Lung cancer is a significant global health issue as it is responsible for the majority of cancer-related deaths (1). Non-small cell lung cancer (NSCLC) is the primary type of lung cancer and constitutes around 85%–90% of all lung cancer (2). Unfortunately, due to a lack of symptoms and accurate detection at an early stage, a considerable proportion of lung cancer patients are diagnosed at an advanced stage and may only be treated with medications (3). In Chinese patients, 40% of lung cancer patients have epidermal growth factor receptor (EGFR) gene mutations, compared with only 15% in European patients, and these EGFR mutations confer sensitivity to tyrosine kinase inhibitors (TKIs) (4, 5). Indeed, the first-line treatment of advanced NSCLC has evolved from traditional chemotherapy to molecular target and immunotherapy, and the clinical results and use of EGFR-TKIs have significantly improved the overall response rate and progression-free survival of patients with advanced NSCLC (6). However, most patients who initially respond to EGFR-TKIs inevitably develop resistance and then relapse, ultimately leading to death (7). Survival is still seriously affected by cancer metastasis, therapeutic resistance, and relapse (8).

The secondary EGFR T790M mutation, identified in approximately 60% of cases, is the most common acquired resistance mechanism, thereby limiting progression-free survival to approximately 9–14 months (9). Hence, it is critical that the patient clearly understands the resistance mechanism of tissue biopsy in order to make individualized treatment decisions based on tumor-related molecular information. At the time of disease progression, several studies have reported that repeat biopsies were physically invasive, procedurally risky, expensive, and time-consuming, making it more technically difficult to obtain tissue than an initial biopsy and sometimes not feasible (10–12). Rebiopsy can be performed in 50% to 80% of NSCLC patients with progressive disease, and tissue samples for histology analysis were only available in 45% of the patients (12, 13). In most situations, a tissue sample for resistance is the test of first choice because tissue rebiopsy could produce more accurate, more reliable results than a liquid biopsy and is sufficient to predict drug susceptibility, and histopathological changes can be detected in tissue samples (14, 15). According to several previous reports, rebiopsy for patients with non‐small cell lung cancer treatment failure can be performed safely and accurately under CT guidance (10, 16, 17). However, no detailed investigation of the risk factors of NSCLC patients resistant to EGFR-TKIs and/or chemotherapy by CT-guided transthoracic needle biopsy has been reported until now. The purpose of this paper is to assess rebiopsy complication risk factors and clinical outcomes in NSCLC patients with progressive disease. Moreover, we also attempted to compare the different incidences of complications between initial biopsy and rebiopsy.

In this study, we have three main findings: First, CT-guided transthoracic needle rebiopsy was safe and feasible for patients with treatment failure and disease progression. Second, compared with the initial biopsy, the complication rates displayed a slight, but not significant, elevation in rebiopsy. Third, male sex, tumor size ≤ 2 cm, transfissural approach, and EGFR-TKIs combined with chemotherapy were independent risk factors for rebiopsy complications.

Currently, tumor heterogeneity is associated with therapy resistance, malignant progression, and recurrence in cancer. Hence, there is a strong demand for rebiopsy to assess the molecular and pathological characterization of NSCLC patients with progressive disease (18–20). A study of repeat biopsies after EGFR-TKI treatment found that repeat biopsies were technically more difficult than initial biopsies and procedures associated with higher complication rates and failure rates (21).

The rate of surgical resection increased from 1.8% at the initial biopsy to 7.8% at rebiopsy when compared to the biopsy collection method, while the rate of lung biopsy rose obviously from 7.6% to 29.1% (10). This evidence illustrates the technical difficulty in obtaining tissue samples for patients at a repeat biopsy. CT-guided transthoracic needle biopsy is one of the invasive diagnostic methods with highly sensitive and accurate procedures, and complications will inevitably occur during the operation. According to previous reports (22–27), the rate of pulmonary parenchymal hemorrhage ranged from 5% to 26.8%, severe pulmonary hemorrhage or hemoptysis was 0.06% to 7.0%, and the rate of pneumothorax was 12% to 45%, with 2.7% to 6.6% requiring chest tube placement. In the meantime, some interesting prior research has reported that the complication rates in patients with repeat biopsy were similar to those who had a first biopsy (16, 28, 29). Both pulmonary hemorrhage and pneumothorax in rebiopsy were accepted, and pneumothorax was the most common. Also, a meta-analysis (30) showed a slight but non-significant reduction in the pooled complication rate for the rebiopsies vs. the initial biopsies (16.8% vs. 22.2%). Although patients showed disease progression after receiving a previous systemic treatment, the overall complication rate of the biopsy was not statistically significant between the two groups. On the contrary, in our study, all patients underwent repeat biopsies according to disease progression, and the incidences of parenchymal hemorrhage and pneumothorax increased from 7.1% to 10.6% and 14.2% to 20.4%, respectively, from the first biopsy to the second biopsy. For CT-guided biopsy, the overall complication rate at the single center study improved from 22.1% in the initial biopsy to 32.7% in the rebiopsy. In all four evaluations (pneumorrhagia, pneumothorax, pleural reaction, and overall complication), there were no significant differences between the rebiopsy and initial biopsy (all p > 0.05). Compared with initial biopsy, the incidence of overall complications, parenchymal hemorrhage, and pneumothorax increased by 10.6%, 3.5%, and 6.2%, respectively, but no serious postoperative complications, including air embolism, severe hemodynamic changes, or death, occurred at the rebiopsy. These findings suggest that rebiopsy is both feasible and safe for NSCLC patients with treatment failure and disease progression.

Male sex, tumor size ≤ 2 cm, transfissural approach, and the use of EGFR-TKIs combined with chemotherapy were independent risk factors for complications even after multivariate analysis. There were several plausible explanations for this result. First, EGFR-TKIs combined with chemotherapy had significant therapeutic benefits, but they may cause or aggravate lung injury, which leads to an increased risk of biopsy-related complications. Previous research has shown that EGFR-TKI-induced lung injury has clinical risk factors, including male sex, smoking status, early treatment initiation after diagnosis, and prior treatment with chemotherapy or radiotherapy (31–33). Likewise, our research also confirmed clinical evidence of a higher risk of complication with concurrent use of EGFR-TKIs combined with chemotherapy relative to chemotherapy alone. Second, the size of the tumor is small, the operation is difficult, and the complication rate is relatively high (34). Notably, accuracy was significantly dependent on tumor size; the accuracy rate of the size of 21–30 mm vs. ≤ 20 mm was significantly higher (97% vs. 85%, p < 0.05) (35). Third, a transfissural approach was a significant predictor of pneumothorax, and the risk of parenchymal hemorrhage is also increased when the puncture needle breaks through the pleura more than two times. The more times of repeated punctures of the pleura, the greater the possibility of pneumothorax and parenchymal hemorrhage (36–38).

In addition, there were other factors that may influence the complications of lung rebiopsy. The main factors were as follows: (1) Sampling location: the volume of primary lesion increased, and a large number of tumor angiogenesis and cells were distributed in marginal areas after progression of treatment failure, where tumor cell growth was active, which was the ideal sampling target for rebiopsy, and biopsy increases the risk of complications (39, 40). (2) Patients with underlying disease and cooperation level: stage IIB/IV tumor patients with long-term systemic treatment, especially those men with a history of smoking, have reduced lung basal and vascular fragility, as well as reduced ability to contract after injury, which may increase the challenge of rebiopsies (41, 42). Therefore, accurate measurement of the depth of the needle during a biopsy, minimizing the number of punctures, and avoiding the needle path by passing through bullae, blood vessels, and interlobar fissures can effectively reduce the incidence of complications. In addition, it is necessary to actively communicate with the patient to alleviate their anxiety before the biopsy. The local anesthesia needle should be inserted as close as possible to the parietal pleura to reduce the occurrence of pleural reaction so that the patient can better cooperate during the biopsy.

Several previous studies have shown that the success rate of rebiopsy of advanced lung cancer by transthoracic puncture is about 82%–85% (10, 18, 29). Our slightly higher success rate (88.5%) may be due only to CT-guided biopsy samples compared to that in prior studies. Driven by drug resistance factors, tumor lesions were more advanced than before, the substance components were more complex and diverse, and the lesions in the central region may have a higher incidence of necrosis, resulting in sampling errors in small sample biopsy. For rebiopsy, combined with an enhanced CT scan or PET-CT scan, biopsy metabolically active lesions can improve the detection rate of malignant tumor cells.

In summary, in the real world, rebiopsy is safe after treatment failure in patients with non-small cell lung cancer. The most common complications are pulmonary parenchymal hemorrhage and pneumothorax. Adequate biopsy samples can be used to monitor disease progression, interpret drug resistance mechanisms, and provide a reference for subsequent treatment planning for patients with targeted drug therapy failure or drug resistance (43).

The limitations of our study can be listed as follows: first, a single-center retrospective study fails to record and access some risk factors if those factors were not systematically reported, such as pain. Second, the relatively small sample size fails to reach statistical significance for a certain risk factor. Third, procedure techniques and operators’ experience may also affect the occurrence of complications.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Ethics Committee of the Third Affiliated Hospital of Zhengzhou University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin because this was a retrospective, single-center study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

YW: Writing – original draft, Writing – review & editing. YZ: Conceptualization, Data curation, Writing – review & editing. NR: Software, Writing – review & editing. FL: Formal analysis, Writing – review & editing. LL: Methodology, Writing – review & editing. ZZ: Data curation, Writing – original draft. MG: Investigation, Writing – original draft. MW: Investigation, Writing – original draft. XZ: Methodology, Writing – original draft.