Selection of Site for Biopsy

For diffuse process, this is not crucial. For localized lesions, we certainly have to select the site for biopsy. For the exact selection of site, you require additional assistance. We have the following options:

• Physical Exam
  History and physical exam can help select the site for biopsy. If there is persistent chest wall pain and/or swelling on exam, then it is an ideal site for biopsy. If the chest x-ray confirms the presence of a mass lesion corresponding to the chest wall abnormality, one can proceed with a biopsy without any other additional localizing procedures. If the mass is large and close to the chest wall, certainly dullness and other physical findings can help with selection of site. However, if the mass lesion is surrounded by lung tissue, physical exam will not be of help to select the site for biopsy.

• Fluoroscopy
  Biplane fluoroscopy is ideal for most cases. I use a C-arm fluoro unit. It is helpful for localization, selection of site for port of entry and direction and placement of the needle in the lesion. Following the procedure, you can also evaluate the patient for pneumothorax.

• Ultrasound
  Ultrasound can help select the site for localization. The point of contact of the mass to the chest wall is ensured if the ultrasound localizes the lesion; thus, minimizing the risk of a pneumothorax. One can even precisely place the needle into the lesion through the hole in the probe.

  I found ultrasound ideal for pancoast lesions where fluoroscopic localization is difficult. However, ultrasound is unable to detect lesions surrounded by lung tissue unless the lesion is deep in the chest.

• Computerized Tomogram
  Computerized tomogram is ideal for lesions that are small or deep in the chest and for mediastinal masses. The needle can be placed in the lesion and confirmed in the same sitting. It is certainly the best way to approach lesions in the mediastinum where other modalities are not suited in distinguishing the mass from other organs. Small lung lesions can be biopsied with assurance of placement of the needle in the lesion only with the guidance of computerized tomograms.

  The disadvantage is the length of time the needle must remain in the chest. It is cumbersome. Both the patient and physician do not find it comfortable.