Abstract
Objective
The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for lung biopsy.
Methods
50 consecutive percutaneous lung biopsies using the Monopty needle between June 2006 and January 2007 and 66 consecutive lung biopsies for 1 nodule in each session using the Temno needle between February 2007 and August 2008 were performed under CT fluoroscopic guidance followed by histopathological evaluation.
Results
In 42/50 lung biopsies performed with the Monopty needle and 54/66 lung biopsies performed with the Temno needle, the final diagnosis was confirmed by independent surgical pathological findings or clinical follow-up. Sufficient samples for histopathological evaluation were obtained in all 50 (100%) biopsies using the Monopty needle and in 55 (83.3%) of the 66 biopsies using the Temno needle (p<0.01). Accurate diagnosis was achieved in 41 (97.6%) of 42 biopsies using the Monopty needle and in 45 (83.3%) of 54 biopsies using the Temno needle (p=0.04). Biopsy-induced complications were pneumothorax, haemoptysis and haemothorax in 44.0%, 10.0% and 6.0% of biopsies, respectively, using the Monopty needle and in 48.3%, 8.3% and 3.3%, respectively, using the Temno needle.
Conclusion
There is a possibility that a fully automated biopsy needle such as the Monopty is more useful for CT scan-guided lung biopsy than semi-automated biopsy needles.
CT scan-guided needle biopsy of lung nodules has become a well-established diagnostic technique [1]. Most CT scan-guided lung biopsies cited in earlier reports [2,3] were performed with fine-needle aspiration for cytology and were useful in differentiating malignant from benign lesions. In addition, a tissue-core biopsy using a cutting needle, which enables histopathological evaluation of the samples obtained [4], has been implemented to enhance diagnostic ability. Owing to the development of the automated cutting needle, tissue-core biopsy can now be performed more easily and higher quality core specimens can be obtained for histopathological analysis [5-11].
There are two types of automated cutting needles: the fully automated biopsy needle and the semi-automated biopsy needle. Comparisons have been made of the use of these needles for autopsy [12] or breast tissue biopsy [13]. To our knowledge, no investigation has been carried out to compare these two types of automated cutting needles for lung biopsy. The aim of this study was to compare two different automated biopsy needles, a fully automated biopsy needle (Monopty; Bard, Covington, GA) and a semi-automated biopsy needle (Temno; Bauer Medical, Clearwater, FL), for use in CT scan-guided lung biopsy.
Subjects and methods
Subjects
Between June 2006 and August 2008, 120 consecutive percutaneous lung biopsies were performed under CT fluoroscopic guidance at our institution. Among these biopsies, between June 2006 and January 2007, 50 consecutive lung biopsies were performed using an 18 gauge Monopty needle, and between February 2007 and August 2008, 70 consecutive lung biopsies were performed using an 18 gauge Temno needle. Among the 70 lung biopsies performed using the Temno needle, in 4 patients biopsies were performed for 2 nodules on the same day. In 14 patients in whom the Temno needle was used, repeat biopsies were carried out using the Monopty needle on the same day (n=6) or on another day (n=8) because specimens obtained by the Temno needle were, or were thought to be, inadequate for histopathological evaluations, although in 3 patients the specimens subsequently proved to be adequate for diagnosis.
Biopsy needle
The Monopty needle is a fully automated biopsy device that automatically triggers a rapid firing side-notch Tru-Cut-type biopsy needle. It uses a two-stage biopsy action. A spring action thrusts the inner trocar forward, followed almost instantaneously by a similar forward thrust of the outer cutting cannula. The specimen is trapped in the side notch of the trocar when the cutting cannula is advanced.
The Temno needle is a semi-automated biopsy device that requires manual advancement of the trocar to expose the side notch. With pressure on its plunger, an automated biopsy action rapidly advances the cutting cannula over the specimen-containing side notch of the trocar.
Biopsy procedure
All procedures were performed after written informed consent was obtained from the patients. Our institution does not require institutional review board approval for retrospective review of previously collected data such as in the present study.
All patients had undergone diagnostic CT scans of the chest with 5 mm thick contiguous axial tomographic sections before undergoing biopsy. At the time of the biopsy, preliminary helical CT scan images (X Vigor Laudator; Toshiba Medical System, Tokyo, Japan) were obtained in 5 mm thick sections through the lesion. From a review of these preliminary images, the patient’s position, level of the needle entry site and direction of the approach were planned to provide the most direct route for the biopsy, to traverse the least amount of aerated lung and to avoid bullae and fissures. The procedure was performed by one of six interventional radiologists who were experienced in CT scan-guided biopsy. A CT fluoroscopic imaging system was used for all CT scan-guided biopsy procedures. Details of CT fluoroscopy have been described elsewhere [14]. Imaging parameters during CT fluoroscopy included a CT beam width collimated to 3 mm, tube voltage with a 120 kV peak, current of 30–50 mA and scanning speed of 0.75 s per rotation (360°). An operator wearing a protective lead apron in the CT room was responsible for control of the CT fluoroscopic exposure via a foot pedal, assisted in table movement and gantry tilt, and directed the laser light beam via the control panel. The control panel was covered with a sterile transparent drape when a single operator performed the procedure. Alternatively, an assistant would help by adjusting the controls. An intermittent real-time CT fluoroscopic technique was preferred while advancing the biopsy needle using the I–I device (Hakko, Tokyo, Japan) that was developed to assist in precisely advancing the needle while avoiding irradiation to the operator's hands [15]. This technique was performed in a stepwise manner [16] with quick application of CT fluoroscopy to confirm the path of the needle while meticulous care was taken to minimise direct radiation to the operator's hands. Patients who could not cooperate with breath-holding underwent the procedure during usual respiration. After confirming that the needle tip had reached the lesion, a specimen was obtained and the needle was withdrawn. When the operator was uncertain as to whether the needle tip had reached the lesion or whether the specimen was insufficient, re-biopsy was performed. An on-site cytopathologist was not present during the procedure, and frozen-section analysis cannot be performed at the time of biopsy at our institution.
All biopsy procedures were performed under local anaesthesia. After the biopsy procedure, axial CT images were obtained during a single breath-hold through the level of the biopsy or, if necessary, through the whole chest using helical CT scanning to determine the presence of complications such as pneumothorax. While still on the scanner table, patients with a moderate or severe pneumothorax or with symptoms of pneumothorax underwent immediate manual aspiration of air from the pleural space by an 18 gauge intravenous catheter. When the pneumothorax did not decrease, or even increased despite manual aspiration, a chest tube was placed.
Specimens obtained by core biopsy were evaluated histologically. All histological evaluations were performed by experienced chest cytopathologists. They were required not only to classify obtained specimens as positive or negative for malignancy but also to identify specific cell types, if possible.
Investigated variables
The following dependent variables were retrospectively investigated: (1) technical success rate, (2) rate of success in obtaining sufficient samples for histopathological evaluation, (3) ability to determine whether the lesion was malignant (i.e. accuracy, sensitivity, specificity, positive predictive value, negative predictive value) and (4) rate of complications. Technical success was declared when it was confirmed that the target was hit or was penetrated with the needle as shown on the CT fluoroscopic image. The biopsy was deemed inadequate if specimens collected contained only blood or normal lung cells. Histological findings of percutaneous lung biopsy were compared with the final diagnosis obtained after needle biopsy by independent surgical pathology or clinical follow-up. Inadequate specimens obtained by percutaneous lung biopsies were defined as “no malignancy” in this study. Final diagnosis of a malignant lesion was accepted if the patient was treated for malignancy and the subsequent clinical course and response to therapy were appropriate. Final diagnosis of a benign lesion was accepted if one of the following three conditions was satisfied: (1) spontaneous resolution; (2) resolution after treatment for conditions other than cancer, such as antibiotic treatment; and (3) no change in lesion size for more than 24 months. As to complications, the incidence of pneumothorax, haemosputum and haemothorax was evaluated. Haemothorax was defined as a new pleural effusion after biopsy that was confirmed by CT performed immediately after biopsy. With regard to pneumothorax, the rates of administration of manual aspiration and tube placement were investigated.
All dependent variables were compared between the Monopty group and the Temno group. Excluded from the analysis were biopsy procedures that were performed on the same day for 2 nodules in each of 4 patients using the Temno needle and the 14 biopsies that were performed using the Monopty needle after initial biopsies with the Temno needle. In summary, 116 biopsies (Monopty, n=50; Temno, n=66) were analysed. The ability to determine whether the lesion was malignant or benign was investigated for cases in which the final diagnosis could be obtained (n=96; Monopty, n=42; Temno, n=54). The rate of complications was investigated for patients who did not undergo an additional biopsy procedure with the Monopty needle on the same day as an initial biopsy was performed with the Temno needle (n=110; Monopty, n=50; Temno, n=60).
Statistical analysis
Patient characteristics as well as lung nodule characteristics in the Monopty and the Temno groups were compared using the χ2 test or Fisher's exact test if the characteristics were qualitative and by the Wilcoxon rank-sum test if the characteristics were quantitative. All variables investigated were compared between the two groups using the χ2 test or Fisher's exact test.
For statistical analysis, commercial software (JMP 5.1; SAS Japan, Tokyo, Japan) was used. A p<0.05 was considered to indicate a statistically significant difference for all analyses.
Results
The mean age, number of females, mean diameter of the lesion, mean depth as measured from the pleural surface to the edge of the mass, average number of punctures in a single biopsy procedure, and the rate of the presence of emphysema in each group are shown in Table 1. There was no significant difference between the two groups except for the number of punctures in a single biopsy procedure. The number of punctures in the Temno group was greater than in the Monopty group [2 (1–3) vs 1 (1–3)] (p<0.01). Table 2 shows the specific cell types of lesions obtained by percutaneous lung biopsy performed with each needle, and Table 3 shows the comparison between the two groups according to results of the final diagnosis. The rate of malignant lesions in the Temno group was higher than in the Monopty group [87% (47/54) vs 61.9% (26/42)] (p<0.01).
Table 1. Baseline characteristics of patients and tumours.
| Monopty (n=50) | Temno (n=66) | Statistical test | p-valuea | |
| Age, years (range)b | 63.0±13.1 (33–90) | 67.1±10.7 (42–84) | Wilcoxon test | 0.09 |
| Female, no. (%) | 24 (48.0) | 26 (39.4) | χ2 test | 0.35 |
| Size of lesion, mm, (range)b | 17.6±14.6 (4–67) | 21.0±14.9 (4–80) | Wilcoxon test | 0.05 |
| Depth of lesion, mm, (range)b | 20.9±19.0 (0–73) | 23.7±18.3 (0–72) | Wilcoxon test | 0.36 |
| Punctures, no., (range)c | 1 (1–3) | 2 (1–3) | Fisher’s exact test | <0.01 |
| Emphysema, no. (%) | 13 (26.0) | 23 (34.9) | χ2 test | 0.31 |
ap<0.05 was considered to indicate a statistically significant difference.
bData are the means±standard deviation.
cData are the median.
Table 2. Characterisation of specific cell types obtained by percutaneous lung biopsy.
| Diagnosed specific cell type | Monopty (n) | Temno (n) |
| Malignancy | 27 | 42 |
| Primary lung cancer | ||
| Adenocarcinoma | 10 | 19 |
| Bronchioalveolar carcinoma | 1 | 3 |
| Squamous cell carcinoma | 3 | 2 |
| Small cell carcinoma | 0 | 3 |
| Large cell carcinoma | 0 | 2 |
| Non-small cell carcinoma | 2 | 2 |
| Acinar cell carcinoma | 1 | 0 |
| Metastatic lung cancer | 8 | 10 |
| Others | ||
| Desmoplastic mesothelioma | 0 | 1 |
| Metaplastic thymoma | 1 | 0 |
| Malignancy | 1 | 0 |
| No malignancy | 23 | 24 |
| Granuloma | 3 | 2 |
| Sarcoidosis | 0 | 1 |
| Tuberculoma | 0 | 1 |
| Pneumonia | 8 | 3 |
| Fungal infection | 1 | 1 |
| Chronic organising pneumonia | 1 | 0 |
| Inflammatory and necrotic nodule | 1 | 0 |
| Abscess | 2 | 0 |
| Fibrosis | 5 | 4 |
| Nodular lymphoid hyperplasia | 1 | 0 |
| Epithelial proliferation | 1 | 0 |
| Necrotic lesion | 0 | 1 |
| Lung tissue | 0 | 2 |
| Inadequate sample | 0 | 9 |
| Total | 50 | 66 |
Table 3. Tumours in which the final diagnosis was obtained.
| Final diagnosis | Monopty (n=42) | Temno (n=54) | Statistical test | p-valuea |
| Benign, no. (%) | 16 (38.1) | 7 (13.0) | ||
| Malignant, no. (%) | 26 (61.9) | 47 (87.0) | χ2 test | <0.01 |
ap<0.05 was considered to indicate a statistically significant difference.
Table 4 shows the results of the analysis of the dependent variables that were investigated. The technical success rate and rate of each complication did not differ significantly between the Monopty group and the Temno group. However, sufficient samples for histopathological evaluation were obtained in all 50 (100%) of the 50 biopsies in the Monopty group and in 55 (83.3%) of the 66 biopsies in the Temno group (p<0.01), indicating a significantly lower rate of success in the Temno group than in the Monopty group. In the Temno group, the mean (±SD) size of the lesion in the 11 cases in which the samples obtained were insufficient was 13.3±7.4 mm (range 4–24 mm), whereas the mean size of the lesions in the other 55 cases in which adequate samples were obtained was 22.5±15.6 mm (range 7–80 mm) (p=0.06). With regard to the ability to determine whether the lesion was malignant, accuracy, sensitivity and negative predictive value were 97.6%, 96.2% and 94.1%, respectively, in the Monopty group and 83.3%, 80.9% and 43.8%, respectively, in the Temno group. The accuracy and negative predictive value in the Temno group were significantly lower than in the Monopty group (p=0.04 and p<0.01, respectively), and sensitivity in the Temno group tended to be lower than in the Monopty group (p=0.09). Moreover, adequate specimens for diagnosis were obtained in 14 biopsies using the Monopty needle after initial biopsies with the use of the Temno needle did not provide sufficient specimens for histopathological evaluations or were thought not to have yielded a sufficient specimen.
Table 4. Statistical comparison of variables between the Monopty and Temno groups.
| Monoptya | Temnoa | Analysis | p-valueb | |
| Technical success rate | 100 (50/50) | 98.5 (65/66) | Fisher’s exact test | 0.99 |
| Sufficient sample | 100 (50/50) | 83.3 (55/66) | Fisher’s exact test | <0.01 |
| Accuracy | 97.6 (41/42) | 83.3 (45/54) | Fisher’s exact test | 0.04 |
| Sensitivity | 96.2 (25/26) | 80.9 (38/47) | Fisher’s exact test | 0.09 |
| Specificity | 100 (16/16) | 100 (7/7) | NA | NA |
| Positive predictive value | 100 (25/25) | 100 (38/38) | NA | NA |
| Negative predictive value | 94.1 (16/17) | 43.8 (7/16) | Fisher’s exact test | <0.01 |
| Pneumothorax | 44.0 (22/50) | 48.3 (29/60) | χ2 test | 0.65 |
| Manual aspiration | 10.0 (5/50) | 8.3 (5/60) | Fisher’s exact test | 0.99 |
| Tube placement | 10.0 (5/50) | 3.3 (2/60) | Fisher’s exact test | 0.24 |
| Haemosputum | 10.0 (5/50) | 8.3 (5/60) | Fisher’s exact test | 0.99 |
| Haemothorax | 6.0 (3/50)c | 3.3 (2/60) | Fisher’s exact test | 0.66 |
NA, not available.
aValues are given as the percentage (%) and numbers are in parentheses.
bp<0.05 was considered to indicate a statistically significant difference.
cOne patient required tube placement for drainage.
Discussion
CT scan-guided lung biopsy is widely accepted as the principal method for evaluating lung nodules. Currently, the automated cutting needle in tissue-core biopsy is considered to be useful for obtaining specimens of lung nodules for histological evaluation [17]. There are numerous automated cutting needles, and comparisons of performance of various automated biopsy needles have been made [12,13,18-20]. Hopper et al [12] evaluated 20 different automated biopsy needles for use in fresh autopsy cases and reported that performance of the semi-automated biopsy needles, including the Temno needle, was worse than that of the fully automated biopsy needles, including the Monopty needle. In a comparison of seven large-core biopsy needles for yield of breast tissue, Krebs et al [13] noted that the Temno needle obtained smaller volumes of tissue than the Monopty needle, although the difference in volume was not significant. Although evaluations of the abilities of different types of biopsy needles have been reported as noted above, a comparison between a fully automated biopsy needle and semi-automated biopsy needle for CT scan-guided lung biopsy has not been reported.
There are many reports of lung biopsy performed by automated cutting needles [5-11,21-24]. The rate of success in obtaining an adequate specimen and accuracy of this method to diagnose malignancy were reported to be 90–100% [5,7,9,21,23] and 64–95% [5-10,21,23], respectively. Hayashi et al [9], in a review of 52 biopsies for lung nodules smaller than 3 cm by the Temno needle, reported that both the rate of success in obtaining sufficient samples for frozen-section diagnosis and the accuracy were 90% (47/52 cases). In the five cases in which samples were insufficient, the lesion was 1.8 cm or smaller. The first samples were sufficient in 44 of the 47 (84%) cases. On the other hand, among previous reports of evaluations of automated cutting needles for lung biopsy, to our knowledge none has evaluated the Monopty needle.
The most common complication of CT scan-guided lung biopsy is pneumothorax, with a frequency ranging from 17.9% [25] to 54.3% [7,25,26-32]. Haemoptysis is also well known as a biopsy-induced complication, with a frequency ranging from 2.0% [32] to 10.1% [6].
In the present study, the rate of success in obtaining sufficient samples for histopathological evaluation and the accuracy and negative predictive value using the Temno needle were significantly worse than with the Monopty needle. These results are similar to those of investigations for autopsy or breast tissue [12,13]. The rate of success in obtaining sufficient samples in the Temno group (83.3%) was slightly lower than in the report by Hayashi et al (90%) [9]. The fact that frozen-section analysis cannot be performed at the time of biopsy in our study might have influenced this result, since the rate of success in diagnosis of the first sample in the report by Hayashi et al [9] was similar to ours (84%). Moreover, in cases in which samples were insufficient, the size of the lesion tended to be small in both the present study and the previous study [9]. We presume that one of the reasons for failure to obtain sufficient samples is that the nodule migrates slightly at the moment of manual advancement of the trocar because of looseness of lung tissue around the nodule and low thrust of the trocar in lung biopsy using the Temno needle.
In our study, the most frequent complication was pneumothorax in both groups (Monopty group, 44.0%; Temno group, 48.3%), which is similar to those in previous reports [7,25,26-32]. Also, the complication rates did not differ significantly between procedures using these two needles and were similar to those in previous reports of lung biopsy.
There are some limitations to this study. This was a non-randomised retrospective and observational study with a small number of subjects. There are differences in the distribution of characteristics of nodules in that the Monopty group included more benign lesions. Also, the numbers of both subjects and lesions were too small to attempt multivariate analysis to adjust for baseline characteristics of patients and tumours. However, we believe that our study is important for interventional radiologists in the thoracic field because some of the information presented here has never, or only seldom, been seen before. Previous reports have mentioned the need to determine the specific cell type in benign lesions as well as in malignant lesions [21]. Otherwise, for example, a diagnosis of simply “negative for malignancy” would indicate the necessity for long-term follow-up or biopsy with another procedure [7]. In the present study, the specific cell type could be characterised in 96% (26/27) of malignant lesions and 100% (23/23) of benign lesions that were evaluated histologically in the Monopty group and in 100% (42/42) of malignant lesions and 54% (13/24) of benign lesions in the Temno group. Moreover, the specific cell type was determined in 14 biopsies using the Monopty needle after initial biopsies with the Temno needle did not provide sufficient specimens for histopathological evaluations or were thought not to have yielded a sufficient specimen.
From the results of our study, there is a possibility that a fully automated biopsy needle such as the Monopty is more useful for CT scan-guided lung biopsy than semi-automated biopsy needles.
References
- 1.Westcott JL. Percutaneous transthoracic needle biopsy. Radiology 1988;169:593–601 [DOI] [PubMed] [Google Scholar]
- 2.Li H, Boiselle PM, Shepard JO, Trotman-Dickenson B, McLoud TC. Diagnostic accuracy and safety of CT-guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules. AJR Am J Roentgenol 1996;167:105–9 [DOI] [PubMed] [Google Scholar]
- 3.Austin JH, Cohen MB. Value of having a cytopathologist present during percutaneous fine-needle aspiration biopsy of lung: report of 55 cancer patients and meta-analysis of the literature. AJR Am J Roentgenol 1993;160:175–7 [DOI] [PubMed] [Google Scholar]
- 4.Greene R, Szyfelbein WM, Isler RJ, Stark P, Jantsch H. Supplementary tissue-core histology from fine-needle transthoracic aspiration biopsy. AJR Am J Roentgenol 1985;144:787–92 [DOI] [PubMed] [Google Scholar]
- 5.Haramati LB. CT-guided automated needle biopsy of the chest. AJR Am J Roentgenol 1995;165:53–5 [DOI] [PubMed] [Google Scholar]
- 6.Lucidarme O, Howarth N, Finet JF, Grenier PA. Intrapulmonary lesions: percutaneous automated biopsy with a detachable, 18-gauge, coaxial cutting needle. Radiology 1998;207:759–65 [DOI] [PubMed] [Google Scholar]
- 7.Klein JS, Salomon G, Stewart EA. Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients. Radiology 1996;198:715–20 [DOI] [PubMed] [Google Scholar]
- 8.Tsukada H, Satou T, Iwashima A, Souma T. Diagnostic accuracy of CT-guided automated needle biopsy of lung nodules. AJR Am J Roentgenol 2000;175:239–43 [DOI] [PubMed] [Google Scholar]
- 9.Hayashi N, Sakai T, Kitagawa M, Kimoto T, Inagaki R, Ishii Y, et al. CT-guided biopsy of pulmonary nodules less than 3 cm: usefulness of the spring-operated core biopsy needle and frozen-section pathologic diagnosis. AJR Am J Roentgenol 1998;170:329–31 [DOI] [PubMed] [Google Scholar]
- 10.Boiselle PM, Shepard JA, Mark EJ, Szyfelbein WM, Fan CM, Slanetz PJ, et al. Routine addition of an automated biopsy device to fine needle biopsy of the lung: a prospective assessment. AJR Am J Roentgenol 1997;169:661–6 [DOI] [PubMed] [Google Scholar]
- 11.Arakawa H, Nakajima Y, Kurihara Y, Niimi H, Ishikawa T. CT-guided transthoracic needle biopsy: a comparison between automated biopsy gun and fine needle aspiration. Clin Radiol 1996;51:503–6 [DOI] [PubMed] [Google Scholar]
- 12.Hopper KD, Abendroth CS, Sturtz KW, Matthews YL, Stevens LA, Shirk SJ. Automated biopsy devices: a blinded evaluation. Radiology 1993;187:653–60 [DOI] [PubMed] [Google Scholar]
- 13.Krebs TL, Berg WA, Severson MJ, Magder LS, Goldberg PA, Campassi C, et al. Large-core biopsy guns: comparison for yield of breast tissue. Radiology 1996;200:365–8 [DOI] [PubMed] [Google Scholar]
- 14.Katada K, Kato R, Anno H, Ogura Y, Koga S, Ida Y, et al. Guidance with real-time CT fluoroscopy: early clinical experience. Radiology 1996;200:851–6 [DOI] [PubMed] [Google Scholar]
- 15.Irie T, Kajitani M, Matsueda K, Arai Y, Inaba Y, Kujiraoka Y, et al. Biopsy of lung nodules with use of I-I device under intermittent CT fluoroscopic guidance: preliminary clinical study. J Vasc Interv Radiol 2001;12:215–19 [DOI] [PubMed] [Google Scholar]
- 16.Meyer CA, White CS, Wu J, Futterer SF, Templeton PA. Real-time CT fluoroscopy: usefulness in thoracic drainage. AJR Am J Roentgenol 1998;171:1097–101 [DOI] [PubMed] [Google Scholar]
- 17.Moulton JS, Moore PT. Coaxial percutaneous biopsy technique with automated biopsy devices: value in improving accuracy and negative predictive value. Radiology 1993;186:515–22 [DOI] [PubMed] [Google Scholar]
- 18.Mladinich CRJ, Ackerman N, Berry CR, Buergelt CD, Longmate J. Evaluation and comparison of automated biopsy device. Radiology 1992;184:845–7 [DOI] [PubMed] [Google Scholar]
- 19.Hopper KD, Baird DE, Reddy VV, Landis JR, Parker SH, Tyler HN, et al. Efficacy of automated biopsy guns versus conventional biopsy needles in the pygmy pig. Radiology 1990;176:671–6 [DOI] [PubMed] [Google Scholar]
- 20.Wagner HJ, Barth P, Schade-Brittinger C, Plein S, Klose KJ. Postmortem evaluation of four randomly selected automated biopsy devices for transthoracic lung biopsy. Cardiovasc Intervent Radiol 1995;18:300–6 [DOI] [PubMed] [Google Scholar]
- 21.Yamagami T, Iida S, Kato T, Tanaka O, Toda S, Kato D, et al. Usefulness of new automated cutting needle for tissue-core biopsy of lung nodules under CT fluoroscopic guidance. Chest 2003;124:147–54 [DOI] [PubMed] [Google Scholar]
- 22.Yamagami T, Iida S, Kato T, Tanaka O, Nishimura T. Combining fine-needle aspiration and core biopsy under CT fluoroscopy guidance: a better way to treat patients with lung nodules? AJR Am J Roentgenol 2003;180:811–15 [DOI] [PubMed] [Google Scholar]
- 23.Yoshimatsu R, Yamagami T, Kato T, Hirota T, Matsumoto T, Shimada J, et al. Percutaneous needle biopsy of lung nodules under CT fluoroscopic guidance with use of the “I-I device”. Br J Radiol 2008;81:107–12 [DOI] [PubMed] [Google Scholar]
- 24.Westcott JL, Rao N, Colley DP. Transthoracic needle biopsy of small pulmonary nodules. Radiology 1997;202:97–103 [DOI] [PubMed] [Google Scholar]
- 25.Laurent F, Latrabe V, Vergier B, Michel P. Percutaneous CT-guided biopsy of the lung: comparison between aspiration and automated cutting needle using a coaxial technique. Cardiovasc Intervent Radiol 2000;23:266–72 [DOI] [PubMed] [Google Scholar]
- 26.Yamagami T, Nakamura T, Iida S, Kato T, Nishimura T. Management of pneumothorax after percutaneous CT-guided lung biopsy. Chest 2002;121:1159–64 [DOI] [PubMed] [Google Scholar]
- 27.Kazerooni EA, Lim FT, Mikhail A, Martinez FJ. Risk of pneumothorax in CT-guided transthoracic needle aspiration biopsy of the lung. Radiology 1996;198:371–5 [DOI] [PubMed] [Google Scholar]
- 28.Cox JE, Chiles C, McManus CM, Aquino SL, Choplin RH. Transthoracic needle aspiration biopsy: variables that affect risk of pneumothorax. Radiology 1996;212:165–8http://radiology.rsna.org/content/212/1/165.Abstract/FREEFullText [DOI] [PubMed] [Google Scholar]
- 29.Laurent F, Michel P, Latrabe V, Tunon deLara M, Marthan R. Pneumothorax and chest tube placement after CT-guided transthoracic lung biopsy using coaxial technique: incidence and risk factors. AJR Am J Roentgenol 1999;172:1049–53 [DOI] [PubMed] [Google Scholar]
- 30.Cattelani L, Campodonico F, Rusca M, Solli P, Carbognani P, Spaggiari L, et al. CT-guided transthoracic needle biopsy in the diagnosis of chest tumors. J Cardiovasc Surg (Torino) 1997;38:539–42 [PubMed] [Google Scholar]
- 31.Collings CL, Westcott JL, Banson NL, Lange RC. Pneumothorax and dependent versus nondependent patient position after needle biopsy of the lung. Radiology 1999;210:59–64 [DOI] [PubMed] [Google Scholar]
- 32.Haramati LB, Austin JHM. Complication after CT-guided needle biopsy through aerated versus non-aerated lung. Radiology 1991;181:778. [DOI] [PubMed] [Google Scholar]