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Imaging-guided Percutaneous Biopsy of Mediastinal Lesions: Different Approaches and Anatomic Considerations¹

¹ From the Department of Diagnostic Radiology, Unit 325, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Recipient of a Magna Cum Laude award for an education exhibit at the 2003 RSNA Scientific Assembly. Received March 9, 2004; revision requested June 4 and received July 21; accepted August 27. All authors have no financial relationships to disclose.

View larger version (83K): [in a new window]   Figure 1.  Drawing of a transverse section through the thorax at the level of the aortic arch shows the parasternal approach. The needles are inserted lateral to the sternum (ST) and advanced into the mediastinal masses (M).

 

View larger version (145K): [in a new window]   Figure 2a.  Parasternal approach. (a) CT scan shows a biopsy needle (arrow) advanced between the lateral edge of the sternum and the internal mammary vessels (arrowhead) for biopsy of an anterior mediastinal mass (M) in direct contact with the chest wall. (b) CT scan shows an anterior mediastinal mass (M) in direct contact with the chest wall, lateral to the internal mammary vessels (arrowhead). The biopsy needle (arrow) passes lateral to the vessels. (c) CT scan shows a biopsy needle (arrow) advanced medial to the internal mammary vessels (arrowhead), through the mediastinal fat, and into an aortopulmonary window node (N). (d) CT scan shows a biopsy needle (arrow) advanced between the right brachiocephalic vein (V) and artery (A) for biopsy of a pretracheal mass (M).

 

View larger version (132K): [in a new window]   Figure 2b.  Parasternal approach. (a) CT scan shows a biopsy needle (arrow) advanced between the lateral edge of the sternum and the internal mammary vessels (arrowhead) for biopsy of an anterior mediastinal mass (M) in direct contact with the chest wall. (b) CT scan shows an anterior mediastinal mass (M) in direct contact with the chest wall, lateral to the internal mammary vessels (arrowhead). The biopsy needle (arrow) passes lateral to the vessels. (c) CT scan shows a biopsy needle (arrow) advanced medial to the internal mammary vessels (arrowhead), through the mediastinal fat, and into an aortopulmonary window node (N). (d) CT scan shows a biopsy needle (arrow) advanced between the right brachiocephalic vein (V) and artery (A) for biopsy of a pretracheal mass (M).

 

View larger version (129K): [in a new window]   Figure 2c.  Parasternal approach. (a) CT scan shows a biopsy needle (arrow) advanced between the lateral edge of the sternum and the internal mammary vessels (arrowhead) for biopsy of an anterior mediastinal mass (M) in direct contact with the chest wall. (b) CT scan shows an anterior mediastinal mass (M) in direct contact with the chest wall, lateral to the internal mammary vessels (arrowhead). The biopsy needle (arrow) passes lateral to the vessels. (c) CT scan shows a biopsy needle (arrow) advanced medial to the internal mammary vessels (arrowhead), through the mediastinal fat, and into an aortopulmonary window node (N). (d) CT scan shows a biopsy needle (arrow) advanced between the right brachiocephalic vein (V) and artery (A) for biopsy of a pretracheal mass (M).

 

View larger version (132K): [in a new window]   Figure 2d.  Parasternal approach. (a) CT scan shows a biopsy needle (arrow) advanced between the lateral edge of the sternum and the internal mammary vessels (arrowhead) for biopsy of an anterior mediastinal mass (M) in direct contact with the chest wall. (b) CT scan shows an anterior mediastinal mass (M) in direct contact with the chest wall, lateral to the internal mammary vessels (arrowhead). The biopsy needle (arrow) passes lateral to the vessels. (c) CT scan shows a biopsy needle (arrow) advanced medial to the internal mammary vessels (arrowhead), through the mediastinal fat, and into an aortopulmonary window node (N). (d) CT scan shows a biopsy needle (arrow) advanced between the right brachiocephalic vein (V) and artery (A) for biopsy of a pretracheal mass (M).

 

View larger version (79K): [in a new window]   Figure 3a.  Drawings show use of lateral decubitus positioning for the parasternal approach. M = mass, ST = sternum. (a) When the patient is in the supine position, aerated lung tissue is interposed between the mass and the chest wall. (b) When the patient is placed in the left lateral decubitus position, the mediastinum shifts to the left, creating a direct mediastinal window for needle placement.

 

View larger version (103K): [in a new window]   Figure 3b.  Drawings show use of lateral decubitus positioning for the parasternal approach. M = mass, ST = sternum. (a) When the patient is in the supine position, aerated lung tissue is interposed between the mass and the chest wall. (b) When the patient is placed in the left lateral decubitus position, the mediastinum shifts to the left, creating a direct mediastinal window for needle placement.

 

View larger version (131K): [in a new window]   Figure 4a.  Artificial widening of the mediastinum for the parasternal approach. (a) CT scan shows an anterior mediastinal mass (M) and a narrow parasternal mediastinal window (arrowhead). The needle (arrow) has been placed in the soft tissues. (b) CT scan obtained after injection of saline solution shows a widened mediastinum (arrowhead), which allows extrapleural placement of the biopsy needle (arrow).

 

View larger version (132K): [in a new window]   Figure 4b.  Artificial widening of the mediastinum for the parasternal approach. (a) CT scan shows an anterior mediastinal mass (M) and a narrow parasternal mediastinal window (arrowhead). The needle (arrow) has been placed in the soft tissues. (b) CT scan obtained after injection of saline solution shows a widened mediastinum (arrowhead), which allows extrapleural placement of the biopsy needle (arrow).

 

View larger version (94K): [in a new window]   Figure 5a.  Parasternal approach with US guidance. (a) CT scan shows an anterior mediastinal mass (M) anterior to the ascending aorta (A). (b) Transverse sonogram shows a biopsy needle (curved arrow) advanced lateral to the internal mammary vessels (straight arrow) and into the mass (M), which is anterior to the aorta (A) and right pulmonary artery (PA). Note the location of the sternum (white arrowheads) and the echogenic margin of the right lung (black arrowheads).

 

View larger version (147K): [in a new window]   Figure 5b.  Parasternal approach with US guidance. (a) CT scan shows an anterior mediastinal mass (M) anterior to the ascending aorta (A). (b) Transverse sonogram shows a biopsy needle (curved arrow) advanced lateral to the internal mammary vessels (straight arrow) and into the mass (M), which is anterior to the aorta (A) and right pulmonary artery (PA). Note the location of the sternum (white arrowheads) and the echogenic margin of the right lung (black arrowheads).

 

View larger version (134K): [in a new window]   Figure 6a.  Effect of breathing on the mediastinum. (a) CT scan shows the needle (arrow) in a parasternal location, a small anterior mediastinal lesion (arrowhead), and a potential extrapleural window. (b) CT scan obtained a few seconds later shows interposition of the lung in the path of the biopsy needle (arrow); this interposition is caused by variation in respiration and precludes extrapleural biopsy. Note that the target lesion is no longer seen in the biopsy plane.

 

View larger version (129K): [in a new window]   Figure 6b.  Effect of breathing on the mediastinum. (a) CT scan shows the needle (arrow) in a parasternal location, a small anterior mediastinal lesion (arrowhead), and a potential extrapleural window. (b) CT scan obtained a few seconds later shows interposition of the lung in the path of the biopsy needle (arrow); this interposition is caused by variation in respiration and precludes extrapleural biopsy. Note that the target lesion is no longer seen in the biopsy plane.

 

View larger version (126K): [in a new window]   Figure 7a.  Inadvertent transgression of the pleura. (a) CT scan shows a biopsy needle (arrow) passed through the mediastinal fat toward a lesion (M), which is anterior to the pulmonary artery (PA). (b) CT scan shows air in the path of the needle. The air is associated with collapse of the lung (arrows), which has caused separation of the mediastinal fat from the anterior chest wall. (c) Drawing shows how interposition of the parietal pleura (arrow) in the path of the needle can result in inadvertent transgression of the pleural space during parasternal biopsy. M = mass, ST = sternum.

 

View larger version (133K): [in a new window]   Figure 7b.  Inadvertent transgression of the pleura. (a) CT scan shows a biopsy needle (arrow) passed through the mediastinal fat toward a lesion (M), which is anterior to the pulmonary artery (PA). (b) CT scan shows air in the path of the needle. The air is associated with collapse of the lung (arrows), which has caused separation of the mediastinal fat from the anterior chest wall. (c) Drawing shows how interposition of the parietal pleura (arrow) in the path of the needle can result in inadvertent transgression of the pleural space during parasternal biopsy. M = mass, ST = sternum.

 

View larger version (110K): [in a new window]   Figure 7c.  Inadvertent transgression of the pleura. (a) CT scan shows a biopsy needle (arrow) passed through the mediastinal fat toward a lesion (M), which is anterior to the pulmonary artery (PA). (b) CT scan shows air in the path of the needle. The air is associated with collapse of the lung (arrows), which has caused separation of the mediastinal fat from the anterior chest wall. (c) Drawing shows how interposition of the parietal pleura (arrow) in the path of the needle can result in inadvertent transgression of the pleural space during parasternal biopsy. M = mass, ST = sternum.

 

View larger version (91K): [in a new window]   Figure 8a.  Injury to the internal mammary artery. (a) CT scan shows a biopsy needle that was advanced parasternally (arrow), causing a mediastinal hematoma (arrowhead) secondary to injury to the internal mammary vessels. (b) Postprocedure CT scan shows enlargement of the mediastinal hematoma (arrowheads) and a left hemothorax (arrows).

 

View larger version (107K): [in a new window]   Figure 8b.  Injury to the internal mammary artery. (a) CT scan shows a biopsy needle that was advanced parasternally (arrow), causing a mediastinal hematoma (arrowhead) secondary to injury to the internal mammary vessels. (b) Postprocedure CT scan shows enlargement of the mediastinal hematoma (arrowheads) and a left hemothorax (arrows).

 

View larger version (68K): [in a new window]   Figure 9.  Drawing shows the extrapleural paravertebral approach for needle biopsy of a posterior mediastinal mass (M) after widening of the mediastinal space by injection of saline solution (Fl).

 

View larger version (137K): [in a new window]   Figure 10a.  Paravertebral approach for biopsy of a subcarinal mass. (a) CT scan shows a subcarinal mass (M); an 18-gauge needle has been advanced to the edge of the paravertebral space (arrowhead). (b) CT scan shows that injection of saline solution through the guide needle (arrow) has widened the mediastinum (arrowhead), creating a safe extrapleural path to the mass (M). (c) CT scan shows a 22-gauge needle (arrowhead) advanced through the 18-gauge needle (arrow) for biopsy of the mass (M).

 

View larger version (142K): [in a new window]   Figure 10b.  Paravertebral approach for biopsy of a subcarinal mass. (a) CT scan shows a subcarinal mass (M); an 18-gauge needle has been advanced to the edge of the paravertebral space (arrowhead). (b) CT scan shows that injection of saline solution through the guide needle (arrow) has widened the mediastinum (arrowhead), creating a safe extrapleural path to the mass (M). (c) CT scan shows a 22-gauge needle (arrowhead) advanced through the 18-gauge needle (arrow) for biopsy of the mass (M).

 

View larger version (146K): [in a new window]   Figure 10c.  Paravertebral approach for biopsy of a subcarinal mass. (a) CT scan shows a subcarinal mass (M); an 18-gauge needle has been advanced to the edge of the paravertebral space (arrowhead). (b) CT scan shows that injection of saline solution through the guide needle (arrow) has widened the mediastinum (arrowhead), creating a safe extrapleural path to the mass (M). (c) CT scan shows a 22-gauge needle (arrowhead) advanced through the 18-gauge needle (arrow) for biopsy of the mass (M).

 

View larger version (130K): [in a new window]   Figure 11a.  Retroaortic paravertebral approach. (a) CT scan shows an 18-gauge guide needle (thick arrow) inserted in the paravertebral space (thin arrows) and advanced between the descending aorta (DA) and vertebral body after widening of these spaces by injection of saline solution. A 22-gauge needle was advanced through the guide needle to obtain aspirates from a subcarinal mass (M). E = esophagus. (b) CT scan shows use of coaxial 18- and 22-gauge needles (black arrow) for biopsy of a left pretracheal mass (M). Saline solution was administered to widen the paravertebral (white arrow) and retroaortic spaces.

 

View larger version (144K): [in a new window]   Figure 11b.  Retroaortic paravertebral approach. (a) CT scan shows an 18-gauge guide needle (thick arrow) inserted in the paravertebral space (thin arrows) and advanced between the descending aorta (DA) and vertebral body after widening of these spaces by injection of saline solution. A 22-gauge needle was advanced through the guide needle to obtain aspirates from a subcarinal mass (M). E = esophagus. (b) CT scan shows use of coaxial 18- and 22-gauge needles (black arrow) for biopsy of a left pretracheal mass (M). Saline solution was administered to widen the paravertebral (white arrow) and retroaortic spaces.

 

View larger version (157K): [in a new window]   Figure 12a.  Paravertebral approach for biopsy of a right paratracheal mass. (a) CT scan shows a right paratracheal mass (M) that lacks an extrapleural window (arrowhead). (b) CT scan shows an extrapleural window (thin arrows) created by injection of saline solution through an 18-gauge needle (thick arrow). This extrapleural window allowed safe biopsy of the mass (M) with a coaxially placed 22-gauge needle (arrowhead).

 

View larger version (143K): [in a new window]   Figure 12b.  Paravertebral approach for biopsy of a right paratracheal mass. (a) CT scan shows a right paratracheal mass (M) that lacks an extrapleural window (arrowhead). (b) CT scan shows an extrapleural window (thin arrows) created by injection of saline solution through an 18-gauge needle (thick arrow). This extrapleural window allowed safe biopsy of the mass (M) with a coaxially placed 22-gauge needle (arrowhead).

 

View larger version (140K): [in a new window]   Figure 13.  CT scan shows a large osteophyte (arrowheads), which prevents paravertebral passage of the biopsy needle into a mediastinal mass (M).

 

View larger version (108K): [in a new window]   Figure 14.  Drawing shows the transsternal approach for biopsy of anterior mediastinal, preaortic, and pretracheal masses (M). The needles traverse the sternum (ST).

 

View larger version (108K): [in a new window]   Figure 15a.  Transsternal approach. (a) CT scan shows an 18-gauge needle (arrow) traversing the sternum and a 20-gauge core biopsy needle (arrowhead), which was advanced through the 18-gauge needle into an anterior mediastinal mass (M). (b) CT scan shows an 18-gauge biopsy needle (arrow) advanced through the sternum into an aortopulmonary window mass (M). A = ascending aorta, PA = pulmonary artery. (c) CT scan shows transsternal biopsy of a pretracheal mass (M) with an inner 22-gauge biopsy needle (arrow) passing between the superior vena cava (V) and aortic arch (A).

 

View larger version (99K): [in a new window]   Figure 15b.  Transsternal approach. (a) CT scan shows an 18-gauge needle (arrow) traversing the sternum and a 20-gauge core biopsy needle (arrowhead), which was advanced through the 18-gauge needle into an anterior mediastinal mass (M). (b) CT scan shows an 18-gauge biopsy needle (arrow) advanced through the sternum into an aortopulmonary window mass (M). A = ascending aorta, PA = pulmonary artery. (c) CT scan shows transsternal biopsy of a pretracheal mass (M) with an inner 22-gauge biopsy needle (arrow) passing between the superior vena cava (V) and aortic arch (A).

 

View larger version (126K): [in a new window]   Figure 15c.  Transsternal approach. (a) CT scan shows an 18-gauge needle (arrow) traversing the sternum and a 20-gauge core biopsy needle (arrowhead), which was advanced through the 18-gauge needle into an anterior mediastinal mass (M). (b) CT scan shows an 18-gauge biopsy needle (arrow) advanced through the sternum into an aortopulmonary window mass (M). A = ascending aorta, PA = pulmonary artery. (c) CT scan shows transsternal biopsy of a pretracheal mass (M) with an inner 22-gauge biopsy needle (arrow) passing between the superior vena cava (V) and aortic arch (A).

 

View larger version (142K): [in a new window]   Figure 16a.  Transsternal approach. (a) Contrast-enhanced CT scan shows a retrotracheal mass (M) posterior to the right and left brachiocephalic veins (V). (b) CT scan shows a 22-gauge biopsy needle (arrowhead) coaxially introduced through an 18-gauge transsternal needle (arrow). The biopsy needle transgresses the left brachiocephalic vein (V) to obtain a sample of the mass (M).

 

View larger version (146K): [in a new window]   Figure 16b.  Transsternal approach. (a) Contrast-enhanced CT scan shows a retrotracheal mass (M) posterior to the right and left brachiocephalic veins (V). (b) CT scan shows a 22-gauge biopsy needle (arrowhead) coaxially introduced through an 18-gauge transsternal needle (arrow). The biopsy needle transgresses the left brachiocephalic vein (V) to obtain a sample of the mass (M).

 

View larger version (110K): [in a new window]   Figure 17.  Transsternal approach. CT scan shows a needle traversing the sternum during biopsy of an anterior mediastinal lesion (M). A small mediastinal hematoma (arrowhead) resulted from the biopsy.

 

View larger version (80K): [in a new window]   Figure 18a.  Suprasternal approach. (a) Drawing (sagittal oblique view) shows the suprasternal approach for biopsy of a superior mediastinal mass (M). ST = sternum. (b) Drawing (coronal oblique view) shows the suprasternal approach for biopsy of a mediastinal mass (M).

 

View larger version (75K): [in a new window]   Figure 18b.  Suprasternal approach. (a) Drawing (sagittal oblique view) shows the suprasternal approach for biopsy of a superior mediastinal mass (M). ST = sternum. (b) Drawing (coronal oblique view) shows the suprasternal approach for biopsy of a mediastinal mass (M).

 

View larger version (105K): [in a new window]   Figure 19a.  Suprasternal approach with semicoronal scanning. (a) Axial CT scan shows a bilobular retrosternal mediastinal mass (M) between the right brachiocephalic vein (V) and artery (A). (b) Semicoronal CT scan, obtained by placing a pillow under the patient’s shoulders and tilting the CT gantry craniocaudally, shows a direct suprasternal access window, which allows safe placement of a biopsy needle (arrow) into the mass (M). A = brachiocephalic artery, V = right brachiocephalic vein.

 

View larger version (108K): [in a new window]   Figure 19b.  Suprasternal approach with semicoronal scanning. (a) Axial CT scan shows a bilobular retrosternal mediastinal mass (M) between the right brachiocephalic vein (V) and artery (A). (b) Semicoronal CT scan, obtained by placing a pillow under the patient’s shoulders and tilting the CT gantry craniocaudally, shows a direct suprasternal access window, which allows safe placement of a biopsy needle (arrow) into the mass (M). A = brachiocephalic artery, V = right brachiocephalic vein.

 

View larger version (130K): [in a new window]   Figure 20a.  Suprasternal approach with the triangulation method. (a) Schematic drawing shows the triangulation method (25). Z represents the point on the skin in the same transaxial plane as the target lesion (M). C or the depth of needle insertion is calculated with the Pythagorean theorem (A2 + B2 = C2). The angle of needle insertion (a) is equal to the angle , which is calculated by means of the tangent B/A. ST = sternum. (b) Axial CT scan shows an anterior mediastinal mass (M) located behind the sternum. (c) Axial CT scan shows the tip of the biopsy needle (arrow) in the mass (M). The needle was inserted through the suprasternal notch and angled downward.

 

View larger version (85K): [in a new window]   Figure 20b.  Suprasternal approach with the triangulation method. (a) Schematic drawing shows the triangulation method (25). Z represents the point on the skin in the same transaxial plane as the target lesion (M). C or the depth of needle insertion is calculated with the Pythagorean theorem (A2 + B2 = C2). The angle of needle insertion (a) is equal to the angle , which is calculated by means of the tangent B/A. ST = sternum. (b) Axial CT scan shows an anterior mediastinal mass (M) located behind the sternum. (c) Axial CT scan shows the tip of the biopsy needle (arrow) in the mass (M). The needle was inserted through the suprasternal notch and angled downward.

 

View larger version (85K): [in a new window]   Figure 20c.  Suprasternal approach with the triangulation method. (a) Schematic drawing shows the triangulation method (25). Z represents the point on the skin in the same transaxial plane as the target lesion (M). C or the depth of needle insertion is calculated with the Pythagorean theorem (A2 + B2 = C2). The angle of needle insertion (a) is equal to the angle , which is calculated by means of the tangent B/A. ST = sternum. (b) Axial CT scan shows an anterior mediastinal mass (M) located behind the sternum. (c) Axial CT scan shows the tip of the biopsy needle (arrow) in the mass (M). The needle was inserted through the suprasternal notch and angled downward.

 

View larger version (114K): [in a new window]   Figure 21a.  Suprasternal approach with US guidance. (a) CT scan shows a right paratracheal mass (M) that extends above the level of the manubrium. (b) Semicoronal sonogram obtained through the suprasternal window shows the needle (arrow) within the mass (M).

 

View larger version (90K): [in a new window]   Figure 21b.  Suprasternal approach with US guidance. (a) CT scan shows a right paratracheal mass (M) that extends above the level of the manubrium. (b) Semicoronal sonogram obtained through the suprasternal window shows the needle (arrow) within the mass (M).

 

View larger version (122K): [in a new window]   Figure 22a.  Suprasternal approach with US guidance. (a) CT scan shows an anterior mediastinal mass (M) located behind the sternum and anterior to the arteries arising from the aorta. (b) Suprasternal sonogram (semicoronal view) shows the mass (M) anterosuperior to the arteries (A). (c) Suprasternal sonogram (semicoronal view) shows the biopsy needle (arrow), which has been advanced into the mass (M) under US guidance.

 

View larger version (165K): [in a new window]   Figure 22b.  Suprasternal approach with US guidance. (a) CT scan shows an anterior mediastinal mass (M) located behind the sternum and anterior to the arteries arising from the aorta. (b) Suprasternal sonogram (semicoronal view) shows the mass (M) anterosuperior to the arteries (A). (c) Suprasternal sonogram (semicoronal view) shows the biopsy needle (arrow), which has been advanced into the mass (M) under US guidance.

 

View larger version (162K): [in a new window]   Figure 22c.  Suprasternal approach with US guidance. (a) CT scan shows an anterior mediastinal mass (M) located behind the sternum and anterior to the arteries arising from the aorta. (b) Suprasternal sonogram (semicoronal view) shows the mass (M) anterosuperior to the arteries (A). (c) Suprasternal sonogram (semicoronal view) shows the biopsy needle (arrow), which has been advanced into the mass (M) under US guidance.

 

View larger version (118K): [in a new window]   Figure 23a.  Suprasternal approach with US guidance. (a) CT scan shows a retrotracheal mass (M). (b) Suprasternal sonogram (semicoronal view) shows a biopsy needle (arrow) that has traversed the thyroid gland (T) on its way to the mass (M).

 

View larger version (131K): [in a new window]   Figure 23b.  Suprasternal approach with US guidance. (a) CT scan shows a retrotracheal mass (M). (b) Suprasternal sonogram (semicoronal view) shows a biopsy needle (arrow) that has traversed the thyroid gland (T) on its way to the mass (M).

 

View larger version (126K): [in a new window]   Figure 24a.  Subxiphoid approach. (a) CT scan shows a large mass (M) in the posterior mediastinum. (b) Semicoronal sonogram obtained by using the subxiphoid approach with the transducer angled upward shows the mass (M) posterosuperior to the left lobe of the liver (L). The biopsy needle was advanced under US guidance. CT was performed to verify the needle trajectory. (c) CT scan shows the needle (arrow) passing through the liver (L). (d) CT scan shows the needle tip (arrow) in the mass (M).

 

View larger version (96K): [in a new window]   Figure 24b.  Subxiphoid approach. (a) CT scan shows a large mass (M) in the posterior mediastinum. (b) Semicoronal sonogram obtained by using the subxiphoid approach with the transducer angled upward shows the mass (M) posterosuperior to the left lobe of the liver (L). The biopsy needle was advanced under US guidance. CT was performed to verify the needle trajectory. (c) CT scan shows the needle (arrow) passing through the liver (L). (d) CT scan shows the needle tip (arrow) in the mass (M).

 

View larger version (148K): [in a new window]   Figure 24c.  Subxiphoid approach. (a) CT scan shows a large mass (M) in the posterior mediastinum. (b) Semicoronal sonogram obtained by using the subxiphoid approach with the transducer angled upward shows the mass (M) posterosuperior to the left lobe of the liver (L). The biopsy needle was advanced under US guidance. CT was performed to verify the needle trajectory. (c) CT scan shows the needle (arrow) passing through the liver (L). (d) CT scan shows the needle tip (arrow) in the mass (M).

 

View larger version (146K): [in a new window]   Figure 24d.  Subxiphoid approach. (a) CT scan shows a large mass (M) in the posterior mediastinum. (b) Semicoronal sonogram obtained by using the subxiphoid approach with the transducer angled upward shows the mass (M) posterosuperior to the left lobe of the liver (L). The biopsy needle was advanced under US guidance. CT was performed to verify the needle trajectory. (c) CT scan shows the needle (arrow) passing through the liver (L). (d) CT scan shows the needle tip (arrow) in the mass (M).

 

View larger version (77K): [in a new window]   Figure 25.  Drawing shows needle placement through a pleural space created by pleural fluid or iatrogenic pneumothorax for biopsy of a posterior mediastinal mass (M).

 

View larger version (119K): [in a new window]   Figure 26.  Pleural space approach. CT scan shows placement of an 18-gauge needle (thick arrow) into a posterior mediastinal mass (M) through a loculated pleural effusion (thin arrows). Note the presence of free pleural fluid (PF) anteriorly.

 

View larger version (110K): [in a new window]   Figure 27a.  Pleural space approach. (a) CT scan shows a large mediastinal mass (M) encasing the descending thoracic aorta (A). Note the presence of a left pleural effusion (FL). The patient was unable to maintain a supine or prone position owing to dyspnea. (b) Transverse sonogram obtained by using the posterior intercostal approach with the patient in a semisitting position shows the mass (M), pleural fluid (FL), spleen (SP), and aorta (A). The biopsy needle (arrow) has been advanced through the pleural fluid into the mass.

 

View larger version (109K): [in a new window]   Figure 27b.  Pleural space approach. (a) CT scan shows a large mediastinal mass (M) encasing the descending thoracic aorta (A). Note the presence of a left pleural effusion (FL). The patient was unable to maintain a supine or prone position owing to dyspnea. (b) Transverse sonogram obtained by using the posterior intercostal approach with the patient in a semisitting position shows the mass (M), pleural fluid (FL), spleen (SP), and aorta (A). The biopsy needle (arrow) has been advanced through the pleural fluid into the mass.

 

View larger version (98K): [in a new window]   Figure 28a.  Pleural space approach. (a) CT scan shows a subcarinal mass (M). (b) CT scan shows an 18-gauge blunt-tip needle (black arrow) advanced through the parietal pleura, thus displacing the visceral pleura (white arrow). M = mass. (c) CT scan shows collapse of the lung (white arrows) caused by introduction of air into the pleural space. The lung collapse has allowed advancement of the biopsy needle (black arrow) through the pleural space. M = mass. The air was evacuated at the end of the biopsy procedure.

 

View larger version (125K): [in a new window]   Figure 28b.  Pleural space approach. (a) CT scan shows a subcarinal mass (M). (b) CT scan shows an 18-gauge blunt-tip needle (black arrow) advanced through the parietal pleura, thus displacing the visceral pleura (white arrow). M = mass. (c) CT scan shows collapse of the lung (white arrows) caused by introduction of air into the pleural space. The lung collapse has allowed advancement of the biopsy needle (black arrow) through the pleural space. M = mass. The air was evacuated at the end of the biopsy procedure.

 

View larger version (139K): [in a new window]   Figure 28c.  Pleural space approach. (a) CT scan shows a subcarinal mass (M). (b) CT scan shows an 18-gauge blunt-tip needle (black arrow) advanced through the parietal pleura, thus displacing the visceral pleura (white arrow). M = mass. (c) CT scan shows collapse of the lung (white arrows) caused by introduction of air into the pleural space. The lung collapse has allowed advancement of the biopsy needle (black arrow) through the pleural space. M = mass. The air was evacuated at the end of the biopsy procedure.

 

View larger version (144K): [in a new window]   Figure 29a.  Failed attempt at biopsy with the pleural space approach. M = mass. (a) CT scan shows placement of an 18-gauge needle (arrow) in what was mistakenly thought to be the pleural space. (b) CT scan shows injected air dissecting into the chest wall and mediastinal soft tissues (arrowheads) because of the inaccurate needle placement.

 

View larger version (155K): [in a new window]   Figure 29b.  Failed attempt at biopsy with the pleural space approach. M = mass. (a) CT scan shows placement of an 18-gauge needle (arrow) in what was mistakenly thought to be the pleural space. (b) CT scan shows injected air dissecting into the chest wall and mediastinal soft tissues (arrowheads) because of the inaccurate needle placement.

 

View larger version (138K): [in a new window]   Figure 30a.  Transpulmonary approach. (a) CT scan shows needle placement (arrow) for transpulmonary biopsy of a subcarinal mass (M). (b) CT scan shows needle placement (arrow) for transpulmonary biopsy of a paratracheal mass (M). (c) CT scan shows needle placement (arrow) for transpulmonary biopsy of an aortopulmonary mass (M). (d) CT scan shows needle placement (straight arrow) for transpulmonary biopsy of a right paratracheal mass (M). The presence of the superior vena cava (SVC) and azygos vein (curved arrow) precluded anterior or posterior approaches. Note the alveolar hemorrhage in the needle track (arrowheads).

 

View larger version (121K): [in a new window]   Figure 30b.  Transpulmonary approach. (a) CT scan shows needle placement (arrow) for transpulmonary biopsy of a subcarinal mass (M). (b) CT scan shows needle placement (arrow) for transpulmonary biopsy of a paratracheal mass (M). (c) CT scan shows needle placement (arrow) for transpulmonary biopsy of an aortopulmonary mass (M). (d) CT scan shows needle placement (straight arrow) for transpulmonary biopsy of a right paratracheal mass (M). The presence of the superior vena cava (SVC) and azygos vein (curved arrow) precluded anterior or posterior approaches. Note the alveolar hemorrhage in the needle track (arrowheads).

 

View larger version (88K): [in a new window]   Figure 30c.  Transpulmonary approach. (a) CT scan shows needle placement (arrow) for transpulmonary biopsy of a subcarinal mass (M). (b) CT scan shows needle placement (arrow) for transpulmonary biopsy of a paratracheal mass (M). (c) CT scan shows needle placement (arrow) for transpulmonary biopsy of an aortopulmonary mass (M). (d) CT scan shows needle placement (straight arrow) for transpulmonary biopsy of a right paratracheal mass (M). The presence of the superior vena cava (SVC) and azygos vein (curved arrow) precluded anterior or posterior approaches. Note the alveolar hemorrhage in the needle track (arrowheads).

 

View larger version (131K): [in a new window]   Figure 30d.  Transpulmonary approach. (a) CT scan shows needle placement (arrow) for transpulmonary biopsy of a subcarinal mass (M). (b) CT scan shows needle placement (arrow) for transpulmonary biopsy of a paratracheal mass (M). (c) CT scan shows needle placement (arrow) for transpulmonary biopsy of an aortopulmonary mass (M). (d) CT scan shows needle placement (straight arrow) for transpulmonary biopsy of a right paratracheal mass (M). The presence of the superior vena cava (SVC) and azygos vein (curved arrow) precluded anterior or posterior approaches. Note the alveolar hemorrhage in the needle track (arrowheads).

 

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