Percutaneous Lung Biopsy: An Ordering Clinician's Guide to Current Practice

ABSTRACT

The discovery of a pulmonary nodule or mass usually leads to a clinical assessment of patient risk factors for malignancy and an imaging workup. The latter may include appropriately timed follow-up, computed tomography with the possible addition of a computed tomographic nodule enhancement study, positron emission tomography, and/or percutaneous biopsy of the lung lesion or associated lymph nodes or metastatic lesions. This article reviews the rationale for the imaging workup of lung lesions and the details of percutaneous needle biopsy, including risks, technical feasibility, techniques, needle systems, cytological/pathological evaluation, accuracy, complications, and complication management.

KEYWORDS

Lung biopsy - complications - techniques

REFERENCES

• 1 Lillington G A. Management of solitary pulmonary nodules.  Dis Mon. 1991;  37 271-318
• 2 Cummings S R, Lillington G A, Richard R J. Estimating the probability of malignancy in solitary pulmonary nodules: a Bayesian approach.  Am Rev Respir Dis. 1986;  134 449-454
• 3 Swensen S J, Silverstein M D, Ilstrup D M et al.. The probability of malignancy in solitary pulmonary nodules: application to small radiologically indeterminate nodules.  Arch Intern Med. 1997;  157 849-855
• 4 Libby D M, Smith J P, Altorki N K et al.. Managing the small pulmonary nodule discovered by CT.  Chest. 2004;  125 1522-1529
• 5 Wahidi M M, Govert J A, Goudar R K et al.. Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition).  Chest. 2007;  132(3, Suppl) 94S-107S
• 6 Swensen S J, Viggiano R W, Midthun D E et al.. Lung nodule enhancement at CT: multicenter study.  Radiology. 2000;  214 73-80
• 7 Bach P B, Kattan M Q, Thornquist M D et al.. Variations in lung cancer risk among smokers.  J Natl Cancer Inst. 2003;  95 470-478
• 8 Gould M K, Sanders G D, Barnett P G et al.. Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules.  Ann Intern Med. 2003;  138 724-735
• 9 Mery C M, Pappas A N, Bueno R et al.. Relationship between a history on antecedent cancer and the probability of malignancy for a solitary pulmonary nodule.  Chest. 2004;  125 2175-2181
• 10 MacMahon H, Austin J H, Gamsu G Fleischner Society et al. Guidelines for Management of Small Pulmonary Nodules Detected on CT Scans: a statement from the Fleischner Society.  Radiology. 2005;  237 395-400
• 11 Leef J L, Klein J S. The solitary pulmonary nodule.  Radiol Clin North Am. 2002;  40 123-143
• 12 Revel M P, Merlin A, Peyrard S et al.. Software volumetric evaluation of doubling times for differentiating benign versus malignant pulmonary nodules.  AJR Am J Roentgenol. 2006;  187 135-142
• 13 Gould M K, Maclean C C, Kushner W G et al.. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions: a meta-analysis.  JAMA. 2001;  285 914-924
• 14 Marom E M, Sarvis S, Herndon J E et al.. T1 lung cancers: sensitivity of diagnosis with fluorodeoxyglucose PET.  Radiology. 2002;  223 453-459
• 15 Antoch G, Stattaus J, Nemat A T et al.. Non-small cell lung cancer: dual-modality PET/CT in preoperative staging.  Radiology. 2003;  229 526-533
• 16 Ho C L. Clinical PET imaging: an Asian perspective.  Ann Acad Med Singapore. 2004;  33 155-165
• 17 Christensen J A, Nathan M A, Mullan B P et al.. Characterization of the solitary pulmonary nodule: 18F-FDG PET versus nodule-enhancement CT.  AJR Am J Roentgenol. 2006;  187 1361-1367
• 18 Toloza E M, Harpole L, McCrory D C. Noninvasive staging of non-small cell lung cancer: a review of the current evidence.  Chest. 2003;  123(1, Suppl) 137S-146S
• 19 De Wever W, Ceyssens S, Mortelmans L et al.. Additional value of PET-CT in the staging of lung cancer: comparison with CT alone, PET alone and visual correlation of PET and CT.  Eur Radiol. 2007;  17 23-32
• 20 Silvestri G A, Gould M K, Margolis M L et al.. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition).  Chest. 2007;  132(3, Suppl) 178S-201S
• 21 De Wever W, Vankan Y, Stroobants S, Verschakelen J. Detection of extrapulmonary lesions with integrated PET/CT in the staging of lung cancer.  Eur Respir J. 2007;  29 995-1002
• 22 Yankelevitz D F, Henschke C I, Altorki N K. Cost analysis of competing strategies for evaluating and treating solitary pulmonary nodules (abstr).  Radiology. 1996;  201 269(Suppl)
• 23 Cox J E, Chiles C, McManus C M et al.. Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax.  Radiology. 1999;  212 165-168
• 24 Topal U, Ediz B. Transthoracic needle biopsy: factors affecting risk of pneumothorax.  Eur J Radiol. 2003;  48 263-267
• 25 Miller J A, Pramanik B K, Lavenhar M A. Predicting the rates of success and complications of computed tomography-guided percutaneous core-needle 45: biopsies of the thorax from the findings of the preprocedure chest computed tomography scan.  J Thorac Imaging. 1998;  13 7-13
• 26 Laurent F, Michel P, Latrabe V et al.. Pneumothoraces and chest tube placement after CT-guided transthoracic lung biopsy using a coaxial technique: incidence and risk factors.  AJR Am J Roentgenol. 1999;  172 1049-1053
• 27 Kazerooni E A, Lim F T, Martinez F J. Risk of pneumothorax in CT guided transthoracic needle aspiration of the lung.  Radiology. 1996;  198 371-375
• 28 Fish G D, Stanley J H, Miller K S et al.. Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.  AJR Am J Roentgenol. 1988;  150 71-74
• 29 Miller K S, Fish G B, Stanley J H. Prediction of pneumothorax rate in percutaneous needle aspiration of the lung.  Chest. 1988;  93 742-745
• 30 Haramati L B, Austin J H. Complications after CT-guided needle biopsy through aerated versus nonaerated lung.  Radiology. 1991;  181 778
• 31 Tomiyama N, Yasuhara Y, Nakajima Y et al.. CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan.  Eur J Radiol. 2006;  59 60-64 , Epub 2006 Mar 10
• 32 Loubeyre P, Copercini M, Dietrich P Y. Percutaneous CT-guided multisampling core needle biopsy of thoracic lesions.  AJR Am J Roentgenol. 2005;  185 1294-1298
• 33 Lucidarme O, Howarth N, Finet J F, Grenier P A. Intrapulmonary lesions: percutaneous automated biopsy with a detachable, 18-gauge, coaxial cutting needle.  Radiology. 1998;  207 759-765
• 34 Klein J S, Salomon G, Stewart E A. Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients.  Radiology. 1996;  198 715-720
• 35 Yeow K M, Su I H, Pan K T et al.. Risk factors of pneumothorax and bleeding: multivariate analysis of 660 CT-guided coaxial cutting needle lung biopsies.  Chest. 2004;  126 748-754
• 36 Kim J H, Kim Y T, Lim H K, Kim Y H, Sung S W. Management for chest wall implantation of non-small cell lung cancer after fine-needle aspiration biopsy.  Eur J Cardiothorac Surg. 2003;  23 828-832
• 37 Yankelevitz D F, Davis S D, Chiarella D, Henschke C I. 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;  11 279-282
• 38 Moore E H, Shelton D K, Wisner E R, Richardson M L, Bishop D M, Brock J M. Needle aspiration lung biopsy: reevaluation of the blood patch technique in an equine model.  Radiology. 1995;  196 183-186
• 39 Moore E H. Percutaneous biopsy in lung cancer.  Semin Roentgenol. 2005;  40 154-170
• 40 Tanaka J, Sonomura T, Shioyama Y et al.. “Oblique path”: the optimal needle path for computed tomography-guided biopsy of small subpleural lesions.  Cardiovasc Intervent Radiol. 1996;  19 332-334
• 41 Li H, Boiselle P, Shepard J O et al.. 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;  167 105-109
• 42 Yeow K M, Tsay P K, Cheung Y C et al.. Factors affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy: retrospective analysis of 631 procedures.  J Vasc Interv Radiol. 2003;  14 581-588
• 43 Wallace M J, Krishnamurthy S, Broemeling L D et al.. CT-guided percutaneous fine-needle aspiration biopsy of small (< or = 1 cm) pulmonary lesions.  Radiology. 2002;  225 823-828
• 44 Montaudon M, Latrabe V, Pariente A, Corneloup O, Begueret H, Laurent F. Factors influencing accuracy of CT-guided percutaneous biopsies of pulmonary lesions.  Eur Radiol. 2004;  14 1234-1240
• 45 Layfield L J, Liu K, Erasmus J J. Radiologically-determined diameter, pathologic diameter, and reactive zone surrounding pulmonary neoplasms: Implications for transthoracic fine-needle aspiration of pulmonary neoplasms.  Diagn Cytopathol. 1999;  21 250-252
• 46 Boiselle P M, Shepard J A, Mark E J et al.. Routine addition of an automated biopsy device to fine-needle aspiration of the lung: a prospective assessment.  AJR Am J Roentgenol. 1997;  169 661-666
• 47 Laurent F, Latrabe V, Vergier B, Michel P. Percutaneous CT-guided biopsy of the lung: comparison between aspiration and automated cutting needles using a coaxial technique.  Cardiovasc Intervent Radiol. 2000;  23 266-272
• 48 Aviram G, Greif J, Man A. Diagnosis of intrathoracic lesions: are sequential fine-needle aspiration (FNA) and core needle biopsy (CNB) better than either investigation alone?.  Clin Radiol. 2007;  62 221-226
• 49 Rivera M P, Mehta A C. American College of Chest Physicians . Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).  Chest. 2007;  132(3, Suppl) 131S-148S
• 50 Savage C, Walser E M, Schnadig V, Woodside K J, Ustuner E, Swischenberger J B. Transthoracic image-guided biopsy of lung nodules: when is benign really benign?.  J Vasc Interv Radiol. 2004;  15(2 Pt 1) 161-164
• 51 Quint L E, Kretschmer M, Chang A, Nan B. CT-guided thoracic core biopsies: value of a negative result.  Cancer Imaging. 2006;  6 163-167
• 52 Giaccone G, Rodriguez J A. EGFR inhibitors: what have we learned from the treatment of lung cancer?.  Nat Clin Pract Oncol. 2005;  2 554-561
• 53 Bepler G. Phase II pharmacogenomics-based adjuvant therapy trial in patients with non-small-cell lung cancer: Southwest Oncology Group Trial 0720.  Clin Lung Cancer. 2007;  8 509-511
• 54 Moore E H. Technical aspects of needle aspiration lung biopsy: a personal perspective.  Radiology. 1998;  208 303-318
• 55 Lang E K, Ghavami R, Schreiner V C et al.. Autologous blood clot seat to prevent pneumothorax at CT-guided lung biopsy.  Radiology. 2000;  216 93-96
• 56 Moore E H, LeBlanc J, Montesi S A, Richardson M L, Shepard J A, McLoud T C. Effect of patient positioning after needle aspiration lung biopsy.  Radiology. 1991;  181 385-387
• 57 Yankelevitz D F, Davis S D, Henschke C I. Aspiration of a large pneumothorax resulting from transthoracic needle biopsy.  Radiology. 1996;  200 695-697
• 58 Perlmutt L M, Braun S D, Newman G E. Transthoracic needle aspiration: use of a small chest tube to treat pneumothorax.  AJR Am J Roentgenol. 1987;  148 849-851
• 59 Lattin Jr G, O'Brien Sr W, McCrary B, Kearney P, Gover D. Massive systemic air embolism treated with hyperbaric oxygen therapy following CT-guided transthoracic needle biopsy of a pulmonary nodule.  J Vasc Interv Radiol. 2006;  17 1355-1358