Percutaneous Biopsy Procedures: Techniques and Indications

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Chapter 13 Percutaneous Biopsy Procedures

Techniques and Indications

This chapter describes the techniques and equipment available to obtain diagnostic samples from intrathoracic and selected extrathoracic lesions by the percutaneous route. The common lesions sampled and their locations are listed in Figure 13-1. The most frequent methods of sampling intrathoracic lesions, depending on their site, are summarized in Figure 13-2. The techniques and indications are different from those required to diagnose more diffuse intrapulmonary disease. The latter, which includes conditions such as idiopathic pulmonary fibrosis, requires a transbronchial lung biopsy or an open lung biopsy through a mini-thoracotomy or video-assisted thoracoscopy (VATS) procedure.

Imaging plays an important role in detecting and confirming the site of lesions and in evaluating their size and the quality of the surrounding tissues. Imaging is also used to assess the extent of pathology and the presence of other diseases. The radiologist determines whether lesions are amenable to percutaneous sampling, selects the optimum target for biopsy (often with the aid of positron emission tomography [PET] imaging), and decides which imaging modality is best suited to guide intervention. The choice and size of needle depend on the site, size, and solidity of the lesion, as well as the operator’s personal preference. Cores of tissue are invariably obtained, in keeping with requirements for immunohistochemistry analysis, and, increasingly, to assess for the presence of mutations to assist targeted therapy in lung cancer.

Methods of Tissue Sampling

Imaging Techniques

Several factors are considered in selecting the most appropriate imaging modality to guide percutaneous tissue sampling. These include the site, size, and depth of the lesion; its proximity to the pleura and neurovascular structures; and performance status of the patient.

Integrated Positron Emission Tomography–Computed Tomography

Positron emission tomography (PET) has an established role in the detection and staging of neoplastic diseases. In lung cancer it provides information on the primary lesion, early nodal involvement, and distant metastases. The positron-emitting agent most frequently used is 18F-fluorodeoxyglucose (FDG). This tracer accumulates at sites of increased glycolysis (e.g., tumor cells), and this activity is then detected by the PET camera. The intensity of activity is displayed on a color scale, and a quantitative assessment is made by measuring the standardized uptake value (SUV).

CT combined with PET allows accurate anatomic localization of FDG-avid foci. This technique is particularly useful in isolating active foci surrounded by benign changes, such as within thickened pleura, or in separating tumor from collapse, allowing greater precision in positioning the biopsy needle (Figure 13-3).

The sensitivity of PET is limited by the size of the lesion. Small lesions (usually less than 1 cm) may not accumulate sufficient FDG to be detected on PET imaging, leading to false-negative results. The latter can also occur in tumors with relatively low metabolic activity such as carcinoids and alveolar cell cancers.

Inflammatory conditions such as bacterial pneumonias, abscesses, tuberculosis, and active sarcoidosis are associated with increased granulocytic activity. Such activity promotes increased uptake of FDG, potentially giving rise to false-positive results.


The two main modes of sampling are fine needle aspiration (FNA) for cytologic study and core biopsy for histopathologic examination. Both methods retrieve samples that are suitable for culture. Although the sensitivity of FNA is improved by having a cytologist present to ensure that an adequate sample is obtained, the diagnostic yield in benign disease remains low (20% to 50%) compared with that for core biopsy (70%) (Greif et al., 1999). In malignant disease, the techniques are analogous, with a sensitivity of 90% to 95% (Klein et al., 1996). The clinical requirement for cores of tissue for immunohistochemical analysis has led to a reduction in the use of FNA, and when feasible, cores are always obtained.

FNA involves inserting a fine needle into a lesion and carefully moving the tip to and fro within the tissue, to obtain an aspirate. Gentle suction can be applied by attaching a 5-mL syringe to the needle hub. A variety of fine needles are available, including the Westcott, Chiba, Franseen, and Rotex needles, which range in size from 20 to 23 gauge. Larger-gauge needles are smaller in caliber and less rigid in design, which can limit their use. The Westcott needle has the advantage of having a trough close to the needle tip, which captures small cores of tissue in approximately 50% of cases. The main use of FNA is to obtain nodal aspirates.

Core biopsy specimens are obtained using cutting needles, which are larger in diameter (14 to 18 gauge) and are available in different lengths (6-, 9-, and 15-cm lengths are commonly used). These needles are more sturdy, allowing greater control in placement. Cutting needles are typically mounted on a spring-loaded mechanism. Older designs such as the Bard Biopty biopsy system, when triggered, simultaneously fire an inner notched stylet and an outer cutting cannula. The handle of the Bard system is bulky but reusable (Figure 13-4). Newer, lighter designs include the Cook Quickcore and Bauer Temno devices, which allow the inner notched stylet to be advanced and secured within the lesion before the cutting cannula is activated. The throw can be increased from 1 to 2 cm to obtain better core samples (Figure 13-5). The Cook device seems to have a slightly sharper needle tip, which in practice can be advanced through tougher tissues.

Historically, it was believed that use of larger cutting needles carried higher complication rates than those associated with fine needles. A 2002 study of practice based in the United Kingdom analyzed data from 5444 lung biopsy and FNA procedures and found no difference between the two methods, a conclusion supported by other studies (Richardson et al., 2002).

With transpulmonary biopsy, the risk of pneumothorax is more closely related to the number of pleural passes. The introduction of a coaxial system has transformed lung biopsies. A single pleural pass is made with a thin-walled introducer needle (usually 16 gauge). A smaller cutting needle (usually 18 gauge with a 1- or 2-cm throw) is inserted through the introducer and multiple cores are taken without repuncturing the pleura. The process is quicker, simpler, and safer than attempting multiple pleural passes, leading to a reduction in the complication rate with an improved diagnostic yield (Figure 13-6).

Percutaneous Biopsy of Intrapulmonary Lesions


The role of percutaneous lung biopsy in diagnosing malignant disease is well established, with a sensitivity of 90% to 95%. Its main application is in patients with inoperable lung cancer, when sputum cytology and bronchoscopy are nondiagnostic, to provide a means of establishing cell type before chemotherapy and radiotherapy. In the past, both FNA and core biopsy have been comparable in diagnosing and distinguishing small cell lung cancer (SCLC) from non-SCLC (NSCLC), providing oncologists with sufficient information to make choices regarding appropriate chemotherapy regimens. New targeted chemotherapy and biologic agents (e.g., the epidermal growth factor receptor [EGFR] inhibitor drugs) have proven prognostic benefit with particular histologic subtypes. This has meant that core sampling is essential to allow routine performance of detailed tissue analysis. FNA can be adequate to differentiate between subtypes of NCSLC, but it remains less accurate overall than core biopsy. The latter allows sufficient material to be obtained for both accurate histologic subtyping and molecular testing (e.g., to determine EGFR mutation status) (Barnes et al., 2010).

Biopsy also is widely used to exclude lung metastases in patients with potentially operable lung tumors, and in those with extrathoracic malignancies (Figure 13-7).

With solitary pulmonary lesions, core biopsy remains the prudent approach for confirming benign disease. The combined use of CT guidance and the coaxial biopsy system, which allows multiple cores to be taken safely, has improved the diagnostic accuracy of this technique in both benign and malignant disease. If malignancy is strongly suspected, it may be best to avoid biopsy and proceed straight to surgery.

Transthoracic biopsy and FNA also have a role in the diagnosis of non-neoplastic disease. Both techniques are increasingly being used to obtain samples for identification of microorganisms, particularly in immunocompromised patients with consolidation and masses. All samples are routinely sent to both histology (or cytology) and microbiology. Communication with the referring clinician is essential. In cases in which infection is suspected, the first sample should be sent to microbiology should the procedure need to be unexpectedly abandoned. The converse is true in suspected cases of malignancy where the first sample is sent to histology. The working diagnosis may also influence the choice of needle size.


The contraindications to percutaneous lung biopsy are largely relative and are summarized in Table 13-1. In general, patients need to be able to cooperate, including lying still in the desired position, resisting excessive coughing, and controlling breathing. In patients with very poor lung function, biopsy of a lesion is still possible, provided that the lesion is peripheral and a carefully considered route is identified (usually with CT) that does not traverse lung parenchyma. In performing the biopsy, care is taken to avoid creating a pneumothorax, which could be life-threatening. Before the procedure, a coagulation screen is performed according to local protocol, and bleeding diatheses are corrected, when appropriate, to keep within safe guidelines. Biopsy of parenchymal hydatid lesions has been documented, but an increased and probably unacceptable risk of anaphylactic reaction has been documented in patients with such lesions.

Table 13-1 Contraindications to Needle Biopsy

Type of Contraindication Comment
Relative Inability of patient to cooperate: uncontrollable cough, inability to lie prone or supine
Poor lung function/chronic obstructive pulmonary disease (FEV1 <40% of predicted normal or multiple bullae)
Bleeding disorder
Pulmonary hypertension
Pulmonary fibrosis
Small nodules (<5 mm in diameter)
Hydatid disease (associated with risk of anaphylactic reaction)
Absolute Arteriovenous malformation with high pulmonary artery pressure

FEV1, forced expiratory volume in 1 second.



Percutaneous biopsy procedures are arranged as short-stay cases, with the expectation that patients will return home the same day, after a period of observation.

Before the appointment, all patients must have a complete blood count (CBC), and the international normalized ratio (INR) must be checked and corrected when appropriate, to reduce the risk of bleeding. A platelet count greater than 150 × 109/L and an INR of 1.4 or less are acceptable lower and upper limits, respectively. Antiplatelet agents (e.g., aspirin, clopidogrel) should be withheld for several days preceding intervention (5 days for aspirin, 7 to 10 days for clopidogrel).

Percutaneous lung biopsy requires that the patient fast beforehand. On the day of the procedure, the patient is admitted to the programmed investigation unit (PIU), where a baseline set of observations are recorded (including heart rate, blood pressure, and oxygen saturation).

The radiologist performing the procedure explains the process, enquires about relevant allergies, and after addressing any queries, obtains written informed consent, documenting potential complications, which occur at a rate greater than 1%. The patient is informed that several samples may need to be taken. Sedation is rarely required but can be used in anxious patients. For administration of such agents, intravenous access is established, and cardiorespiratory monitoring is required. Audio aids (e.g., iPods) are invaluable in relaxing younger patients and adults who are restless.