Percutaneous Transthoracic Lung Biopsy

  • Antonio Gutierrez
  • Fereidoun Abtin
  • Robert D. Suh


Percutaneous transthoracic needle biopsy (TNB) has emerged as a viable and minimally invasive procedure for the diagnosis of indeterminate pulmonary nodules, masses, and consolidations. Over the past two decades with continued improvements in small gauge coaxial core needle systems and biopsy technique, coaxial core biopsy is now a preferred technique for pulmonary lesions as it can obtain larger specimens for diagnosis and molecular analysis. Core needle samples are becoming increasingly important as recent advances in molecular profiling require adequate tumor tissue to identify specific mutations allowing for targeted cancer therapy and for accurate prognosis. With the continued improvement in imaging technology, needle design, biopsy technique, enhanced targeting, and strategies for preventing and managing potential complications, previously inaccessible pulmonary lesions can be biopsied in a safe and reliable manner. This chapter gives an overview of TNB including its indications, contraindications, the imaging modalities currently used for guidance, and the special techniques utilized in performing the procedure and minimizing complications.


Needle Placement Compute Tomography Fluoroscopy Chest Tube Placement Chest Tube Insertion Needle Path 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Cham MD, Lane ME, Henschke CI, Yankelevitz DF. Lung biopsy: special techniques. Semin Respir Crit Care Med. 2008;29(4):335–49.PubMedCrossRefGoogle Scholar
  2. 2.
    Moore EH. Percutaneous lung biopsy: an ordering clinician's guide to current practice. Semin Respir Crit Care Med. 2008;29(4):323–34.PubMedCrossRefGoogle Scholar
  3. 3.
    Maemondo M, Inoue A, Kobayashi K, et al. Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. N Engl J Med. 2010;362(25):2380–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Borczuk AC, Shah L, Pearson GD, et al. Molecular signatures in biopsy specimens of lung cancer. Am J Respir Crit Care Med. 2004;170(2):167–74.PubMedCrossRefGoogle Scholar
  5. 5.
    Laurent F, Montaudon M, Latrabe V, et al. Percutaneous biopsy in lung cancer. Eur J Radiol. 2003;45:60–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Murphy JM, Gleeson FV, Flower CD. Percutaneous needle biopsy of the lung and its impact on patient management. World J Surg. 2001;25:373–80.PubMedCrossRefGoogle Scholar
  7. 7.
    Klein JS, Zarka MA. Transthoracic needle biopsy. Radiol Clin North Am. 2000;38:235–66.PubMedCrossRefGoogle Scholar
  8. 8.
    Manhire A, Charig M, Clelland C, et al. Guidelines for radiologically guided lung biopsy. Thorax. 2003;58(11):920–36.PubMedCrossRefGoogle Scholar
  9. 9.
    Castellino RA, Blank N. Etiologic diagnosis of focal pulmonary infection in immunocompromised patients by fluoroscopically guided percutaneous needle aspiration. Radiology. 1979;132:563–7.PubMedGoogle Scholar
  10. 10.
    Conces DJ, Clark SA, Tarver RD, et al. Transthoracic aspiration needle biopsy: value in the diagnosis of pulmonary infections. AJR Am J Roentgenol. 1989;152:31–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Hur J, Lee HJ, Nam JE, et al. Diagnostic accuracy of CT fluoroscopy-guided needle aspiration biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2009;192(3):629–34.PubMedCrossRefGoogle Scholar
  12. 12.
    Kim TJ, Lee JH, Lee CT, et al. Diagnostic accuracy of CT-guided core biopsy of ground-glass opacity pulmonary lesions. AJR Am J Roentgenol. 2008;190:234–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Wallace MJ, Krishnamurthy S, Broemeling LD, et al. CT guided percutaneous fine-needle aspiration biopsy of small (< or ¼1-cm) pulmonary lesions. Radiology. 2002;225:823–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Charig MJ, Stutley JE, Padley SPG, et al. The value of negative needle biopsy in suspected operable lung cancer. Clin Radiol. 1991;44(3):147–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Wallace AB, Suh RD. Percutaneous transthoracic needle biopsy: special considerations and techniques used in lung transplant recipients. Semin Intervent Radiol. 2004;21(4):247–58; Scholar
  16. 16.
    Aziz A, Ashizawa K, Nagaoki K, Hayashi K. High resolution CT anatomy of the pulmonary fissures. J Thorac Imaging. 2004;19:186–91.PubMedCrossRefGoogle Scholar
  17. 17.
    Yildiz A, Gölpinar F, Calikoğlu M, Duce MN, Ozer C, Apaydin FD. HRCT evaluation of the accessory fissures of the lung. Eur J Radiol. 2004;49(3):245–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Moore EH. Technical aspects of needle aspiration lung biopsy: a personal perspective. Radiology. 1998;208:303–18.PubMedGoogle Scholar
  19. 19.
    Cahill AM, Baskin KM, Kaye RD, Fitz CR, Towbin RB. CT-guided percutaneous lung biopsy in children. J Vasc Interv Radiol. 2004;15(9):955–60.PubMedCrossRefGoogle Scholar
  20. 20.
    Yankelevitz DF, Henschke CI, Koizumi JH, et al. CT-guided transthoracic needle biopsy of small solitary pulmonary nodules. Clin Imaging. 1997;21:107–10. (alternative – Ng YL CT-Guided percut 2008).PubMedCrossRefGoogle Scholar
  21. 21.
    Froelich JJ, Ishaque N, Regn J, et al. Guidance of percutaneous pulmonary biopsies with real-time CT fluoroscopy. Eur J Radiol. 2002;42:74–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Katada K, Kato R, Anno H, et al. Guidance with real-time CT fluoroscopy: early clinical experience. Radiology. 1996;200:851–6.PubMedGoogle Scholar
  23. 23.
    Li H, Boiselle PM, Shepard JO. Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules. AJR Am J Roentgenol. 1996;167:105–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Haramati LB. CT-guided automated needle biopsy of the chest. AJR Am J Roentgenol. 1995;165:53–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Greif J, Marmur S, Schwarz Y, et al. Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients. Cancer. 1998;84:144–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Klein JS, Schultz S. Interventional chest radiology. Curr Probl Diagn Radiol. 1992;21:219–77.PubMedCrossRefGoogle Scholar
  27. 27.
    Klein JS, Salomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients. Radiology. 1996;198:715–20.PubMedGoogle Scholar
  28. 28.
    Greif J, Marmur S, Schwarz Y, et al. Percutaneous core needle biopsy vs. fine-needle aspiration in diagnosing benign lung lesions. Acta Cytol. 1999;43:756–60.PubMedCrossRefGoogle Scholar
  29. 29.
    Staroselsky AN, Schwarz Y, Man A, et al. Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions. Chest. 1998;113:1522–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Yankelevitz DF, Vazquez M, Henschke CI. Special techniques in transthoracic needle biopsy of pulmonary nodules. Radiol Clin North Am. 2000;38:267–79.PubMedCrossRefGoogle Scholar
  31. 31.
    Haramati LB, Austin JHM. Complications after CT-guided needle biopsy through aerated versus nonaerated lung. Radiology. 1991;181:778.PubMedGoogle Scholar
  32. 32.
    Stern EJ, Webb WR, Gamsu G. CT gantry tilt: utility in transthoracic fine-needle aspiration biopsy. Radiology. 1993;187:873–4.PubMedGoogle Scholar
  33. 33.
    Yankelevitz DF, Henschke CI, Davis SD. Percutaneous CT biopsy of chest lesions: an in vitro analysis of the effect of partial volume averaging on needle positioning. AJR Am J Roentgenol. 1993;161:273–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Sandhu J, Meglin AJ, Trerotola SO. Thoracic and visceral nonvascular interventions. Fairfax: The Society of Cardiovascular and Interventional Radiology; 1997. p. 159–70.Google Scholar
  35. 35.
    Klose KC. CT-guided large-bore biopsy: extrapleural injection of saline for safe transpleural access to pulmonary lesions. Cardiovasc Intervent Radiol. 1993;16:259–61.PubMedCrossRefGoogle Scholar
  36. 36.
    Horton JA, Bank WO, Kerber CW. Guiding the thin spinal needle. AJR Am J Roentgenol. 1980;134:845–84.PubMedCrossRefGoogle Scholar
  37. 37.
    Yankelevitz DF, Davis SD, Chiarella D, et al. Needle-tip repositioning during computed-tomography-guided transthoracic needle aspiration biopsy of small deep pulmonary lesions: minor adjustments make a big difference. J Thorac Imaging. 1996;11:279–82.PubMedCrossRefGoogle Scholar
  38. 38.
    Ohno Y, Hatabu H, Takenaka D, Imai M, Ohbayashi C, Sugimura K. Transthoracic CT-guided biopsy with multiplanar reconstruction image improves diagnostic accuracy of solitary pulmonary nodules. Eur J Radiol. 2004;51(2):160–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Santos RS, Gupta A, Ebright MI. Electromagnetic navigation to aid radiofrequency ablation and biopsy of lung tumors. Ann Thorac Surg. 2010;89(1):265–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Layfield LJ, Liu K, Erasmus JJ. Radiologically determined diameter, pathologic diameter, and reactive zone surrounding pulmonary neoplasms: implications for transthoracic fine needle aspiration of pulmonary neoplasms. Diagn Cytopathol. 1999;21:250–2.PubMedCrossRefGoogle Scholar
  41. 41.
    Aerospace Medical Association Medical Guidelines Task Force. Medical guidelines for airline travel, 2nd ed. Aviat Space Environ Med. 2003;74(5 Suppl):A1–19.Google Scholar
  42. 42.
    Moore EH, Shepard JO, McLoud TC, et al. Positional precautions in needle aspiration lung biopsy. Radiology. 1990;175:733–5.PubMedGoogle Scholar
  43. 43.
    Berquist TH, Bailey PB, Cortese DA, et al. Transthoracic needle biopsy: accuracy and complications in relation to location and type of lesion. Mayo Clin Proc. 1980;55:475–81.PubMedGoogle Scholar
  44. 44.
    Fish GD, Stanley JH, Miller S, et al. Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests. AJR Am J Roentgenol. 1988;150:71–4.PubMedCrossRefGoogle Scholar
  45. 45.
    Yankelevitz DF, Davis SD, Henschke CI. Aspiration of a large pneumothorax resulting from transthoracic needle biopsy. Radiology. 1996;200:695–7.PubMedGoogle Scholar
  46. 46.
    Yamagami T, Nakamura T, Iida S, et al. Management of pneumothorax after percutaneous CT-guided lung biopsy. Chest. 2002;121:1159–64.PubMedCrossRefGoogle Scholar
  47. 47.
    Lang EK, Ghavami R, Schreiner VC, et al. Autologous blood clot seal to prevent pneumothorax at CT-guided lung biopsy. Radiology. 2000;216:93–6.PubMedGoogle Scholar
  48. 48.
    Herman SJ, Weisbrod GL. Usefulness of the blood patch technique after transthoracic needle aspiration biopsy. Radiology. 1990;176:395–7.PubMedGoogle Scholar
  49. 49.
    Engeler CE, Hunter DW, Castaneda-Zuniga W, et al. Pneumothorax after lung biopsy: prevention with transpleural placement of compressed collagen foam plugs. Radiology. 1992;184:787–9.PubMedGoogle Scholar
  50. 50.
    Man A, Schwarz Y, Greif J. Case report: cardiac tamponade following fine needle aspiration (FNA) of a mediastinal mass. Clin Radiol. 1998;53:151–2.PubMedCrossRefGoogle Scholar
  51. 51.
    Milner LB, Ryan K, Gullo J. Fatal intrathoracic hemorrhage after percutaneous aspiration lung biopsy. AJR Am J Roentgenol. 1979;132:280–1.PubMedCrossRefGoogle Scholar
  52. 52.
    Arakawa H, Nakajima Y, Kurihara H, et al. CT-guided transthoracic needle biopsy: a comparison between automated biopsy gun and fine needle aspiration. Clin Radiol. 1996;51:503–6.PubMedCrossRefGoogle Scholar
  53. 53.
    Aberle DR, Gamsu G, Golden JA. Fatal systemic arterial air embolism following lung needle aspiration. Radiology. 1987;165:351–3.PubMedGoogle Scholar
  54. 54.
    Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures: treatment and hyperbaric oxygen. Ann Surg. 1985;201:242–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Berger RL, Dargan EL, Huang BL. Dissemination of cancer cells by needle biopsy of the lung. J Thorac Cardiovasc Surg. 1972;63:430–2.PubMedGoogle Scholar
  56. 56.
    Khouri NF, Stitik FP, Erozan YS, et al. Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR Am J Roentgenol. 1985;144:281–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Zarbo RJ, Fenoglio-Presier CM. Inter-institutional database for comparison of performance in lung fine-needle aspiration cytology: a College of American Pathologists Q-probe study of 5264 cases with histologic correlation. Arch Pathol Lab Med. 1992;116:463–70.PubMedGoogle Scholar
  58. 58.
    Westcott JL, Najmussaqib R, Colley DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology. 1997;202:97–103.PubMedGoogle Scholar
  59. 59.
    Protopapas Z, Westcott JL. Transthoracic needle biopsy of mediastinal lymph nodes for staging lung and other cancers. Radiology. 1996;199:489–96.PubMedGoogle Scholar
  60. 60.
    Grinan NP, Lucena FM, Romero JV, et al. Yield of percutaneous needle lung aspiration in lung abscess. Chest. 1990;97:69–74.CrossRefGoogle Scholar
  61. 61.
    Gruden JF, Klein JS, Webb WR. Percutaneous transthoracic needle biopsy in AIDS: analysis in 32 patients. Radiology. 1993;189:567–71.PubMedGoogle Scholar
  62. 62.
    Scott WW, Kuhlman JE. Focal pulmonary lesions in patients with AIDS: percutaneous transthoracic needle biopsy. Radiology. 1991;180:419–21.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Antonio Gutierrez
    • 1
  • Fereidoun Abtin
    • 2
  • Robert D. Suh
    • 3
    • 4
  1. 1.Department of Radiological SciencesDavid Geffen School of Medicine at UCLA Medical Center, Ronald Reagan UCLA Medical CenterLos AngelesUSA
  2. 2.Department of Radiological SciencesRonald Reagan UCLA Medical CenterLos AngelesUSA
  3. 3.Department of Radiological SciencesDavid Geffen School of Medicine at UCLA Medical CenterLos AngelesUSA
  4. 4.Thoracic Imaging and Intervention, Department of RadiologyRonald Reagan UCLA Medical CenterLos AngelesUSA

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