Transthoracic Needle Biopsy

Transthoracic needle biopsy is performed to evaluate:

• Peripheral lung nodules or masses

• Hilar, mediastinal, and pleural abnormalities

• Undiagnosed infiltrates or pneumonias when bronchoscopy is contraindicated or nondiagnostic

When performed with the use of computed tomography (CT) guidance and with a skilled cytopathologist in attendance, transthoracic needle biopsy confirms the diagnosis of cancer with approximately 90 to 95% accuracy (1, 2, 3).

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

Absolute contraindications:

• Thrombocytopenia (platelet count < 50,000 mcL [< 50 × 10⁹/L])

• Abnormal coagulation that cannot be corrected

• Bleeding diathesis

Relative contraindications:

• Bullous lung disease (increases risk of pneumothorax)

• Contralateral pneumonectomy (impaired ability to tolerate a pneumothorax)

• Intractable coughing (increases risk of pneumothorax)

• Mechanical ventilation (increases risk of pneumothorax)

• Pulmonary hypertension

The procedure should be deferred if a pneumothorax cannot be tolerated such as if there is a history of contralateral pneumonectomy.

Hydatid cysts, lung abscesses, and vascular lesions should in general not be biopsied.

Transthoracic needle biopsy is usually performed by an interventional radiologist, often with a cytopathologist present.

• Under sterile conditions, local anesthesia, and imaging guidance—usually CT but sometimes ultrasound 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 or chest radiograph is used to exclude pneumothorax and hemorrhage.

Complications (1, 2, 3) include the following:

• Pneumothorax (9 to 30%)

• Hemoptysis (1 to 21%)

• Parenchymal hemorrhage (0 to 4%)

• Air embolism

• Subcutaneous emphysema