Reply to Chiappetta et al.

We thank Chiappetta et al. for providing hints [ 1 ] for further discussion on our recently published study [ 2 ]. We agree with their comments on the higher incidence of high-grade pulmonary parenchymal haemorrhage and haemothorax when compared with what is reported in other patient series, in particular by Khan et al. [ 3 ]. However, as mentioned in the discussion section of our paper, we underlined how the more frequent use of CT as a follow-up method after lung biopsy probably increased the rate of identification of parenchymal pulmonary haemorrhage (PPH) and how the frequency of type 2 high-grade PPH (18.1%) is within the limits of what is reported by authors using the same grading criteria (PPH frequency >30%) [ 4 ]. In particular, Khan et al. provide a different classification of PPH, clinically describing moderate haemorrhage as ‘less than five episodes of haemoptysis’ and severe haemoptysis as ‘hemothorax associated with haemodynamic instability’, while the classification adopted in our series differentiates low-grade PPH and high-grade PPH using a 6-mm cut-off range from the target lesion, not taking into account haemoptysis. Similarly, the incidence of haemothorax was higher in our study when compared with the literature (3.5% of procedures vs 0.09–1.5%), but this discrepancy also seems to be related to the fact that we chose to describe haemothorax as any hyperdense fluid collection in the pleural space and classified it as mild (anteroposterior thickness on axial slices <1.5 cm) or severe (anteroposterior thickness on axial slices >1.5 cm) following previous studies [ 5 ], while Tomiyama et al. [ 6 ] refer only to cases requiring prolonged hospitalization or additional procedures to treat haemorrhage or prevent shock. Lastly, with regard to the number of pleural passages, our biopsy technique attempts to avoid in any case repeated pleural puncture, trying to reach adequate needle orientation before crossing the pleural plane or to correct the needle path into the lung parenchyma rather than extracting and reorienting the needle, even when targeting very small nodules; we chose not to include repeated pleural puncture in the statistical analysis since it occurred in just 5 cases in our series, without significant complications. In conclusion, to answer Chiappetta et al. , we believe that the higher frequency of complications reported in our paper when compared with some of the studies published in the literature is probably related to different reporting methods rather than procedural problems or patients’ characteristics. In light of these considerations, the score system presented in our study could be used as a base and expanded with data from meta-analyses in the literature in order to provide a more solid and reliable tool that can be validated and used in daily clinical practice.

Conflict of interest: none declared.

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