DOI:10.2214/AJR.05.0226
AJR 2006; 187:926-932
© American Roentgen Ray Society
CT-Guided Transthoracic Needle Biopsy Using a Puncture Site-Down Positioning Technique
Fumiko Kinoshita1,2,
Takashi Kato3,
Kimihiko Sugiura1,
Masamichi Nishimura4,
Toshibumi Kinoshita1,
Masayuki Hashimoto1,
Toshio Kaminoh1 and
Toshihide Ogawa1
1 Division of Radiology, Department of Pathophysiological and Therapeutic
Science, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago,
Tottori 683-8506, Japan.
2 Department of Radiology, Matsue National Hospital, Matsue, Shimane,
Japan.
3 Kato Clinic, Yonago, Tottori, Japan.
4 Clinical Laboratory, Hamada Medical Center, Hamada, Shimane, Japan.
Received February 9, 2005;
accepted after revision August 12, 2005.
Address correspondence to F. Kinoshita
(fkino{at}luke.or.jp).
Abstract
OBJECTIVE. We have developed a new CT-guided technique using
puncture site-down positioning during the biopsy. The goal of our study was to
determine the efficacy and safety of this technique for biopsy of lung lesions
compared with the standard technique.
MATERIALS AND METHODS. Medical records of 236 patients who underwent
CT-guided transthoracic needle biopsy were retrospectively evaluated. This
study included 89 cases that were biopsied using the standard technique (group
A) and 147 cases that were biopsied using the puncture site-down positioning
technique (group B). A 20-gauge automated cutting needle without coaxial
technique was used in all patients. Medical records were reviewed for lesion
size and location, biopsy results, and complications.
RESULTS. When using the standard technique, the sensitivity for
malignant lesions was 96.1%; the sensitivity for benign lesions, 92.1%; and
diagnostic accuracy, 94.4%. Thirty-seven patients (41.6%) had pneumothorax,
with 16 (18.0%) requiring chest tube placement. When using the puncture
site-down positioning technique, the sensitivity for malignant lesions was
95.4%; the sensitivity for benign lesions, 93.3%; and diagnostic accuracy,
94.6%. Nineteen patients (12.9%) had pneumothorax, with four (2.7%) requiring
chest tube placement. Other complications were minimal.
CONCLUSION. CT-guided transthoracic needle biopsy using the puncture
site-down positioning technique is an effective and safe procedure with a high
diagnostic accuracy and low complication rate. This new technique is
especially useful in reducing the rate of pneumothorax.
Keywords: biopsy • CT • interventional radiology • lung tumor • pneumothorax • pulmonary lesions
Introduction
CT-guided transthoracic needle biopsies are a widely accepted procedure for
diagnosing intrathoracic lesions
[1,
2]. They provide high
diagnostic accuracy and have a relatively low complication rate. Although the
complications can include bleeding, air embolisms (rare), and neoplastic
seeding, the most common one is pneumothorax. According to the authors of
several articles, the prevalence of pneumothorax ranges from 10% to 40% of
biopsies
[3-6].
A number of attempts have been made to prevent this complication, and
precautions in positioning the patient are among them. Several authors have
suggested that dependent positioning of the puncture site reduces the rate of
pneumothorax that requires chest tube placement after lung biopsy
[7,
8]. We developed a new
CT-guided technique using a puncture site-down position during biopsy to
reduce the rate of pneumothorax and improve the diagnostic accuracy of this
procedure. In this article, we report our preliminary experience using this
technique to prove its efficacy and safety compared with the standard
technique.
Materials and Methods
CT-guided transthoracic needle biopsies were performed on 535 patients from
April 1996 to April 2001. Of these patients, 57 with mediastinal lesions and
31 with pleural lesions were excluded from this study. One hundred four
patients who underwent biopsies using only an aspiration needle were also
excluded. The records of the remaining 343 patients who underwent biopsies
using an automated cutting needle (186 men and 157 women; age range, 23-89
years; average age, 66.8 years) were reviewed. Of these, 236 were selected for
this study because the final diagnosis satisfied one of the following
criteria: surgical confirmation was obtained after surgery (n = 129);
histologic findings obtained by biopsy were compatible with the patient's
known malignancy (n = 11); malignant lesions were clinically
diagnosed because the disease progressed or the lesions regressed after
oncologic treatment (n = 6); microbiologic examinations identified
organisms (n = 16); benign lesions were serologically diagnosed
(n = 1); and benign lesions were clinically diagnosed because they
either showed apparent regression or disappearance or were stable for 2 years
or more on the follow-up CT examinations in the absence of therapy (n
= 73). Atypical adenomatous hyperplasia was treated as malignancy in this
series. Data concerning the maximum diameter and location of the lesions, the
biopsy results, any complications, and the presence of emphysema on CT were
collected.
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Fig. 1C —Equipment for puncture site-down technique. Photograph shows
10 cm by 10 cm puncture window (PW) and biopsy needle in needle holder
attached under puncture window, which slides horizontally in all directions
and its angle can also be changed (arrows).
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Eighty-nine of the study patients underwent CT-guided biopsy using the
standard technique: a puncture site-up technique (group A), and 147 underwent
biopsy using a puncture site-down positioning technique (group B). In the
first 2 years 2 months, all of the 82 biopsies were performed using the
standard technique. The puncture site-down positioning technique was developed
in 1998; therefore, many of the patients with pulmonary lesions accessible in
this position seen after that time underwent biopsies using the new technique.
Of the 154 biopsies performed in the second half of this study, 147 were
conducted using the puncture site-down positioning technique. No patients
underwent biopsies using both the new and standard techniques.
CT scans were obtained using an X-force SH scanner (Toshiba). All images
were obtained through the region of interest using a 5-mm collimation and were
viewed using lung window settings. To access this area from under the CT
table, a supporting board made of 10-mm acrylic lamina with a 10-cm square
hole in the center, which we refer to as the "puncture window,"
was constructed (Figs. 1A,
1B, and
1C). A needle holder was
attached below the puncture window so that it could slide horizontally in all
directions and its angle could also be changed. The supporting board was set
in a position that allowed the puncture window to protrude over the upper edge
of the CT table. The board was fixed to the CT table with four Velcro straps
(width, 10-30 cm) that were used to secure the patient to the board.
All procedures were performed by one of three staff radiologists
experienced in performing CT-guided needle biopsy. For the 89 biopsies
performed using the standard technique, a physician with 14 years of
experience performed 30, a physician with 9 years of experience performed 19,
and a physician with 17 years of experience performed 40; for the 147 biopsies
performed using the new technique, 30, 37, and 80 biopsies were performed by
the same physicians, respectively. Figures
2A,
2B,
2C, and
2D shows a practical example of
how to perform a biopsy using the puncture site-down technique. The patients,
all of whom gave informed consent before the procedure, were placed under
local anesthesia while in a puncture site-down position on the supporting
board. CT-guided transthoracic biopsies were performed using a 20-gauge
automated cutting needle (Monopty, Bard). Biopsies were performed while the
patient was in suspended mid inspiration, and the obtained specimens were cut
in half. One half was smeared on a glass slide and stained for rapid cytologic
examination, and the other half was preserved in formalin for histologic
examination. Cytologic examinations were performed by a pathologist with
experience in lung cytology. Patients remained in the biopsy position
(puncture site up or down) until the rapid cytologic evaluation was complete,
which took approximately 15 minutes. Additional biopsies were considered when
the material obtained was not sufficient for diagnosis. If infection was
suspected, a tiny fragment of the obtained specimen was ejected into 1 mL of
nonbacteriostatic saline for stains, cultures, and polymerase chain
reaction.
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Fig. 2A —74-year-old man with primary lung cancer. Transverse
high-resolution CT scan obtained before biopsy with patient in spine position
shows right upper lobe mass at depth of 3 cm from pleura surface.
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Fig. 2B —74-year-old man with primary lung cancer. CT scan obtained
before biopsy with patient in right lateral decubitus position shows mass has
shifted to puncture site and is at depth of 2 cm from pleura surface. Skin and
subcutaneous tissue are fixed in puncture window due to patient's body
weight.
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Fig. 2D —74-year-old man with primary lung cancer. No pneumothorax was
observed on CT scan obtained after biopsy. Minimal parenchymal bleeding after
biopsy was visible surrounding needle track.
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Pathologic and microbiologic biopsy results were compared and correlated
with the surgical results and clinical course. A positive core biopsy result
was considered true-positive when the histologic diagnosis was compatible with
the surgical histopathology or a known malignancy. A negative core biopsy
result was considered true-negative if surgical, microbiologic, or serologic
confirmation of a benign diagnosis was available or if the lesion was stable
or regressed in diameter during follow-up. The sensitivity, specificity, and
accuracy of this technique and the pneumothorax rates were calculated.
Statistical analysis was performed using the chi-square test.
CT images were obtained immediately after the procedure to detect any
complications. Two hours after biopsy and the next day, expiratory
posteroanterior chest radiographs were obtained to check for pneumothorax.
Asymptomatic individuals with pneumothorax who showed no pneumothorax
progression were discharged after 1 night of observation. In the event of
severe pneumothorax symptoms that required treatment, a chest tube was
inserted.
Results
The average age (± SD) of the patients in group A was 66.8 ±
13 years and 67.0 ± 13 years in group B. Eighteen patients (20.2%) in
group A and 34 patients (23.1%) in group B had emphysema. Of the 89 lung
lesions in group A, 24 (27.0%) were located in the right upper lobe; eight
(9.0%), in the right middle lobe; 21 (23.6%), in the right lower lobe; 20
(22.5%), in the left upper lobe; and 16 (18.0%), in the left lower lobe. The
average maximum diameter (± SD) of the lesions in group A was 21.3
± 5 mm: the nodules were less than 10 mm in 37 cases (41.6%), 11-20 mm
in 22 (24.7%), and larger than 21 mm in 30 (33.7%).
Of the 147 lung lesions in group B, 42 (28.6%) were located in the right
upper lobe; 16 (10.9), in the right middle lobe; 26 (17.7%), in the right
lower lobe; 32 (21.8%), in the left upper lobe; and 31 (21.1%), in the left
lower lobe. The average maximum diameter of the lesions in group B was 17.7
± 7 mm: the nodules were less than 10 mm in 56 cases (38.1%), 11-20 mm
in 40 (27.2%), and larger than 21 mm in 51 (34.7%).
Standard Technique
Sampling of the target lesions using the standard technique was successful
in 88 of the 89 cases in group A (Table
1). Biopsy specimens were adequate for interpretation in 87 of
those 88 cases. Malignant and benign lesions were diagnosed in 51 and 38
patients, respectively. Biopsy results were correctly positive for malignancy
in 49 patients, with one false-positive and two false-negative results. For
malignant lesions, the sensitivity was 96.1% (49 of 51 lesions) and the
specificity, 97.4% (37 of 38). Biopsy results were correctly positive for
benign lesions in 35 of 38 patients, with one false-positive and three
false-negative results. For benign lesions, the sensitivity was 92.1% (35 of
38 lesions) and the specificity, 96.1% (49 of 51). The overall diagnostic
accuracy of CT-guided transthoracic needle biopsies using the standard
technique was 94.4% (84 of the 89 lesions).
The final diagnoses were as follows: primary lung cancer (n = 45),
metastatic tumor consistent with an existing malignancy (n = 5),
atypical adenomatous hyperplasia (n = 1), inflammatory changes seen
at a subsequent CT study (n = 25), tuberculosis or mycosis identified
at culture (n = 8), hamartoma (n = 2), sarcoidosis
(n = 1), Wegener's granulomatosis (n = 1), and
intrapulmonary lymph node (n = 1). Two biopsy results provided an
incorrect diagnosis as follows: primary lung cancer and inflammation diagnosed
at biopsy were revealed to be an intrapulmonary lymph node and primary lung
cancer in the surgical specimens, respectively. One case was false-negative
for a benign lesion; a lesion that was diagnosed as connective tissue at
biopsy was a hamartoma. The two failed biopsies with a nondiagnostic specimen
were obtained from lesions that were 7 and 15 mm in diameter, and the final
diagnoses were primary lung cancer and nonspecific inflammation,
respectively.
Tiny asymptomatic pneumothorax was noted after biopsy in 37 (41.6%) of the
89 patients treated using the standard technique. Of these, 16 (18.0%)
required placement of a chest tube. Pneumothorax developed in 24 (64.9%) of
the 37 patients with lesions less than 10 mm in diameter. Small hemoptysis
occurred in one patient (1.1%) and mild parenchymal hemorrhage occurred in 19
patients (21.3%), all of which resolved spontaneously. There were no other
complications and no fatalities. The overall complication rate was 42.7%.
Puncture Site-Down Technique
Sampling the target lesions using a puncture site-down positioning
technique was successful in all 147 cases, and all biopsy specimens were
adequate for interpretation (Table
2). Malignant and benign lesions were diagnosed in 87 and 60
patients, respectively. Biopsy results were correctly positive for malignancy
in 83 patients, with two false-positive and four false-negative results. For
malignant lesions, the sensitivity was 95.4% (83 of 87 lesions) and the
specificity, 93.5% (58 of 62). Biopsy results were correctly positive for
benign lesions in 56 patients, with two false-positive and four false-negative
results. For benign lesions, the sensitivity was 93.3% (56 of 60 lesions) and
the specificity, 97.7% (85 of 87). The overall diagnostic accuracy of the
CT-guided transthoracic needle biopsies performed using a puncture site-down
positioning technique was 94.6% (139 of the 147 lesions).
The final diagnoses were as follows: primary lung cancer (n = 81),
metastatic tumor consistent with an existing malignancy (n = 5),
carcinoid tumor (n = 1), inflammatory changes detected at a
subsequent CT study (n = 46), tuberculosis or mycosis identified at
culture (n = 9), neurofibroma (n = 1), Langerhans cell
histiocytosis (n = 1), cryptococcosis (n = 1), tumorlet
(n = 1), and sclerosing hemangioma (n = 1). Four biopsy
results provided an incorrect diagnosis as follows: two cases diagnosed as
primary lung cancers and two as inflammatory changes at biopsy were, according
to surgical specimen results, tumorlet, sclerosing hemangioma, and two primary
lung cancers, respectively. Two cases were false-negative for a malignant
lesion. Lesions diagnosed as adenocarcinoma and atypical adenomatous
hyperplasia at biopsy were found to be squamous cell carcinoma and
adenocarcinoma, respectively. Another two cases were false-negative for benign
lesion. Lesions diagnosed as connective tissue and inflammation at biopsy were
found to be nontuberculous Mycobacterium infection and
cryptococcosis, respectively.
Tiny asymptomatic pneumothorax was noted after biopsy in 19 (12.9%) of the
147 cases biopsied using this new technique. The operator's experience did not
affect pneumothorax rates; pneumothorax occurred in three (10.0%) of 30 cases
when the procedure was performed by the physician with 14 years of experience;
four (10.8%) of 37 cases, by the physician with 9 years of experience; and 12
(15.0%) of 80 cases, by the physician with 17 years of experience. Of these 19
cases, four (2.7%) required placement of a chest tube. Pneumothorax developed
in nine (16.1%) of the 56 lesions less than 10 mm in diameter. Small
hemoptysis and parenchymal hemorrhage occurred in three (2.0%) and 19 (12.9%)
cases, respectively. Hemoptysis resolved within 1 hour after biopsy. There
were no other complications and no fatalities. The overall complication rate
was 27.9%. The rate of pneumothorax and chest tube placement was statistically
lower in group B than in group A (p < 0.01).
Discussion
The most important complication of CT-guided transthoracic needle biopsies
is pneumothorax. A number of techniques, including precautions in positioning
the patient, have been studied to decrease the incidence of pneumothorax after
biopsy. In general, patients are placed in a nondependent position, which does
not compress the lesions; however, this has the following disadvantages:
relative hyperinflation of the lungs, variable degrees of respiration, and
respiratory and body motion, all of which make biopsies difficult. The
technique of placing the patient in a puncture site-down position after biopsy
was experimentally developed in dogs by Zidulka et al.
[9]. Cassel and Birnberg
[10] developed a rollover
technique that significantly reduced the incidence of pneumothorax, and Moore
et al. [7] reported that the
puncture site-down positioning of the patient after biopsy decreased the
number of patients who required chest tube placement. Recently, however, the
authors of another prospective study evaluated the effect of positional
precautions and they reported that dependent positioning after biopsy might
not affect the incidence of pneumothorax
[11].
Meanwhile, Rozenblit et al.
[12] developed an ipsilateral
dependent position technique for CT-guided transthoracic needle biopsy. They
found that lesions located near the lateral and anterolateral chest wall were
difficult to access with their technique due to crowding by the ribs and
prominent soft tissues, especially breast tissue in women. The puncture
site-down positioning technique that we developed solved those problems and
allowed lesions located in almost all areas to be punctured easily.
Of the 154 biopsies performed in the latter part of the study period, the
puncture site-down positioning technique was not indicated for only seven
cases (4.5%). Those excluded could not lie in a puncture site-down position;
had gravity-dependent lesions that "disappeared"—that is,
were not visible on CT—when in the puncture site-down position; had
lesions that were inaccessible when in this position, mostly due to crowding
by the ribs and scapula. The technical difficulties associated with this
procedure decreased due to the following: first, the skin and soft tissue
within the puncture window are settled tightly; and, second, rib excursions at
the puncture site were limited by body weight, which also limits respiratory
motion. The reported accuracy of CT-guided biopsies for pulmonary lesions
ranges from 83% to 96%
[13-15].
The accuracy observed in this study is similar to or comparatively higher than
those reported previously. These factors might have contributed to the ease
with which this procedure was performed and its high accuracy.
In this study, when using a puncture site-down positioning technique, the
frequency of pneumothorax was 12.9%, which is very low compared with other
studies
[16-18].
Researchers of many studies have reported risk factors affecting pneumothorax
rate, some of which include needle size, duration of the intervention, number
of needle passes, lesion diameter, and depth of the lesion from the pleura
[19,
20]. Results of studies have
shown no correlation between pneumothorax development and needle size, number
of passages, and dwell time
[16]. However, the depth and
size of the lesion and emphysema might have an impact on pneumothorax rate
[6,
21,
22]. Cox et al.
[21] reported that smaller
lesion size correlated with the development of pneumothorax. They hypothesized
that when the lesion is relatively small, the up-and-down movement of the
needle tip results in more tearing of adjacent lung parenchyma. In this study,
37 and 56 lesions less than 10 mm in diameter were punctured using the
standard and new techniques, respectively, and pneumothorax occurred in 64.9%
and 16.1% of those cases, respectively. Even though smaller lesions were
punctured using a new technique, the pneumothorax rate was similar to or
better than those in other reports that included larger lesions
[1]. Various theories have been
proposed to explain this efficacy, and diminishing the compliance of the
dependent portion, which limits respiratory motion and prevents the needle tip
from moving, might be one.
The limitation of this study is that it is a retrospective study, and bias
might have existed. Moreover, there were problems with incomplete data
collection. For example, in our study no records about the depth of the lesion
from the pleura surface were available, unfortunately. Concerning the lesion
depth as a risk factor of pneumothorax, some researchers have described the
pneumothorax rate as being significantly higher for lesions without contact
with pleura than for lesions in direct contact with pleura
[21]. On the other hand, there
is still considerable disagreement about the correlation between pneumothorax
rate and the pleura-to-lesion distance. Many authors have reported that
greater lesion depth caused the pneumothorax rate to increase
[22-24].
It would be reasonable to hypothesize that a longer needle path may have a
greater chance to tear pleura and normal lung tissue as patients breathe
during the procedure [1]. In
contrast, Yeow et al. [6]
reported that subpleural lesions that were 
2 cm from the pleura surface
correlated with a higher pneumothorax rate than those farther from the pleura
because shallow anchoring made dislodgement of the needle to the pleural
cavity easy, causing air ingress.
We believe that lesion depth in this study was decreased by using the
puncture site-down technique because lung parenchyma tends to fall to the
puncture site due to gravity, thus causing relative hypoinflation, which
allows closer contact between the punctured lesion and pleura surface.
Furthermore, our new positioning technique causes compression of the lung
parenchyma, which might be useful in preventing the needle from dislodging.
After removing the needle, the needle track might be sealed by the
gravity-dependent lung, thus inhibiting further air leakage
[7]. Diminishing air delivery
to the puncture site might help prevent the development of pneumothorax. As a
matter of fact, even if pneumothorax occurred after the first biopsy,
pneumothorax did not worsen and repeat biopsies were still possible using this
position. Engeler et al. [25]
reported that transpleural placement of a collagen foam plug might be
effective in preventing the development of pneumothorax. Compared with the
techniques described in previous reports, the technique described here is more
practical and simple to use.
In summary, CT-guided transthoracic needle biopsy using a puncture
site-down positioning technique is safe and effective. This procedure allows
easy access to lesions located in almost all areas and might allow easy
sampling using an automated cutting needle. Overall, the diagnostic accuracy
of this technique was as high as that of the standard technique, and
pneumothorax occurred at a lower rate than has been reported in previous
studies. In addition, hemoptysis and parenchymal bleeding occurred but were
minimal. We believe that the puncture site-down positioning technique is a
highly appropriate biopsy technique. Further studies are necessary to improve
the equipment required, such as the supporting board and needle holder, and
also to develop a remote control system.
References
- Ohno Y, Hatabu H, Takenaka D, et al. CT-guided transthoracic needle
aspiration biopsy of small ( 20 mm) solitary pulmonary nodules.
AJR 2003; 180:1665
-1669[Abstract/Free Full Text]
- Wallace MJ, Krishnamurthy S, Broemeling LD, et al. CT-guided
percutaneous fine-needle aspiration biopsy of small ( 1-cm) pulmonary
lesions. Radiology 2002;225
: 823-828[Abstract/Free Full Text]
- Bungay HK, Berger J, Traill ZC, Gleeson FV. Pneumothorax post
CT-guided lung biopsy: a comparison between detection on chest radiographs and
CT. Br J Radiol 1999;72
: 1160-1163[Abstract]
- Yamagami T, Iida S, Kato T, et al. Usefulness of new automated
cutting needle for tissue-core biopsy of lung nodules under CT fluoroscopic
guidance. Chest 2003;124
: 147-154[CrossRef][Medline]
- Lopez Hanninen E, Vogl TJ, Ricke J, Felix R. CT-guided percutaneous
core biopsies of pulmonary lesions: diagnostic accuracy, complications and
therapeutic impact. Acta Radiol 2001;42
: 151-155[Medline]
- Yeow KM, See LC, Lui KW, et al. Risk factors for pneumothorax and
bleeding after CT-guided percutaneous coaxial cutting needle biopsy of lung
lesions. J Vasc Interv Radiol 2001;12
: 1305-1312[Medline]
- Moore EH, LeBlanc J, Montesi SA, Richardson ML, Shepard JA, McLoud
TC. Effect of patient positioning after needle aspiration lung biopsy.
Radiology 1991;181
: 385-387[Abstract/Free Full Text]
- Dellinger RP, Francois D, Savage PJ, Zidulka A. Effect of patient
positioning on pneumothorax rate following fine needle lung aspiration.
(letter) Am Rev Respir Dis 1983;28
: 210
- Zidulka A, Braidy TF, Rizzi MC, Shiner RJ. Position may stop
pneumothorax progression in dogs. Am Rev Respir Dis1982; 126:51
-53[Medline]
- Cassel DM, Birnberg FA. Preventing pneumothorax after lung biopsy:
the roll-over technique. (letter) Radiology1990; 174:282[Free Full Text]
- Collings CL, Westcott JL, Banson NL, Lange RC. Pneumothorax and
dependent versus nondependent patient position after needle biopsy of the
lung. Radiology 1999;210
: 59-64[Abstract/Free Full Text]
- Rozenblit AM, Tuvia J, Rozenblit GN, Klink A. CT-guided
transthoracic needle biopsy using an ipsilateral dependent position.
AJR 2000; 174:1759
-1764[Abstract/Free Full Text]
- Arakawa H, Nakajima Y, Kurihara Y, Niimi H, Ishikawa T. CT-guided
transthoracic needle biopsy: a comparison between automated biopsy gun and
fine needle aspiration. Clin Radiol 1996;51
: 503-506[CrossRef][Medline]
- Yeow KM, Tsay PK, Cheung YC, Lui KW, Pan KT, Chou AS. Factors
affecting diagnostic accuracy of CT-guided coaxial cutting needle lung biopsy:
retrospective analysis of 631 procedures. J Vasc Interv
Radiol 2003; 14:581
-588[Medline]
- Lucidarme O, Howarth N, Finet JF, Grenier PA. Intrapulmonary
lesions: percutaneous automated biopsy with a detachable, 18-gauge, coaxial
cutting needle. Radiology 1998;207
: 759-765[Abstract/Free Full Text]
- Ko JP, Shepard JO, Drucker EA, et al. Factors influencing
pneumothorax rate at lung biopsy: are dwell time and angle of pleural puncture
contributing factors? Radiology 2001;218
: 491-496[Abstract/Free Full Text]
- Yeow KM, Su IH, Pan KT, et al. Risk factors of pneumothorax and
bleeding: multivariate analysis of 660 CT-guided coaxial cutting needle lung
biopsies. Chest 2004;126
: 748-754[CrossRef][Medline]
- Geraghty PR, Kee ST, McFarlane G, Razavi MK, Sze DY, Dake MD.
CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle
size and pneumothorax rate. Radiology2003; 229:475
-481[Abstract/Free Full Text]
- Sinner WN. Risk factors in percutaneous transthoracic needle
biopsy. Rofo 1980;132
: 363-368[Medline]
- Westcott JL. Percutaneous transthoracic needle biopsy.
Radiology 1988;169
: 593-601[Free Full Text]
- Cox JE, Chiles C, McManus CM, Aquino SL, Choplin RH. Transthoracic
needle aspiration biopsy: variables that affect risk of pneumothorax.
Radiology 1999;212
: 165-168[Abstract/Free Full Text]
- Topal U, Ediz B. Transthoracic needle biopsy: factors effecting
risk of pneumothorax. Eur J Radiol 2003;48
: 263-267[CrossRef][Medline]
- Kazerooni EA, Lim FT, Mikhail A, Martinez FJ. Risk of pneumothorax
in CT-guided transthoracic needle aspiration biopsy of the lung.
Radiology 1996;198
: 371-375[Abstract/Free Full Text]
- Laurent F, Michel P, Latrabe V, Tunon de Lara M, Marthan R.
Pneumothoraces and chest tube placement after CT-guided transthoracic lung
biopsy using a coaxial technique: incidence and risk factors.
AJR 1999; 172:1049
-1053[Abstract/Free Full Text]
- Engeler CE, Hunter DW, Castaneda-Zuniga W, Tashjian JH, Yedlicka
JW, Amplatz K. Pneumothorax after lung biopsy: prevention with transpleural
placement of compressed collagen foam plugs. Radiology1992; 184:787
-789[Abstract/Free Full Text]
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Abstract
Introduction
