Learning Curve for CT-Guided Percutaneous Transthoracic Needle Biopsy: Retrospective Evaluation Among 17 Thoracic Imaging Fellows at a Tertiary Referral Hospital

Abstract

BACKGROUND. CT-guided percutaneous transthoracic needle biopsy (PTNB) is widely used for evaluation of indeterminate pulmonary lesions, although guidelines are lacking regarding the experience needed to gain sufficient skill. OBJECTIVE. The purpose of our study was to investigate the learning curve among a large number of operators in a tertiary referral hospital and to determine the number of procedures required to obtain acceptable performance. METHODS. This retrospective study included CT-guided PTNBs with coaxial technique performed by 17 thoracic imaging fellows from March 2, 2011, to August 8, 2017, who were novices in the procedure. A maximum number of 200 consecutive procedures per operator were included. The cumulative summation method was used to assess learning curves for diagnostic accuracy, false-negative rate, pneumothorax rate, and hemoptysis rate. Operators were assessed individually and in a pooled analysis. Pneumothorax risk was also assessed in a model adjusting for risk factors. Acceptable failure rates were defined as 0.1 for diagnostic accuracy and false-negative rate, 0.45 for pneumothorax rate, and 0.05 for hemoptysis rate. RESULTS. The study included 3261 procedures in 3134 patients (1876 men, 1258 women; mean age, 67.7 ± 12.1 [SD] years). Overall diagnostic accuracy was 94.2% (2960/3141). All 17 operators achieved acceptable diagnostic accuracy (37 procedures required in the pooled analysis; median, 33 procedures required [range, 19-67 procedures required]). Overall false-negative rate was 7.6% (179/2370). All 17 operators achieved acceptable false-negative rate (52 procedures required in the pooled analysis; median, 33 procedures required [range, 19-95 procedures required]). Pneumothorax occurred in 32.6% of the procedures (1063/3261 procedures), and hemoptysis occurred in 2.7% of the procedures (89/3261 procedures). All 17 operators achieved acceptable pneumothorax rate (20 procedures required in the pooled analysis; median, 19 procedures required [range, 7-63 procedures required]). In the risk-adjusted model, 15 operators achieved acceptable pneumothorax rate (54 procedures required in the pooled analysis; median, 36 procedures required [range, 10-192 procedures required]). Sixteen operators achieved acceptable hemoptysis rate (67 procedures required in the pooled analysis; median, 55 procedures required [range, 41-152 procedures required]). CONCLUSION. For CT-guided PTNB, at least 37 and 52 procedures are required to achieve acceptable diagnostic accuracy and false-negative rate, respectively. Not all operators achieved acceptable complication rates. CLINICAL IMPACT. The findings may help set standards for training, supervision, and ongoing assessment of operator proficiency for this procedure.