The clinical role and use of percutaneous transthoracic needle biopsy (TTNB) and ablation of lung tumors are evolving. Here we discuss important considerations for referring providers, including current and emerging indications supported by guidelines, critical aspects of pre and postprocedure patient management, and expected postprocedure imaging findings.

BACKGROUND: Molecular testing can detect actionable genomic alterations and tumor cell surface proteins in patients with non-small cell lung cancer (NSCLC). However, utilization remains suboptimal, representing missed treatment opportunities. This study aimed to identify challenges and potential solutions to obtaining percutaneous lung needle biopsy specimens for successful molecular testing in patients with advanced NSCLC.
METHODS: This interdisciplinary qualitative study included ten radiologists and four pathologists from academic and community settings across the United States who routinely perform and analyze percutaneous lung needle biopsies. Participants underwent semi-structured one-on-one interviews (Phase 1). Interview questionnaires were constructed based on a literature review of key lines of inquiry and conducted by professional market researchers using the theoretical domains framework. Primary barriers to molecular testing were identified using thematic analysis. Subsequently, multidisciplinary focus groups were convened to identify potential solutions (Phase 2).
RESULTS: Four themes emerged as barriers to molecular testing and were matched to the clinical workflow: (1) biopsy request, (2) biopsy procedure, (3) specimen analysis, and (4) communication. The nineteen potential solutions included adding a \"checkbox\" to indicate molecular testing in the biopsy request, leveraging pre-procedural imaging to guide biopsies, conserving tissue through appropriate allocation strategies and next generation sequencing panels instead of sequential single-gene assays, instituting reflex-molecular testing upon NSCLC diagnosis, tracking and communicating biopsy outcomes at multidisciplinary tumor boards, and improving integration of radiologists and pathologists into oncology care teams.
CONCLUSIONS: Potential solutions exist to increase successful molecular testing of lung needle biopsy specimens in patients with advanced NSCLC.

Image-guided lung needle biopsy allows for minimally invasive diagnosis of lung pathology. In the setting of suspected malignancy, the biopsy not only confirms the diagnosis but also allows for molecular profiling, a requisite for tailored systemic therapy. Needle biopsy can also characterize non-neoplastic entities such as infections not responding to treatment and other inflammatory processes. A successful and safe lung needle biopsy starts with lesion and patient selection and careful pre-procedural evaluation. Here we review the indications and contraindications, diagnostic alternatives, approach planning and sequential procedural steps with the goal of maximizing both yield and patient safety. We discuss technical tips for preventing complications such as pleural anesthesia, the saline seal, the blood patch, the banana bend, hydro dissection, and the rapid needle out/patient rollover maneuver. We also review how to manage complications, avoid non-diagnostic biopsies, and provide recommendations for post-procedural observation and imaging follow-up.

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