Lung Biopsy

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Pre-Procedure Prep


• Diagnosis for indeterminate lung lesions
• Diagnosis for suspected primary bronchogenic tumor
• Diagnosis and evaluation of suspected/known metastatic disease such as molecular and genetic markers
• Evaluation of chronic infectious diseases


• No absolute contraindications
• Severe emphysema or poor lung capacity as patients may not tolerate or heal from pneumothorax
• Bleeding diathesis (Platelets < 50,000/mm³ and INR > 1.5)
• On positive pressure ventilation
• Potential hydatid cyst

Pre-Procedural Evaluation

• H&P: specifically prior bronchoscopy or failed percutaneous biopsy in past
• Understand indication: simple diagnosis vs molecular markers/genetic testing
• Core biopsy needed for molecular diagnosis
• Labs: platelets and INR
Review prior imaging:
• Review all imaging to evaluate for safest lesion to biopsy (potentially may be outside of lung)
• Location and size of lesion
• Plan approach
• Degree of underlying lung disease

Procedure Steps


• No routine prophylaxis recommended
• Exception: endocarditis prophylaxis for patients with prosthetic valves, a history of infective endocarditis, congenital heart disease repaired with foreign material, or cardiac transplant with valvulopathy
• 1 g cefazolin (Ancef) IV or 2 g amoxicillin PO/IV
• 600 mg Clindamycin IV for PCN allergy


• Typically CT guidance
• Pleural based lesions can be targeted with US
• Some lesions can be targeted with combination of fluoro and cone-beam CT


• Lidocaine only vs moderate sedation
• Consider exclusively local anesthetic with lesions near the lung bases. Breath-hold maneuvers can help target a "mobile" lesion

Core vs. Fine Needle Aspiration (FNA)

• Diagnostic yield may be increased by using both
• FNA for cytology and flow cytometry; 20-25 g needle
• Core for histology, molecular markers, genetic testing; 14-20 g biopsy device

Position Patient

• Typically based on location of lesion
• Prone has some advantages: supine recovery may facilitate pleural apposition, wider intercostal space posteriorly, posterior ribs less mobile than anterior ribs

Plan Trajectory

• Do not cross fissure (one of strongest risk factors for pneumothorax)
• Needle entry perpendicular to pleura reduces risk of pneumothorax
• Shortest distance from pleura to target reduces risk of pneumothorax
• Above considerations must be weighed with choosing a trajectory that maximizes chance lesion can be targeted effectively, particularly with small lung lesions

CT Guidance Discus

• Administer anesthetic - evaluate trajectory and potential movement of lesion
• Advance 17 or 19 g trocar to edge of pleura and re-evaluate trajectory
• Advance needle into lung and then into lesion
• Remove trocar needle and obtain FNA and/or core samples
• Administer autologous blood patch as needle is withdrawn
• Sterile dressing to site. Some operators prefer vaseline gauze

Blood Patch

• Reduces rate of pneumothorax and thoracostomy tube
• Remove 8-10 ml of patient's blood
• Use two 10 mL syringes connected to stopcock to fragment clots
• Administer blood along biopsy track as needle is withdrawn across pleural surface


Complications (with Core Biopsy)

• Pneumothorax: 25%
• Pneumothorax (PTX) necessitating intervention: 6%
• Pulmonary hemorrhage: 18%
• Hemoptysis: 4%
• Track seeding: < 1%
• Air embolism and death (rare)

Post-Procedural Care

Assuming no pneumothorax
• Bedrest at least 2 hours following biopsy
• Chest X-ray (CXR) 2 hours post biopsy
• If no PTX, ok for discharge
• If small and asymptomatic PTX, place patient on oxygen and repeat CXR in 1 hour to assess stability
• If large and/or symptomatic PTX, likely will need chest tube

Assuming small asymptomatic PTX
• Supplemental oxygen
• Place biopsy site down to improve pleural apposition
• CXR 2 hours post biopsy
• Reassess patient with and without supplemental oxygen
• If PTX stable or decreasing in size, discharge
• If PTX increasing or symptoms worsening, chest tube

Important patient be sent home with instruction on potential symptoms for delayed pneumothorax
Restricted to light activity for 24 hours

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[1] Heerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol. 2017;27(1):138‐148. doi:10.1007/s00330-016-4357-8
[2] Graffy P, Loomis SB, Pickhardt PJ, et al. Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT-Guided Needle Biopsy. J Vasc Interv Radiol. 2017;28(4):608‐613.e1. doi:10.1016/j.jvir.2016.12.1217
[3] Kim JI, Park CM, Lee SM, Goo JM. Rapid needle-out patient-rollover approach after cone beam CT-guided lung biopsy: effect on pneumothorax rate in 1,191 consecutive patients. Eur Radiol. 2015;25(7):1845‐1853. doi:10.1007/s00330-015-3601-y
[4] Malone LJ, Stanfill RM, Wang H, Fahey KM, Bertino RE. Effect of intraparenchymal blood patch on rates of pneumothorax and pneumothorax requiring chest tube placement after percutaneous lung biopsy. AJR Am J Roentgenol. 2013;200(6):1238‐1243. doi:10.2214/AJR.12.8980
[5] Winokur RS, Pua BB, Sullivan BW, Madoff DC. Percutaneous lung biopsy: technique, efficacy, and complications. Semin Intervent Radiol. 2013;30(2):121-127. doi:10.1055/s-0033-1342952
[6] O'Neill AC, McCarthy C, Ridge CA, et al. Rapid needle-out patient-rollover time after percutaneous CT-guided transthoracic biopsy of lung nodules: effect on pneumothorax rate. Radiology. 2012;262(1):314‐319. doi:10.1148/radiol.11103506
[7] Hiraki T, Mimura H, Gobara H, et al. Incidence of and risk factors for pneumothorax and chest tube placement after CT fluoroscopy-guided percutaneous lung biopsy: retrospective analysis of the procedures conducted over a 9-year period. AJR Am J Roentgenol. 2010;194(3):809‐814. doi:10.2214/AJR.09.3224

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

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