“Percutaneous Needle Biopsy of Intrapulmonary Lesions With Real-Time Computed Tomography Fluoroscopy” by M. Meysman highlights the author's experience and results in performing transthoracic chest biopsies using a relatively recent imaging technology as their guiding device.1 When first introduced, computed tomography (CT) fluoroscopy cost and the associated high radiation doses to the patient and to the operator have prevented its wide dissemination limiting it to a few large institutions. Advances in CT technology have allowed for a marked reduction in radiation dosages, improvement in image resolution, and reduction in purchasing and maintaining costs. The authors have presented the same biopsy-guiding principles that have been widely published in the last 4 decades and widely practiced by the radiology community.2-5 It is not until recently that the use of CT fluoroscopy has been well known and used outside of the radiology community. Historically, interventional procedures such as percutaneous biopsies and drainage procedures rely on imaging tools for guidance for both accuracy and safety. Before the advent of CT, fluoroscopy was the main imaging method for such procedures. Computed tomography, introduced 30 years ago, has gradually replaced fluoroscopy as the favorite imaging guiding tool, becoming now the most commonly used method for biopsies of the thorax. The need for real-time imaging has been answered by the introduction 10 years ago of CT fluoroscopy, which combines the advantages of both CT and fluoroscopy.6,7 CT scan images offer cross-sectional imaging of the target and its surrounding structures, whereas fluoroscopy offers real-time, imaging, tracking any movement of the target, and its reaction to the biopsy needle. The benefits are of importance for interventions in the thorax where accuracy is crucial in the diagnosis of small pulmonary, mediastinal, or hilar lesions. Real-time observation of the motion of the needle in its trajectory to the intended target maximizes the diagnostic yield and minimizes the need to redirect the needle or perform multiple passes, therefore minimizing the risks of complications.8 Today's units allow a dose reduction to the patient's sensitive organs and to the operator's hands by automatically switching off the generation of x-rays when they are not needed. The latest developments have allowed to obtain a very high rate of images (up to 10 times per second at full resolution [512-image reconstruction]) allowing for improved image quality and therefore allowing accurate biopsies of subcentimeter pulmonary nodules. Although a whole range of invasive procedures can be performed with the help of CT fluoroscopy, biopsies of pulmonary nodules remain the most common application. Other invasive procedures that can be performed by CT fluoroscopy include radiofrequency ablation, laser nucleotomy, vertebroplasty, stereotaxis, and pain therapy. There is a continuous and increasing need for performing various, challenging, and complex invasive procedures in the thorax. Before the advent of real-time cross-sectional imaging, some procedures were deemed too risky or carried a small chance of success. CT fluoroscopy is the ideal guiding device for transbronchial biopsies of mediastinal and hilar lesions that are small or difficult to reach. It allows for the accurate tracking of the transbronchial device through its trajectory and into its intended target, increasing the diagnostic yield and minimizing the risk of complications by avoiding major structures of the hila and mediastinum. Such procedures are best performed when there is collaboration among different specialists such as radiologists, pulmonologists, thoracic surgeons, and oncologists. This team approach in sharing expertise and technology has allowed better success in improving accuracy and patient safety. Future generations of portable CT fluoroscopy will allow such a device to be used outside of the radiology department and in the bronchoscopy suite or operating room.
1. Meysman M. Percutaneous needle biopsy of intrapulmonary lesions with real-time CT fluoroscopy. Journal of Bronchology
2. Nordenstrom B. Transthoracic needle biopsy. N Engl J Med
3. Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology
4. Khouri NF, Meziane MA. Transthoracic needle aspiration biopsy; optimizing the yield. J Thorac Imaging
5. Meziane MA. Nonvascular intervention: percutaneous fluoroscopically guided transthoracic biopsy of lung lesions. In: Kadir S, ed. Current Practice of Interventional Radiology
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6. Barry D, Templeton PA. Real-time CT fluoroscopy: evolution of an interventional tool. Radiology
7. Paulson ED, Sheafor DH, Enterline DS, et al. CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Radiology
8. Endo M, Kotani Y, Satouchi M, et al. CT fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules. Chest