A paravertebral approach for CT-guided percutaneous biopsy of presumably inaccessible, posterior and centrally located pulmonary nodules

Abstract

Introduction: To present 3 cases were a paravertebral approach had to be used for the biopsy of posterior and centrally located pulmonary nodules. Case presentation: Three patients underwent percutaneous CT-guided transthoracic biopsy of pulmonary nodules that were initially thought to be inaccessible because of their central, posterior location by a paravertebral approach. The first 2 patients had a history of extra thoracic malignancy and the third patient presented with a bone metastasis and an isolated pulmonary nodule in the right lower lobe, corresponding to potential stage IV lung cancer. Biopsy was feasible in all 3 patients using the paravertebral approach. Pulmonary metastases were confirmed in the first 2 patients, while a TTF-1 positive pulmonary adenocarcinoma was diagnosed in the last patient. No complications occurred. Conclusion: A paravertebral approach is feasible for posterior and centrally located pulmonary nodules.

Keywords: Lung cancer; Paravertebral biopsy; Pulmonary nodule biopsy.

Fig. 1

Unenhanced CT scan showing pulmonary nodules in both lower lobes. (A) Lung window. The main nodule is located in the right lower lobe (white arrow) in a very central position. (B) On the mediastinal window, the nodule (white arrow) appears in close contact with the retrohepatic segment of the inferior vena cava. (C) With the patient placed in the contralateral decubitus position, access to the nodule is possible along the right paravertebral space and the coaxial needle reaches the lung nodule after crossing a very limited portion of normal aerated lung. (D) There were no complications after coaxial needle withdrawal; a small amount of intra-alveolar hemorrhage is seen along the needle path.

Fig. 2

Unenhanced CT scan showing a 13-mm right lower lobe pulmonary nodule. (A) The nodule (white arrow) is in a prevertebral, peripheral location. (B) The coaxial needle is inserted between the rib and the transverse process of the vertebra and reaches the target lesion without crossing normal aerated lung.

Fig. 3

Unenhanced CT showing a single pulmonary nodule in the right lower lobe (white arrow). (A) In the supine position, the nodule seems impossible to reach because of its central location in the para-azygos recess, between the vein for the upper segment of the right lower lobe (V6) and the esophagus. (B) With the patient placed in left lateral decubitus position, the lung nodule can be reached through the right paravertebral space.