Contrast ultrasound guidance raised subpleural lung biopsy yield and cut complications

Design

Prospective multicentre randomised trial (three arms)

Population

2,485 patients undergoing percutaneous biopsy of subpleural lung lesions

Primary outcome

Diagnostic yield and diagnostic sensitivity

Effect

Yield 88.8% CEUS vs 78.9% CT vs 76.0% US; complications 4.6% vs 15.8% vs 7.5%

A multicentre randomised trial in Chest assigned 2,485 patients needing percutaneous biopsy of a subpleural lung lesion to guidance by contrast-enhanced ultrasound (CEUS), conventional ultrasound or CT.

Diagnostic yield, using the strict ATS/ACCP definition, was 88.8% with CEUS, 78.9% with CT and 76.0% with ultrasound. Sensitivity for confirmed disease followed the same order (86.1%, 74.3%, 68.7%), including for malignancy (91.8%, 83.2%, 75.2%) and specific benign diagnoses. Complications were lowest with CEUS (4.6%) and highest with CT (15.8%).

Contrast lets the operator target enhancing, viable tissue and avoid necrotic areas and vessels, which plausibly explains both the higher yield and fewer complications. CT guidance remains necessary for lesions ultrasound cannot see.

The trial was done in experienced Chinese centres, and results depend on operator skill and contrast availability. For lesions abutting the pleura, ultrasound-based guidance with contrast is a reasonable first choice where expertise exists.

• Consider contrast-enhanced ultrasound guidance for biopsy of subpleural lesions where expertise exists
• Use ultrasound rather than CT guidance first for lesions in contact with the pleura, to reduce complications
• Keep CT guidance for lesions not visible on ultrasound
• Target enhancing tissue and avoid necrotic areas to improve yield

Why it matters

It challenges CT as the default guidance for lesions that touch the pleura.

Don't overread it

Results from expert centres in one country may not transfer where CEUS experience is limited.

The statistics, in plain English

A 10-point gain in diagnostic yield over CT means about one in ten patients avoided a non-diagnostic biopsy. The complication rate with CT was more than three times that with CEUS.

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