Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations.

Deep-seated head and neck lesions, which traditionally were evaluated by surgical means, are now accessible with less invasive computed tomography-guided percutaneous needle biopsy techniques. Major vessels, the trachea, and osseous structures like the maxilla, mandible, and vertebrae often preclude direct access to these lesions. It is important to understand the anatomy relevant to safe access route planning and the techniques, advantages, and limitations associated with various approaches used for percutaneous biopsy of head and neck lesions. For biopsy of suprahyoid head and neck lesions, including those of the skull base and upper cervical vertebrae, various approaches such as the subzygomatic, retromandibular, paramaxillary, submastoid, transoral, and posterior approaches can be used. Lesions in the infrahyoid portion of the neck and lower cervical vertebrae can be accessed with the anterolateral approach (between the airways and the carotid sheath), posterolateral approach (posterior to the carotid sheath), and direct posterior approach. The location and extent of the lesions and their relationship to adjacent structures influence the choice of the trajectory to use. Careful planning of the procedure and considerable familiarity with head and neck anatomy are necessary for a biopsy that is both precise and safe.

Imaging-guided percutaneous biopsy of mediastinal lesions: different approaches and anatomic considerations.

Percutaneous needle biopsy with imaging guidance allows access to lesions in virtually all mediastinal locations. A direct mediastinal approach, which enables extrapleural needle placement, is the preferred method to avoid the risk of pneumothorax. Techniques that allow extrapleural access include the parasternal, paravertebral, transsternal, and suprasternal approaches, which are performed with computed tomographic or ultrasonographic guidance. The parasternal approach is used for biopsy of anterior or middle mediastinal lesions when the lesion or intervening mediastinal fat extends to the anterior chest wall, lateral to the sternum; injury to the internal mammary vessels is a potential complication. The paravertebral approach is used for biopsy of subcarinal and other posterior mediastinal lesions; saline solution is often injected to widen the mediastinum. The transsternal approach, which involves needle placement through the sternum, is used for biopsy of anterior or middle mediastinal lesions that are not accessible with the parasternal approach. Biopsy of superior mediastinal lesions can be performed with a suprasternal approach. An alternative to these direct mediastinal approaches involves advancing the needle through a pleural space created by an existing pleural effusion or iatrogenic pneumothorax. Another alternative is the transpulmonary approach, which involves transgression of the lung and visceral pleura by the needle and is associated with a substantial risk of pneumothorax.

New suction guide needle designed to reduce the incidence of biopsy-related pneumothorax: experimental evaluation in canine model.

In an attempt to remove air that enters the pleural space during computed tomography (CT)-guided coaxial transthoracic needle biopsy, the authors fashioned an 18-gauge experimental suction guide needle and evaluated the incidence of pneumothorax with this needle in comparison to the incidence of pneumothorax with a standard 18-gauge guide needle in a canine model. This experiment had animal care and use committee approval. Ten dogs underwent a biopsy of each lung, for a total of 20 lung biopsies. Half of the biopsies were performed by using the experimental needle (five right lungs, five left lungs), and half were performed by using a standard guide needle. CT revealed pneumothorax during the procedure and was performed to reveal pneumothorax 1 and 3 hours after the procedure. A significant reduction (P < .016) in intraprocedural lung biopsy-associated pneumothorax was found when the experimental guide needle was used.

Transhepatic ipsilateral right portal vein embolization extended to segment IV: improving hypertrophy and resection outcomes with spherical particles and coils.

PURPOSE: To analyze outcomes after right portal vein embolization extended to segment IV (right PVE + IV) before extended right hepatectomy, including liver hypertrophy, resection rates, and complications after embolization and resection, and to assess differences in outcomes with two different particulate embolic agents. MATERIALS AND METHODS: Between 1998 and 2004, transhepatic ipsilateral right PVE + IV with particles and coils was performed in 44 patients with malignant hepatobiliary disease, including metastases (n = 24), biliary cancer (n = 14), and hepatocellular carcinoma (n = 6). Right PVE + IV was considered if the future liver remnant (FLR; segments II/III with or without I) was less than 25% of the total estimated liver volume (TELV). Tris-acryl microspheres (100-700 microm; n = 21) or polyvinyl alcohol (PVA) particles (355-1,000 microm; n = 23) were administered in a stepwise fashion. Smaller particles were used to occlude distal branches, followed by larger particles to occlude proximal branches until near-complete stasis. Coils were then placed in secondary portal branches. Computed tomographic volumetry was performed before and 3-4 weeks after right PVE + IV to assess FLR hypertrophy. Liver volumes and postembolization and postoperative outcomes were measured. RESULTS: After right PVE + IV with PVA particles, FLR volume increased 45.5% +/- 40.9% and FLR/TELV ratio increased 6.9% +/- 5.6%. After right PVE + IV with tris-acryl microspheres, FLR volume increased 69.0% +/- 30.7% and FLR/TELV ratio increased 9.7% +/- 3.3%. Differences in FLR volume (P = .0011), FLR/TELV ratio (P = .027), and resection rates (P = .02) were statistically significant. Seventy-one percent of patients underwent extended right hepatectomy (86% after receiving tris-acryl microspheres, 57% after receiving PVA). Thirteen patients (29%) did not undergo resection (extrahepatic spread [n = 9], inadequate hypertrophy [n = 3], other reasons [n = 1]). No patient developed postembolization syndrome or progressive liver insufficiency after embolization or resection. One death after resection occurred as a result of sepsis and hemorrhage. Median hospital stays were 1 day after right PVE + IV and 7 days after resection. CONCLUSION: Transhepatic ipsilateral right PVE + IV with use of particles and coils is a safe, effective method for inducing contralateral hypertrophy before extended right hepatectomy. Embolization with small spherical particles provides improved hypertrophy and resection rates compared with larger, nonspherical particles.

Small (

PURPOSE: To retrospectively compare the diagnostic yield and complications associated with the use of short versus long needle paths for computed tomography (CT)-guided biopsy of small subpleural lung lesions. MATERIALS AND METHODS: The study was approved by the institutional review board, and the requirement for informed patient consent was waived. The medical and imaging records of patients who underwent CT-guided biopsy of subpleural pulmonary nodules measuring up to 2 cm in diameter were reviewed. The study included 176 patients (79 men, 97 women; age range, 18-84 years) who were divided into two groups: In group A, a direct approach in which the needle traversed a short lung segment was used. In group B, an indirect approach involving the use of a longer needle path was used. Diagnostic yield, accuracy, and pneumothorax and chest tube placement rates were compared between the two groups. Two-tailed t tests and Pearson chi(2) tests were used to analyze continuous and categorized variables, respectively. RESULTS: Group A comprised 48 patients; and group B, 128 patients. The mean needle path length was 0.4 cm in group A and 5.6 cm in group B. The short-path approach necessitated more needle punctures (mean, 2.9 vs 1.8 with long-path approach, P < .001) through the pleura. The diagnostic yield in group A was significantly lower than that in group B (71% vs 94%, P < .001), particularly in patients with small (0-1-cm) nodules (40% in group A vs 94% in group B, P < .001). The frequency of postbiopsy pneumothorax was identical (69%) in the two groups. However, more group B than group A patients required chest tube placement for treatment of pneumothorax (38% vs 17%, P = .006). CONCLUSION: Use of long-needle-path biopsy of subpleural lesions resulted in a higher diagnostic yield, especially for small nodules. However, compared with the short-needle-path technique, this approach was associated with a higher frequency of chest tube placement for pneumothorax.

Percutaneous ultrasound-guided biopsy in the definitive diagnosis of osteosarcoma.

Thirty-three patients with 35 bone lesions suspicious for osteosarcoma underwent image-guided biopsy. Of those 35 biopsies, 12 were performed with use of fluoroscopy or computed tomography (CT) guidance to target the osseous abnormality. Diagnostic magnetic resonance imaging revealed a soft tissue component in 23 cases; in these cases, biopsies were performed with use of ultrasonography (US) to target the soft tissue component of the tumor. Of the 35 tumors in which biopsy was performed, 33 (94%) were definitively diagnosed as osteosarcoma by image-guided biopsy. All 23 US-guided biopsies resulted in definitive diagnosis. Two of the 12 fluoroscopy- or CT-guided biopsies (17%) were inconclusive.

Fistulas of the lower urinary tract: percutaneous approaches for the management of a difficult clinical entity.

Fistulas of the lower urinary tract are uncommon conditions that may occur spontaneously or after therapy in patients with various pelvic abnormalities. When present, these fistulas are associated with urine leakage, which is often socially distressing and disabling. Unfortunately, factors that lead to the formation of genitourinary fistulas often increase their complexity or preclude surgical repair. A high failure rate is associated with surgical repair, and many patients are not optimal surgical candidates. For such patients, a percutaneous treatment approach is highly desirable. Percutaneous ureteral occlusion combined with insertion of a functioning nephrostomy tube allows complete diversion of urine in those patients in whom nephrostomy alone does not provide adequate relief. Many approaches to percutaneous ureteral occlusion have been used with variable success, including coils and gelatin sponge, isobutyl-2-cyanoacrylate, detachable balloons, radiofrequency electrocautery, ureteral clipping, and solid and soft polymer agents. Furthermore, percutaneous or retrograde ureteral stents may be used to preserve antegrade urine flow, and surgical options are also available. It is essential that the interventional radiologist involved in the care of these patients be familiar with these different techniques as well as with the limitations, pitfalls, and possible complications of their use.

Use of inferior vena caval filters and survival in patients with malignancy.

BACKGROUND: Inferior vena cava (IVC) filters have proven to be a viable alternative to anticoagulation therapy for the prevention of life-threatening pulmonary emboli (PE) for patients who have contraindications to anticoagulation therapy. The clinical benefit of placing IVC filters in patients with advanced-stage cancer is controversial. The current study reported the authors' experience with IVC filters in patients with cancer. METHODS: Between January 2000 and May 2003, IVC filters were placed in 308 patients with venous thromboembolic (VTE) disease. Of these patients, 267 had solid tumors and 41 had liquid tumors. Outcome was reviewed retrospectively with regards to patient survival as well as procedural and filter-related complications. Patients with solid and liquid tumors were used to generate Kaplan-Meier estimates for survival and the probability of surviving 30, 90, and 365 days was also calculated. The prognostic effect of age, primary malignancy, gender, extent of disease, indication, admission to the intensive care unit, and IVC thrombus on overall survival was also evaluated using univariate and multivariate Cox models for patients with solid tumors. RESULTS: The median survival periods for patients with solid and liquid tumors were 145 days and 207 days, respectively. The probability of survival at 30, 90, and 365 days was 0.81, 0.60, and 0.35, respectively, for patients with solid tumors and 0.85, 0.67, and 0.48, respectively, for patients with liquid tumors. There was no statistically significant difference in survival based on primary malignancy for solid tumors (P = 0.628) or between solid and liquid tumors (P = 0.16). For patients with solid tumors, a statistically significant difference in survival was found by extent of disease (P = 0.002). Patients with solid tumors classified as local disease (n = 15), locally advanced disease (n = 95), and widely metastatic or disseminated disease (n = 153) had a probability of survival at 30 days of 0.93, 0.87, and 0.76, respectively. Compared with patients with local disease, patients with metastatic or disseminated disease were 3.7 times more likely to die (P = 0.013). Patients with a history of deep venous thrombosis (DVT) and hemorrhage were 2 times more likely to die than patients with DVT and no history of hemorrhage (P = 0.0057). Documented complications occurred in 22 of 308 (7.1%) patients and included PE (n = 4), new caval thrombosis (n = 14), retroperitoneal hemorrhage (n = 2), and maldeployed filters (n = 2). CONCLUSIONS: IVC filters were shown to be safe and highly effective in preventing PE-related deaths in patients with cancer with VTE disease. Patients with a history of DVT and bleeding or metastatic/disseminated stage of disease had the lowest survival after IVC filter placement.

Various approaches for CT-guided percutaneous biopsy of deep pelvic lesions: anatomic and technical considerations.

Access route planning for computed tomography-guided biopsy of deep pelvic masses remains challenging because vital structures often obstruct the projected needle path. The classical approach through the lower anterior abdominal wall allows access to lesions located anterior, superior, or lateral to the urinary bladder. However, this approach has limitations: Deep masses are difficult to reach because of intervening structures, the bowel or bladder may be unavoidably traversed, and peritoneal transgression is often painful. A transgluteal approach is useful for biopsy of presacral and perirectal lesions and lesions located posterolateral to the bladder. An anterolateral approach through the iliopsoas muscle allows safe extraperitoneal access to external and internal iliac nodes, masses located along the lateral pelvic sidewall, and adnexal lesions. A transosseous (transsacral or transiliac) approach can occasionally be used for otherwise inaccessible lesions. Use of a curved needle, change in patient position, or injection of saline solution to displace intervening structures may also be helpful. Familiarity with normal cross-sectional pelvic anatomy facilitates planning of a safe access route and helps avoid injury to adjacent structures. A thorough understanding of the advantages and disadvantages of each approach allows the clinician to choose the most appropriate approach in a given situation.

Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: the M.D. Anderson experience.

BACKGROUND: Carcinoid tumors have a predilection for metastasizing to the liver. The presence of liver metastases is associated with poor prognosis and also results in significant deterioration of patient's quality of life. Several reports suggest that hepatic artery embolization or chemoembolization can be used for control of liver disease in these patients. We retrospectively reviewed our experience with the use of hepatic arterial embolization or chemoembolization in patients with liver-dominant metastatic carcinoid disease, evaluating the clinical and radiologic response rates, duration of response, and progression-free and overall survival rates of these patients. MATERIALS AND METHODS: The medical records of all patients with carcinoid tumors metastatic to the liver who underwent hepatic artery embolization or chemoembolization between January 1992 and December 2000 were reviewed. For the purposes of this study, we compared the follow-up computed tomography or magnetic resonance imaging with the baseline imaging to determine each patient's objective tumor response. The interval between the dates of response and disease progression was considered the response duration. Progression-free survival duration was calculated from the date of initial treatment to the date disease progression was recorded or the date of death. Survival durations were calculated using the Kaplan-Meier method. RESULTS: Eighty-one patients (48 men and 33 women; age range, 38-79 years) were included in this study. The mean duration of disease from the initial discovery of liver metastases until embolization was 24.5 months. Fifty patients were treated with bland hepatic artery embolization, and 31 underwent chemoembolization. Of the 69 patients in whom radiologic response could be evaluated, partial response was observed in 46 patients (67%), minimal response (MR) in six (8.7%), stable disease in 11 (16%), and progressive disease in six (8.7%). The median duration of response in the 42 patients with partial response was 17 months (range, 4-51 months). Sixty-three percent of patients had a reduction in their tumor-related symptoms. The median progression-free survival duration was 19 months (95% confidence interval, 17-21 months); the probability of progression-free survival was 75%, 35%, and 11% at 1, 2, and 3 years, respectively. The median overall survival time was 31 months (95% confidence interval, 23-38 months); the survival probability was 93% at 1 year, 62% at 2 years, and 24% at 5 years. CONCLUSIONS: Hepatic arterial occlusive therapy using hepatic artery embolization or chemoembolization results in symptomatic and radiologic response in most patients with carcinoid metastases in the liver. The progression-free survival of 19 months achieved with embolization in our study is encouraging, given that most patients had extensive liver involvement and had shown disease progression while receiving systemic treatment.

Percutaneous radiofrequency ablation of lung tumors in a large animal model.

PURPOSE: Percutaneous radiofrequency ablation (RFA) is accepted therapy for liver tumors in the appropriate clinical setting, but its use in lung neoplasms remains investigational. We undertook this study to evaluate the feasibility and immediate effectiveness of RFA for treatment of both solitary pulmonary nodules and clusters of lung tumors in a large animal model. MATERIALS AND METHODS: Percutaneous RFA of 14 lung tumors in five dogs was performed under CT guidance. Animals were euthanatized 8-48 hours after the procedure. The lungs and adjacent structures were harvested for gross and histopathologic evaluation. RESULTS: Five solitary pulmonary nodules (range, 17-26 mm) and three clusters of three nodules each (range, 7-17 mm per nodule) were treated with RFA. All ablations were technically successful. Perilesional ground-glass opacity and small asymptomatic pneumothoraces (n = 4) were visualized during the RFA sessions. One dog developed a large pneumothorax treated with tube thoracostomy but was euthanatized 8 hours post-RFA for persistent pneumothorax and continued breathing difficulty. Follow-up CT 48 hours post-RFA revealed opacification of the whole lung segment. Gross and histopathologic evaluation showed complete thermal coagulation necrosis of all treated lesions without evidence of any viable tumor. The region of thermal coagulation necrosis typically extended to the lung surface. Small regions of pulmonary hemorrhage and congestion often surrounded the areas of coagulation necrosis. CONCLUSIONS: RFA can be used to treat both solitary pulmonary nodules and clusters of tumor nodules in the canine lung tumor model. This model may be useful for development of specific RFA protocols for human lung tumors.

Transjugular liver biopsy in patients with hematologic malignancy and severe thrombocytopenia.

PURPOSE: The purposes of this study are to report experience with transjugular liver biopsy (TJLB) in patients with hematologic malignancy and severe thrombocytopenia and to determine the incidence of hemorrhage-related complications in patients with prebiopsy and pretransfusion platelet counts of 30 x 10(9) /L or lower to propose a threshold platelet count above which TJLB can be safely performed without transfusion. MATERIALS AND METHODS: Medical records and laboratory reports of 50 patients with severe thrombocytopenia who had undergone 51 TJLB procedures and prebiopsy platelet transfusions between August 1999 and September 2001 were retrospectively reviewed. Biopsy success and procedural complications were recorded. RESULTS: TJLB was technically successful in 49 of 51 procedures (96%). The mean prebiopsy, pretransfusion platelet count was 17 x 10(9)/L (range, 3-30 x 10(9)/L) and a mean of 11 U (range, 6-32 U) of platelets per patient were transfused. The overall mean postbiopsy platelet count was 38 x 10(9)/L (range, 5-105 x 10(9)/L), but it remained 30 x 10(9)/L or lower in 24 TJLB procedures. No hemorrhage-related complications were encountered, but ventricular fibrillation occurred in one patient during the procedure. CONCLUSION: A threshold platelet count for safe TJLB resides below 30 x 10(9)/L. A prospective study is necessary to better define a lower threshold above which TJLB can be performed without platelet transfusion.

CT-guided needle biopsy of deep pelvic lesions by extraperitoneal approach through iliopsoas muscle.

We report our experience with computed tomography (CT)-guided coaxial needle biopsy of deep pelvic lesions by an extraperitoneal approach through the iliopsoas muscle, using a curved needle for difficult-to-reach lesions. We reviewed the records of all patients with pelvic masses who underwent CT-guided percutaneous biopsy via iliopsoas muscle between January 1999 and December 2001. Direct anterior or posterior approach to the lesion was obstructed by bowel, bladder, vessels, or bones in all patients. An 18-gauge guide needle was advanced through the iliopsoas muscle and a 22-gauge Chiba needle was used to perform the biopsy. A custom-tailored curved 22-g needle was used in 17 procedures when the location of the iliac vessels and the slope of the iliac wing obstructed a straight path to the lesion. Fifty-three patients underwent 57 CT-guided needle biopsies during the study period. The lesions comprised obturator (n = 25), internal iliac (n = 11), anterior external iliac (n = 4), and common iliac nodes (n = 4); soft tissue masses along pelvic side-wall (n = 6); adnexal lesions (n = 5); a loculated fluid collection, and a perirectal node. All lesions were safely accessed, and major vessels and viscera were avoided in all cases. Of the 57 biopsies, 53 (93%) yielded diagnostic specimens. No major complications were encountered. CT-guided coaxial needle biopsy by an anterolateral approach through the iliopsoas muscle, with the use of a curved needle in selected cases is safe and effective for obtaining samples from deep pelvic lesions.

CT-guided percutaneous fine-needle aspiration biopsy of small (< or =1-cm) pulmonary lesions.

PURPOSE: To determine the accuracy of percutaneous computed tomography (CT)-guided fine-needle aspiration biopsy (FNAB) of small (< or =1.0-cm in diameter) pulmonary lesions. MATERIALS AND METHODS: Sixty-one patients (34 men and 27 women) 21-89 years old (mean age, 61.3 years) with lung nodules 1.0 cm or smaller underwent CT-guided transthoracic FNAB. Fifty-seven of the 61 patients had an underlying primary malignancy. Maximum nodule diameters were 0.5-0.7 cm in 10 patients and 0.8-1.0 cm in 51 patients. Cytopathologic evaluation of FNAB samples was immediate in all patients. Sensitivity and accuracy were calculated, and each case was reviewed for complications, including pneumothorax and thoracostomy tube insertion. Four patients were not included in our statistical analysis because of a lack of follow-up information. RESULTS: FNAB samples were adequate for diagnosis in 47 (77%) of 61 patients. Diagnoses were malignancy (n = 29) or suspected malignancy (n = 3) in 52% (n = 32) and benign or atypical findings in 25% (n = 15). Findings were nondiagnostic in 23% (n = 14). Of the 29 patients without evidence of malignancy, 25 had follow-up findings available. Follow-up included chest CT in 16 patients and surgical resection in nine. Four patients were not included in statistical analysis because of a lack of follow-up information. Overall sensitivity was 82% (32 of 39); specificity, 100% (18 of 18); and diagnostic accuracy, 88% (50 of 57) on the basis of 57 patients being evaluable. Results for 47 0.8-1.0-cm lesions were considerably better (sensitivity, 88%; accuracy, 92%) than those for 10 0.5-0.7-cm lesions (sensitivity, 50%; accuracy, 70%). Sensitivity (75% vs 87%) and accuracy (87% vs 89%) also improved when comparing subpleural (< or =1.0 cm from pleural surface, n = 30) with deeper (>1 cm from pleural surface, n = 27) pulmonary lesions, but the improvement did not indicate statistical significance. Core biopsy did not reveal malignancy in any of the nine patients in whom preliminary cytologic results were inconclusive and did not improve diagnostic yield. Thirty-eight (62%) patients had pneumothorax, with 19 (31%) requiring thoracostomy tube placement. CONCLUSION: CT-guided FNAB of pulmonary lesions 1.0 cm or smaller can yield high diagnostic accuracy rates approaching those of larger lesions; FNAB of 0.8-1.0-cm lesions that are not subpleural offers the best opportunity for success.

Transhepatic portal vein embolization: anatomy, indications, and technical considerations.

Portal vein embolization (PVE) is increasingly being accepted as a useful procedure in the preoperative treatment of patients selected for major hepatic resection. PVE is performed via either the percutaneous transhepatic or the transileocolic route and is usually reserved for patients whose future liver remnants are too small to allow resection. It is a safe and effective method for inducing selective hepatic hypertrophy of the nondiseased portion of the liver and may thereby reduce complications and shorten hospital stays after resection. A thorough knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications and contraindications for PVE, the methods for assessing hepatic lobar hypertrophy, the means of determining optimal timing of resection, and the possible complications of PVE need to be fully understood before undertaking the procedure. Technique may vary among operators, and further research is necessary to determine the best embolic agents available and the expected rates of liver regeneration for PVE. Nevertheless, as hepatobiliary surgeons become more experienced at performing extended hepatic resections, PVE may be requested more frequently.

Long-term follow-up of patients with giant cell tumor of the sacrum treated with selective arterial embolization.

BACKGROUND: Giant cell tumors of the bone can behave as aggressive and sometimes lethal tumors. In the sacrum, the tumor can be extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. The goal of this study is to evaluate the long-term outcome of selective arterial embolization as an alternative treatment modality. METHODS: From 1975 to 2001, 18 patients were treated with selective intraarterial embolization. The embolization method was a combination of Gelfoam particles and coils for peripheral and central occlusions, respectively. The number of embolizations was based on clinical symptoms, radiographic response, and the vascularity of the tumor. Nine patients received intraarterial cisplatin as part of their treatment. The median follow-up was 105 months. RESULTS: Of 18 patients, 14 responded favorably to embolization with improvement in pain and neurologic symptoms. Computed tomographic and magnetic resonance imaging scans showed reossification and stabilization of tumor size. Arteriograms showed diminished vascularity. With long-term follow-up, three patients developed late disease recurrences within the sacrum. Kaplan-Meier analysis showed that the risk of local recurrence is 31% at 10 years and 43% at 15 and 20 years. The long-term outcome was not affected by intraarterial cisplatin. There was one death that occurred 1 day after embolization. CONCLUSIONS: Most patients demonstrate an objective early radiographic response to embolization. Long-term follow-up shows that the response is durable in approximately one half of the patients. Given the potential morbidity of other treatments, embolization should be included in the armamentarium of treatment for this difficult disease. Embolization may be used alone or in conjunction with other therapy. Long-term follow-up is recommended for all patients because late disease recurrence or sarcomatous change can occur.

CT-guided percutaneous needle biopsy of intrathoracic lesions by using the transsternal approach: experience in 37 patients.

PURPOSE: To report our experience with computed tomography (CT)-guided coaxial needle biopsy of intrathoracic lesions by using the transsternal approach. MATERIALS AND METHODS: Medical records of 37 consecutive patients who underwent CT-guided transsternal biopsy of intrathoracic lesions were evaluated retrospectively. A coaxial needle technique was used in all patients; an 18-gauge needle was used for transsternal penetration, through which a 22-gauge needle was passed to obtain fine-needle aspirates. Five patients also underwent core-needle biopsy with a coaxially introduced 20-gauge needle. Medical records were reviewed for lesion size and location, needle path, number of needle penetrations, reasons for failure, biopsy results, and complications. RESULTS: The transsternal approach was used in mediastinal (n = 32) or intrapulmonary (n = 5) lesions. Transsternal needle sampling of the target lesion was successful in 35 patients. In the remaining two, adequate angling of the transsternal needle could not be achieved. Extrapleural access to the mediastinal lesions was achieved in all but one patient in whom the 22-gauge needle traversed the lung. Major vessels were avoided in most patients; the 22-gauge needle was safely passed through the brachiocephalic vein in one patient with a retrotracheal mass. Thirty-two (91%) of the 35 biopsies yielded diagnostic specimens. No major complications were encountered. Minor complications were pneumothorax in one patient and mediastinal hematoma in another. CONCLUSION: The CT-guided transsternal approach for coaxial core-needle biopsy allows safe access to masses in various locations in the mediastinum and anteromedial lung.