In 1883, Leyden successfully performed percutaneous transthoracic needle biopsy (PTNB) of the lung in three patients with pneumonia according the records (1); three years later, Menetrier was the first recorded to employ this technique for the diagnosis of lung cancer (2). So far, PTNB has a history of more than 100 years (3-5). In recent years, PTNB has increasingly been applied in clinical settings along with innovations in imaging devices (6,7), improvement of puncture needles, and advances in cellular pathology (8,9). Currently, PTNB is often performed under the guidance of ultrasound or computed tomography (CT) (10,11).
The indications for PTNB of unidentified lung lesions with high suspicion of lung cancer include:
- Unidentified peripheral pulmonary nodules or masses especially if localized close to the chest wall, whose pathological nature cannot be identified even after repeated sputum cytology and bronchoscopy (12-22);
- Radiologic imaging suggestive of neoplastic lung lesions with no surgical indication (e.g., lymphomas) or currently non-resectable lung cancer amenable to neoadjuvant chemo-radiotherapy (15);
- Unidentified mediastinal mass or pleural lesion with high suspicion of cancer (10,12-14);
- Patients who cannot tolerate bronchoscopy but require pathological or cytological characterization of an unidentified lung lesion (10);
- Staging of histologically proven malignancies that have spread to the pulmonary hilum, mediastinum, chest wall, or to more distant sites (14).
Contraindications for PTNB of lung lesions include:
- Isolated pulmonary lesions that are highly suspected to be malignant and are potentially surgically resectable in order to minimize potential risks of PNB-related cancer seeding and dissemination (23);
- High risk of bleeding (e.g., patients undergoing anticoagulant therapy or with conditions such as von Willebrand disease or severe thrombocytopenia) (24);
- Radiologic imaging suggestive of vascular lesions such as arterial or venous malformations, arteriovenous fistula, and aneurysms (22,25);
- Severe diffuse or bullous emphysema, severe pulmonary fibrosis;
- Severe pulmonary hypertension; cor pulmonale and/or myocardial infarction; severe cardiopulmonary insufficiency (21);
- Radiologic imaging suggestive of pulmonary Hydatid disease;
- Poor general clinical status making PTNB intolerable (24).
Before performing PTNB a rapid work-up must be conducted, including:
- Baseline blood tests, including coagulation profiles, hepatitis/HIV/syphilis status, and urine testing (26);
- ECG and complete pulmonary function tests including transfer factor;
- Chest computed tomography (CT). Enhanced CT is preferred if the lesion is close to the mediastinum and/or major vessel (27-29).
Types of PTNB needles
Percutaneous puncture needles are divided into three classes: aspiration needle, cutting or core needle, and bone-drilling needle.
- Aspiration needles (30-31). These needles are used to obtain cytological specimens. Model sizes range between 16–24 G with an external diameter of 0.6–1.6 mm. They are characterised by a small external diameter and thin walls and thus will cause lesser injury to the tissues with fewer complications. The types of aspiration needles commercially available include Chiba needles, Turner needle, and Greene needles;
- Cutting needles (32-34). These needles are used to obtain tissues samples for histological examinations. They have a relatively large diameter, and are associated with more severe injuries to the tissues and more frequent complications. The types of cutting needles commercially available include Vin-Silverman needles, Trucut needles, and Rotex needles. In recent years, the spring-loaded automatic biopsy needle (also known as biopsy gun) has replaced the conventional cutting needle in many centers. This new device reduces operative time, has higher high success rate, is more convenient in sampling, and reduces the risk of needle track implantation;
- Bone-drilling needles (35). Bone-drilling needles are employed for the biopsy of bone lesions. Their tips have sharp cutting teeth, which enable them to pass through hard bone/cartilage tissues to harvest histological specimens. If appropriate, the Ackermann needles can be used.
Percutaneous lung puncture biopsy can be performed under the guidance of fluoroscopy, ultrasound, CT, or magnetic resonance imaging (MRI). Currently, CT-guided PTNB is the most commonly used approach (10,36-37). The addition of spiral CT-based real-time fluoroscopy can make the procedure safer, quicker, and more accurate. For lesions close to the chest wall and if sufficiently large, ultrasound-guided PTNB may be more appropriate (38). MRI-guided biopsy can be performed in multiple axial planes and at any angle, which helps to increase the success rate (39); however, specially designed puncture instruments that can be used in a magnetic field are required.
Technical details of PTNB
Technical details of PTNB can be summarized in a few main steps:
- The patient will be asked to lie in supine, prone, or lateral position based on the location of the lesion. The chest wall side close to the lesion should be placed upward to facilitate the procedure (13);
- A catheter position-ruler is attached to the site to be punctured, which is then scanned at slice thickness of 5 mm and slice interval of 5 mm (the slice thickness and slice interval can be 2–3 mm for small lesions);
- The optimal puncture level and site are decided, and the angle and depth of the needle insertion are measured (4,40-43);
- The lesion center is selected as the target puncture level. At this step it is important to avoid skeletal structures, heart/great vessels or pulmonary emphysematous bullae if present (40);
- After the body surface puncture site is marked, disinfection and draping should be routinely performed with the puncture site at the center. Subsequently, the chest wall is anesthetized layer by layer using 2% lidocaine (4,44,45);
- The patient is asked to take a relaxed breath, and then the needle is inserted via the pre-set needling angle. After the needle approaches the pleura, the patient is asked to hold breath before the needle is quickly advanced to the target site; CT scan is performed immediately at the target level to ensure that the needle tip has reached the target site, after which aspiration biopsy or sampling using an automatic biopsy gun can then be performed (10);
- The content of the aspiration biopsy needle is gently expelled onto a glass slide, evenly smeared, and then fixed using 95% ethanol. After the tissue needle is withdrawn, the tissue specimen strip is fixed in 10% formalin. Multiple slides are prepared for histological analysis (44,45);
- Routine CT scan is performed after puncture to promptly identify any possible complications such as pneumothorax or significant bleeding visible as pleural effusion (40);
- At the completion of the procedure, the patient is observed for 2–4 hours. Chest X-ray in posterior-anterior and lateral views are performed after 24 hours.
Percutaneous needle biopsy of lung lesions can cause a variety of complications (31,46-66), which can become even life-threatening complications requiring prompt diagnosis and adequate treatment. While no special treatment is needed for mild complications, active management and surgical consultation/rescue may be required for severe conditions. After the procedure, the patient has bed rest and avoid vigorous physical activity for the first 24 hours.
The most frequently reported complications include:
- Pneumothorax (5,46-59): pneumothorax is the most common complication. A small pneumothorax may spontaneously resolve without any treatment. Conversely, patients with large pneumothoraces greater than 30% of the lung volume on chest X-ray or becomes symptomatic should have a chest tube inserted;
- Hemorrhage (46-62): localized hematoma in lungs may resolve without treatment. In a similar manner no special treatment is required if small amount of hemoptysis (e.g., phlegm with blood) occurs. Hemostatic drugs may be administered in presence of major or massive hemoptysis. Massive hemothorax is often caused by the injury of intercostal arteries or the pulmonary artery, for which an open or video-assisted thoracoscopic surgery may be required to achieve hemostasis;
- Air embolism (43,55,64,65): air embolism is an extremely rare complication but may cause cerebral or spinal cord infarction, myocardial infarction, arrhythmia, heart failure, or even death. Once air embolism occurs, the patient should be immediately placed left lateral decubitus or Trendelenburg’s position to prevent residual air in left atrium to pass into the systemic circulation; concurrently, 100% oxygen must be administered to the patient to promote the absorption of the air embolus. The patient can also be transferred for hyperbaric oxygen treatment;
- Needle-tract seeding of tumor cells (17,64,65): needle-tract seeding is a relatively common complication of percutaneous lung puncture biopsy, particularly in biopsies performed for sub-pleural lung lesions. Despite its frequency, its risk is often underestimated in the clinical setting. To minimize this risk, negative pressure should be maintained during needle withdrawal while the needle core be protected with a cannula. Repeated use of puncture needle or cutting needle should be avoided;
- Vasovagal pleural irritation (12,66): pleural irritation, characterized by constant cough, dizziness, sweating, paleness, palpitations, weak pulse, cold extremities, decreased blood pressure, a feeling of chest oppression, prostration, and even consciousness disorders, occurs more frequently in young adults and in women. Once pleural irritation symptoms do occur, chest puncture should be stopped immediately; the patient is then made supine and the hemodynamic parameters be closely monitored. Mild symptoms can resolve spontaneously after rest or psychological counseling. In patients with excessive sweating and/or hypotension, administration of oxygen through a Venturi mask and of intravenous supplementation of fluid boluses of 500 mL of 10% glucose can be given to provide energy while supplementing body fluids. If necessary, 0.3–0.5 mL of adrenaline (1:1,000) should be injected subcutaneously to prevent shock according to the usual clinical experience;
- Reactive cardiopulmonary arrest (64): reactive cardiopulmonary arrest is an extremely rare and life-threatening complication. Once it occurs, the patient must be immediately rescued according to the standard cardiopulmonary resuscitation care.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Leyden H. Uber infectiose Pneumonie. Deutsch Med Wochenschr, 9.
- Menetrier P. Cancer primitif du poumon. Bull Soc Anat 1886;61:643.
- Haaga JR, Alfidi RJ. Precise biopsy localization by computer tomography. Radiology 1976;118:603-7. [Crossref] [PubMed]
- Westcott JL. Percutaneous transthoracic needle biopsy. Radiology 1988;169:593-601. [Crossref] [PubMed]
- Kazerooni EA, Lim FT, Mikhail A, et al. Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung. Radiology 1996;198:371-5. [Crossref] [PubMed]
- Sone S, Takashima S, Li F, et al. Mass screening for lung cancer with mobile spiral computed tomography scanner. Lancet 1998;351:1242-5. [Crossref] [PubMed]
- Marshall D, Simpson KN, Earle CC, et al. Potential cost-effectiveness of one-time screening for lung cancer (LC) in a high risk cohort. Lung Cancer 2001;32:227-36. [Crossref] [PubMed]
- Stanley JH, Fish GD, Andriole JG, et al. Lung lesions: cytologic diagnosis by fine-needle biopsy. Radiology 1987;162:389-91. [Crossref] [PubMed]
- Travis WD, Brambilla E, Burke AP, et al. Introduction to The 2015 World Health Organization Classification of Tumors of the Lung, Pleura, Thymus, and Heart. J Thorac Oncol 2015;10:1240-2. [Crossref] [PubMed]
- Manhire A, Charig M, Clelland C, et al. Guidelines for radiologically guided lung biopsy. Thorax 2003;58:920-36. [Crossref] [PubMed]
- Nakajima T, Yasufuku K, Fujiwara T, et al. Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration. Respir Investig 2016;54:230-6. [Crossref] [PubMed]
- Shaham D. SEMI-INVASIVE AND INVASIVE PROCEDURES FOR THE DIAGNOSIS AND STAGING OF LUNG CANCER I: Percutaneous Transthoracic Needle Biopsy. Radiol Clin N Am 2000;38:525-34. [Crossref] [PubMed]
- Yankelevitz DF, Vazquez M, Henschke CI. Special techniques in transthoracic needle biopsy of pulmonary nodules. Radiol Clin N Am 2000;38:267-79. [Crossref] [PubMed]
- Conces DJ Jr, Schwenk GR Jr, Doering PR, et al. Thoracic needle biopsy. Improved results utilizing a team approach. Chest 1987;91:813-6. [Crossref] [PubMed]
- Penketh AR, Robinson AA, Barker V, et al. Use of percutaneous needle biopsy in the investigation of solitary pulmonary nodules. Thorax 1987;42:967. [Crossref] [PubMed]
- Poe RH, Tobin RE. Sensitivity and specificity of needle biopsy in lung malignancy. Am Rev Respir Dis 1980;122:725. [Crossref] [PubMed]
- Komiya T, Kusunoki Y, Kobayashi M, et al. Transcutaneous needle biopsy of the lung. Acta Radiol 1997;38:821. [Crossref] [PubMed]
- Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology 1997;202:97-103. [Crossref] [PubMed]
- Greif J, Marmor S, Schwarz Y, et al. Percutaneous Core Needle Biopsy vs. Fine Needle Aspiration in Diagnosing Benign Lung Lesions. Acta Cytol 1999;43:756-60. [Crossref] [PubMed]
- The diagnosis, assessment and treatment of diffuse parenchymal lung disease in adults. Introduction. Thorax 1999;54 Suppl 1:S1-14. [PubMed]
- Harrison BD, Thorpe RS, Kitchener PG, et al. Percutaneous Trucut lung biopsy in the diagnosis of localised pulmonary lesions. Thorax 1984;39:493. [Crossref] [PubMed]
- Klein JS, Zarka MA. Transthoracic needle biopsy: an overview. J Thorac Imaging 1997;12:232-49. [Crossref] [PubMed]
- Haramati LB, Austin JH. Complications after CT-guided needle biopsy through aerated versus nonaerated lung. Radiology 1991;181:778. [Crossref] [PubMed]
- Sharma A, Shepard JO. Lung Cancer Biopsies. Radiol Clin North Am 2018;56:377-90. [Crossref] [PubMed]
- Kocijancic I, Kocijancic K. CT-guided percutaneous transthoracic needle biopsy of lung lesions – 2-year experience at the Institute of Radiology in Ljubljana. Radiol Oncol 2007;41:99-106. [Crossref]
- British Thoracic Society Bronchoscopy Guidelines Committee. a Subcommittee of Standards of Care Committee of British Thoracic Society. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax 2001;56 Suppl 1:i1-21. [Crossref]
- Laroche C, Fairbairn I, Moss H, et al. Role of computed tomographic scanning of the thorax prior to bronchoscopy in the investigation of suspected lung cancer. Thorax 2000;55:359-63. [Crossref] [PubMed]
- Bungay HK, Pal CR, Davies CW, et al. An evaluation of computed tomography as an aid to diagnosis in patients undergoing bronchoscopy for suspected bronchial carcinoma. Clin Radiol 2000;55:554-60. [Crossref] [PubMed]
- Henschke CI, Davis SD, Auh Y, et al. Detection of bronchial abnormalities: comparison of CT and bronchoscopy. J Comput Assist Tomogr 1987;11:432-5. [Crossref] [PubMed]
- Burt ME, Flye MW, Webber BL, et al. Prospective evaluation of aspiration needle, cutting needle, transbronchial, and open lung biopsy in patients with pulmonary infiltrates. Ann Thorac Surg 1981;32:146-53. [Crossref] [PubMed]
- Yap J, Tan KP. A comparative study of the Chiba and Turner needles in percutaneous lung biopsy. Singapore Med J 1988;29:14-16. [PubMed]
- Klein JS, Salomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients. Radiology 1996;198:715-20. [Crossref] [PubMed]
- Greif J, Marmur S, Schwarz Y, et al. Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients. Cancer 1998;84:144-7. [Crossref] [PubMed]
- Lee KL, Griffith JF, Ng WH, et al. CT-guided bone biposy using battery-powered needle drilling biopsy system: comparison with manual system. Essr Annual Scientific Meeting 2013. doi: [Crossref]
- Milman N. Percutaneous lung biopsy with a fine bore cutting needle (Vacu-Cut): improved results using drill technique. Thorax 1995;50:560. [Crossref] [PubMed]
- Cardella JF, Bakal CW, Bertino RE, et al. Quality Improvement Guidelines for Image-guided Percutaneous Biopsy in Adults. J Vasc Interv Radiol 2003;14:S227-30. [PubMed]
- Yang W, Sun W, Li Q, et al. Diagnostic Accuracy of CT-Guided Transthoracic Needle Biopsy for Solitary Pulmonary Nodules. Plos One 2015;10. [Crossref] [PubMed]
- Mao F, Dong Y, Ji Z, et al. Comparison of contrast-enhanced ultrasound and conventional ultrasound for guiding peripheral pulmonary biopsies. Int J Clin Exp Med 2017;10:3677-84.
- Liu S, Li C, Yu X, et al. Diagnostic accuracy of MRI-guided percutaneous transthoracic needle biopsy of solitary pulmonary nodules. Cardiovasc Intervent Radiol 2015;38:416-21. [Crossref] [PubMed]
- Romanes GJ. Cunningham's Textbook of Anatomy. Oxford: Oxford University Press, 1981.
- Glassberg RM, Sussman SK, Glickstein MF. CT anatomy of the internal mammary vessels: importance in planning percutaneous transthoracic procedures. Ajr Am J Roentgenol 1990;155:397. [Crossref] [PubMed]
- Kreula J. A new method for investigating the sampling technique of fine needle aspiration biopsy. Invest Radiol 1990;25:245. [Crossref] [PubMed]
- Aberle DR, Gamsu G, Golden JA. Fatal systemic arterial air embolism following lung needle aspiration. Radiology 1987;165:351. [Crossref] [PubMed]
- Weisbrod GL. Percutaneous fine-needle aspiration biopsy of the mediastinum. Clin Chest Med 1987;8:27. [PubMed]
- Wang KP, Kelly SJ, Britt JE. Percutaneous needle aspiration biopsy of chest lesions. New instrument and new technique. Chest 1988;93:993-7. [Crossref] [PubMed]
- Hwang HS, Chung MJ, Lee JW, et al. C-arm cone-beam CT-guided percutaneous transthoracic lung biopsy: usefulness in evaluation of small pulmonary nodules. AJR Am J Roentgenol 2010;195. [Crossref] [PubMed]
- Braak SJ. Pulmonary Masses: Initial Results of Cone-beam CT Guidance with Needle Planning Software for Percutaneous Lung Biopsy. Cardiovasc Intervent Radiol 2012;35:1414-21. [Crossref] [PubMed]
- Lee WJ, Chong S, Seo JS, et al. Transthoracic fine-needle aspiration biopsy of the lungs using a C-arm cone-beam CT system: diagnostic accuracy and post-procedural complications. Br J Radiol. 2012;85:e217-22. [Crossref] [PubMed]
- Choi MJ, Kim Y, Hong YS, et al. Transthoracic needle biopsy using a C-arm cone-beam CT system: diagnostic accuracy and safety. Br J Radiol 2012;85:e182-7. [Crossref] [PubMed]
- Lee SM, Park CM, Lee KH, et al. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of lung nodules: clinical experience in 1108 patients. Radiology 2014;271:291-300. [Crossref] [PubMed]
- Cheng YC, Tsai SH, Cheng Y, et al. Percutaneous Transthoracic Lung Biopsy: Comparison Between C-Arm Cone-Beam CT and Conventional CT Guidance. Transl Oncol 2015;8:258-64. [Crossref] [PubMed]
- Jiao D, Yuan H, Zhang Q, et al. Flat detector C-arm CT-guided transthoracic needle biopsy of small (≤2.0 cm) pulmonary nodules: diagnostic accuracy and complication in 100 patients. Radiol Med 2016;121:268-78. [Crossref] [PubMed]
- Rotolo N, Floridi C, Imperatori A, et al. Comparison of cone-beam CT-guided and CT fluoroscopy-guided transthoracic needle biopsy of lung nodules. Eur Radiol 2016;26:381-9. [Crossref] [PubMed]
- Jin KN, Park CM, Goo JM, et al. Initial experience of percutaneous transthoracic needle biopsy of lung nodules using C-arm cone-beam CT systems. Eur Radiol 2010;20:2108. [Crossref] [PubMed]
- Choi JW, Park CM, Goo JM, et al. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of small (≤ 20 mm) lung nodules: diagnostic accuracy and complications in 161 patients. AJR Am J Roentgenol 2012;199. [Crossref] [PubMed]
- Choo JY, Park CM, Lee NK, et al. Percutaneous transthoracic needle biopsy of small (≤ 1 cm) lung nodules under C-arm cone-beam CT virtual navigation guidance. Eur Radiol 2013;23:712-9. [Crossref] [PubMed]
- Cheung JY, Kim Y, Shim SS, et al. Combined fluoroscopy- and CT-guided transthoracic needle biopsy using a C-arm cone-beam CT system: comparison with fluoroscopy-guided biopsy. Korean J Radiol 2011;12:89-96. [Crossref] [PubMed]
- Floridi C, Muollo A, Fontana F, et al. C-arm cone-beam computed tomography needle path overlay for percutaneous biopsy of pulmonary nodules. Radiol Med 2014;119:820-7. [Crossref] [PubMed]
- Jiao de C, Li TF, Han XW, et al. Clinical applications of the C-arm cone-beam CT-based 3D needle guidance system in performing percutaneous transthoracic needle biopsy of pulmonary lesions. Diagn Interv Radiol 2014;20:470-4. [Crossref] [PubMed]
- Jiao DC, Li ZM, Yuan HF, et al. Flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy of small (≤3 cm) pulmonary lesions. Acta Radiol 2016;57:677. [Crossref] [PubMed]
- Busser WM, Braak SJ, Fütterer JJ, et al. Cone beam CT guidance provides superior accuracy for complex needle paths compared with CT guidance. Br J Radiol 2013;86. [Crossref] [PubMed]
- Hohenforst-Schmidt W, Zarogoulidis P, Vogl T, et al. Cone Beam Computertomography (CBCT) in Interventional Chest Medicine - High Feasibility for Endobronchial Realtime Navigation. J Cancer 2014;5:231-41. [Crossref] [PubMed]
- Hiraki T, Fujiwara H, Sakurai J, et al. Nonfatal Systemic Air Embolism Complicating Percutaneous CT-Guided Transthoracic Needle Biopsy: Four Cases From a Single Institution. Chest 2007;132:684-90. [Crossref] [PubMed]
- Yan GW, Bhetuwal A, Yan GW, et al. A Systematic Review and Meta-Analysis of C-Arm Cone-Beam CT-Guided Percutaneous Transthoracic Needle Biopsy of Lung Nodules. Pol J Radiol 2017;82:152-60. [Crossref] [PubMed]
- Požek I, Rozman A. Lung cancer seeding along needle track after CT guided transthoracic fine-needle aspiration biopsy - case report. Zdravniški Vestnik 2010;79:659-62.
- Lazguet Y, Maarouf R, Karrou M, et al. CT guided percutaneous needle biopsy of the chest: initial experience. Pan Afr Med J 2016;23:211. [Crossref] [PubMed]