The Core Curriculum: Cardiopulmonary Imaging, 1st Edition (2004)

Chapter 22. Thoracic Interventional Techniques

Percutaneous Transthoracic Needle Biopsy

Image-guided percutaneous transthoracic needle biopsy (PTNB) of the lung is an important procedure in the diagnosis of thoracic and extrathoracic malignancies. It is also used, though less commonly, in the diagnosis of infectious and inflammatory disease. Suspected malignancies can be quickly and safely diagnosed, and sometimes staged, and appropriate therapies or surgical intervention can be planned. PTNB can also be used to evaluate potentially benign conditions. Although a benign entity such as hamartoma or infection is difficult to confirm, when it is obtained it may obviate the need for surgery. Fluoroscopically directed and ultrasound-directed procedures are fast and relatively inexpensive to perform and allow real-time imaging. Computed tomography (CT) and CT fluoroscopy have made it easier and more feasible to sample smaller and more awkwardly placed lesions with greater accuracy and efficiency.

Methods

Performing needle biopsies with biplane fluoroscopic guidance can be faster and less expensive than performing the same procedure with CT guidance. When the lesion can be visualized in two planes, a fluoroscopic procedure may be preferred because the lung and lesion can be directly visualized in real-time (Fig. 22.1). Fluoroscopy, however, should not be used when the lesion cannot be reliably demonstrated on both the frontal and lateral chest radiographs or for lesions that are in difficult locations, such as adjacent to the hilum, mediastinum, or juxtavascular. For these lesions, CT is favored (Fig. 22.2). The main disadvantages of CT are its greater cost and longer procedure times. Detection of complications, such as pneumothorax, is frequently delayed because the patient is not imaged in real-time.

In recent years, CT fluoroscopy has become available. CT fluoroscopy provides a real-time cross-sectional image, updated about six times per second. X-ray tube cooling issues often limit the imaging time to 5 seconds per application, so it is most useful for brief looks rather than continuous real-time guidance.

Figure 22.1 Multiple pulmonary nodules. Fine-needle aspiration and cytology confirmed metastatic melanoma. A. Posteroanterior and lateral chest x-ray shows numerous bilateral pulmonary nodules. B. Anteroposterior and (C) lateral fluoroscopic spot images confirm needle position in a right lower lobe nodule (arrowheads).

Ultrasound is a very useful imaging modality for guiding interventional procedures. Several advantages include its real-time imaging, lack of ionizing radiation, low cost, and portability. For patients in the intensive care unit, intubated patients, or patients otherwise unable to be safely brought to the radiology department, ultrasound may be the only alternative. Ultrasound can be used to localize fluid collections for thoracentesis for guidance during drainage tube placement or for needle biopsies of lesions adjacent to the pleura or chest wall (1) (Fig. 22.3).

Methods for performing PTNB are use of a fine-caliber needle for aspiration sampling or use of a spring-loaded cutting needle to obtain larger and more intact core samples (Fig. 22.4). Fine-needle aspiration (FNA) is typically less traumatic on the surrounding tissue and has the benefit of allowing the cytopathologist to make a rapid diagnosis. It is best to have the cytopathologist present at the procedure to determine if the specimens are adequate for diagnosis rather than requiring a repeat biopsy. This is particularly helpful when the patient is in need of immediate treatment. Cutting needle systems are helpful when a larger amount of tissue is needed for histologic diagnosis or special staining. Core samples are also more accurate in the diagnosis of benign conditions and for certain malignancies, such as lymphoma, where the relatively small amount of tissue obtained by FNA may be equivocal or nondiagnostic.

Aspirating needles obtain cells for cytology.

Core needles obtain tissue cores for histology.

Figure 22.2 Computed tomography-guided needle biopsy of a left lower lobe nodule. Note proximity of nodule to the descending thoracic aorta and left lower lobe pulmonary veins.

Figure 22.3 Prebiopsy ultrasound image demonstrating a lobulated pulmonary nodule (arrow), pleural thickening (arrowheads), and pleural effusion (asterisk).

Figure 22.4 Examples of cutting and aspiration needles. A. a. Fifteen-centimeter 20-gauge cutting needle, b. 15 cm 22-gauge spinal needle, c. 9 cm 20-gauge coaxial introducing needle. B. Close-up view of a Franseen needle (top) and a spinal needle (bottom). Notice the toothed end of the Franseen needle, designed for macerating small bits of solid tissue to permit aspiration. The spinal needle has a smooth bevel for aspirations with less trauma to the tissue.

Either method can be performed via direct puncture or coaxial technique. In the latter, a larger caliber guiding needle, typically 19 gauge for lung and 17 gauge for chest wall, is first placed to the margin of the lesion and the biopsy device is passed through the center into the lesion. This allows multiple samples with only one pleural puncture; the risk of pneumothorax increases each time the pleural surface is transgressed. Coaxial systems are often advantageous when the need for multiple biopsy samples is anticipated or when the target lesion is small or difficult to reach.

Tissue sampling with FNA, regardless of the needle type used, can be performed in essentially the same way. By placing a syringe on the needle hub, gentile suction can be applied while agitating the needle tip within the lesion. It is best to release the suction as soon as there is a flash of blood at the needle hub to prevent obscuring cytopathologic visualization of abnormal cells with excessive blood. FNA and core needle systems should be positioned along the periphery of the lesion to reduce the amount of potentially necrotic tissue in the sample (Fig. 22.5). With either FNA or cutting needles, the patient should suspend respiration during the sampling process, particularly when the device is open to the atmosphere.

Indications

There are many indications for PTNB (Table 22.1), the most common of which is the presence of an indeterminate pulmonary nodule (2,3). Even in patients with a known history of extrathoracic malignancy, the presence of pulmonary metastasis can have significant impact on treatment. Presence of a new mediastinal or hilar mass are also valid indications for PTNB. PTNB can also be used for staging of known malignancies. It is also very useful in obtaining samples for culture and sensitivity testing in suspected infections, particularly in immunocompromised patients.

Figure 22.5 Right upper lobe cavitary mass. Fine-needle aspiration with cytology revealed squamous cell carcinoma. A. Localizing image from computed tomography-guided biopsy. B. Aspiration needle in place. Note the needle is positioned along the periphery of the lesion to reduce the chance of aspirating necrotic material.

Table 22.1: Indications for Percutaneous Transthoracic Needle Aspiration Biopsy

Indeterminate pulmonary nodule
Evaluation of suspected metastases
Mediastinal mass
Hilar mass
Staging of an extrathoracic neoplasm
Culture for infection

Imaging and Site Preparation

Before performing any procedure, the patient’s laboratory studies should be reviewed. Important tests include prothrombin time, partial thromboplastin time, and platelet count (4). When necessary, conscious sedation can be administered to the patient; however, it is important to keep any sedative light enough for the patient to follow commands appropriately, particularly breath-hold instructions. Patients with persistent coughing may have some temporary relief from a cough suppressant containing codeine, to help minimize motion while the needle is in place. Patients should be monitored with continuous pulse oxymetry and periodic blood pressure and heart rate measurements. Two liters of oxygen via nasal cannula is very helpful in making patients more comfortable and may be necessary for the patient with chronic obstructive pulmonary disease who has breathing difficulties while supine. Supplemental oxygen should be given to any patient receiving sedation.

Bleeding status should be evaluated before performing percutaneous lung biopsy.

The basic technique for either direct puncture or coaxial technique is similar. Based on scout imaging, the patient is placed on the CT table in an appropriate but secure position. The patient can be positioned in almost any orientation—supine, prone, lateral decubitus, or oblique. The two most important factors in choosing a position for the patient are (a) ease of lesion access across the shortest distance with avoidance of the fissures and (b) patient comfort, so they are more likely to remain motionless. For this reason, supine and prone positions are preferred. Easy needle trajectory is not helpful if the patient cannot maintain the position for the duration of the procedure. Once a position has been chosen, radiopaque markers are placed on the skin at the expected entry site and a scout image is obtained to select the level for needle placement. Small peripheral lesions can often present a problem due to their proximity to the ribs, which may prevent a direct trajectory. Angling the CT gantry a few degrees to be in-plane with the ribs is often helpful in displaying the intercostal spaces better and can help with biopsy planning. When imaging the lesion for biopsy planning, it is often helpful to have the patient breathe quietly instead of suspending respirations. This will give a good idea of how much the lesion can be expected to move during the procedure.

Coaxial technique is preferred for lung biopsies, using one pleural puncture.

For procedures where the intercostal space must be traversed, the needle should be positioned so it remains as close to the superior surface of the adjacent rib as possible, because the neurovascular bundle runs directly below the inferior margin of each rib. Crossing the neurovascular bundle with a needle or catheter can result in significant pain and bleeding. The shortest path from skin to lesion should also be chosen. It is best to avoid crossing fissures, vessels, bronchi, and abnormal lung parenchyma, such as emphysema and bullae. Ideally, crossing as little aerated lung as possible is preferred (5) (Figs. 22.6 and 22.7).

After a proper entry site is selected, the site is cleaned and prepped with sterile technique, taking care to disinfect the entry site and surrounding region. A sterile operative field should be maintained at all times, and surgical-site drapes and covers should be used. Shaving any hair from the entry site is also recommended to maintain a clean skin surface. Local anesthesia can be achieved by using 1% to 2% lidocaine solution injected subcutaneously and then deeper into the soft tissues as needed.

Using periodic imaging either via axial CT images or real-time CT fluoroscopy, the biopsy device or introducing needle is carefully inserted through the chest wall to the margin of the target lesion. Ideally, the pleura should be crossed only once, because potential risk of pneumothorax increases with each pleura transgression. Ideally, the needle should be first positioned in the chest wall to establish the correct trajectory before any pleural punctures. When the chest wall is thin, the lidocaine needle can be used to assist with establishing the trajectory. The patient should be instructed to suspend respiration while crossing the pleura with the needle and to breathe quietly after the needle is across. This will help to prevent a large pleural puncture site and reduce the risk of pneumothorax. While the needle is within the lung or pleural space, the hub should remain closed to the atmosphere while the patient is breathing to limit the amount of air entering the thorax.

Figure 22.6 Solitary lung and brain masses in a 42-year-old man presenting with headache and nausea. Computed tomography image of the chest (A) and head (B) demonstrated a solitary right upper lobe mass and a solitary mass in the right cerebral hemisphere. C.Needle aspiration of the lung mass revealed bronchogenic adenocarcinoma. The chosen needle course passes through the smallest amount of aerated lung possible.

Technical Factors

Typically, three good core or FNA specimens are sufficient to make a diagnosis of malignancy, though more may be necessary if cultures or special pathologic stains are requested. In one study of 38 malignant lesions aspirated with a 25/22 gauge coaxial FNA system, 85% of the lesions were positive for malignancy with one, two, or three passes (6). Only 15% of lesions required up to six needle passes; 69% were positive with a single aspirate alone. When performing FNA, it is helpful to have cytopathology standing by to examine the specimens as they are obtained. This reduces the possibility of a nondiagnostic biopsy and gives an opportunity to obtain additional material if necessary. In a series of 896 malignant lesions, an 87% positive diagnostic rate after one procedure was shown, which rose to 96% after a second PTNB procedure in 75 patients (7). For patients in whom PTNB is indicated, particularly nonsurgical candidates, a second biopsy procedure should be considered if malignancy is suspected, rather than a more invasive open thoracotomy or thoracoscopic procedure.

In general, three tissue samples are sufficient for diagnosis.

Figure 22.7 Multiple pulmonary nodules. A and B. Computed tomography images demonstrate multiple bilateral pulmonary nodules. C.Cutting needle biopsy of the largest nodule. Note the biopsy needle crosses through no aerated lung. Tissue cores demonstrated cryptogenic organizing pneumonia. D and E. After 6 weeks of corticosteroid therapy, the nodules nearly completely resolved.

Figure 22.8 Infiltrating mediastinal mass in a 19 year-old man, 13 years after heart transplant. Histology revealed pericardial lymphoma. A. Localizing image through the main pulmonary artery from a contrast-enhanced computed tomography. B. Cutting needle biopsy of the mediastinal mass. Note the inability to visualize the aorta and pulmonary artery on the noncontrast images. The contrast-enhanced computed tomography was required to map the vital structures at the time of biopsy.

PTNB of the chest wall, pleura, and mediastinum are performed in essentially the same manner as biopsies of the lung. Selecting a trajectory that avoids aerated lung reduces or eliminates the risk of pneumothorax (5). Percutaneous biopsy of pleural lesions has been shown to be quite effective (8), and in sampling a pleural lesion or a segment of pleural thickening, choosing a trajectory that passes tangentially to the pleura and lung is preferred. Additionally, careful contrast-enhanced CT may be necessary before the procedure to map locations of vital structures and vessels, which may not otherwise be adequately seen on noncontrast imaging (Fig. 22.8).

Contraindications

Virtually all contraindications to PTNB are relative (Table 22.2). Coagulopathies should be corrected before the procedure. Aspirin, Coumadin, and other oral anticoagulant therapies should be discontinued for at least 5 days before the procedure. Heparin can be discontinued about 6 hours before the procedure. If necessary, platelet or fresh frozen plasma transfusions should be timed to be completed just before beginning the biopsy. For patients with severe emphysema, careful risk versus benefit discussions with both patient and consulting physician is suggested, because these patients can have significant respiratory problems if they develop a pneumothorax and require a chest tube. Patients with contralateral pneumonectomy also face similar issues (Fig. 22.9). When a biopsy in a postpneumonectomy patient becomes necessary, it should only be attempted with appropriate medical personnel present in case it becomes necessary to emergently intubate the patient or place a large-caliber chest tube. In patients with pulmonary hypertension, deep lesions should be avoided due to risk of injury to the central pulmonary arteries and excessive bleeding. Biopsy of suspected malignant thymoma should be discussed with the thoracic surgeons before proceeding, because it is often desirable to have an intact capsule before surgery and prevent converting a noninvasive thymoma into an invasive one. Potential pulmonary arteriovenous malformations should not be biopsied, because it can lead to severe bleeding and potential air embolism.

Table 22.2: Relative Contraindications to Percutaneous Transthoracic Needle Biopsy

Coagulopathies
Emphysema
Contralateral pneumonectomy
Pulmonary hypertension
Intractable cough
Uncooperative patient

A contrast-enhanced CT should be performed before biopsy of mediastinal masses to evaluate vascular anatomy.

A good contrast-enhanced CT and evaluation for feeding arteries or draining veins are important when planning a biopsy. Patients with intractable cough may make safe biopsy difficult due to repetitive motion with the needle in place. A patient who cannot maintain a stable position may be the only absolute contraindication.

For lung nodules, a contrast-enhanced CT should be taken to evaluate for possible arteriovenous malformation before biopsy.

Postbiopsy Management

Most postbiopsy pneumothoraces usually develop within the first hour after the procedure (9), therefore, imaging the patient with an upright chest radiograph is suggested at 1 and 3 hours after the procedure. Patients are monitored in a postprocedure recovery area for 4 hours after the procedure. Small pneumothoraces shown to be stable over several radiographs in asymptomatic patients usually resolve spontaneously, and outpatients may be discharged with detailed instructions about signs and symptoms of pneumothorax and contact information in the event of symptoms, as well as activity instructions for the next few days. Positioning the patient with the biopsy site dependent and supplying nasal cannula oxygen can help speed resolution of a small pneumothorax. Development of a large or symptomatic pneumothorax may necessitate the placement of a chest tube or direct aspiration of air.

Figure 22.9 New right upper lobe mass (asterisk) in a 68-year-old man, status post–left pneumonectomy for lung carcinoma. The chosen trajectory passes obliquely through the mediastinum, into the lesion, without passing into any aerated right lung.

Complications and Treatment

PTNB is a safe procedure, and most complications are minor and self-limited. There are, however, dangerous and potentially life-threatening complications that can arise (Table 22.3). Prompt identification and treatment can prevent significant morbidity and mortality.

Pneumothorax

The risk of pneumothorax increases with each successive puncture of the pleura or a pleural fissure. A small asymptomatic pneumothorax often requires only observation, whereas large or symptomatic pneumothoraces may require evacuation. Several different treatment techniques are available, including needle aspiration, small caliber chest tube with a Heimlich valve (10), or the Tru-Close Thoracic Vent system (11) (Figs. 22.10 and 22.11) and larger surgical caliber chest tubes with continuous suction for a very large pneumothorax or a pneumothorax with a persistent air leak. A technique advocated by some to reduce the risk of pneumothorax during the procedure is to use about 10 mL of the patient’s partially clotted blood to seal the needle tract. This “blood patch” technique has been shown by some to demonstrate no significant reduction in the pneumothorax rate (12,13), whereas other investigation of the blood patch technique in resected equine lungs suggested that the technique warrants further clinical evaluation (14). However, these results may not hold in living humans in which respiratory motion may be a confounding element.

Pneumothorax is the most common complication of lung biopsy, occurring in 10% to 60% of cases; it is more common with CT-guided procedures than fluoroscopy.

Pneumothorax risk also increases with the severity of obstructive lung disease (Fig. 22.12), as demonstrated in several publications based on evaluation of chest radiographs both with and without spirometry (15,16,17,18). One study demonstrated a 52.5% pneumothorax rate for patients with severe obstructive disease as evidenced by spirometry, compared with 20.6% for patients with mild obstructive deficits (18). The chest tube rate was also higher, 22.5% in patients with severe obstructive disease and 2.9% in patients with mild disease. Arterial oxygenation also correlated with the incidence of pneumothorax. With arterial partial pressure of oxygen less than 50 mm Hg, the pneumothorax rate was 80%, as compared with a 0% rate with partial pressure of oxygen more than 80 mm Hg. Another study demonstrated a 46% pneumothorax rate when both chest radiograph and pulmonary function tests were consistent with emphysema (16). This study had a 19% chest tube rate. Compared with a 7% pneumothorax rate and 0% chest tube rate for patients with no chest radiograph or spirometric evidence of obstructive lung disease.

Once a pneumothorax develops, administering 2 to 3 L O2 by nasal cannula will help speed resorption. In patients with severe emphysema, it may be better to perform a thoracoscopic resection or follow a lesion radiographically before attempting PTNB, because these patients can have significant morbidity and need for long-term drainage for persistent pneumothorax (19).

Table 22.3: Complications of Percutaneous Transthoracic Needle Biopsy

Pneumothorax
Bleeding
Air embolism
Infection or empyema
Bronchopleural fistula
Lung torsion
Pericardial tamponade
Death

Figure 22.10 Tru-Close thoracic vent system and insertion trocar. The catheter is 14 French in diameter and has multiple side holes. A one-way Heimlich valve allows air to escape with the patient’s respiratory motion, evacuating the pneumothorax. Adhesive wings holds the device onto the patient’s chest.

Figure 22.11 Pneumothorax complicating needle biopsy of a right upper lobe nodule (asterisk). A. Moderate-sized symptomatic pneumothorax (arrowheads) developed at the end of the procedure. B. Posterolateral and (C) lateral radiograph taken 10 minutes after Tru-Close thoracic vent placement. The pneumothorax has nearly completely resozlved. The tube was removed 5 hours later.

Figure 22.12 Seven-millimeter spiculated nodule in male with severe emphysema. A. Computed tomography-guided biopsy of RLL lobe lesion (arrow). B. Pneumothorax (asterisks) after the first aspiration.

 

Bleeding

Pulmonary parenchymal hemorrhage can occur at the biopsy site, particularly when the lesion is small or when multiple needle passes are necessary. Although a small amount of hemorrhage is usually asymptomatic for the patient, it can result in obscuration of the lesion, making additional samples difficult (Fig. 22.13). Some patients experience a small amount of self-limited hemoptysis. Patients should be coached before the procedure that this may happen to decrease anxiety if it occurs. Heavy hemoptysis during or after the biopsy, however, should be investigated, usually with CT angiography or catheter-directed angiography. Intercostal or internal mammary artery bleeding into pleural space (hemothorax) can be difficult to control percutaneously, can be life threatening, and requires surgical control (20). Massive life-threatening hemoptysis can occur with either bronchoarterial or bronchovenous fistula formation, especially when large-caliber or cutting needle devices are used, and may also require angiography. Excessive superficial bleeding can be treated with direct pressure but is uncommon during needle biopsy.

Patients should be warned before lung biopsy that they may experience hemoptysis, because this can be a source of considerable patient anxiety if unexpected.

Air Embolism

Air embolism is a very rare complication that can occur when there is communication between a pulmonary vein and the atmosphere via the biopsy device or after formation of a bronchovenous fistula. Air embolism should be suspected if new neurologic symptoms or chest pain occur acutely during the procedure, which can lead to stroke, seizure, myocardial infarction, and death. To prevent further embolism, particularly to the central nervous system, the patient should be immediately placed in the left lateral decubitus position to prevent air from escaping the left atrium. Administering 100% O2 by face mask may help speed resorption. Large emboli may require hyperbaric chamber treatment.

Although air embolism is rare, it should be suspected if neurologic or cardiovascular symptoms develop during a lung biopsy.

If air embolism is suspected, place the patient in the left lateral decubitus position and administer 100% oxygen by face mask.

Other Complications

Empyema is uncommon but may occur if infected material escapes into the pleural space. Rarer complications include tumor seeding along the needle tract (21), bronchopleural fistula formation, pericardial tamponade, lung torsion (22), and death. Of 28 cases of death related to PTNB in the literature, most were performed with large 16- to 18-gauge cutting needles. This includes 18 cases of pulmonary hemorrhage (1 severe pulmonary hypertension, 1 oversedated), 2 cases of tension pneumothorax, 5 cases of air embolism (3 proven; 1 performed with a 22-gauge needle on an intubated patient with acute respiratory distress syndrome), and 3 cases where deaths were temporally related to the procedure but without an identified reason (23,24).

Figure 22.13 Computed tomography-guided biopsy of a right upper lobe nodule in a 61-year-old smoker. A. Localizing image from biopsy planning computed tomography. Lobulated lesion (asterisk) in the right upper lobe. B. Needle aspiration of the right upper lobe nodule. C. New alveolar opacity surrounding the nodule represents focal pulmonary hemorrhage. Note, the original lesion is significantly obscured.

Percutaneous Drainage Procedures

The radiologist is often called upon to help manage a large or loculated pleural effusion, empyema, or intrapulmonary abscess. Drainage procedures may be performed for either diagnostic or therapeutic purposes, and catheters can be placed to gravity drainage or continuous suction. Preintervention imaging is important to determine accessibility and to anticipate any potential complications. Essentially, any fluid collection in the chest wall, pleural space, lung, or mediastinum can be managed by a percutaneous image-guided drainage or aspiration as long as a safe and viable path to the fluid collection can be found (25).

Methods

For CT-guided procedures, positioning the patient and prepping the entry site is typically done in the same manner as with needle biopsy. For diagnostic pleural fluid sampling, a long large-caliber angiocatheter may be all that is required. The angiocatheter can be placed into the fluid collection and the stylet removed. This will leave the softer and more flexible plastic sheath within the fluid. Tubing and a syringe are attached to the sheath, and fluid can be aspirated. Use of a soft sheath rather than leaving a sharp needle in place can reduce chances of further trauma to lung parenchyma or pleura should the fluid collection be drained completely.

When it is necessary to place a catheter for drainage, a multipurpose pigtail drainage catheter placed over a trocar is often the simplest device to insert (Fig. 22.14). These are usually available in sizes ranging from 8 to 16 French. It may be necessary to use serial dilatations over a short guidewire, however, when placing larger size drainage catheters, particularly in larger or muscular patients; the intercostal muscles can frequently impede direct placement of a larger size catheter. Once in place, the pigtail should be locked and the catheter affixed to the skin either with suture or an adhesive. Flushing the catheter with 5 to 10 mL of sterile heparinized saline two times daily can help reduce catheter clogging. Presence of pus or other infected material within a fluid collection may necessitate placement of a larger catheter for adequate drainage. This is often achievable by exchanging the catheter over a guidewire.

Superficial fluid collections may be amenable to ultrasound-guided procedures (26) (Fig. 22.15). The fluid collection can be marked and its depth determined. This can be done at a patient’s bedside rather than transporting the patient to the radiology department. Ultrasound-guided procedures can be performed relatively quickly and often allow better characterization of fluid and potential septations than CT. However, conventional chest radiography is usually necessary because pneumothorax may be difficult to detect on ultrasound.

Figure 22.14 Pigtail catheter drainage of a mediastinal fluid collection. Drainage catheter placed with computed tomography guidance into infected fluid surrounding a descending aortic graft.

Figure 22.15 Ultrasound image demonstrating a pigtail catheter (arrows) within a pleural effusion (asterisk).

Loculated or fibrinous fluid collections are usually not amenable to a simple aspiration and drainage procedure. Often, they can be broken up by instilling 80,000 to 250,000 units of streptokinase (27,28,29,30) and leaving it in place for several hours before attempting drainage. The systemic effect of intracavitary thrombolytics is negligible (31). An alternate method is to use a C-shaped guidewire and torque it through the fluid collection for several minutes to break up any adhesions or thin septations before attempting further aspiration.

Consider streptokinase injection into loculated fluid collections to break down adhesions.

Complications of drainage procedures are similar to the risks of PTNB. Pneumothorax risk can be minimized by using stopcocks on tubing to keep the pleural space sealed from the atmosphere.

Localization for Thoracoscopic Resection

There may be time where it is desirable to have a lesion completely excised without first obtaining histology. The use of video-assisted thoracoscopic surgery (VATS) has helped reduce the need for open thoracotomy in many cases (32). VATS allows visualization of nearly the entire hemithorax and the superficial surface of the lung (33,34). VATS is performed under general anesthesia, and the patient is intubated with a double-lumen endotracheal tube to allow ventilation of one lung and controlled deflation of the other. A fiberoptic video camera and other instrumentation are inserted via one or more intercostal spaces. Subpleural nodules are found at VATS when the lung is collapsed by physical deformation of the lung contour. Unfortunately, nodules deep to the pleural surface or very small nodules show no such contour deformities. In these cases, wire or dye localization can be performed before VATS to assist the surgeon in finding the lesion for resection (34). The radiologist can percutaneously anchor a wire in the lesion, place a small metallic coil at the lesion site (35), or stain the area of the lesion percutaneously with methylene blue dye (36). The blue stain or coil will be visible at the time of VATS and allows the surgeon to perform an appropriate wedge resection (Fig. 22.16). The main disadvantages of VATS are its need for general anesthesia and inability to be used in the presence of significant pleura adhesions. VATS also cannot be used in patients who will not tolerate single-lung ventilation (37).

Figure 22.16 Methylene blue dye localization before video-assisted thoracoscopy. A. Localizing computed tomography image shows a 5 mm right lower lobe nodule (arrowhead)B. After dye injection, the dye is seen as ground glass opacity (asterisk) adjacent to the nodule (arrowhead)C. Image obtained during video-assisted thoracoscopic surgery. The blue stain (arrows) in the center of the image is the methylene blue dye used to mark the nodule. D. Wedge resection in progress. The blue dye and surrounding tissues are removed.

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