CT-Guided Percutaneous Lung Biopsy: Important Steps with “Tips and Tricks” for Optimal Yield

Abstract

Tissue diagnosis plays a major role in the management of patients with lung lesions, especially if malignancy is suspected. Computed tomography-guided biopsy of lung lesions is a well-established procedure. We share a few “tips and tricks” to keep the procedure safe and comfortable to the patient with optimal yield.

Keywords

lung biopsy - CT-guided - lung lesion - lung malignancy - pneumothorax

Introduction

The first computed tomography (CT)-guided lung biopsy was performed by Haaga and Alfidi in 1976.[1] Over time, CT-guided percutaneous lung biopsy has become the standard of care for lung pathologies. Currently, malignancies are classified based on their immunohistochemical and genetic analysis. Hence, histological diagnosis is now mandatory.[2] There are many available guidelines by various societies like the British Thoracic Society,[3] Society of Interventional Radiology, American College of Radiology,[4] Society of Pediatric Radiology,[5] [6] and Cardiovascular and Interventional Radiological Society of Europe.[7] [8] These guidelines help radiologists to customize to individual case scenarios. In this article, we describe few tips and tricks that help radiologist in their daily practice for good yield and teaching tool for young radiologist.

Preprocedural Workup

Selection of Biopsy Method

Decision for image-guided biopsy should be made after discussing the indications and imaging in a multidisciplinary team (MDT) meeting with a specialist radiologist, pulmonologist, thoracic surgeon, and pathologist. Bronchoscope-guided biopsy is preferred for centrally located (endo- or peribronchial) lesions, which are easily accessible through bronchoscope.[9] Other methods include ultrasound-guided biopsy for pleural-based lesions, and video-assisted thoracoscopic surgery for subpleural lesions or lesions close to the diaphragm. Open surgical biopsy is indicated when other modalities have failed, for lesions inaccessible by above-mentioned methods, or for a curative intent procedure if lesions are small or confined to a single lobe.[10] The benefits and risks involved with each method should be discussed in MDT meeting and the most appropriate method must be followed to minimize complications.[3] The common indications and contraindications for biopsy are enlisted in [Tables 1] and [2].

Table 1 Indications of percutaneous lung biopsy

• Indeterminate solitary pulmonary nodule or mass

• New or enlarging pulmonary nodule

• Pulmonary nodules in a case of two primary malignancies (in syndromes) or to rule out second pulmonary malignancy

• Molecular (immunohistochemistry) markers in a known lung cancer

• Pulmonary lesions closer to mediastinum/hilum, pleural-based or chest wall inaccessible through other modalities

• Persistent focal pulmonary infiltrates, either single or multiple, indeterminate on sputum, blood culture, serology, or bronchoscopy

Table 2 Contraindications for percutaneous lung biopsy

▪ Deranged bleeding parameters, specifically:

o INR > 1.4, platelet count < 50,000/μL

o Intravenous anticoagulation agents such as heparin or warfarin

▪ Uncooperative patient (altered mental status) ▪ Intractable cough

▪ Severe emphysema or interstitial lung diseases

▪ Contralateral pneumonectomy

▪ Severe pulmonary arterial hypertension

▪ Mechanical ventilation

▪ Lesions of relatively small size, or close to major vessels or diaphragm

▪ PFTs: FEV1 < 35%

Abbreviations: FEV, forced expiratory volume; INR, international normalized ratio; PFT, pulmonary function test.

Prebiopsy Imaging

CT is the preferred modality for prebiopsy imaging of intrathoracic pathologies. It helps in preselecting the component of the lesion that can give maximum yield, for example, the solid lesions or solid components within the lesion. Contrast administration can help with identifying areas of necrosis in lesions. Targeting nonnecrotic areas will result in a higher yield[11] [12] [13] ([Fig. 1], [Supplementary Fig. S1]). Various imaging techniques that can be used are discussed in [Table 3]. The imaging should be as close to the date of the procedure as possible. Increased time gap may lead to differences in the disease morphology and orientation[3] and may require a change in biopsy technique. Whenever required, repeat imaging should be considered prior to the procedure.

Fig. 1 (A–C) Importance of prebiopsy imaging. Schematic diagrams of axial computed tomography (CT) (A and C) and positron emission tomography (PET)-CT (B) showing multiple randomly distributed lesions in both lungs. PET-CT depicts varying metabolic activities in these lesions, with highest activity in the lesions located in lower lobes. The metabolically active lesions should be targeted for best yield. CT (C) also showed enlarged mediastinal and axillary lymph nodes, which can be easily accessed by bronchoscopy or ultrasound guidance, respectively.

Table 3 Role of prebiopsy imaging

Imaging	Role
Noncontrast chest CT Contrast-enhanced chest CT (imaging of choice)	1. Decide target lesion
	2. Plan the path of approach
	3.Assess intrinsic tumor vascularity, detect any vascular malformations
	4. Assess surrounding lung parenchyma for fissures or vessels
	5. Anticipate possible complications
	6. Guiding bronchoscopy-guided biopsy and VATS
18F-FDG PET-CT	1. Target hypermetabolic component of the lesion ([Fig. 1])
	2. Determine number of lesions (thoracic and extrathoracic locations)
	3. May help in arriving at a diagnosis based on lesion multiplicity and metabolic activity, and thus avoid biopsy
MRI-DWI (rarely used)	1. Superior soft-tissue resolution for hilar, perihilar, and mediastinal lesions

Abbreviations: CT, computed tomography; ¹⁸F-FDG, fluorodeoxyglucose F 18; MRI-DWI, magnetic resonance imaging-diffusion-weighted imaging; PET, positron emission tomography; VATS, video-assisted thoracoscopic surgery.

Prebiopsy Workup

Coagulation abnormalities are a relative contraindication to the procedure as it increases the risk of prolonged bleeding. Platelet count, prothrombin time/international normalized ratio (INR), and activated partial thromboplastin time done within 1 month prior to the procedure is recommended. INR of more than 1.4 will need fresh frozen plasma transfusion or three doses of oral or intravenous vitamin K before the procedure. The acceptable platelet count for the procedure should be more than 50,000/mm³.[14] [15] [16]

Prior to intravenous contrast administration, as for all other CT contrast studies, estimated glomerular filtration rate should be within acceptable levels.

Pulmonary function tests are indicated before procedure if there is a suspicion of an underlying lung parenchymal disease. On spirometry, forced expiratory volume at 1 second of more than 35% of the predicted value is acceptable for the procedure.[3] If the values are deranged, the risk versus benefit assessment should be done in the MDT meeting.

Echocardiography may be included in the prebiopsy workup in suspected cases of pulmonary arterial hypertension. Lung biopsy can be performed in cases of mild to moderate pulmonary arterial hypertension without an added risk of hemorrhage.[17]

Patient Counseling and Consent

The patient and relatives should be explained about the need for the biopsy, procedure details, and possible complications. The steps that are going to be followed to prevent or treat any untoward complications should be explained in their native language. All queries related to the procedure, including those related to complications and the steps taken to prevent or treat them, if they arise must be discussed and clarified.[16]

Complication rates discussed with patients can be based on internal audits done at institutional level. Informed written consent must be obtained before the procedure.[3] [18] Patient cooperation during the procedure is the “key to success.”[19]

Relevant medication history such as the use of anticoagulants should be obtained prior to procedure. Percutaneous lung biopsy is considered as moderate to high bleeding risk procedure.[7] Warfarin interferes with platelet function and takes 4 days before INR becomes normal after stopping the drug. Aspirin should be preferably stopped for 5 to 7 days and clopidogrel for 5 days before the procedure.[9] Novel oral anticoagulation and direct oral anticoagulant drugs should be held for at least 24 hours prior to procedure. Bridging anticoagulation can be achieved with heparin injection in cases of high bleeding risk, which can be stopped 6 hours prior to the procedure.[7] [20]

Procedure Technique

Conscious Sedation

Local anesthesia is routinely administered for CT-guided lung biopsy. General anesthesia is reserved for pediatric and uncooperative patients.[21] Mild sedation relieves the patient's anxiety and helps in normal and regular breathing.[10] [22] [23] [24] At our institute, we administer fentanyl and Phenergan injection intramuscularly, preferably 15 minutes before the procedure.

Image Guidance

CT is the preferred imaging modality for guiding percutaneous lung biopsy. Ultrasound may be useful only for subpleural lesions. Another method is CT fluoroscopy that allows for real-time visualization of the needle tip position, reducing the procedure time and the chances of complications. However, increased radiation dose to both the patient as well as the radiologist, compared with conventional CT, is the main disadvantage. The radiation dose can be reduced by intermittent CT fluoroscopy with the “quick-check” method.[22]

Cone-beam CT is also known to be used for CT-guided procedures. It is a combination of fluoroscopy and CT and has the advantage of real-time visualization of needle tip along with reduced radiation dose. Cone-beam CT offers reduced procedure times while maintaining high accuracy with no additional risk of complications.[25]

Patient Positioning

Patient position should be determined by reviewing the preprocedural imaging. It depends on the lesion location, structures in the biopsy path, patient comfort, and operator preference. The position should be documented in the procedure information sheet for the technician's reference before positioning the patient onto the scan table. This avoids unnecessary repositioning and repeat planning CTs. Bed sheets or pillows should be kept under the patient to make them comfortable. Lung capacity should also be taken into consideration while positioning, as patients with reduced lung capacity may find it difficult to remain in prone position for a long duration.

Due to less respiration-related excursion of posterior ribs, and better access through wider and more uniform posterior intercostal spaces, the prone position is preferred. This position also helps in reducing patient anxiety and movement during the procedure as the patient cannot view needle insertion.[26] It also allows for better patient recovery since subsequent compression of the skin entry point in supine position creates an optimum plug effect. Supine or prone positions have the advantage of observing symmetrical movement of the chest wall.

Oblique or lateral decubitus position is less preferred due to increased chances of patient motion. They are preferred for subpleural lesions to minimize the needle trajectory through lung parenchyma.[10] [22] Drumm et al proposed that positioning a patient with biopsy side down during the procedure and accessing the lesion from anterior or posterior, reduces incidence of complications. This is because of settling of parenchymal hemorrhage in the dependent smaller airways instead of entering into the contralateral lung, pleural apposition, and sealing of biopsy track due to the weight of the lung, minimizing the risk of pneumothorax.[27]

Needle Access Path

The needle trajectory should be planned in such a way that it traverses the shortest and vertical path and avoids large vessels, airways, fissures, blebs, and bullae ([Fig. 2]). If the procedure is planned in a prone position, the ribs and scapula are the structures that can hinder the needle path. If the procedure is planned in supine position, the ribs, clavicle, sternum, vessels, heart, and breast tissue (in females) are the limiting factors.

Fig. 2 (A, B) Approach to lesion and patient position. Schematic diagrams of axial computed tomography (CT) showing two pulmonary lesions. The first lesion (L1) is located in the right middle lobe, with the fissure traversing posterior to it. The second lesion (L2) is located in the left lower lobe with the major fissure located anterior to it. L1 should be approached anteriorly or laterally (A), and not from the posterior chest wall (B), to avoid crossing the fissure. Similarly, L2 should be approached from a posterior direction (A), and not from the anterior chest wall (B). The patient should be positioned supine or prone depending upon the site of needle entry.

Scan Techniques: Radiation Dose

Measures should be taken to keep radiation exposure to the minimum. The need for additional CTs with intravenous contrast (to delineate lesion relationship with vessels and heart) and anatomy of the bony landmarks around the lesion should be noted from first preprocedural noncontrast CT, avoiding unnecessary repeat scans.[28] The tube current (mA) and voltage (kVp) should be reduced in subsequent scans during the course of the procedure. Also, the number of slices (along the z-axis) should be minimized to cover only the target lesion with an appropriate slice thickness.[10] [28] [29]

The initial planning CT accounts for a major share of absorbed dose to the patient as it scans a wider area. Subsequent CT scans are largely confined to a smaller area, and contribute to skin radiation dose. Alternatively, intermittent fluoroscopy can be done for checking the needle tip position. The radiologist and the technicians performing the scan should be aware of the radiation safety guidelines.[30] Regular audits can also aid to keep a check on radiation dose.

Patient Preparation

Careful attention should be paid to the correct side for entry, especially when preprocedural CT is done in the supine position and the procedure is planned in a prone position. The needle entry point should be marked on the skin with a radiopaque marker. Communicating the site of biopsy to everyone in the biopsy suite and sticking line diagrams inside the gantry room to help plan are a few tips to prevent wrong entry. Safety checklist run through prior to starting the actual procedure has also shown to prevent inadvertent mistakes.[16] [31]

Routine antibiotic prophylaxis prior to the procedure is not recommended,[8] [32] rather strict asepsis should be followed during the procedure. After marking the needle entry site, the skin should be cleaned with antiseptic solution over a wide area, to account for any slight variations in needle entry site. Sterile drapes should be placed over the region of interest.

Needle Entry

Local anesthetic is administered along the route of biopsy. Care should be taken not to overinsert the local anesthesia needle into the pleural cavity. This needle can also serve as a marker to the biopsy entry point. This is followed by a small incision with a surgical blade, to facilitate the entry of the biopsy needle. The biopsy needle should be inserted directly into the lung parenchyma, crossing the pleura with a single attempt after checking the needle alignment along the planned direction.[22] [33] Needle repositioning, if required, can be done without withdrawing the full length of the needle out of the lung. The needle tip is best positioned at the lesion periphery.[10] In an attempt to reach the center of the lesion, one should not cause inadvertent injury as “perfection is enemy of good.” Always use the latest scan for planning the next step in the procedure, as dynamic changes can occur due to patient motion or respiration.[19]

Coaxial Technique Biopsy versus Fine-Needle Aspiration Cytology

Biopsy with a coaxial needle is preferred, as it allows multiple sampling with a single pleural puncture.[34] It also establishes needle stability in the chest wall during the procedure.[35] Varying needle sizes are available and need to be chosen based on the size of the lesion and location. A commonly used coaxial system is a 17G introducer needle, which allows for a 18G cutting needle. A 15 to 16G combination can be used for larger lesions. Studies have reported increased complication rates with larger bore needles.[36] [37] The choice between automatic and semiautomatic biopsy guns depends on individual preference and availability, as both types are well-documented in the literature.[38] [39]

The coaxial system can also be used for fine-needle aspiration cytology (FNAC), by introducing the 22G Chiba needle (attached to a syringe) through the outer 17G introducer needle followed by jabbing movement up and down within the lesion while applying constant suction.[10] [22] This process can be repeated as long as the introducer needle is within the lesion and an adequate sample is obtained for cytology.

FNAC is preferred for smaller lesions, although the yield may be less compared with a biopsy.[40] [41] Availability of an onsite cytologist helps in assessing sample adequacy.[3] [22] [42] [43] [44] [45] When a cytologist is not available, as many samples as possible should be collected.[46] However, this increases the number of pleural punctures and risk of complications. Few studies have shown that there is no difference in the rate of complications between core needle biopsy and FNAC.[42] However, coaxial biopsy is always preferable to keep the pleural punctures to the minimum and for better yield. Also, with the need for molecular analysis, tissue rather than cells is essential.[9]

Few Tips and Tricks

Respiratory Motion

The lower zones of the lungs are more affected by respiratory motion than the upper zones,[19] hence lesions close to the diaphragm may be challenging. Likewise, movement of lateral ribs is more compared with the anterior or posterior ribs due to their bucket-handle-like joints. Some radiologists prefer patients to breath hold during needle insertion or obtaining samples, while others prefer free breathing. Conventional practice of breath hold may result in patients taking a deep inspiration after the breath hold, altering the needle position in relation to the lesion and increasing the risk of complications, especially if the lesion is closer to vessels or pleura. Hence, free breathing with needle insertion during the inspiration phase is recommended, especially for upper lobe lesions.[19] Likewise, breath hold may be practiced for lesions in lower lobes.

Cardiac Motion

The position of the lesion may get affected by the constant cardiac motion, especially for lesions in its close proximity such as in the lingula.[19] In such cases, the needle trajectory should be directed away from the heart to prevent inadvertent injury to the heart or mediastinal vessels.

Diaphragm

While sampling lesions in the lower lobes, avoid traversing the diaphragm as it causes severe pain leading to needle dislodgement and increases the risk of pneumothorax.

Fissures

Traversing pleural fissures increases risk of pneumothorax and should be avoided. In addition, tumor seeding across fissures is also possible, though not substantiated with evidence.[28]

Vessels

Apart from mediastinal vessels, other vessels of importance during biopsy include internal mammary and intercostal arteries. Internal mammary arteries run parallel on either side of the sternum. These vessels can be injured when the procedure is done in supine position. This can be avoided by choosing needle entry point as close as possible to the lateral border of the sternum ([Fig. 3]). Intercostal arteries run along the inferior margin of the ribs, hence needle entry should be above the rib rather than below the rib. If a lesion lies in close relation to a vessel, the needle should be directed away from the vessel ([Fig. 3], [Supplementary Fig. S2]).

Fig. 3 (A, B) Approach to an anterior paracardiac lesion. Schematic diagram of axial computed tomography (CT) section shows a left paracardiac lesion. Approach 1–Needle path close to the internal mammary vessels. Internal mammary vessels traversing along the lateral sternal border may get injured leading to intrapulmonary hemorrhage or hemothorax. The needle path should be medial to the vessels and as close to the sternum as possible. Approach 2–Needle path directed toward the mediastinum. Inadvertent needle advancement may injure the main pulmonary artery located deep to the lesion. The needle should be directed away from the mediastinal vessels. Approach 3–Needle path as close to the lateral sternal border as possible and directed away from the mediastinal structures. This is the preferred approach.

Position of the Radiologist

The radiologist's position is not constant on a particular side of the patient, but can vary according to the biopsy side and technique. The radiologist should preferably stand along the line of needle trajectory for a better assessment of the point of needle entry ([Fig. 4]).

Fig. 4 (A, B) Position of the radiologist during the procedure. Schematic diagram of axial computed tomography (CT) sections in prone position shows a right lower lobe pulmonary nodule. If the radiologist stands on the left side of the patient, the assessment of needle angulation (blue) will be difficult (A). If the radiologist stands on the right side, the assessment of needle angulation will be accurate and easy (B).

Mind the Distance

The needle length should be selected based on the skin to lesion distance measured on the preprocedural CT as coaxial needles are available in various lengths. When the biopsy needle is fully inserted, it extends 2 to 3 mm beyond the outer introducer needle ([Fig. 5]). When biopsy gun is fired, the needle moves forward for a specific distance (for example, 15 or 22 mm) to acquire the tissue. This length is known as the cutting length of the needle ([Fig. 6]). The initial 2 to 3 mm at the tip does not collect any sample.

Fig. 5 Various biopsy needle lengths. Biopsy needles can be available in various lengths, for example, 4 cm (short) and 10 cm (long) needles shown here (top row). When the biopsy needle is inserted, the needle advances in the outer introducer needle by few millimeters (short double-headed arrow, middle row). When the biopsy needle is fired, it advances to a predetermined length through the lesion (long double-headed arrow, last row). Note that few millimeters at the front of the needle (dotted line) would not take part in sample collection (vertical image).

Fig. 6 Pictorial representation of biopsy needle motion during biopsy. Biopsy needle placed close to the lesion (top row). When a biopsy gun or spring-loaded system is fired, the inner stylet with notch moves forward to an adjustable length (second row) followed by the outer core over the inner stylet (third row) and obtains a small portion of the tissue of interest and the sample is obtained (fourth row).

Injury to the Lung during Biopsy

The cutting length of the needle causes injury to the lung distal to the needle tip. The tissue lateral to the needle tip is affected by vibration. Thus, these regions are known as danger zones due to the shock wave of the biopsy gun. It should be taken care that are no large/major vessels in this region ([Fig. 3]).[19]

Needle Manipulations in Different Situations

Although the planning of biopsy under CT guidance appears simple, sometimes it becomes difficult to plan trajectory due to the position of the lesion or its relation to the surrounding structures.

If a lesion is under the scapula and if the anterior approach not accessible, keeping the patient in prone position with hands by the side of the body with internal rotation of the humerus can move the scapula laterally and the lesion can be accessed ([Fig. 7]).

Fig. 7 (A, B) Patient position when lesion is deep to the scapula. Schematic diagram of prone axial computed tomography (CT) sections show a right posterior subpleural lesion. (A) Placing the patient in prone position with hands by the side of the head will not provide a window for biopsy as the scapula and ribs will obstruct the needle path. Anterior approach is also not preferred as the needle will traverse the fissures and more lung tissue. (B) When the hands are kept by the side of the body and internally rotated, the scapula will be protracted and move away from the lesion. This favors needle insertion through the posterior chest wall.

If a lesion is below a rib, gantry angulation can be done to achieve cranial needle entry point with caudal angulation of the needle ([Fig. 8]). This is particularly useful in lesions located in the inferior part of the upper lobe with major fissure in the path of expected needle entry.

Fig. 8 (A–C) Use of computed tomography (CT) gantry rotation. Schematic diagram of axial CT sections shows a left lower lobe cavitary lesion with a solid component along its cranial aspect. This solid area is located underneath a rib (A). Inserting the needle through the adjacent intercostal space will direct the tip toward the inferior aspect of the lesion, missing the solid area (B). However, if the gantry is angulated, and the needle is aligned along the gantry angulation, the needle will reach the solid component easily (C). In addition, the needle should enter along the superior margin of the rib rather than along its inferior margin, to avoid injury to the intercostal vessels.

If the needle tip reaches the periphery of the lesion, the needle can be angulated ([Fig. 9], [Supplementary Fig. S3]) during the firing of the biopsy gun to collect samples from the center of the lesion, to avoid removing and reinserting the needle, which may increase the chances of complication.[19]

Fig. 9 Needle manipulation when the needle reaches the edge of the lesion rather than the center of the lesion. If the needle reaches the edge of the lesion (first image), the needle can be slightly removed (second image), and the needle hub is angulated away from the lesion so that the tip of the lesion reaches the center part of the lesion (last image).

Studies suggest that biopsy can be done even if minimal pneumothorax develops after needle insertion and before the sampling provided pneumothorax remains stable. However, recent studies show that pneumothorax can be created artificially for biopsy of small pleural-based lesions. If pneumothorax is increasing, the procedure should be abandoned, and drainage tube should be inserted.[19]

Pleural-Based Lesions

Pleural-based lesions can be accessed directly ([Fig. 10]); however, some studies suggest that the needle should not track along the pleura, rather along a longer path traversing through the normal lung ([Supplementary Fig. S4]). As the lesion is shifted away from the pleura due to force of the biopsy, thereby resulting in risk of pneumothorax.[22]

Fig. 10 Approach to chest wall lesions. Schematic representation of prone axial computed tomography (CT) shows a left chest wall soft tissue lesion arising from the right posterior rib (A). It can be best biopsied in the prone position, using a posterior approach. This will avoid piercing the pleura or the lung parenchyma. Note that the needle is inserted along the greatest length of the lesion and parallel to the rib, rather than perpendicular to it, to prevent pleural injury during firing of the needle (B). Lesions with large soft tissue component can also be targeted with ultrasound guidance.

Patient Monitoring

Intravenous access should be acquired before the procedure. Patient's heart rate, respiratory rate, blood pressure, and oxygen saturation should be monitored by nursing staff. Any deviation from agreed normal levels should be alerted to the radiologist.[47] The radiologist should be trained to recognize and handle the possible complications. All the emergency medication should be available in the biopsy suite and intensive care unit backup should be available if necessary.

Sample Collection

While taking samples, the bore of the outer introducer needle should never be left open without the inner stylet. Few drops of saline can be put in the needle introducer to prevent air entry or can be connected to an empty syringe.

The number of biopsy cores to be collected is best determined before starting the procedure. When an infectious process is suspected on routine imaging, culture samples should be collected first to prevent unnecessary contamination. Sample can be aspirated for cell block from necrotic or cystic lesions. For suspected neoplasms, immunohistochemistry samples should be collected. When in doubt, additional samples should be obtained and preserved to prevent repeat biopsy. Visual assessment of the sample adequacy should be done by an experienced radiologist.[3]

The histopathology specimen is collected in 10% formalin,[8] whereas culture samples are collected in normal saline solution. If lymphoproliferative disorders are suspected, samples should be collected in the Roswell Park Memorial Institute solution for flow cytometry.[10] [22] The samples must be appropriately labeled with patient information and sent to the laboratory at the earliest.[16]

Postprocedure Advice

Gentle massage at the skin after removing the biopsy needle prevents entry of air.[48] The PEARL (positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching) technique has been described with reduced rates of pneumothorax and chest tube insertions, which can be used in various combinations. Patient positioning in biopsy-side down position reduces the risk of pneumothorax as well as hemoptysis.[3] [27] [49] Deep expiration and breath hold during needle removal helps in the reduction of pneumothorax and chest tube placement, attributed to positive intrapleural pressure during expiration. Rapid needle removal and patient rollover technique was performed rapidly with biopsy side position. Several studies reported usage of sealant along the biopsy tract like autologous blood patch (which is most commonly used), saline, and gelfoam slurry; however, some studied showed no added advantage.[3] [22] Some studies suggested aspiration of pleural air for better reapposition of the pleura and thereby reduction of pneumothorax rates.

Patients are advised not to talk, cough, or strain in the immediate postprocedure period to prevent complications.[10] [29] Vitals should be monitored for at least 3 to 6 hours. If needed, a chest radiograph can be done in an upright position to check for complications such as pneumothorax or hemorrhage. Recommendations regarding the time gap of chest radiograph vary from 3 to 6 hours to 24 hours postprocedure.[50] Clinical assessment is more important in identifying complications rather than chest radiograph, as it contributes to additional radiation exposure and should be limited to high-risk patients only.

Procedures may be performed with day care admission or as an outpatient procedure.[43] At our institution, all patients are admitted in a day care ward and discharged after 8 hours if no untoward complications arise. With day care admissions, complications can be detected and managed promptly.

Follow-Up and Review

Biopsy results should be followed up by the radiologist who performed the procedure. Regular internal audits describing success rate, histopathology diagnosis, inadequate samples, and inconclusive reports improve the biopsy skills and boost the confidence. It also adds to data for patient education and contributes to quality improvement and research.

Inconclusive cases should be reviewed to assess challenges during the procedure. Need for a repeat biopsy should be ideally decided in a multidisciplinary meeting. Few studies have shown positive detection of malignancies in a significant number of repeat biopsies in initially negative ones.[51] [52] [53] If a repeat biopsy is planned, an attempt must be made to collect the sample from the solid component of the lesion. Alternatively, smaller lesions can be followed up to assess stability after discussing with the MDT team.[3]

Complications

Being a minimally invasive procedure, the complication rates with image-guided lung biopsy are minimal, requiring conservative management or observation in most cases. Factors increasing the risk of complications are enlisted in [Table 4]. A recent meta-analysis has shown that the overall complication rates for core biopsy and FNAC is 38.8 and 24%, respectively, without a significant difference in the rate of major complications.[49] Some of the common complications are enlisted below,

Table 4 Factors associated with increased risk of complications

Pneumothorax	Hemorrhage	Air embolism
● Small lesion size (< 1 cm) ● Increased lesion depth[56] ● Wider insertion needle angle (acute angle between the needle and pleural surface)[57] [58] [59] ● Pleural effusion ● Multiple pleural punctures ● Underlying interstitial lung diseases	● Small lesion size (< 1 cm) ● Increased lesion depth[56] ● Underlying interstitial lung diseases ● Pulmonary arterial hypertension	● Cystic or cavitary lesions ● Coughing ● Manipulation of the open trocar without the inner stylet ● Needle puncturing pulmonary veins through the emphysematous tissue[22]

Pneumothorax

This is the most common (up to 61%) complication of percutaneous lung biopsy.[22] Patients can be asymptomatic or present with acute breathlessness, chest tightness, and a drop in oxygen saturation level. These symptomatic cases range from 6 to 18%.[54] It can be managed conservatively majority of the time depending on the degree of pneumothorax and the patient's vitals.

Mild pneumothorax is managed conservatively with O₂ inhalation via nasal prongs or mask. Drainage catheter insertion is required in 3 to 15% of cases.[3] [22] Management of pneumothorax at various stages of the procedure is described in [Table 5]. As a precautionary measure, if biopsy is contemplated from more than one lesion (in both lungs), the procedures should be planned in different sittings to avoid bilateral pneumothorax. Pneumothorax can develop as late as 24 hours after the procedure, hence patients should be informed about the symptoms for which they need to report to the emergency.

Table 5 Management of pneumothorax during the biopsy

Time of pneumothorax detection	Management
During the procedure with the biopsy needle in situ ([Fig. 11])	Biopsy needle can be connected to a 20-mL syringe through a three-way cannula, to aspirate the air until the lung expands Sometimes, during aspiration, the expanded lung can obstruct the needle tip, giving a false impression of full expansion of the lung. The needle tip can be slightly manipulated to check for any residual pneumothorax and removed after confirming near-complete expansion of the lung
Postprocedure, after needle removal	Minimal amount of air: observation Significant amount of air: Manual aspiration can be done by inserting intravenous catheter and aspiration using three-way stopcock[60] or pigtail catheter through the same incision as the biopsy needle[58] [61]
Anytime during or after the procedure, if patient's vitals are unstable	A needle can be inserted in the 4th intercostal space/through biopsy needle entry site, followed by pigtail catheter insertion after stabilizing the patient.[52] These catheters should be connected to a Heimlich valve or underwater seal drain[22] [53]

Fig. 11 (A–F) Management of pneumothorax during the biopsy. Schematic diagram of axial computed tomography (CT) sections shows: (A) Right upper lobe spiculated lesion with traction bronchiectasis in the adjacent parenchyma. Care should be taken not to traverse the abnormal lung. (B) Needle should be advanced in small increments till it reaches the lesion and the biopsy gun should be fired. (C) If patient develops pneumothorax while the needle in situ, (D) connect the outer needle to a three-way stopcock and 50 mL syringe and the air should be aspirated. (E) Expanded lung may obstruct the needle bore giving a false impression of complete lung expansion. The needle should be slightly withdrawn, and air should be aspirated until complete or near-complete resolution of pneumothorax (F).

Pulmonary Hemorrhage

This is the second most common (up to 27%) complication of percutaneous lung biopsy.[22] It can manifest as intrapulmonary alveolar hemorrhage or hemothorax. Postprocedure imaging can show new development of perilesional or perineedle-tract ground-glass opacity[45] or high attenuation pleural effusion.

Alveolar hemorrhage is usually asymptomatic, noticed as a mild decrease in saturation, and can be conservatively managed. If the hemorrhage communicates with a bronchus, hemoptysis can occur in 1.25 to 5% of cases.[3] Patients should be reassured and placed in lateral decubitus with the biopsy side placed in the dependent position. In cases of moderate to severe hemoptysis, patients should be asked to spit out the blood to prevent accumulation in the mouth[29] or it can be suctioned out to prevent aspiration and airway blockage. Resuscitation with O₂ inhalation and intravenous fluids to be started immediately and continued further based on the vitals status.

Hemothorax occurs due to an injury to internal mammary or intercostal vessels. Percutaneous tube drainage may be required if the hemorrhage is massive or causing compression on vital structures.

Air Embolism

Air embolism is a very rare (0.04–0.07%) but a life-threatening complication.[29] [55] Patients can present with chest discomfort, focal cerebral neurological deficits, and seizures due to coronary or cerebral arterial blockage. If air embolism is suspected, the patient should be placed in Trendelenburg position. Hyperbaric oxygen inhalation, heparin, and anticonvulsant can also help in such cases.[3] [29] [55]

Tumor Seeding

Tumor seeding across the lung, pleura, or chest wall is a debatable concept. Although exceedingly rare (0.01–0.06%), few cases with pleural mesothelioma and thymoma have been reported in the literature.[29]

Conclusion

CT-guided lung biopsy is a relatively safe and minimally invasive percutaneous procedure with high accuracy for obtaining tissue diagnosis and customizing the treatment for lung pathologies. Careful selection of patients with proper preprocedural evaluation and intra- and postprocedural care increases the positive yield and minimizes the rate of complications.

Conflict of Interest

None declared.

Copyright Regarding Drawings

The drawings used in the manuscript are original works of the primary author (Ch Jagadeesh Kumar) of the manuscript. Permission is given for use of this in the manuscript.

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Publication History

Article published online:
27 March 2025