and CT fluoroscopy | A | II |
| - We recommend that ultrasonography can be considered as the primary guidance modality for subpleural pulmonary lesions abutting the chest wall | A | II |
| - We suggest that CT-based guidance modalities or multi-planar reconstruction can be considered for pulmonary lesions 2 cm or smaller to increase the diagnostic accuracy of PTNB | B | III |
| 3-3) Which needle size, how many samples, and which technique (biopsy vs. aspiration) should be used for PTNB? | ||
| - We recommend selecting either needle aspiration or cutting biopsy given the availability of cytopathologists, the risk of malignancy, lesion diameter, required amount of tissue specimens, and the interventionist’s experience | A | II |
| - We recommend determining the needle gauge and the number of samples based on the difficulty and risk of the biopsy procedure, the gross quality of the biopsy specimens, and the need for a subsequent examination | A | II |
| Key Question 4. What is the appropriate management of acute PTNB-related complications? | ||
| 4-1) What is the appropriate management of pneumothorax? | ||
| - We recommend assessing the risk of pneumothorax before performing a biopsy and minimizing the risk of pneumothorax during the procedure | A | II |
| - We recommend evaluating the occurrence of pneumothorax using chest radiographs or the guidance modality by an interventionist after performing the biopsy | A | II |
| - We recommend determining the necessity of chest tube insertion by considering the status of the patient, amount of pneumothorax, and medical availability | A | II |
| 4-2) What is the appropriate management of hemoptysis? | ||
| - When hemoptysis occurs, we recommend monitoring vital signs and blood oxygen saturation levels, along with assessing the amount of hemoptysis | A | II |
| - In cases of mild hemoptysis, we recommend conservative management with biopsy-site-down positioning | A | II |
| - When massive hemoptysis occurs, we recommend supplying oxygen to maintain blood oxygen saturation, along with considering single-lumen endotracheal tube insertion | A | II |
| 4-3) What is the appropriate management of air embolism and hemothorax? | ||
| - When systemic air embolism occurs, we recommend supplying oxygen at as high a concentration as possible, including hyperbaric oxygen therapy, and anticonvulsants, if needed | A | III |
| - When a large amount of hemothorax occurs, we recommend conservative management, while contacting clinicians such as thoracic or general surgeons and interventional radiologists | A | III |
CT = computed tomography, PTNB = percutaneous transthoracic needle biopsy