To explore the role of the relationship between pulmonary nodules and pleura in the prediction of pneumothorax risk after computed tomography-guided lung needle biopsy (CT-LNB).

A retrospective selection was conducted on 111 patients with pulmonary nodules who underwent CT-LNB treatment in our hospital from January 2021 to December 2024. The patients were divided into groups based on whether pneumothorax occurred after CT-LNB surgery. 27 cases with pneumothorax were classified as the observation group, and 84 cases without pneumothorax were classified as the control group. Least absolute shrinkage and selection operator (LASSO) regression and multivariate Logistic regression were used to analyze the risk factors for pneumothorax after CT-LNB and to construct a nomogram.

Among the 111 cases, 32 cases had nodules in contact with the pleura, 29 cases had nodules not in contact with the pleura (with a median distance of 3.40 cm), and 50 cases had nodules with the pleural tail sign (PTS). In the observation group, 2 cases (7.41%) had nodules in contact with the pleura, which was lower than 30 cases (35.71%) in the control group (P=0.005); 14 cases (51.85%) in the observation group had PTS in the puncture path, which was higher than 17 cases (20.24%) in the control group (P=0.001). LASSO and Logistic regression analysis showed that the presence of PTS in the puncture path (OR=6.450, P=0.005), nodule diameter <2 cm (OR=4.151, P=0.020), repeated puncture (OR=3.479, P=0.034), intrapulmonary puncture depth >2 cm (OR=8.079, P=0.011), and PTS in the puncture path were risk factors for pneumothorax after CT-LNB. Receiver operating characteristic (ROC) curve analysis showed that the area under the curve (AUC)for predicting pneumothorax by the nomogram was 0.88 (95%CI: 0.81~0.94). Clinical decision curve analysis showed that when the high-risk threshold was 0.05~0.78, the nomogram had better net clinical benefit for predicting pneumothorax.

The presence of PTS in the puncture path, emphysema, nodule diameter <2 cm, repeated puncture, and intrapulmonary puncture depth >2 cm are risk factors for pneumothorax after CT-LNB surgery. The pneumothorax risk prediction model may be used clinically for individualized risk decision-making for pneumothorax, and when performing biopsy on pulmonary nodules with PTS, avoid puncturing through the PTS puncture trajectory to reduce the risk of pneumothorax.