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US Guidance for Thoracic Biopsy: A Valuable Alternative to CT

¹ Russell H. Morgan Department of Radiology and Radiological Science, the Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287.

View larger version (145K): [in a new window]   Figure 1a. Images in a 63-year-old woman with dyspnea and clinical superior vena cava syndrome. (a) Contrast-enhanced axial CT scan obtained just above the level of the aortic arch shows a right suprahilar mass (arrow) invading the superior vena cava, which rendered the mass unresectable on the basis of imaging criteria. Also visible is a 3-cm peripheral parenchymal mass (m). (b) Sagittal right chest US scan obtained during the biopsy shows a peripheral hypoechoic mass (arrows). The echogenic interface between the lesion and aerated lung is clearly visible. The biopsy needle tip (arrowhead) is visible within the mass. Cursors (+, *) indicate the projected path of the needle. This dyspneic patient could not lie supine, and the procedure was performed in the semisitting position. The histopathologic diagnosis was squamous cell carcinoma.

View larger version (180K): [in a new window]   Figure 1b. Images in a 63-year-old woman with dyspnea and clinical superior vena cava syndrome. (a) Contrast-enhanced axial CT scan obtained just above the level of the aortic arch shows a right suprahilar mass (arrow) invading the superior vena cava, which rendered the mass unresectable on the basis of imaging criteria. Also visible is a 3-cm peripheral parenchymal mass (m). (b) Sagittal right chest US scan obtained during the biopsy shows a peripheral hypoechoic mass (arrows). The echogenic interface between the lesion and aerated lung is clearly visible. The biopsy needle tip (arrowhead) is visible within the mass. Cursors (+, *) indicate the projected path of the needle. This dyspneic patient could not lie supine, and the procedure was performed in the semisitting position. The histopathologic diagnosis was squamous cell carcinoma.

View larger version (165K): [in a new window]   Figure 2a. Images in a 26-year-old woman with fever and weight loss. (a) Contrast-enhanced axial CT scan shows a large, partially necrotic anterior mediastinal mass (arrows) displacing the great vessels posteriorly. A left pleural effusion (p) is present. (b) Transverse left chest US scan shows a heterogeneous mass; areas of necrosis (arrowheads) appear cystic, as well as echogenic. The ascending aorta (A), descending aorta (a), and pulmonary artery (p) are easily identified. Color Doppler US (not shown) was used to avoid the anterior mammary artery and to target viable perfused tissue. The histopathologic diagnosis was B-cell lymphoma.

View larger version (157K): [in a new window]   Figure 2b. Images in a 26-year-old woman with fever and weight loss. (a) Contrast-enhanced axial CT scan shows a large, partially necrotic anterior mediastinal mass (arrows) displacing the great vessels posteriorly. A left pleural effusion (p) is present. (b) Transverse left chest US scan shows a heterogeneous mass; areas of necrosis (arrowheads) appear cystic, as well as echogenic. The ascending aorta (A), descending aorta (a), and pulmonary artery (p) are easily identified. Color Doppler US (not shown) was used to avoid the anterior mammary artery and to target viable perfused tissue. The histopathologic diagnosis was B-cell lymphoma.

View larger version (135K): [in a new window]   Figure 3a. Images in a 59-year-old woman with a cavitary mass. (a) Axial chest CT scan shows a peripheral cavitary mass (arrow). (b) Transverse right chest US scan demonstrates a hypoechoic mass (m). The cavity appears as a small, central, echogenic focus (arrowhead). The histopathologic diagnosis was an inflammatory pseudotumor.

View larger version (124K): [in a new window]   Figure 3b. Images in a 59-year-old woman with a cavitary mass. (a) Axial chest CT scan shows a peripheral cavitary mass (arrow). (b) Transverse right chest US scan demonstrates a hypoechoic mass (m). The cavity appears as a small, central, echogenic focus (arrowhead). The histopathologic diagnosis was an inflammatory pseudotumor.

View larger version (101K): [in a new window]   Figure 4a. Images in a 79-year-old man with a large liver mass and an elevated -fetoprotein level. (a) Axial chest CT scan shows a 1.2-cm juxtadiaphragmatic nodule (arrow). (b) Transverse right chest US scan demonstrates the small hypoechoic lesion (arrow). The mass was hidden behind a rib and was accessible only during deep inspiration. The histopathologic diagnosis was malignant neoplasm consistent with metastatic hepatocellular carcinoma.

View larger version (128K): [in a new window]   Figure 4b. Images in a 79-year-old man with a large liver mass and an elevated -fetoprotein level. (a) Axial chest CT scan shows a 1.2-cm juxtadiaphragmatic nodule (arrow). (b) Transverse right chest US scan demonstrates the small hypoechoic lesion (arrow). The mass was hidden behind a rib and was accessible only during deep inspiration. The histopathologic diagnosis was malignant neoplasm consistent with metastatic hepatocellular carcinoma.

View larger version (20K): [in a new window]   Figure 5. Diagram shows the algorithm for triaging patients for thoracic biopsies.