Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis. Transthoracic needle biopsy is done to evaluate peripheral lung nodules or masses; hilar, mediastinal, and pleural abnormalities; and undiagnosed infiltrates or pneumonias when bronchoscopy is contraindicated or nondiagnostic. When done with the use of CT guidance and with a skilled cytopathologist in attendance, transthoracic needle biopsy confirms the diagnosis of cancer with > 95% accuracy. Needle biopsy yields an accurate diagnosis in benign processes only 50 to 60% of the time.

Contraindications

Contraindications are similar to those of thoracentesis. Additional contraindications include the following:

• Mechanical ventilation
• Contralateral pneumonectomy
• Suspected vascular lesions
• Putrid lung abscess
• Hydatid cyst
• Pulmonary hypertension
• Bullous lung disease
• Intractable coughing
• Coagulopathy, platelet count < 50,000/μL, and other bleeding diatheses

Procedure

Transthoracic needle biopsy is usually done by an interventional radiologist, often with a cytopathologist present. Under sterile conditions, local anesthesia, and imaging guidance—usually CT but sometimes ultrasonography for pleural-based lesions—a biopsy needle is passed into the suspected lesion while patients hold their breath. Lesions are aspirated with or without saline; 2 or 3 samples are collected for cytologic and bacteriologic processing. After the procedure, fluoroscopy and chest x-rays are used to rule out pneumothorax and hemorrhage. Core needle biopsies are used to obtain a cylinder of tissue suitable for histologic examination.

Complications

Complications include pneumothorax (10 to 37%), hemoptysis (10 to 25%), parenchymal hemorrhage, air embolism, and subcutaneous emphysema.

Last full review/revision June 2009 by Noah Lechtzin, MD, MHS