Percutaneous Biopsy and Drainage of the Lung, Mediastinum, and Pleura

Percutaneous biopsy of focal lung lesions, mediastinal or hilar masses, and pleural or chest wall lesions has become an essential part of staging of pulmonary and extrathoracic tumors.

In the case of lung carcinoma, aspiration biopsy results in a positive diagnosis in 80% to 90% of cases. If a cutting needle is used, a positive diagnosis is expected in 95% to 98% of patients unless the lesion is necrotic. A cutting needle ( Fig. 103.1 ) is generally required for benign lesions because more material is required to allow use of the special stains necessary for the pathologist to make a definitive diagnosis. The attendance of a cytopathologist at biopsy reduces the number of passes needed for diagnosis and avoids the unfortunate necessity for repeated examinations because of an inadequate sample.

With computed tomography (CT) guidance, it is possible to perform a biopsy on almost any portion of the chest with a high degree of safety and minimal morbidity because of the ability to plan a needle path such that major vascular structures are avoided ( Fig. 103.2 ). The smallest needle suitable for the biopsy should be used to reduce complications.

Percutaneous Biopsy of the Lung, Mediastinum, and Pleura

Indications

Staging of bronchial carcinoma
Diagnosis of focal lung lesions (nodules or consolidation)
Diagnosis of metastatic lung lesions
Evaluation of chronic infectious diseases when bronchoscopy is unsuccessful
Diagnosis of mediastinal masses or lymphadenopathy
Diagnosis of focal or diffuse pleural thickening

Contraindications

Severe emphysema or insufficient lung capacity in the case of unilateral pneumothorax
Bleeding diathesis (international normalized ratio > 1.5 or platelets < 50,000/mm ³ )
Uncooperative patients, including those with an intractable cough
Positive pressure ventilation, which increases the risk for pneumothorax and bronchopleural fistula
Pulmonary arterial hypertension when a central biopsy is contemplated. A cardiothoracic surgeon should be informed of central biopsy where there is potential for pericardial tamponade.
Suspected hydatid cyst. There is a possible risk for anaphylaxis if the cyst is intact.

Equipment

An appropriate imaging modality (usually a CT scanner but may be a fixed fluoroscopy unit or ultrasound)
Informed consent including pneumothorax and hemoptysis
Intravenous access
Equipment suitable for resuscitation
Aspiration needle (Chiba or Westcott, 20–25-gauge)
Coaxial needle system (19-gauge outer, 22-gauge inner)
Core-cutting needle (spring activated, 18–20-gauge)
Cytologist to assess the aspiration sample immediately
Microscope, slides, stains, and specimen pots (air and formalin)
Percutaneous pneumothorax drainage system

Technique

Anatomy and Approach

Take the shortest possible path to the lesion crossing the least aerated lung avoiding vital structures.

Biopsy of a pleural mass almost always requires a cutting needle and a sample for histologic rather than cytopathologic analysis. If multiple samples are required a coaxial technique should be used.

A direct vertical approach is preferred, with the skin entry site upright. After the biopsy the patient is turned so that the punctured side is lowermost to reduce ventilation of that lung and, the incidence of pneumothorax.

Biopsy of the ribs requires special bone biopsy kits such as the Arrow OnControl (Teleflex, Morrisville, NC) powered bone biopsy system

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