CT guided thoracic biopsy
Citation, DOI & article data
- CT guided lung biopsy
- CT guided pleural biopsy
- CT guided mediastinal biopsy
- CT lung thoracic biopsy
- CT guided thoracic biopsies
CT guided thoracic biopsy is usually performed for the diagnosis of suspicious lung, pleural, or mediastinal lesions. It can be performed as an outpatient procedure where patient monitoring and complications support are available. A small percentage of lung and pleural biopsies may be performed under ultrasound guidance in specific circumstances.
On this page:
Indications
- pulmonary lesion inaccessible to bronchoscopy, or in which prior bronchoscopic biopsy is nondiagnostic
- mediastinal or pleural mass
Contraindications
The contraindications must be considered individually in each case. Overall, the most important contraindications are:
- poor respiratory function or reserve
- uncooperative patient
- lack of safe access
- uncorrectable bleeding diathesis (abnormal coagulation indices)
Procedure
Laboratory parameters for a safe procedure
Interventional procedures like thoracic biopsy require special attention to coagulation indices. There are widely divergent opinions about the safe values of these indices for percutaneous biopsies. The values suggested below were considered based on the literature review, whose references are cited below:
- complete blood count (CBC)
- platelet > 50000/mm3 (some institutions determine other values between 50000-100000/mm3) 2
- coagulation profile
- international normalized ratio (INR) ≤ 1.5 2
- normal prothrombin time (PT), partial thromboplastin time (PTT)
- some studies showed that having a normal INR or prothrombin time is no reassurance that the patient will not bleed after the procedure 3
Pre-procedure evaluation
Review the diagnostic CT and other relevant imaging first (e.g. PET-CT) to clarify the lesion that is requested to be biopsied. Consideration of the various factors, that influence suitability and degree of risk should be reviewed, including the site and size of the nodule/mass and its relationship to structures that must be avoided 3:
- vessels
- bleb
- bullae
- central bronchi
- fissures (it is important to minimize the number of pleural surfaces crossed)
Remember, with cavitating lesions the needle must be targeted to the periphery.
For lung lesions, be aware of the postobstructive atelectasis commonly with large central lesions. FDG PET-CT is superior to CT in differentiating between tumor and postobstructive atelectasis and, therefore, essential in those cases to avoid false-negative biopsies 8.
Positioning
The patient can be positioned prone, supine or laterally (decubitus) depending on the location of the lesion and their respiratory function. Many of these patients will have an underlying respiratory disease and may be unable to lie completely flat. Some advocate the patient is best-positioned decubitus with the lesion inferior:
- limits respiratory motion
- minimizes local aeration; reduces pneumothoraces 9
- comfortable
Biopsy
- a radiopaque grid or skin marker should be utilized to focus the optimal access point then, after preliminary images, this point is marked with a pen
- make antisepsis and anesthesia with lidocaine as per the institution's protocol
- a skin orifice is made using a scalpel blade
- the biopsy needle is introduced as previous planning
- activate biopsy gun
Post-procedure care
A period of 'bed-rest' is advised as well as regular observations for some hours after the procedure. The observation period should allow an ample opportunity to identify and treat a potential complication in a timely manner to prevent a serious or catastrophic outcome; it could vary from each institution protocol.
Often, post-procedural x-rays are performed, usually at four hours post-biopsy.
There is a growing trend for ambulatory lung biopsy, in which case the patient has the procedure performed as an outpatient without admission to hospital.7
Complications
-
pneumothorax
- most common
- the reported rate of pneumothorax varies widely from 8-64% 6
-
alveolar hemorrhage: may be seen in ~10% (range 5-16.9%)
- hemoptysis: occurs in 1-5% of patients 4
- air embolism
- can be venous or systemic
- systemic air embolism occurs in up to 0.2% of patients 5
References
- 1. Li Y, Du Y, Yang HF et-al. CT-guided percutaneous core needle biopsy for small (≤20 mm) pulmonary lesions. Clin Radiol. 2013;68 (1): e43-8. doi:10.1016/j.crad.2012.09.008 - Pubmed citation
- 2. Sue M, Caldwell S, Dickson R et-al. Variation between centers in technique and guidelines for liver biopsy. Liver. 1996;16 (4): 267-270. Liver (abstract) - doi:10.1111/j.1600-0676.1996.tb00741.x
- 3. Walker TG. Interventional Procedures. Lippincott Williams & Wilkins. (2012) ISBN:1931884862. Read it at Google Books - Find it at Amazon
- 4. Manhire A, Charig M, Clelland C et-al. Guidelines for radiologically guided lung biopsy. Thorax. 2003;58 (11): 920-36. Thorax (full text) - doi:10.1136/thorax.58.11.920 - Free text at pubmed - Pubmed citation
- 5. Hare SS, Gupta A, Goncalves AT et-al. Systemic arterial air embolism after percutaneous lung biopsy. Clin Radiol. 2011;66 (7): 589-96. doi:10.1016/j.crad.2011.03.005 - Pubmed citation
- 6. Boskovic T, Stanic J, Pena-Karan S, Zarogoulidis P, Drevelegas K, Katsikogiannis N, Machairiotis N, Mpakas A, Tsakiridis K, Kesisis G, Tsiouda T, Kougioumtzi I, Arikas S, Zarogoulidis K. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. Journal of thoracic disease. 6 Suppl 1: S99-S107. doi:10.3978/j.issn.2072-1439.2013.12.08 - Pubmed
- 7. Tavare AN, Creer DD, Khan S, Vancheeswaran R, Hare SS. Ambulatory percutaneous lung biopsy with early discharge and Heimlich valve management of iatrogenic pneumothorax: more for less. (2016) Thorax. 71 (2): 190-2. doi:10.1136/thoraxjnl-2015-207352 - Pubmed
- 8. Kandathil A, Kay FU, Butt YM, Wachsmann JW, Subramaniam RM. Role of FDG PET/CT in the Eighth Edition of TNM Staging of Non-Small Cell Lung Cancer. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (7): 2134-2149. doi:10.1148/rg.2018180060 - Pubmed
- 9. Orla Drumm, Eimear A. Joyce, Catherine de Blacam, Tom Gleeson, John Kavanagh, Eoghan McCarthy, Ronan McDermott, Peter Beddy. CT-guided Lung Biopsy: Effect of Biopsy-side Down Position on Pneumothorax and Chest Tube Placement. (2019) Radiology. doi:10.1148/radiol.2019182321
Related articles: Imaging in practice
- imaging in practice
-
general radiography (adult)
- portable radiography
- chest radiography
- abdominal radiography
-
upper limb radiography
-
shoulder girdle radiography
- scapula series
-
shoulder series
- shoulder (AP view)
- shoulder (internal rotation view)
- shoulder (external rotation view)
- shoulder (superior-inferior axial view)
- shoulder (inferior-superior axial)
- shoulder (West Point view)
- shoulder (Velpeau view)
- shoulder (modified trauma axial view)
- shoulder (supine lateral view)
- shoulder (modified transthoracic supine lateral)
- shoulder (lateral scapula view)
- shoulder (AP glenoid view)
- shoulder (Garth view)
- shoulder (outlet view)
- shoulder (Stryker notch view)
- acromioclavicular joint series
-
clavicle series
- clavicle (AP view)
- clavicle (AP cephalic view)
- clavicle (oblique view)
- sternoclavicular joint series
- arm and forearm radiography
- wrist and hand radiography
- wrist series
- scaphoid series
- hand series
- thumb series
- fingers series
- rheumatology hands series
- bone age (radiograph)
-
shoulder girdle radiography
-
lower limb radiography
- pelvic girdle radiography
- thigh and leg radiography
- ankle and foot radiography
- skull radiography
-
paranasal sinus and facial bone radiography
- facial bones
- mandible
- nasal bone
- zygomatic arches
- paranasal sinuses
- temporal bones
- dental radiography
- orthopantomography
- temporomandibular joints
- temporomandibular joint (AP axial view)
- temporomandibular joint (axiolateral oblique view)
-
spinal radiography
- cervical spine series
-
thoracic spine series
- thoracic spine (AP view)
- thoracic spine (lateral view)
- thoracic spine (oblique view)
- lumbar spine series
- sacrococcygeal radiography
- scoliosis radiography
-
pediatric radiography
- radiographic positioning terminology
- systematic radiographic technical evaluation (mnemonic)
- pediatric immobilization
- foreign body ingestion series (pediatric)
- foreign body inhalation series (pediatric)
- shunt series
- chest radiograph (pediatric)
- abdomen radiograph (pediatric)
- upper limb radiography (pediatric)
-
lower limb radiography (pediatric)
- pelvis radiograph (pediatric)
- femur series (pediatric)
- pediatric femur (AP view)
- pediatric femur (lateral view)
- leg length view
- knee series (pediatric)
- pediatric knee (AP view)
- pediatric knee (lateral view)
- tibia fibula series (pediatric)
- pediatric tibia fibula (AP view)
- pediatric tibia fibula (lateral view)
- pediatric tibia fibula (oblique view)
- ankle series (pediatric)
- foot series (pediatric)
- skull radiography (pediatric)
- spine radiography (pediatric)
-
skeletal survey
-
skeletal survey (non-accidental injury)
- torso
- pediatric chest (AP erect view)
- pediatric chest (oblique ribs view)
- pediatric abdomen (AP supine view)
- pediatric spine (whole lateral view)
- upper limb (both sides)
- lower limb (both sides)
- pediatric femur (AP view)
- pediatric knee (lateral view)
- pediatric tibia fibula (AP view)
- pediatric ankle (lateral view)
- pediatric foot (DP view)
- torso
-
skeletal survey (non-accidental injury)
-
CT
- iodinated contrast media
- CT IV contrast media administration
-
CT protocol
- composite
- whole-body CT (protocol)
- CT Chest abdomen-pelvis (protocol)
- CT NCAP (neck, chest, abdomen and pelvis)
- head & neck
- chest
- abdomen and pelvis
- CT abdomen-pelvis (protocol)
- CT abdominal aorta
- CT adrenals (protocol)
- CT cholangiography (protocol)
- CT colonography (protocol)
- CT enteroclysis (protocol)
- CT enterography (protocol)
- CT gastrography (protocol)
- CT kidneys, ureters and bladder (protocol)
- CT urography (protocol)
- CT Renal mass (protocol)
- CT angiography of the splanchnic vessels (protocol)
- CT renal split bolus
- CT pancreas (protocol)
- liver
- composite
- barium studies
-
MRI
- cine imaging
-
brain
- screen protocol
- stereotaxis protocol
- tumor protocol
- stroke protocol
- infection protocol
- trauma protocol
- demyelination protocol
- epilepsy protocol
- neurodegenerative protocol
- trigeminal neuralgia protocol
- posterior fossa protocol
- temporal bone/IAM/CPA protocol
- pineal and tectal plate protocol
- pituitary gland protocol
- CSF flow
- angiographic protocols
- MRA
- circle of Willis (COW)
- carotid-vertebral system
- MRV
- MRA
- head and neck
- orbits protocol
- sinonasal tract protocol
- salivary glands protocol
- oropharynx and oral cavity protocol
- suprahyoid neck protocol
- infrahyoid neck protocol
- chest
- mediastinum
- cardiac
- abdomen and pelvis
- abdomen
- liver and biliary tree
- liver protocol
- MRCP: cholangiopancreatography
- pancreas protocol
- elastography
- anus and rectum
- uterus and ovaries
- urological
- prostate cancer protocol
- bladder cancer protocol
- kidneys protocol
- musculoskeletal
-
ultrasound
- ultrasound signs
-
obstetric ultrasound
- other
- placenta
-
second trimester
- fetal biometry
- fetal morphology assessment
-
soft markers
- nuchal fold thickness
- ventriculomegaly
- absent nasal bone
- echogenic intracardiac focus
- choroid plexus cysts
- echogenic bowel
- aberrant right subclavian artery
- amnioreduction
- echogenic fetal bowel
- umbilical artery Doppler assessment
- chorionic villus sampling (CVS) and amniocentesis
- nuchal translucency
- failed early pregnancy
- subchorionic hematoma
- multiple gestations
- ectopic pregnancy
-
first trimester and early pregnancy
- gestational sac
- yolk sac
- embryo/fetus
- amnion
- chorion
- Beta-hCG levels
- gynecologic ultrasound
- vascular ultrasound
- carotids
- extremities
- mesenteric vessels
- other
- breast ultrasound
-
musculoskeletal ultrasound
- technique/artifacts
- ultrasound of arthropathies
- skin/soft tissue ultrasound
- lipoma
- parasitic infection
- other
- pediatric musculoskeletal ultrasound
- ankle/foot ultrasound
-
knee ultrasound
- Baker cyst (popliteal cyst)
- infrapatellar bursitis
- hip ultrasound
- hand ultrasound
- wrist ultrasound
- elbow ultrasound
- shoulder ultrasound
- liver ultrasound
- hyperechoic liver lesion
- sonographic halo sign
- ultrasound appearances of liver metastases
- periportal hyperechogenicity
- periportal hypoechogenicity
- generalized increase in hepatic echogenicity
- generalized reduced hepatic echogenicity
- coarsened hepatic echotexture
- starry sky appearance (ultrasound)
- normal hepatic vein Doppler
- hepatic arterial resistive index
- gallbladder ultrasound
- pancreatic ultrasound
- gastrointestinal ultrasound
- renal ultrasound
- bladder ultrasound
-
testicular and scrotal ultrasound
- other
- epididymis
- paratesticular lesions
- bilateral testicular lesion
-
unilateral testicular lesion
- testicular torsion
- orchitis
- testicular rupture
-
germ cell tumor of the testis
- testicular seminoma
-
non seminomatous germ cell tumors
- mixed germ cell tumor
- yolk sac tumor (endodermal sinus tumor)
- embryonal cell carcinoma
- choriocarcinoma
- testicular teratoma
- testicular epidermoid (teratoma with ectodermal elements only)
- burned out testis tumor
- sex cord / stromal tumors of the testis
- prostate ultrasound
- neck and thyroid ultrasound
- echocardiography
- speckle tracking echocardiography
- fetal echocardiography
- contrast-enhanced echocardiography
- epicardial echocardiography
- three dimensional (3D) echocardiography
- transesophageal echocardiography (TEE)
- transthoracic echocardiography (TTE)
- left ventricular systolic and diastolic function
- structure and morphology
- systolic function
- diastolic function
- right ventricular assessment
- right and left atria
- valvular structure and function
- mitral valve
- aortic valve
- pulmonic valve
- tricuspid valve
- hemodynamics
- pericardium
- cardiomyopathies
- congenital heart disease
- great vessels
- pediatric ultrasound
- ultrasound interventions
- ultrasound-guided biopsy
- ultrasound-guided percutaneous drainage
- ultrasound-guided musculoskeletal interventions
- joint injection
- nerve blocks
- ultrasound-guided intravenous cannulation
- contrast-enhanced ultrasound
- physics and imaging modes
- grey-scale (B-mode)
- motion mode (M-mode)
- color flow Doppler (CFD)
-
spectral Doppler
- pulsed wave Doppler (PWD)
- continuous wave Doppler (CWD)
- superb microvascular imaging (SMI)
- tissue Doppler imaging (TDI)
- nuclear medicine
-
radiation therapy
- external beam radiation therapy (EBRT)
- sealed source radiation therapy (brachytherapy)
- unsealed source radiation therapy
-
interventional
- procedure overview
- neck
- thyroid gland
- breast
- chest
- hepatobiliary
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
-
arthrogram
- upper limb
- lower limb
-
hip
- hip joint injection (technique)
- greater trochanteric bursa injection
- gluteus minimus/medius tendon calcific tendinopathy barbotage
- iliopsoas tendon bursa injection
- lateral cutaneous femoral nerve of the thigh injection
- piriformis injection
- common hamstrings origin injections
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
foot
- calcaneocuboid joint injection
- metatarsophalangeal joint (MTPJ) injection
- naviculocuneiform joint injection
- plantar fascia microtenotomy
- subtalar joint injection
- talonavicular joint injection
- tarsometatarsal joint (TMTJ) injection
-
hip
- spine
- breast imaging
-
mammography
- breast screening
- breast imaging and the technologist
- forbidden (check) areas in mammography
-
mammography views
- craniocaudal view
- mediolateral oblique view
- additional (supplementary) views
- true lateral view
- lateromedial oblique view
- late mediolateral view
- step oblique views
- spot view
- double spot compression view
- magnification view
- exaggerated craniocaudal (axillary) view
- cleavage view
- tangential views
- caudocranial view
- bullseye CC view
- rolled CC view
- elevated craniocaudal projection
- caudal cranial projection
- 20° oblique projection
- inferomedial superolateral oblique projection
- Eklund technique
- normal breast imaging examples
-
mammography
- digital breast tomosynthesis
- breast ultrasound
- breast ductography
- breast MRI
- breast morphology
- breast intervention