Balancing diagnostic approach and oncologic risk in surgically resected lung cancer: propensity-matched analysis of intraoperative versus percutaneous biopsy by tumor location and morphology

Background: Lung cancer remains the leading cause of cancer-related death, and earlier detection has increased the demand for accurate histological diagnosis While percutaneous transthoracic needle biopsy (PCNB) and surgical biopsy are widely used, concerns remain about PCNB-related tumor dissemination and recurrence. These risks are influenced by tumor location and morphology, which affect procedural feasibility and oncologic outcomes. This study investigated the association between biopsy method and recurrence-free survival (RFS) in surgically resected lung cancer and evaluated how tumor characteristics may identify subgroups at higher risk. Materials and Methods: Medical records of 363 patients with surgically resected primary lung cancer who underwent preoperative PCNB ( n = 221) or intraoperative surgical biopsy ( n = 142) at a tertiary center between 2015 and 2020 were retrospectively reviewed. Patients were grouped according to biopsy methods and compared. Demographics, preoperative chest CT findings such as consolidation to tumor ratio (CTR) and intralobar tumor location, pathologic findings, and recurrences were evaluated. Results: In the propensity-matched cohort (103 patients per group), multivariate analysis showed male (HR 2.11), current smoking (HR 2.12), central tumors (HR 5.47), and higher CTR (HR 16.6) as independent predictors of reduced RFS, whereas PCNB itself was not ( P = 0.16). CTR and tumor location remained important risk factors in both groups. Notably, locoregional and pleural recurrences were more frequent in the PCNB group, although not statistically significant. Five-year RFS was significantly lower in the PCNB group (85.0% vs. 74.3%, P = 0.013), with the negative impact of higher CTR and central tumors being more pronounced in the PCNB group. Conclusion: PCNB was not an independent risk factor for recurrence. However, its association with higher rates of locoregional and pleural recurrence along with a trend toward decreased RFS in tumors with adverse CT features suggests careful clinical consideration when choosing biopsy method.