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* This is the Professional Version. *

Transthoracic Needle Biopsy

By Noah Lechtzin, MD, MHS, Associate Professor of Medicine and Director, Adult Cystic Fibrosis Program, Johns Hopkins University School of Medicine

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Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis.

Indications

Transthoracic needle biopsy is done to evaluate

  • Peripheral lung nodules or masses

  • Hilar, mediastinal, and pleural abnormalities

  • 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

  • Bleeding disorder or anticoagulation that cannot be corrected and platelet count <50,000/μL

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.

Two 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

  • Subcutaneous emphysema

* This is the Professional Version. *