CT guided lung biopsy - step by step guide

Case contributed by Dr Ian Bickle

Presentation

Symptomatic smoker. Diagnositic imaging reveals a right upper lobe lung cancer. Biopsy to aid management plan.

Patient Data

Age: 70 years
Gender: Male

This case demonstrates in a step-by-step fashion the stages in performing a CT guided lung biopsy.

The procedure is peformed using a 18G co-axial core biopsy set.

Equipment required

  1. Skin surface marker grid.
  2. Co-axial biopsy set.
  3. Basic procedure pack with lidocaine, as for any minor procedure.

An important technique to practice with the patient before even infiltrating local anaesthetic is a consistent breath hold. Clear instructions that the patient is to take a comfortable breath in, and note how big this breath is, and to take the same sized breath hold each time they are instructed to do so. This will ensure that the nodule is in approximately the same position each time the needle is advanced .  

Step 1: Perform a limited CT of the chest with the skin surfaces markers in place, over the planned site of entry. This also allows for assessment of the pulmonary nodule and mass and if there has been change suggestive of a benign process (e.g. infection) then biopsy may be delayed or cancelled and close follow-up performed. 

You can make your own surface marker grid for these purposes - see surface marker grid for CT guided biopsy.

Proceed to insert local anaesthetic (1% lidocaine) along the route of the proposed biopsy down to and including the outer pleura.

Step 2:  Check of infiltration needle position and angulation in relation to the mass. Ensure it is on track, no patient movement, etc, before the co-axial needle is placed.

Tip: Use lung windows and 'narrow' the windows to see the needle optimally.

Step 3:  Insert the co-axial needle in as far as, but not through the pleura. Re-check alignment.

** Note: in this case adjustment is needed for ideal angulation prior to the next step breeching the pleura.

Step 4:  Re-alignment of the co-axial needle performed. The co-axial is now perfectly placed for taking the biopsy. The minimal time necessary with the pleura breeched and no re-positioning after pleura breeched has been necessary.

Step 6:  On table check of post-procedural pneumothorax.

A very thin pneumothorax is present.

A chest x-ray will be taken in 4 hours to assess for any progression.

Case Discussion

CT guided thoracic (lung) biopsy is a everyday important procedure undertaken in clinical radiology departments.

The majority of biopsies are in those with presumed lung cancer, although a wider spectrum of pathologies in both the lung and mediastinum may be biopsied.

Technique and a measured approach is key.   The procedure is not without complication, the chief and most frequent being pneumothorax.

This case guides the unfamiliar in a step-by-step manner how to undertake the procedure.

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Case information

rID: 30697
Case created: 29th Aug 2014
Last edited: 13th Mar 2016
Inclusion in quiz mode: Included

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