25% of smokers undergoing chest CT have incidentally discovered pulmonary nodules. As questions of national policy re: lung cancer screening with chest CT are considered, Soylemez Wiener et al report the complication rates of 15,865 adults who had transthoracic needle biopsy of a pulmonary nodule in 4 states over the past decade, using a database of insurance claims:

• Pneumothorax: 15%

• Pneumothorax requiring chest tube: 6.6%

• Hemorrhage: 1% (requiring transfusion: 0.18%)

Patients getting a scheduled biopsy had a 0.1% risk for respiratory failure and a ~0.5% chance of dying in the hospital. Even those suffering a pneumothorax and chest tube only had a 0.7% chance of respiratory failure.

But patients undergoing biopsy while already hospitalized had >4% chance of dying in-hospital, and a 1-3% chance of respiratory failure.

The quality of this analysis is of course dependent on the accuracy of the ICD-9 coding -- which was probably good for these clinically important and billable outcomes.

Although seriously bad outcomes were uncommon among outpatients, if you're thinking in terms of screening, you're subjecting a huge number of essentially healthy people to these risks, as well as to the discomfort of "nonserious" pneumothoraces and chest tubes. (Remember that 40% of the >25,000 screened with CT in the Lung Cancer Screening Trial had a positive CT scan during the study, and 95% were false positives). I don't recall how many or what percentage in the NLST went for needle biopsy and their complication rates. Does anyone know this?

Ann Intern Med 2011;155:137-144.