C a r d i o p u l m o n a r y I m a g i n g • P i c t o r i a l E s s ay

Tsai et al.
CT-Guided Lung Biopsy

Cardiopulmonary Imaging
Pictorial Essay

I-Chen Tsai1,2
Wei-Lin Tsai1,2
CT-Guided Core Biopsy of Lung
Min-Chi Chen1,3
Gee-Chen Chang 4,5,6
Lesions: A Primer
Wen-Sheng Tzeng 3,7,8
Si-Wa Chan1 OBJECTIVE. CT-guided core biopsy is playing an increasing role in the diagnosis of benign
Clayton Chi-Chang Chen1,3,9,10 disease, cellular differentiation, somatic mutation analysis, and molecular fingerprint analysis.
CONCLUSION. In this article, we summarize the basic concepts, protocols, and tech-
Tsai IC, Tsai
Keywords: WL, Chen
biopsy, MC,
CT, lung, etcancer
lung al.
niques that we use for CT-guided core biopsy of lung lesions to assist radiologists in obtaining
DOI:10.2214/AJR.08.2113 diagnostic specimens while reducing preventable complications.
Received November 15, 2008; accepted after revision

W
ith recent advances in target Basic Concepts
American Journal of Roentgenology 2009.193:1228-1235.

April 17, 2009.

1
Department of Radiology, Taichung Veterans General
Hospital, Taichung, Taiwan.
2
Institute of Clinical Medicine, National Yang Ming
University, Taichung, Taiwan.
3
Department of Radiological Technology and Graduate
Institute of Radiological Science, Central Taiwan
University of Science and Technology, Taichung, Taiwan.
4
Division of Chest Medicine, Department of Internal
Medicine, Taichung Veterans General Hospital, Taichung,
Taiwan.
5
School of Medicine, China Medical University, Taichung,
Taiwan.
6
Institute of Biomedical Sciences, National Chung-Hsing
University, Taichung, Taiwan.
7
Department of Medical Imaging, Chi-Mei Foundation
Medical Center, No. 901, Chung Hwa Rd., Yong Kang City,
Tainan 710, Taiwan. Address correspondence to
W. S. Tzeng.
8
Department of Radiology, Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan.
9
Department of Physical Therapy, Hungkuang University
of Technology, Taichung, Taiwan.
10
Department of Physical Therapy and Assistive
Technology, National Yang Ming University, Taipei,
Taiwan.
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2009; 193:1228–1235
0361–803X/09/1935–1228
© American Roentgen Ray Society
therapy [1], obtaining tumor
tissue to analyze for the molec-
ular fingerprint of somatic mu-
tation for personalized medicine will be a
major trend in the future [1]. In addition to its
traditional diagnostic role, CT-guided lung
biopsy also plays a key role in personalized
treatment [2]. Compared with aspiration cy-
tology, coaxial core biopsy is preferred be-
cause it can obtain multiple large specimens
for diagnosis [3] and molecular analysis [2].
Thus, in the near future, CT-guided coaxial
core biopsy will be an important technique
in the personalized treatment of lung cancer.
Many radiologists around the world are
well trained for fine-needle aspiration of lung
lesions. However, a coaxial needle requires
careful manipulation to avoid an air embolism.
Core biopsy requires special attention to avoid
cutting the vessel surrounding the tumor in or-
der to prevent major hemorrhage. Many expe-
rienced medical centers report the low compli-
cation rate and safety of CT-guided biopsy. At
our institute, the complication rates are 27.9%
for pneumothorax (21.3% resolved spontane-
ously, 6.6% requiring tube drainage), 14.8%
for hemoptysis, 0.3% for severe hemothorax
requiring endotracheal intubation, and 0% for
procedure-related mortality, which is similar
to previous reports [2–4]. Overall, national
surveys [5, 6] continue to show major compli-
cations and death. This means many radiolo-
gists may benefit from a guide to help improve
their technique and to reduce procedure-relat-
ed complications. In this article, we share our
key concepts and techniques regarding CT-
guided core biopsies of lung lesions.
Respiratory Motion
The lower lung zones (below the hili) are
more affected by respiratory motion than the
upper (Figs. 1–3). Contrary to conventional
practice, we allow the patient to breathe freely
and quietly during the biopsy procedure (Fig.
3). There are two reasons for not making them
hold their breath: Reproducibility of diaphragm
position between breath-holds is not good, and
after a breath-hold, the following deep respira-
tion may cause needle laceration to the pleura.
We directly observe the patient’s breath rhythm
and insert the needle during inspiration.
Cardiac Motion
The left lingula, near the left ventricle and
pulmonary trunk, is most affected by cardiac
motion (Fig. 4). While performing biopsy in
the lingula, take care to avoid myocardium
or epicardial coronary artery injury.
Chest Wall Vessels
Generally, avoid all vessels greater than
5 mm seen on chest CT. When biopsying
an anterior lesion behind vessels in the up-
per chest, such as the subclavian or internal
thoracic vessels, a path should be chosen that
avoids the vessels (Fig. 5). Also, to avoid in-
tercostal arteries, insert the coaxial needle
above rather than below the rib.
Preprocedural Laboratory Check
Coagulation factors, such as platelet
count, prothrombin time, and activated par-
tial thromboplastin time, should be checked
before the procedure. Any anticoagulants or
platelet inhibitors such as aspirin should be

1228 AJR:193, November 2009


withheld. Use the British Thoracic Society
guideline as a general reference for proper
biopsy procedures [7].
Fissures
In our experience, traversing the fissure
with a 17-gauge coaxial needle results in a
high probability of pneumothorax. Informed
consent should be obtained for all biopsies, but
if there is likelihood of traversing a fissure, the
patient should be informed of the increased
risk of a pneumothorax as a complication.
Shock Wave Injury During Biopsy
When the biopsy gun fires, the shock wave
distal to the biopsy needle tip is strong. The ar-
eas lateral to the needle will be also affected
by the vibration. Shock wave injury to lung pa-
renchyma is usually evidenced by mild hemor-
rhage (Figs. 1 and 6). Thus, these regions, dis-
tal to the tip and lateral to the needle, should be
American Journal of Roentgenology 2009.193:1228-1235.
considered danger zones. Major vessels should
be well away from these danger zones.
Informed Consent
Because CT-guided lung biopsy is an in-
vasive procedure with potential complica-
tions, including death [5, 6], obtaining in-
formed consent with the patient and his or
her family understanding the procedure and
potential risks is important. The British Tho-
racic Society [7] guideline further suggests,
“Operators should audit their own practice
and calculate their complication rates to in-
form patients before consent is given.”
Scan Protocols
During the procedure, we obtain a routine
low-dose axial scan with 120 kVp, 30 mAs
per slice, 0.75-second rotation time, and col-
limation of 8 × 5 mm on a 64-MDCT scan-
ner (Brilliance 64, Philips Healthcare). For
scanners of other vendors, the suggested
axial scanning parameters are 120 kVp, 30
mAs per slice, 0.5- to 1-second rotation time,
and collimation of 5 mm. The window cen-
ter and width are 0 and 2,800 HU, respec-
tively, which allows simultaneous visualiza-
tion of vessels, tumor, pneumothorax, bone,
muscle, and fat. The procedure is performed
with a “move off and scan” approach [2–4,
8–10] (Fig. 7) to minimize radiation expo-
sure to the operator as compared with CT
fluoroscopy [11]. If multiplanar reforma-
tion or volume-rendering images are needed
for detailed needle localization, we obtain a
low-dose thin-collimation spiral scan (120
kV, 40 mAs per slice, rotation time of 0.75
AJR:193, November 2009 1229
CT-Guided Lung Biopsy
second, pitch of 0.924, collimation of 64 ×
0.625 mm) (Figs. 3 and 8).
“The patient as partner” approach cannot
be overemphasized [8]. We routinely inform
the patient that the procedure takes only
about 30 minutes and that his or her coop-
eration is the key to success [8].
Techniques
Coaxial Technique
The coaxial technique to obtain a core bi-
opsy is suggested for the following reasons:
It yields good stabilization in the chest wall
because of the lightness of the coaxial nee-
dle; and it allows multiple sampling, improv-
ing diagnostic yield [12]. When performing
the coaxial technique, never leave the outer
cannula inside the patient without the inner
stylet (Fig. 9). To do so in a small branch of a
pulmonary vein could result in a devastating
air embolism, leading to myocardial infarc-
tion, stroke, or even death [13].
At our institute, we use a 17-gauge coaxi-
al needle (TruGuide, Bard) with a length of
13 cm for most cases. Sometimes, a 17-gauge
coaxial needle with a length of 17 cm is used
for deep lesions. The core biopsy is routinely
performed with the matching 18-gauge cut-
ting needle (Magnum Needles, Bard) and bi-
opsy gun (Magnum, Bard).
Local Anesthesia
The distance between the skin and pleura
should be measured. The needle tip should
never advance through pleura (Fig. 2) when
injecting local anesthesia (Xylocaine 2% [li-
docaine], AstraZeneca). Otherwise, pneu-
mothorax might develop, making the follow-
ing procedure more difficult.
Sterile Drape as Needle Holder
If the distance between skin and pleura
is short, the fixing force from the chest wall
to stabilize the coaxial needle may be weak
(Fig. 2). In such circumstances, we shape
a sterile drape into a needle holder during
scanning. The needle can then be fixed in the
planned direction to provide more informa-
tion during the following scan (Fig. 2). If the
needle is aimed at the lesion on the follow-
ing scan, you may insert the needle farther
according to the direction indicated by your
handmade needle holder.
Dynamic Needle Manipulation
When inserting the coaxial needle, a rapid
thrust to the subpleural region for at least 1 cm
should be done (Figs. 1 and 10) to avoid nee-
dle tip laceration to the pleura and to avoid
the outer cannula slipping into the pleural
space during breathing. It is a dynamic pro-
cess (Fig. 1) from skin to the lesion; always
use the latest scan for planning, and do not
strictly adhere to the initial planning and an-
gle. During the whole procedure, the patient
moves, lung parenchyma moves, and pneu-
mothorax might develop. Thus, only some
procedures exactly follow your initial plan-
ning; most cases require adaptation and mod-
ification during the procedure (Fig. 1).
Final Manipulation
Final manipulation is an important tech-
nique for increasing diagnostic yield and
avoiding complications. If the coaxial needle
is inserted to the periphery of the tumor rath-
er than the center, we still can get diagnostic
tissue by aligning the coaxial needle to the
lesion before biopsy. Direct inspection can
confirm if the specimen is adequate (Fig. 6).
Also, postbiopsy scanning can help in local-
izing the biopsy direction by visualizing the
small hemorrhage caused by the shock wave
of the biopsy gun (Fig. 6). The final manipu-
lation technique is particularly useful in con-
ducting small nodule core biopsy (Fig. 6) on
lesions located near the diaphragm (Fig. 3)
and avoiding vessel injury (Fig. 11).
Biopsy Under Pneumothorax
CT-guided biopsy of lung lesions can be
done under stable pneumothorax, if the le-
sion is close to the pleural surface [10]. The
pneumothorax may be caused by previous
sonographically guided biopsy or by the first
coaxial needle entry. When pneumothorax
occurs, scan the same position 3 minutes
later to see if the pneumothorax is progress-
ing. If progressing, we suggest insertion of a
pigtail catheter and stopping the procedure.
If the pneumothorax is stable, with the final
manipulation technique, diagnostic speci-
mens can be obtained [10] (Fig. 12).
Biopsy Groove Length Selection
In our system, two biopsy sample lengths
can be selected, 22 and 15 mm. The gener-
al principle is to use the long groove for ob-
taining more tissue (Fig. 6). The short biopsy
groove is only used for avoiding injury to the
vessels behind the tumor.
Review Your Cases
After the procedure, review to see how
closely the procedure followed your plan
(Figs. 1–3, 6, 8, 11, 12), to see if the specimen
 Tsai et al.

obtained was adequate for the pathologist,
and to determine whether the patient devel-
oped complications.
Conclusion
Because CT-guided core biopsy is playing an
increasing role in benign disease diagnosis, cel-
lular differentiation, somatic mutation analysis,
and molecular fingerprint analysis, radiologists
should be familiar with the associated tech-
niques so that they may safely obtain diagnostic
specimens while minimizing complications.
Acknowledgments
We thank Chih-Ming Chiang, Yung-Chieh
Chang, and Wan-Chun Liao for preparation
of the figures.
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12. Lucidarme O, Howarth N, Finet JF, Grenier PA.
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Fig. 1—57-year-old woman with 1.5-cm ground-

glass opacity lesion over right lung apex who
underwent CT-guided biopsy. Pathology revealed
adenocarcinoma. Case shows that biopsy procedure
is dynamic process.
A, Axial low-dose CT scan over right lung apex.
After injection of local anesthesia, leave hypodermic
needle (arrow) as you planned to see whether needle
is really aimed at lesion (T). In this image, needle is
aimed at left periphery, not center, of tumor.
B, After several courses of needle advancement
and manipulation, coaxial needle (arrow) is placed
at periphery of tumor (T) and biopsy track traverses
tumor center. Exchange inner stylet for biopsy
needle, which is attached to biopsy gun. After biopsy,
because of shock wave produced by biopsy gun,
mild hemorrhage is seen in distal portion of needle
tip (white arrowheads) and lateral to biopsy needle
(black arrowheads). See Figure S1 in supplemental
data at www.ajronline.org to view dynamic process,
from injecting local anesthesia to final biopsy.
A B

1230 AJR:193, November 2009

 CT-Guided Lung Biopsy

A B
American Journal of Roentgenology 2009.193:1228-1235.

C D E

F G
Fig. 2—82-year-old man with lymphoma after treatment, now with growing tumor over right upper lobe of lung, who was referred for CT-guided lung biopsy. Pathology
revealed tuberculosis. This case shows sterile-drape-as-needle-holder technique for trajectory alignment.
A, Initial CT scan and trajectory planning. In initial localization scan, plan trajectory from right lateral chest wall to tumor (T) with 55° angle from vertical line (white double
arrow). Then skin-to-pleura (black double arrow) and skin-to-lesion distances are measured. Skin-to-pleura distance is only 22 mm. Because hypodermic needle for local
anesthesia is 32 mm long, needle cannot be totally inserted, or puncture to pleura may cause pneumothorax.
B, CT scan after administration of local anesthesia. Because of thin chest wall, needle (arrow) angle (61°) differs from that initially planned (55°). Distal extended line,
as shown by beam-hardening artifact (white arrowheads), is not aimed at tumor (T). Plan was to pass coaxial needle between two visualized small vessels (black
arrowheads) and biopsy tumor.
C, Photograph during biopsy after coaxial needle insertion with hand support. With assistance of technologist, operator inserted coaxial needle (arrow) into chest wall at
55° angle. Sterile drape (D) was prepared for later use.
D, Photograph during biopsy after coaxial needle insertion without hand support. Because chest wall is thin, fixation force is insufficient. Needle toppled (arrow),
making angle much larger than 55°. This is not angle we want, and scan will not provide information for further needle adjustment. Sterile drape (D) was prepared for
later use.
E, Photograph during coaxial needle insertion with sterile drape as needle holder. Sterile drape (D) is shaped to support needle (arrow). With assistance of technologist,
needle is now at 55°, angle we want. At this time, operator can leave scanning room and obtain another axial scan to confirm trajectory.
F, Next CT scan with coaxial needle (arrow) supported by sterile drape (D). Needle angle now is exactly 55°. Beam-hardening artifact (white arrowheads), which serves as
extension of needle, is also aimed at tumor. Two vessels (black arrowheads) near tumor (T) should be avoided during further needle insertion.
G, Axial low-dose CT scan with coaxial needle on periphery of tumor. After two attempts, coaxial needle (arrow) is now on periphery of tumor (T) without having injured
any visible vessel (black arrowheads). With beam-hardening artifact (white arrowheads), biopsy track is confirmed to traverse tumor. Biopsy is then successfully
completed without complication. Note that 4° of inaccuracy would injure major pulmonary vessel branch.

AJR:193, November 2009 1231

 Tsai et al.

A B C
Fig. 3—76-year-old man with underlying hepatocellular carcinoma. New nodule in right lower lobe of lung was noted in routine follow-up abdominal CT scan. CT-guided
biopsy revealed organizing pneumonia. Case shows techniques of near-diaphragm lesion biopsy and z-axis final manipulation.
A, Localization prone CT scan. This image shows two potential approaches (white and black arrows) to lesion (T). Posterolateral approach (white arrow) is feasible, but
sharp angle between needle path and pleura could potentially result in pneumothorax. Distal shock wave of posterolateral approach might injure paravertebral vessels
such as intercostal arteries. Thus, we decided to use posterior approach (black arrow). Rib is blocking posterior approach, so we decided to use z-axis manipulation to
approach tumor.
B, CT scan after coaxial needle approached lesion (T). Scan level is slightly caudad to that in A. We inserted needle in periphery of tumor (T), and we planned to do final
manipulation in z-axis to approach tumor. Biopsy could not be performed without manipulation (arrowheads) because diaphragm would be injured.
C, Sagittal reformation of needle and lesion (T) after biopsy. Coaxial needle is now inserted in tumor periphery, where, with z-axis final manipulation (curved arrow),
American Journal of Roentgenology 2009.193:1228-1235.

needle can aim at center of tumor (T). With postbiopsy hemorrhage posterior to tumor, biopsy direction is confirmed. Actual biopsy track (black arrowheads) is different
from original needle direction (white arrowheads). In this case, diaphragm was successfully avoided and tumor biopsied without complication.

A B
Fig. 4—72-year-old man undergoing ECG-gated cardiac CT. Images and cine figures are reconstructed in lung window with large field of view to show effect of cardiac
motion on lung parenchyma and implications for CT-guided biopsy.
A, Axial nongated image at aortic root. If cardiac CT raw data are reconstructed without ECG signal, reconstructed still image is same as routine chest CT scan. In lungs,
regions near left ventricle (black arrowheads), right ventricular outflow tract (RVOT), and pulmonary trunk are affected by cardiac motion, as shown by motion artifact
(white and black arrowheads). Left lingula (black arrowheads) is affected most, followed by right middle lobe (white arrowhead). Note that perihilar areas and regions
near descending aorta (DAO) are not affected. See Figure S4A in supplemental data at www.ajronline.org to view lung movement during heart cycle at this level. LAA =
left atrial appendage, AAO = ascending aorta.
B, Axial nongated image at level of left ventricular outflow tract. Left lingula (black arrowheads) is affected by left ventricular (LV) motion. At this level, right middle lobe
(white arrowhead) is not obviously affected by right ventricular (RV) motion. See Figure S4B in supplemental data at www.ajronline.org to view lung movement during
heart cycle. DAO = descending aorta, LA = left atrium, RA = right atrium.

1232 AJR:193, November 2009

 CT-Guided Lung Biopsy

A B C
Fig. 5—Chest wall vessels related to CT-guided biopsy. Images from different patients show anatomic details.
A, Axial chest CT scan at level of subclavian vessels in 68-year-old man. Tumor (T) over left lung apex is noted. Anterolateral approach (dashed arrow) would injure
American Journal of Roentgenology 2009.193:1228-1235.

subclavian vessels (arrowheads). Thus, posterior approach (solid arrow) is better. Even though image here shows rib blocking posterior approach, with patient in prone
position, relationship between lesion and rib may change. Otherwise, z-axis manipulation can be used to approach lesion, as shown in Figure 3.
B, Axial low-dose scan during CT-guided biopsy in 56-year-old woman. Even with low-dose CT scan during biopsy, internal thoracic vessels (white arrowheads) and
lateral thoracic vessels (black arrowheads) can be well visualized; these are vessels to be avoided. Injuring internal thoracic artery in patient after coronary artery
bypass surgery may cause myocardial infarction.
C, Volume-rendering technique of intercostal arteries (arrows and arrowheads), ribs, and scapula (S) in 56-year-old woman. Intercostal arteries above lower margin of
scapula are small and almost invisible (arrows). However, intercostal arteries below scapula are larger (white and black arrowheads). In lateral and posterolateral wall
(white arrowheads), intercostal arteries are located at inferior margin of ribs. However, at posteromedial wall, course is unpredictable. Intercostal arteries could be
in center of intercostal space or even at superior margin of rib (black arrowheads). Thus, when doing CT-guided biopsy for apical lung lesion with posterior approach,
intercostal arteries are not of concern. If lateral or posterolateral approach is used, avoid inserting needle from inferior margin of ribs. On axial low-dose CT scan,
intercostal arteries are not visible because of volume averaging.

A B C
Fig. 6—65-year-old woman with 7-mm ground-glass nodule over right lower lung. Case shows importance of final manipulation in small-nodule core biopsy. Pathology
revealed adenocarcinoma.
A, Axial image with coaxial needle inserted. Even after meticulous manipulations, coaxial needle is not aiming at small nodule. Thus, we use final manipulation technique
(arrow) to align coaxial needle to small nodule (arrowheads) before performing biopsy. In small-nodule biopsy, remember to use long biopsy groove (in this case, 22 mm)
to totally traverse small nodule so as to obtain large diagnostic specimen.
B, Axial CT scan after biopsy. Notice shock wave hemorrhage (white arrowheads) traversing small nodule (black arrowheads), confirming correct direction of final
manipulation.
C, Photograph of biopsy groove shows 7-mm nodule (arrowheads) is successfully sampled. Pathology revealed adenocarcinoma.

AJR:193, November 2009 1233

 Tsai et al.

A B
Fig. 7—Photograph of scene of CT-guided biopsy. Fig. 8—62-year-old man with left upper lobe nodule near hilum. CT-guided biopsy revealed adenocarcinoma.
We use IV stand, bracket (B), and plank, available With proper planning and good technique, even hilar lesions can be biopsied successfully without complication.
American Journal of Roentgenology 2009.193:1228-1235.

from any hardware store, to make portable platform
to position protractor (P) close to coaxial needle
to avoid visualization bias. Protractor should be
calibrated by spirit level (SL) with paper or tongue
depressors. Also, we designed rear sight (such as
one on rifle) to aim at coaxial needle for precision. In
technologist’s (T) eye, coaxial needle will appear in
long slit of rear sight, making it easy to confirm angle.
Isolation gown on radiologist (R) is not sterile; thus,
sleeve is rolled up to avoid contaminating sterile
gloves and sterile area.
A, Axial low-dose CT scan after coaxial needle is inserted into tumor periphery. With precise planning and
meticulous manipulation, all visible vessels are avoided. Closest vessel is only 5 mm away from needle.
Although tree-in-bud pattern (black arrowheads) is noted in adjacent region, tumor (white arrowhead) proves to
be adenocarcinoma. Surgical pathology revealed tree-in-bud pattern to be tuberculosis. This is case of mixed
tuberculosis and adenocarcinoma.
B, Slab volume-rendering image of CT scan. Tumor (arrowhead) is surrounded by many hilar vessels. If we can
find trajectory avoiding all visible vessels, biopsy can still be done without complication.

Fig. 9—Stylet exchange technique to avoid air

embolism.
A, Photograph during stylet exchange. After coaxial
needle is inserted into tumor periphery, we exchange
inner stylet for biopsy needle. During exchange, left
hand (LH) should fix outer needle (white arrowhead)
position on patient to prevent further insertion. Little
finger (arrow) rests on patient and remaining fingers
are used to fix outer cannula, while right hand (RH) is
screwing inner stylet (black arrowhead).
B, Photograph during stylet exchange. When inner
stylet is removed, thumb (black arrowhead) should
be used to cover proximal hole of outer needle
before biopsy needle, attached to biopsy gun (G),
enters. Little finger (arrow) still rests on patient
and remaining fingers fix outer cannula (white
arrowhead). This is important technique to prevent air
embolism, which can result in myocardial infarction,
stroke, or death.
A B

1234 AJR:193, November 2009

 CT-Guided Lung Biopsy

Fig. 10—Distance between tips of outer cannula and Fig. 11—38-year-old woman with right lower lobe Fig. 12—56-year-old man with right lower lobe
inner stylet is shown in photograph of tip of coaxial mass who underwent CT-guided biopsy. Pathology subpleural nodule needing CT-guided biopsy. Case
needle. Most coaxial needles, like one seen here, revealed adenocarcinoma. Case shows importance shows that biopsy can still be done under stable
American Journal of Roentgenology 2009.193:1228-1235.

have 5-mm gap between inner needle tip (black
arrowhead) and outer cannula tip (white arrowhead).
When performing subpleural lesion biopsy, never let
outer needle tip slip into pleural space because that
will result in pneumothorax. Also notice that scale
on needle counts from tip of outer needle (white
arrowhead), which means that first tick (arrow) is 1.5
cm, rather than 1.0 cm, from inner needle tip.
of final manipulation to avoid vessel injury. Axial
low-dose CT scan during procedure shows needle
is inserted into periphery of tumor (T). Bronchus
(white arrowhead) and vessel (black arrowhead)
behind tumor should be avoided during biopsy. If
biopsy is done without any manipulation, vessel
(black arrowhead) behind tumor will be injured
because beam-hardening artifact (straight arrows)
is traversing vessel wall. Thus, before biopsy, we
manipulate coaxial needle (curved arrow) to aim
at medial portion of tumor. Specimen was then
successfully obtained without complication such as
pulmonary hemorrhage.
pneumothorax. After coaxial needle was inserted
through pleura, pneumothorax (asterisk) developed
immediately. Although location of needle tip is as
planned, nodule (T) is going distally with partially
collapsed lung. With final manipulation, coaxial
needle is angled (curved arrow) and inserted deeper
(straight arrow) before biopsy gun is fired. Specimen
was successfully obtained. Culture revealed
nontuberculous Mycobacterium organism. H =
hematoma caused by injection of local anesthetic.

F O R YO U R I N F O R M AT I O N
• This article is available for CME credit. See www.arrs.org for more information.
• The data supplement accompanying this article can be viewed from the information box in the upper
right corner of the article at: www.ajronline.org.

AJR:193, November 2009 1235

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1. Ali Fuat Tekin, Bekir Turgut, Fatih Öncü. 2020. Should We Perform Transthoracic Trucut Lung Biopsies of Pleural-Based
Lung Masses Under Ultrasound Guidance or Computed Tomography Guidance?. Ultrasound Quarterly 36:1, 49-53. [Crossref]
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