European Journal of Radiology 45 (2003) 60
/68

www.elsevier.com/locate/ejrad

Percutaneous biopsy in lung cancer

François Laurent , Michel Montaudon, Valérie Latrabe, Hugues Bégueret
Unité d’Imagerie Thoracique et Cardiovasculaire, Hôpital du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Avenue de Magellan, Pessac
33604, France

Received 17 September 2002; received in revised form 18 September 2002; accepted 19 September 2002

Abstract

This paper presents current indications, contraindications, technical aspects, complications and yield of diagnosis of percutaneous
lung biopsy in the setting of lung cancer. Percutaneous lung biopsy should be performed each time that the therapeutic strategy can
be significantly influenced, when the procedure is technically feasible and to patients for which the benefits outweigh the risks, that
are pneumothorax and pulmonary haemorrhage. Factors identified as potentially favouring post-biopsy pneumothorax are
numerous whereas the use of a needle size larger than 18 gauge is the major risk factor of bleeding. Although a coaxial system is
highly suitable in any case, two categories of needles can be used; those providing aspiration and those for core biopsies. Both offer
similar yields for the diagnosis of malignancy, but core biopsies are more efficient for the specific diagnosis of benignity and
lymphoma. Technical improvements of guidance, needle design and pathological techniques may contribute to lower the size limit of
the nodule to be biopsied, to decrease the complication rate and their severity and to increase the yield of diagnosis.
# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Lung; Tumour; Percutaneous biopsy; Complications

1. Introduction 2. Indications

Percutaneous biopsy has emerged as an invasive Biopsy during flexible bronchoscopy and percuta-
procedure of choice for the diagnosis of lung cancer neous biopsy are the techniques most widely used for
over the past three decades. The technique has been providing an accurate cytologic or histologic diagnosis
popularized by Nordenstrom [1] with the introduction of lung cancer. They should be considered as comple-
of thin-walled needles with an outer diameter of 1 mm mentary procedures, although their position in the
or less, quieting early concerns about the safety of diagnostic algorithm remains a subject of debate.
biopsies using large cutting needles. Increased expertise Percutaneous biopsy is mainly indicated when the
of cytopathologists and operators and advances in histological diagnosis can influence the therapeutic
imaging technique guidance have mainly contributed strategy or modify the staging of the disease and when
to the growing acceptance of the method. Nevertheless, the diagnosis cannot be established by bronchoscopic
many aspects of the topic have not been submitted to techniques. For central lesions with an endobronchial
large control trials and remain controversial. component, the various sampling techniques associated
with flexible bronchoscopy have a high diagnostic
accuracy, but peripheral tumours not visible on endo-
bronchial examination are diagnosed less readily. For
most experts, peripheral lesions smaller than 3 cm in
 Corresponding author. Tel.: /33-5-57-65-65-42; fax: /33-5-57- diameter and not showing the computed tomography
65-68-80
E-mail address: francois.laurent@chu-bordeaux.fr (F. Laurent).
(CT) bronchus sign, e.g. a bronchus seen entering the

0720-048X/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0 7 2 0 - 0 4 8 X ( 0 2 ) 0 0 2 8 6 - 3
 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68 61

proximal portion of the lesion, are diagnosed more 3. Contraindications

accurately by percutaneous biopsy [2,3].
Percutaneous biopsy has a high accuracy when Percutaneous biopsy should be limited to cases that
positive for malignancy, but the question whether a are both truly indicated, technically feasible and for
non-specific benign diagnosis can obviate surgery re- which the possible benefits outweigh the risks. Abnor-
mains open. This situation is frequent since the sensi- mal clotting function or thrombocytopenia should be
tivity for a specific benign diagnosis has been reported recognized and corrected before the procedure. Sus-
to be ranged from 11.7 to 68% [4]. A meta-analysis pected hydatid cyst or arterio-venous malformation
performed on 48 studies calculated the likelihood ratio should not be biopsied but can be identified or at least
for malignancy based on the percutaneous biopsy result, strongly suspected on CT. Mechanical ventilation which
given a pretest probability of malignancy of 50%. A may lead to pneumothorax and favours air embolism,
result of malignancy carried a likelihood ratio of 72 inability of a patient to cooperate during the procedure
whereas a benign result had a likelihood ratio of 0.07 [4]. or to suspend respiration on request or control cough
Therefore, whereas findings of malignant or specific are the major contraindications. A unique functional
diagnosis of a benign condition provide definitive lung, severe chronic obstructive pulmonary disease,
results, a ‘‘suspicious’’ benign markedly decreases the pulmonary hypertension or cardiac insufficiency do
probability of malignancy but cannot be considered as not constitute absolute contraindications but render
definitive and requires further evaluation. any complication more significant [9]. In any case, the
The need for preoperative diagnosis of a pulmonary risks must be weighted against the benefit judiciously,
nodule that would obviate an unnecessary surgical the availability of alternate procedures must be taken
thoracoscopy or thoracotomy varies from one institu- into account. Some of the contraindications with tradi-
tion to the other, and depends on the pretest probability tional guidance methods may be overcome in the near
of diagnosing a lesion. There is a general agreement that future by the use of sophisticated real-time guidance
biopsy is indicated in patients who are inoperable techniques such as fluoro-CT.
because of tumour invasion, metastatic disease or
general condition and to determine the cell type in a
lesion suspected of being either a metastasis or a second 4. Technique
primary pulmonary carcinoma. Conversely, proceeding
directly to thoracotomy is appropriate when preopera- 4.1. Imaging modality
tive diagnosis is unlikely to alter patient management,
especially in the case of an operable patient with a high Fluoroscopic guidance has represented the traditional
probability of malignancy. Debate exists, however, to imaging modality for percutaneous biopsy [1]. The main
know whether percutaneous biopsy should also be advantages over CT guidance are the short procedure
performed in patients who are at surgical risk, in time, the real-time visualization of needle advancement
whom a positive biopsy would permit acceptance of and the low cost. Disadvantages include difficult access
the risk. Advantages of a preoperative diagnosis of lung to central lesions and difficult avoidance of bullae and
cancer are identification of small cell carcinomas, vascular structures in the needle pass [10].
planning therapy and avoidance of unnecessary resec- CT has been used for 20 years and has become the
tion of benign lesions. standard in many institutions. CT permits planning a
Percutaneous biopsy of mediastinal or hilar lymph trajectory that avoids passage through aerated lung,
nodes has been recommended by several investigators avoidance of bullae, fissures or vessels and that allows
for obtaining tissue from enlarged lymph nodes or possible access to central lesions. CT also helps to
suspected mediastinal invasion in patients with known distinguish necrotic from solid portions of the lesion and
or suspected lung carcinoma, based on the accuracy and to document unequivocally the needle tip within the
advantages compared with mediastinoscopy [5
/7]. All lesion, a point of major value in the interpretation of
regions of the mediastinum are potentially accessible absence of malignant cells [11]. The length of the
with percutaneous biopsy. However, the main limitation procedure, one of the most reported drawbacks of CT
of the technique is that a negative percutaneous biopsy guidance, has significantly decreased with spiral CT and
of a single enlarged lymph node does not mean that the today with CT fluoroscopy. CT fluoroscopy offers
mediastinum is benign. In addition, normal-sized nodes advantages combining those of both fluoroscopy and
are not evaluated by the method which is, therefore, CT, permitting to biopsy smaller lesions, lesions that are
only used in selected cases [7]. The diagnosis of chest situated in less favourable locations such as those in the
wall and pleural lesions by percutaneous biopsy [8] as costophrenic recess or close to the mediastinum, and to
well as the diagnosis of extrathoracic malignancy such perform the procedure more quickly in less cooperative
as adrenal masses can also be performed by percuta- patients [12]. One of the major concerns of CT fluoro-
neous biopsy in the clinical setting of a lung cancer. scopy is the increased radiation dose compared with that
62 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68

of spiral CT, although irradiation may be lowered dles is depending on many factors including personal
substantially [13]. experience, the risk of complication and the availability
US has a limited use to peripheral, pleural-based of a pathologist on-site. In many institutions, with no
lesions producing an acoustic window but avoids pathologist available on-site, the use of core biopsy
irradiation. Both fine and cutting needles have been needle is recommended at a first approach when there is
employed safely with this guidance modality with a strong suspicion of a benign lesion or of a lymphoma.
excellent performances. Major advantages are the pos- In other situations, especially when there is a strong
sible fine adjustments of the tip of the needle monitored suspicion of malignancy and when a pathologist is
quickly and precisely throughout the procedure and the available on-site, fine-needle aspiration is recommended
value in the biopsy of large necrotic masses [14,15]. first [24].

4.2. Needles 4.3. Biopsy process

The use of various needle sizes, tip design and Recent reports have detailed the technical aspect of
sampling mechanism have been reported in percuta- the procedure that varies somewhat with the type of
neous biopsy of the lung. Requirements for an ideal needle used [9,10,16,25]. When fine-needles are used,
biopsy needle are to minimize bleeding complications suction generated by a syringe, back and forth move-
and maximize the specimen obtained. Minimizing the ments of the needle and multiple needle passes improved
bleeding complications is achieved today by using the yield of the method compared with the capillary
needles smaller than 18 gauge. Single-pass and multi- technique. A recent study has shown that the majority of
ple-pass coaxial needles have been used in percutaneous carcinomas contain a reactive zone of variable thickness,
biopsy of thoracic lesions. The coaxial system, which representing about 10% of the total tumour diameter
consists of inserting a thin inner needle through a larger [26], reinforcing the concept that multiple sampling
outer needle placed at the edge or within the lesion, has should be done in several parts of a lesion. The wall of
numerous advantages over the single needle technique a necrotic or cavitary lesion should be carefully sampled.
including the limitation of the number of pleural However, malignant cells tend to desquamate especially
punctures, easy repositioning of the needle when correc- in squamous cell carcinoma and aspiration of necrosis is
tion of the course is needed and the possible use of also recommended (Fig. 3). Ideally, a portion of the
techniques preventing air leakage [16]. Ultra-thin nee- aspirate is stained and examined by a cytopathologist at
dles cannot be employed with a coaxial system (24 and the time of the procedure. This practice enables rapid
25 gauge) although they have been advocated by some assessment of the specimen so that repeat aspirations or
authors to provide similar yield with fewer complica- cutting needle biopsy can be performed immediately.
tions [17]. Needles are divided into two broad categories, Specimen adequacy is determined by the cytopathologist
aspiration needles providing cytology and cutting nee- who evaluates both cellularity and cellular preparation
dles able to provide histology samples. With some for reaching a definitive diagnosis. Cellular and necrotic
specifically designed fine-needles, in addition to aspira- specimens are smeared with various staining methods,
tion materials, small tissue fragments can be obtained and the needle is rinsed in appropriate solutions whereas
for histologic examination in about 50% of cases [9]. blood-containing specimens are fixed in formalin for
Large cores of tissue are obtained with powered Tru-Cut cellblock preparation [25].
type of needle with throw-lengths of 1
/2 cm and
variable throw options (Fig. 1). Recently, coaxial
models with small diameter have become available 5. Results
allowing to obtain multiple core specimens with a single
pleural puncture [18
/20]. However, there is no proof An overall sensitivity of 70
/100% has been reported
that any type of needle design is superior to other types for the diagnosis of malignancy, most reports being in
in terms of diagnostic yield and complication rate. the 85
/95% range [10]. In a large study involving almost
Histology offers no advantage over fine-needle aspira- 12 000 transthoracic needle aspiration specimen and
tion (Fig. 2) in the diagnosis of pulmonary carcinoma more than 400 institutions, sensitivity was 89%, speci-
[21]. Nevertheless, cutting needles have been demon- ficity 95%, positive predictive value 99% and negative
strated to be more accurate in the specific diagnosis of predictive value 70% [27]. The most common causes of
benign lesions, in the diagnosis of lymphoma and in the false-negative are sampling error and inaccurate needle
case of absence of a cytopathologist on-site [18,19,22]. placement [25]. Some investigators have stressed the
Both techniques are often complementary, aspiration importance of repeating biopsy when the initial result
being used initially and cutting needle proposed when was negative [28,29]. The rate of false-positive diagnosis
malignant diagnosis is not made [23]. Therefore, the first remains very low in the hands of experienced cyto-
choice between fine-needle aspiration and cutting nee- pathologists [30]. The duration of the procedure due to
 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68 63

Fig. 1. Percutaneous biopsy of a pulmonary nodule using a coaxial cutting needle. Mediastinal window setting shows the needle tip of the needle
within the edge of the lesion (a). Photograph of the biopsy specimen (b). The diagnosis of malignancy is based on abnormal architectural distortion
and cellular atypia. Diagnosis was adenocarcinoma. CT immediately after the biopsy (c) showing area of ground-glass intensity indicating alveolar
haemorrhage along the needle-track.

his presence in the biopsy room to provide immediate literature concerning the diagnostic yield of small
examination of the sample does not increase the nodules, some authors report a lower accuracy with
complication rate but controversial results have been nodules smaller than 15 mm [35,36] whereas such a
published regarding the impact on diagnostic yield [31
/ result has not been found by others using aspiration [37]
34]. Conflicting results have also been reported in the or cutting needles [38]. Inter- and intra-observer repro-
64 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68

Fig. 2. Percutaneous biopsy of a central pulmonary nodule. Prone CT during biopsy of the nodule and a small pneumothorax. Aspirated specimen
showing malignant cells with high nuclear cytoplasmic ratio. Diagnosis was adenocarcinoma.

ducibilities have been shown to reach more than 90% cases between the percutaneous biopsy cancer cell type
agreement for the diagnosis of malignancy but slightly and surgical pathology cell type [40,41]. Fortunately,
less for determining the specific histologic type [39]. disagreement mostly occurs among undifferenciated and
Agreement has been reported between 60 and 90% of poorly differenciated non-small cell types.
 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68 65

Fig. 3. Percutaneous biopsy of a pulmonary lesion extending within the mediastinum. CT during biopsy (a) showing a needle pass between the
sternum and mammary vessels enabling to biopsy the lesion without passing through aerated lung. The lesion was necrotic and necrosis aspirated.
Aspirated specimen (b) showing typical carcinomatous cells with large nucleolus and inflammatory cells. Diagnosis was squamous cell carcinoma.

6. Complications has been reported from 0 to 61%, 20% in most recent

large series and the rate of pneumothoraces requiring
Common complications of percutaneous biopsy of the treatment with chest tube varies from 1.6 to 17% [10].
lung are pneumothorax and bleeding. Pneumothorax Most pneumothoraces are detected within the first hour
66 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68

post-procedure, do not require drainage, and can be

managed conservatively. Large, symptomatic and ex-
panding pneumothoraces need a chest tube placement,
usually of small bore type. Aspiration of air at the end of
the procedure may decrease the need for a chest tube
placement [25]. One or serial chest X-ray 1
/3 h
following the procedure are usually performed to detect
those undetected immediately after the needle has been
withdrawn. Today the practice of percutaneous biopsy
is performed in many institutions on an outpatient basis
and early discharge has been shown to be safe [42].
Recent reports have demonstrated that pneumothoraces
can be managed safely in such outpatients in about half
of the cases [43,44].
Risk factors for the development of pneumothorax
have been the subject of intensive research and a lot of
controversy in the literature regarding the presence of
obstructive lung disease and hyperinflation. In the most
recent series, the risk factors identified were the lesion
size [45] and its depth [45,46], the presence of emphy-
sema on CT, a small angle of the needle with the
thoracic pleura, multiple repositioning of the needle and
a great number of sampling, but not the duration of the
procedure [47]. Various techniques such as positioning
Fig. 4. Percutaneous biopsy of an undifferenciated carcinoma via an
the patient biopsy-side down [16] and plugging the anterior pass to avoid peripheral bullae. CT after the biopsy showing
needle with a clot, the so-called blood-patch technique an area of ground-glass attenuation due to alveolar haemorrhage but
[16], or foam plugs [48] have been proposed to reduce no pneumothorax.
the incidence of a significant pneumothorax but their
true efficacy remains unclear [49].
Haemorrhage, most often a self-limited complication,
is the second most common and the most dangerous
potential complication of percutaneous biopsy. Massive
7. Conclusion
haemoptysis requiring bronchoscopic tamponade, arter-
ial embolization or surgery has become extremely rare
Percutaneous biopsy is today a well-established tech-
with small calibre needles. Haemoptysis occurs in
nique for the diagnosis of lung cancer. Technical
approximately 5
/10% in most series and is slightly
improvements of guidance, needle design and patholo-
more frequent with cutting needles [9,10]. Unusually
gical techniques may contribute to push back technical
blood emerging from the hub of the outer needle and
limitations, to decrease the rate of biopsies technically
alveolar haemorrhage identified as a ground-glass
impracticable, the rate of complications and their
attenuation in the area of the biopsy or along the needle
severity and to increase the yield of specific diagnosis.
tract are often the only manifestations of bleeding
during the procedure but should be considered as clues
to the onset of haemoptysis (Fig. 4). Rare reported
complications are vaso-vagal reaction, lung torsion, air References
embolism, needle tract implantation of tumour cells and
cardiac tamponade [10]. Air embolism is an often fatal [1] Nordenstrom B. Transthoracic needle biopsy. New Engl J Med
condition due to entry of air in the pulmonary venous 1967;276(19):1081
/2.
circulation and subsequent myocardial infarction, [2] Aristizabal JF, Young KR, Nath H. Can chest CT decrease the
use of preoperative bronchoscopy in the evaluation of suspected
stroke or death. This complication is often fatal, but bronchogenic carcinoma? Chest 1998;113:1244
/9.
fortunately very rare [50]. The incidence of needle tract [3] Mazzone P, Jain P, Arroliga AC, Matthay RA. Bronchoscopy
metastasis is also very rare, estimated 0.012%, with a and needle biopsy techniques for diagnosis and staging of lung
mean time of 2.6 months between the moment of the cancer. Clin Chest Med 2002;23:137
/58.
biopsy and the development of metastasis [51]. The [4] Lacasse Y, Wong E, Guyatt GH, Cook DJ. Transthoracic needle
aspiration biopsy for the diagnosis of localised pulmonary lesions:
mortality rate of percutaneous biopsy has been esti- a meta-analysis. Thorax 1999;54:884
/93.
mated globally to 0.02%, mainly by air embolism or [5] Zafar N, Moinuddin S. Mediastinal needle biopsy: a 15-year
massive haemoptysis [10]. experience with 139 cases. Cancer 1995;76:1065
/8.
 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68 67

[6] Westcott JL. Percutaneous needle aspiration of hilar and med- [28] Wescott JL. Percutaneous transthoracic needle biopsy. Radiology
iastinal masses. Radiology 1981;141:323
/9. 1988;169:593
/601.
[7] Protopapas Z, Westcott JL. Transthoracic needle biopsy of [29] Westcott JL. Direct percutaneous needle aspiration of localized
mediastinal lymph nodes for staging lung and other cancers. pulmonary lesions: result in 422 patients. Radiology 1980;137:31
/
Radiology 1996;199:489
/96. 5.
[8] Screaton NJ, Flower CD. Percutaneous needle biopsy of the [30] Charig MJ, Stutley JE, Padley SP, Hansell DM. The value of
pleura. Radiol Clin North Am 2000;38:293
/301. negative needle biopsy in suspected operable lung cancer. Clin
[9] Shaham D. Semi-invasive and invasive procedures for the Radiol 1991;44:147
/9.
diagnosis and staging of lung cancer. I. Percutaneous transthor- [31] Santambrogio L, Nosotti M, Bellaviti N, Pavoni G, Radice F,
acic needle biopsy. Radiol Clin North Am 2000;38:525
/34. Caputo V. CT-guided fine-needle aspiration cytology of solitary
[10] Klein JS, Zarka MA. Transthoracic needle biopsy. Radiol Clin pulmonary nodules: a prospective, randomized study of immedi-
North Am 2000;38:235
/66. ate cytologic evaluation. Chest 1997;112:423
/5.
[11] Yankelevitz DF, Henschke CI, Koizumi JH, Altorki NK, Libby [32] Austin JH, Cohen MB. Value of having a cytopathologist present
D. CT-guided transthoracic needle biopsy of small solitary during percutaneous fine-needle aspiration biopsy of lung: report
pulmonary nodules. Clin Imaging 1997;21:107
/10. of 55 cancer patients and meta-analysis of the literature. Am J
[12] Daly B, Templeton PA. Real-time CT fluoroscopy: evolution of Roentgenol 1993;160:175
/7.
an interventional tool. Radiology 1999;211:309
/15. [33] Padhani AR, Scott WW, Jr., Cheema M, Kearney D, Erozan YS.
[13] Paulson EK, Sheafor DH, Enterline DS, McAdams HP, Yoshi- The value of immediate cytologic evaluation for needle aspiration
zumi TT. CT fluoroscopy-guided interventional procedures: lung biopsy. Invest Radiol 1997;32:453
/8.
techniques and radiation dose to radiologists. Radiology [34] Miller DA, Carrasco CH, Katz RL, Cramer FM, Wallace S,
2001;220:161
/7. Charnsangavej C. Fine-needle aspiration biopsy: the role of
[14] Liao WY, Chen MZ, Chang YL, Wu HD, Yu CJ, Kuo PH, et al. immediate cytologic assessment. Am J Roentgenol
US-guided transthoracic cutting biopsy for peripheral thoracic 1986;147:155
/8.
lesions less than 3 cm in diameter. Radiology 2000;217:685
/91. [35] Li H, Boiselle PM, Shepard JO, Trotman-Dickenson B, McLoud
[15] Pan JF, Yang PC, Chang DB, Lee YC, Kuo SH, Luh KT. Needle TC. Diagnostic accuracy and safety of CT-guided percutaneous
aspiration biopsy of malignant lung masses with necrotic centers: needle aspiration biopsy of the lung: comparison of small and
improved sensitivity with ultrasonic guidance. Chest
large pulmonary nodules. Am J Roentgenol 1996;167:105
/9.
1993;103:1452
/6.
[36] Layfield LJ, Coogan A, Johnston WW, Patz EF. Transthoracic
[16] Moore EH. Technical aspects of needle aspiration lung biopsy: a
fine-needle aspiration biopsy: sensitivity in relation to guidance
personal perspective. Radiology 1998;208:303
/18.
technique and lesion size and location. Acta Cytol 1996;40:687
/
[17] Zavala DC, Schoell JE. Ultra-thin needle aspiration of the lung in
90.
infectious and malignant disease. Am Rev Respir Dis
[37] Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy of
1981;123:125
/31.
small pulmonary nodules. Radiology 1997;202:97
/103.
[18] Haramati LB. CT-guided automated needle biopsy of the chest.
[38] Laurent F, Latrabe V, Vergier B, Montaudon M, Vernejoux JM,
Am J Roentgenol 1995;165:53
/5.
Dubrez J. CT-guided transthoracic needle biopsy of pulmonary
[19] Klein JS, Salomon G, Stewart EA. Transthoracic needle biopsy
nodules smaller than 20 mm: results with an automated 20-gauge
with a coaxially placed 20-gauge automated cutting needle: results
coaxial cutting needle. Clin Radiol 2000;55:281
/7.
in 122 patients. Radiology 1996;198:715
/20.
[39] Taft PD, Szyfelbein WM, Greene R. A study of variability in
[20] Lucidarme O, Howarth N, Finet JF, Grenier PA. Intrapulmonary
cytologic diagnosis based on pulmonary aspiration specimens.
lesions: percutaneous automated biopsy with a detachable, 18-
gauge, coaxial cutting needle. Radiology 1998;207:759
/65. Am J Clin Pathol 1980;73:36
/40.
[21] Greif J, Marmur S, Schwarz Y, Man A, Staroselsky AN. [40] Thornbury JR, Burke DP, Naylor B. Transthoracic needle
Percutaneous core cutting needle biopsy compared with fine- aspiration biopsy: accuracy of cytologic typing of malignant
needle aspiration in the diagnosis of peripheral lung malignant neoplasms. Am J Roentgenol 1981;136:719
/24.
lesions: results in 156 patients. Cancer 1998;84:144
/7. [41] Horrigan TP, Bergin KT, Snow N. Correlation between needle
[22] Greif J, Marmor S, Schwarz Y, Staroselsky AN. Percutaneous biopsy of lung tumours and histopathologic analysis of resected
core needle biopsy vs. fine-needle aspiration in diagnosing benign specimens. Chest 1986;90:638
/40.
lung lesions. Acta Cytol 1999;43:756
/60. [42] Dennie CJ, Matzinger FR, Marriner JR, Maziak DE. Transthor-
[23] Staroselsky AN, Schwarz Y, Man A, Marmur S, Greif J. acic needle biopsy of the lung: results of early discharge in 506
Additional information from percutaneous cutting needle biopsy outpatients. Radiology 2001;219:247
/51.
following fine-needle aspiration in the diagnosis of chest lesions. [43] Gurley MB, Richli WR, Waugh KA. Outpatient management of
Chest 1998;113:1522
/5. pneumothorax after fine-needle aspiration: economic advantages
[24] McLoud TC. Should cutting needles replace needle aspiration of for the hospital and patient. Radiology 1998;209:717
/22.
lung lesions? Radiology 1998;207:569
/70. [44] Brown KT, Brody LA, Getrajdman GI, Napp TE. Outpatient
[25] Yankelevitz DF, Vazquez M, Henschke CI. Special techniques in treatment of iatrogenic pneumothorax after needle biopsy. Radi-
transthoracic needle biopsy of pulmonary nodules. Radiol Clin ology 1997;205:249
/52.
North Am 2000;38:267
/79. [45] Cox JE, Chiles C, McManus CM, Aquino SL, Choplin RH.
[26] Layfield LJ, Liu K, Erasmus JJ. Radiologically determined Transthoracic needle aspiration biopsy: variables that affect risk
diameter, pathologic diameter, and reactive zone surrounding of pneumothorax. Radiology 1999;212:165
/8.
pulmonary neoplasms: implications for transthoracic fine-needle [46] Laurent F, Michel P, Latrabe V, Tunon de Lara M, Marthan R.
aspiration of pulmonary neoplasms. Diagn Cytopathol Pneumothoraces and chest tube placement after CT-guided
1999;21:250
/2. transthoracic lung biopsy using a coaxial technique: incidence
[27] Zarbo RJ, Fenoglio-Preiser CM. Inter-institutional database for and risk factors. Am J Roentgenol 1999;172:1049
/53.
comparison of performance in lung fine-needle aspiration cytol- [47] Ko JP, Shepard JO, Drucker EA, Aquino SL, Sharma A, Sabloff
ogy: a College of American Pathologists Q-Probe Study of 5264 B, et al. Factors influencing pneumothorax rate at lung biopsy:
cases with histologic correlation. Arch Pathol Lab Med are dwell time and angle of pleural puncture contributing factors?
1992;116:463
/70. Radiology 2001;218:491
/6.
68 F. Laurent et al. / European Journal of Radiology 45 (2003) 60
/68

[48] Engeler CE, Hunter DW, Castaneda-Zuniga W, Tashjian JH, [50] Aberle DR, Gamsu G, Golden JA. Fatal systemic arterial air
Yedlicka JW, Amplatz K. Pneumothorax after lung biopsy: embolism following lung needle aspiration. Radiology
prevention with transpleural placement of compressed collagen 1987;165:351
/3.
foam plugs. Radiology 1992;184:787
/9. [51] Ayar D, Golla B, Lee JY, Nath H. Needle-track metastasis after
[49] Collings CL, Westcott JL, Banson NL, Lange RC. Pneumothorax transthoracic needle biopsy. J Thorac Imaging 1998;13:2
/6.
and dependent vs. nondependent patient position after needle
biopsy of the lung. Radiology 1999;210:59
/64.