title: Imaging-guided percutaneous biopsy of mediastinal lesions: different approaches and anatomic considerations.
abstract: Percutaneous needle biopsy with imaging guidance allows access to lesions in virtually all mediastinal locations. A direct mediastinal approach, which enables extrapleural needle placement, is the preferred method to avoid the risk of pneumothorax. Techniques that allow extrapleural access include the parasternal, paravertebral, transsternal, and suprasternal approaches, which are performed with computed tomographic or ultrasonographic guidance. The parasternal approach is used for biopsy of anterior or middle mediastinal lesions when the lesion or intervening mediastinal fat extends to the anterior chest wall, lateral to the sternum; injury to the internal mammary vessels is a potential complication. The paravertebral approach is used for biopsy of subcarinal and other posterior mediastinal lesions; saline solution is often injected to widen the mediastinum. The transsternal approach, which involves needle placement through the sternum, is used for biopsy of anterior or middle mediastinal lesions that are not accessible with the parasternal approach. Biopsy of superior mediastinal lesions can be performed with a suprasternal approach. An alternative to these direct mediastinal approaches involves advancing the needle through a pleural space created by an existing pleural effusion or iatrogenic pneumothorax. Another alternative is the transpulmonary approach, which involves transgression of the lung and visceral pleura by the needle and is associated with a substantial risk of pneumothorax.
authors.affiliation: Department of Diagnostic Radiology, Unit 325, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA. sgupta@mdanderson.org
authors.forename: Sanjay
authors.initials: S
authors.lastname: Gupta
authors.forename: Karen
authors.initials: K
authors.lastname: Seaberg
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Wallace
authors.forename: David C
authors.initials: DC
authors.lastname: Madoff
authors.forename: Frank A
authors.initials: FA
authors.lastname: Morello
authors.forename: Kamran
authors.initials: K
authors.lastname: Ahrar
authors.forename: Ravi
authors.initials: R
authors.lastname: Murthy
authors.forename: Marshall E
authors.initials: ME
authors.lastname: Hicks
mesh_terms: D001707:Biopsy, Needle / Q000009:adverse effects / Q000379:methods; D006801:Humans; D008479:Mediastinal Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography