Multicenter external validation of a novel aggregated technique for percutaneous CT guided lung biopsy for multiple samplings: the ExtraPEARL study

Objectives: To evaluate the reproducibility of the PEARL approach to decrease pneumothorax rates by different board-certified radiologists across multiple medical centers using standard CT units. Materials and methods: This multicenter observational study included four average volume centers in two countries. Data for the PEARL cohort were prospectively collected between January 2022 and May 2023, while the control cohort data were retrospectively collected from procedures performed between June 2021 and April 2022. Patient demographics, lesion characteristics, intraprocedural data, complications, and procedural accuracy were compared. Results: A total of 413 CT-guided lung biopsies were performed (204 PEARL vs 209 Control) without differences in patient demographics, lesion size (26.8 mm ± 20.3 PEARL group vs 27.7 mm ± 19.6 Control, p = 0.4), or emphysema rate (34% PEARL vs 27% Control, p = 0.15). Adequate pathological yield was observed in both groups (PEARL group 95%, Control group 97%; p = 0.255). The overall incidence of pneumothorax was 9% (18/204) in the PEARL vs 23% in the control group (48/209); p < 0.05. Chest tube insertion was necessary in one patient in the PEARL group (0.5%), and in nine in the Control (4%); p = 0.011. Conclusions: Application of PEARL protocol for CT-guided percutaneous biopsy of lung nodules provides a reproducible method across multiple institutions and physicians to maintain a high diagnostic yield while significantly reducing pneumothorax risk. Key Points: Question Reducing the rate of pneumothorax following percutaneous lung biopsy is crucial. The PEARL approach was proposed in an interventional radiology single-center study; external validation still missing. Findings The PEARL approach effectively reduced pneumothorax incidence, with only one chest tube insertion in 204 cases, and both groups demonstrated adequate pathological yield. Clinical relevance The PEARL protocol demonstrated efficiency and cost-effectiveness in minimizing pneumothorax risk during percutaneous CT-guided lung biopsies in a multicenter study, with board-certified radiologists using standard CT equipment in average-volume centers.