SPECIAL TECHNIQUES IN TRANSTHORACIC NEEDLE BIOPSY OF PULMONARY NODULES

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Transthoracic needle biopsy (TNB) of pulmonary nodules requires the skills of two specialists: (1) the radiologist and (2) the pathologist. From the radiologist's perspective, the goal is very simple: to obtain a sufficient amount of material through the needle to allow the pathologist to make a diagnosis with a minimum of complications to the patient. Similarly, the goal of the pathologist is to determine quickly and accurately whether the specimen procured is adequate, thereby avoiding having the radiologist obtain additional samples that would lengthen the procedure and increase the risk of complications. The pathologist must then determine how the specimen should be analyzed to maximize yield. Special techniques in TNB are used with a view toward these goals. This article defines three distinct aspects of TNB and for each describes various techniques that we believe are helpful in enhancing them. These include placement of the needle tip within the nodule, cytologic techniques for maximizing specimen yield for immediate review, and strategies for pathologic analysis and minimizing complications.

Section snippets

NEEDLE PLACEMENT

One cannot achieve accurate results from TNB if the tip of the needle is not placed within the nodule. Needle misplacement probably represents the single most common cause for a false-negative biopsy.7 Even missing the nodule by a fraction of a millimeter is not sufficient, especially when entertaining the idea of accepting a nonspecific benign diagnosis as truly representative of a benign lesion. Each aspect in the performance of the procedure can lead to difficulties with placement of the

CYTOLOGIC EVALUATION

As with the biopsy procedure itself, there are several cytologic techniques that help maximize the yield from the specimen provided. The goal of the radiologist performing TNB of pulmonary nodules is to obtain diagnostic samples. These samples are then examined microscopically to detect the presence of a neoplastic or infectious process. Excluding geometric miscalculation, the diagnostic sensitivity and specificity of TNB depends on several factors, including the quality of the specimen

COMPLICATIONS

Once the procedure has been performed and the specimen obtained, our remaining goal is to minimize complications. To accomplish this final goal effectively, potential complications should be considered before the procedure.4 The two most common complications of TNB are hemorrhage and pneumothorax. We focus on methods to reduce pneumothorax, because bleeding is primarily related to factors intrinsic to the patient or because of medications.

The rate of pneumothorax has been variously reported to

SUMMARY

We believe that each aspect of the performance of TNB needs to be considered carefully. Meticulous attention to detail allows any nodule in the chest to successfully undergo biopsy. There are techniques of needle tip repositioning that can be quite helpful for obtaining diagnostic material from lung lesions, particularly small nodules. A strong working relationship with pathologists experienced in lung cytology is a vital element of any successful biopsy program. Techniques available to the

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Address reprint requests to David F. Yankelevitz, MD, Department of Radiology, The New York Presbyterian Hospital, Weil Medical College of Cornell University, 525 East 68th Street, New York, NY 10021

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