Fine
Needle
Aspiration
Biopsy
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
ALEXANDER
in the Diagnosis
ROSENBERGER1
In the presence of a mediastinal mass, fine needle aspiration biopsy is an alternative to other time-consuming and expensive diagnostic procedures. We have performed a total of 25 fine needle aspiration biopsies of mediastinal lesions in 18 patIents. Although our material is too limited to reach definite conclusions as to risks, we have found the technique enables
a high
tolerated
by the
We describe aspiration nation is cytologic Fine needle a valuable peripheral technique
percentage
of positive
diagnoses
and
AND
tion tinal
field
of the needle,
the aspirate
Illustrative Case
fixed
done;
Case
onto
96% alcohol.
from
healthy
showed as
was
was
Fine needle
the diagnosis
patient
the
second
needle
male
referred
patient,
no pulsations. examination
aspiration
Physical of
biopsy
was negative. the sternum
was reticulum to the oncologic
a routine
a polycyclic mass in the into the right upper lung the
exami-
sputum
yielded
and
reticulum
During hospitalization, from which biopsy was
cell type lymphoma. The department for treatment.
8
This
was blown in
mass
negative
cells. Pedal lymphography a bulge developed above
A total of 25 fine needle aspiration biopsies of mediastinal masses were performed in 18 patients (table 1). The location and depth of the lesions were determined on posteroanterior and lateral chest radiographs. In many cases tomography was also employed to detect calcification. The most suitable puncture site was identified under single phase television-monitored fluoroscopy, and was always the shortest distance from the skin to the lesion. After the skin was sterilized a 22 gauge needle was introduced vertically into the lesion near the upper edge of the ribs, while the patient maintained shallow breathing. Often an increased tissue resistance could be felt when the needle tip was in the desired position. Following needle placement, a 10-20 ml syringe was connected to the needle, and several suction movements were performed with the plunger and slight rotation of the needle tip. removal
otherwise
2). The
was
bronchoscopy.
Methods
dry glass plates and immediately cessful procedures were repeated.
diagnosis
examinations.
28-year-old
(fig.
nation
Case
After
cytologic
employment chest radiograph detected upper anterior mediastinum protruding
the technique and results of 25 fine needle biopsies of mediastinal lesions. This examiwell tolerated by the patient and provides diagnosis in a relatively easy and rapid way. aspiration biopsy of the lung has been found method of assessing cytologic diagnosis in lung lesions [1-4]. We have applied the same in the diagnosis of mediastinal masses.
and
The
6
In this
Materials
ADLER’
additional
Case
patient.
Lesions
was oat cell carcinoma metastasizing into the mediasnodes. As a result of this diagnosis, therapy was instituted
without
is well
OLGA
biopsy.
biopsy
of Mediastinal
55-year-old
male
patient
complained
of back
pain
for
some months; the pain became more severe in the 2 weeks before study. Radiographs of the chest and thoracic spine showed a round mass in the left posterior mediastinum at the height of T8 (figs. 3A and 3B). The mass was well delineated,
clean
Unsuc-
Reports
5
A 62-year-old male had undergone laryngectomy for carcinoma of the larynx 6 years earlier when a permanent tracheostomy cannula was placed. For several months he had complained signs
of shortness compatible
examination
of breath.
with
including
superior
Physical vena
cytology
cava
examination syndrome.
of the sputum
revealed Laboratory
were
negative.
A
chest radiograph (fig. 1) showed widening of the right anterior superior mediastinum with slightly polycyclic borders. The mass was not pulsatile under fluoroscopic examination. Mediastinoscopy
was referred
Received
August
‘Department Address
was thought
to the radiology
reprint
Am J Ro.ntg.nol © 1978 American
10, 1977;
of Diagnostic requests
to 0.
to pose
department
accepted
Radiology,
after
a risk,
and the patient
for fine needle
revision
Rambam
Fig. 1.-Case
aspira-
March
29, 1978.
Medical
Center,
widened
Abba Khoushy
School
right
5. Posteroanterior superior mediastinum.
of Medicine,
Israel Institute
chest
radiograph
of Technology,
showing
Haifa,
Israel.
Adler.
131:239-242, August Roentgen Ray Society
1978
239
0361
-803X/78/08-0239
$00.00
ROSENBERGER
240
AND
TABLE Summary Case
Age and
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
0.
Clinical
ex
Findings
ADLER
1 of Cases
Radiologic
Findings
Cytologic
Complications,
Diagnosis
Remarks
1
.
.
.48,F
Pain
2
.
.
.47,F
Mastectomy
3
.
.
.50,F
4
.
.
.52,M
Dyspnea, superior drome Cough, pain
5
.
.
.62,M
6
.
.
.28,M
7
.
.
.72,F
Dyspnea; drome
8
.
.
.55,M
Back pain
9
. .
.17,M
10
.
.
.28,M
Cough
ii
.
,
.32,M
Cough
vena
cava
Larynx carcinoma, dyspnea, nor vena cava syndrome
superior
vena
syn-
supe-
cava
syn-
Widened left anterosuperior mediastinum Widened left anterosuperior mediastinum Widened right posterosuperior mediastinum Lobulated right anterosuperior tumor Widened right anterosuperior mediastinum Polycyclic right anterosuperior tumor Widened right anterosuperior mediastinum, pleural effusion Round left posterosuperior mass, destruction body T8 Bilateral anterosuperiorwidening of mediastinum Round right anterosuperior tumor Polycyclic right anterosuperior
12
. .
.18,M
Fever
13
.
.
.34,F
Fever
14
.
.
.52,M
Superior
15
.
.
.69,M
Cough,
pain
16
.
.
.70,M
Weight
loss, cough
17
.
.
.27,M
18
.
.
.60,M
Superior
mass
vena cava syndrome
squamous
cell
.
.
anaplastic
car-
.
.
anaplastic
car-
Metastasis noma Lymphoma
oat
Metastasis noma
oat
cell
Pneumothorax Surgery
carci-
.
.
.
.
.
.
Myeloma
.
.
Lymphoma
.
.
Benign
cell
carci-
teratoma
Metastasis
squamous
Surgery cell
.
.
carcinoma
Bilaterally widened anterosuperior mediastinum Bilaterally widened anterosuperior mediastinum Widened right anterosuperior mediastinum Huge mass right anterosuperior mediastinum Huge mass left anterosuperor mediastinum Bilaterally widened anterosuperior mediastinum; right pleural fluid Widened right anterosuperior
vena cava syndrome
Metastasis, carcinoma Metastasis, cinoma Metastasis, cinoma Thymoma
Insufficient
material
Insufficient
material
Squamous
cell carcinoma
.
Squamous
cell carcinoma
.
.
Squamous
cell carcinoma
.
.
Insufficient
material
Oat cell carcinoma
Surgery, Hodgkin’s Surgery, Hodgkin’s .
Surgery, Hodgkin’s .
.
mediastinum .
No signs or sym ptoms;
incidental
finding.
adjacent to the spine, and displaced the posterior paravertebral line laterally (fig. 3C). In the chest radiograph it protruded beyond the left hilum (fig. 3A). The intervertebral foramina of the dorsal vertebrae were normal in size, but the structure of the T8 vertebral body was osteoporotic; on tomography a motheaten type osteolytic lesion could be observed within it. Laboratory examinations were negative. Cytologic examination by fine needle aspiration biopsy showed cells characteristic of myeloma. A thorough examination for other sites of involvement was
ment, sion.
unrewarding,
the mass
and
bone
disappeared
marrow
was
normal.
and the patient
After
treat-
is now in remis-
Discussion
The diagnosis of mediastinal lesions may be based on radiologic examinations, bronchoscopy, mediastinoscopy, and sometimes thoracotomy. While most radiologic examinations are unable to provide histologic or cytologic diagnosis, bronchoscopy has a limited value in mediastinal lesions. Mediastinoscopy allows direct visualization and biopsy of the upper mediastinum and allows histologic diagnosis. However, the posterior me-
diastinum is inaccessible by this method. These procedures all require anesthesia. Nordenstr#{228}m introduced a paraxyphoid [5] and transjugular [6] approach to the anterior mediastinum and a paravertebral approach [7] to the posterior mediastinum; his method requires a cannula, guide wire, and catheter and enables biopsy, catheterization, and contrast examination of mediastinal structures. These methods have not gained widespread acceptance. In 1972 Klatte and Yune [8] reported two cases of pericardial cysts situated in the right anterior cardiophrenic angle which were punctured with a 20 gauge needle by an anterior approach through the fifth and seventh intercostal spaces and in 1970 Dahlgren and Ovenfors [9] reported biopsy of the posterior mediastinum to diagnose neu rogenous tumors. Our method is essentially the application of fine needle aspiration biopsy technique to the mediastinum. We have limited ourselves to masses situated in the anteriorsuperior or posterior mediastinum, and we have avoided puncturing lesions situated in the middle mediastinum which contain the large arteries and veins.
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
FINE
Fig. 2.-Case Right
lateral
chest
6. A, Posteroanterior radiograph showing
NEEDLE
BIOPSY
chest radiograph poorly defined
OF
MEDIASTINUM
241
showing small bulge protruding from right superior mass density in anterosuperior mediastinum (arrows).
____
Fig. 3.-Case situated
posteriorly.
8. Posteroanterior C, Anteroposterior
mediastinum.
B,
‘1
chest radiograph tomograph
showing of thoracic
well delineated spine
mass protruding
at T8 level.
Before biopsy, we make every effort to exclude the presence of a vascular lesion like an aortic aneurysm which could appear as a mediastinal mass. In the supenor vena cava syndrome a rich collateral circulation may be present and an incidental puncture of such a vessel
Posterior
beyond
left paravertebral
left hilar region. line is pushed
B, Lateral view showing away
from
spine
mass
by mass.
could occur. In our cases of superior vena cava obstruction, we believed fine needle aspiration biopsy of the mediastinum to be the most convenient and least traumatic procedure for the patient. There were no complications. In patients who underwent thoracotomy, no
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
242
ROSENBERGER
.hematoma or other traces of the puncture were detected by the surgeon following the procedure (H. Pelleg, personal communication). In our case material the only complication encountered was a small pneumothorax (case 3). In this patient three attempts were made to obtain sufficient aspirate for examination. In most of our patients one (and rarely two) punctures yielded enough material for cytology. In patients for whom fine needle aspiration biopsy failed to yield representative cell material (cases 12, 13, 17), the definitive diagnosis at surgery was Hodgkin’s disease, scleronodular type. In each case a stonelike resistance was felt as the needle was advanced. A similar experience has been de.cribed in percutaneous transabdominal fine needle aspiration biopsies of lymph nodes in Hodgkin’s disease, especially of the nodularsclerosing type [10]. REFERENCES 1. Fennessy JJ: Bronchographic criteria of inflammatory disease and radiologic lung biopsy techniques. Radiol C/in North Am 11:371-392,1973 2. Sinner WN: Transthoracic needle biopsy of small peripheral
AND
ADLER
malignant 3. Sinner
lung lesions. WN:
Wert
und
InvestRadiol 8:305-314, Bedeutung der perkutanen
1973 transtho-
rakalen Nadelbiopsien f#{252}r die Diagnose intrathorakaler Krankheitsprozesse Fortschr Gab R#{246}ntgenstr Nuk/earmed 123:203-206, 1975 .
4. Stevens
M,
Weigen
biopsy of localized roscopic guidance.
JF,
Lillington
pulmonary
Am J Roentgenol 5. Nordenstr#{228}m B: Paraxyphoid approach for mediastinography and mediastinal Radiol
2:i4i-i46,
8. 9.
10.
Needle
aspiration
with amplified fluo103 : 561-571 1968 ,
to the mediastinum needle biopsy. Invest
1967
6. Nordenstr#{244}m B: Transjugular
7.
GA:
lesions
approach
to the mediastinum
for mediastinal needle biopsy. Invest Radiol 2: 134-140, 1967 Nordenstr#{244}m B: Paravertebral approach to the posterior med iastinum for mediastinography and needle biopsy. Acta Radiol [Diagn] (Stockh) 13:298-304, 1972 Klatte EC, Yune HY: Diagnosis and treatment of pericardial cysts. Radiology 104: 541-544, 1972 Dahlgren SE, Ovenfors CO: Aspiration biopsy diagnosis of neurogenous mediastinum tumors. Acta Radiol [Diagn] (Stockh) 10:289-296, 1970 G#{244}thlinJH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy. Radiology 120:205-207, 1976
Needle
Aspiration
Biopsy
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
ALEXANDER
in the Diagnosis
ROSENBERGER1
In the presence of a mediastinal mass, fine needle aspiration biopsy is an alternative to other time-consuming and expensive diagnostic procedures. We have performed a total of 25 fine needle aspiration biopsies of mediastinal lesions in 18 patIents. Although our material is too limited to reach definite conclusions as to risks, we have found the technique enables
a high
tolerated
by the
We describe aspiration nation is cytologic Fine needle a valuable peripheral technique
percentage
of positive
diagnoses
and
AND
tion tinal
field
of the needle,
the aspirate
Illustrative Case
fixed
done;
Case
onto
96% alcohol.
from
healthy
showed as
was
was
Fine needle
the diagnosis
patient
the
second
needle
male
referred
patient,
no pulsations. examination
aspiration
Physical of
biopsy
was negative. the sternum
was reticulum to the oncologic
a routine
a polycyclic mass in the into the right upper lung the
exami-
sputum
yielded
and
reticulum
During hospitalization, from which biopsy was
cell type lymphoma. The department for treatment.
8
This
was blown in
mass
negative
cells. Pedal lymphography a bulge developed above
A total of 25 fine needle aspiration biopsies of mediastinal masses were performed in 18 patients (table 1). The location and depth of the lesions were determined on posteroanterior and lateral chest radiographs. In many cases tomography was also employed to detect calcification. The most suitable puncture site was identified under single phase television-monitored fluoroscopy, and was always the shortest distance from the skin to the lesion. After the skin was sterilized a 22 gauge needle was introduced vertically into the lesion near the upper edge of the ribs, while the patient maintained shallow breathing. Often an increased tissue resistance could be felt when the needle tip was in the desired position. Following needle placement, a 10-20 ml syringe was connected to the needle, and several suction movements were performed with the plunger and slight rotation of the needle tip. removal
otherwise
2). The
was
bronchoscopy.
Methods
dry glass plates and immediately cessful procedures were repeated.
diagnosis
examinations.
28-year-old
(fig.
nation
Case
After
cytologic
employment chest radiograph detected upper anterior mediastinum protruding
the technique and results of 25 fine needle biopsies of mediastinal lesions. This examiwell tolerated by the patient and provides diagnosis in a relatively easy and rapid way. aspiration biopsy of the lung has been found method of assessing cytologic diagnosis in lung lesions [1-4]. We have applied the same in the diagnosis of mediastinal masses.
and
The
6
In this
Materials
ADLER’
additional
Case
patient.
Lesions
was oat cell carcinoma metastasizing into the mediasnodes. As a result of this diagnosis, therapy was instituted
without
is well
OLGA
biopsy.
biopsy
of Mediastinal
55-year-old
male
patient
complained
of back
pain
for
some months; the pain became more severe in the 2 weeks before study. Radiographs of the chest and thoracic spine showed a round mass in the left posterior mediastinum at the height of T8 (figs. 3A and 3B). The mass was well delineated,
clean
Unsuc-
Reports
5
A 62-year-old male had undergone laryngectomy for carcinoma of the larynx 6 years earlier when a permanent tracheostomy cannula was placed. For several months he had complained signs
of shortness compatible
examination
of breath.
with
including
superior
Physical vena
cytology
cava
examination syndrome.
of the sputum
revealed Laboratory
were
negative.
A
chest radiograph (fig. 1) showed widening of the right anterior superior mediastinum with slightly polycyclic borders. The mass was not pulsatile under fluoroscopic examination. Mediastinoscopy
was referred
Received
August
‘Department Address
was thought
to the radiology
reprint
Am J Ro.ntg.nol © 1978 American
10, 1977;
of Diagnostic requests
to 0.
to pose
department
accepted
Radiology,
after
a risk,
and the patient
for fine needle
revision
Rambam
Fig. 1.-Case
aspira-
March
29, 1978.
Medical
Center,
widened
Abba Khoushy
School
right
5. Posteroanterior superior mediastinum.
of Medicine,
Israel Institute
chest
radiograph
of Technology,
showing
Haifa,
Israel.
Adler.
131:239-242, August Roentgen Ray Society
1978
239
0361
-803X/78/08-0239
$00.00
ROSENBERGER
240
AND
TABLE Summary Case
Age and
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
0.
Clinical
ex
Findings
ADLER
1 of Cases
Radiologic
Findings
Cytologic
Complications,
Diagnosis
Remarks
1
.
.
.48,F
Pain
2
.
.
.47,F
Mastectomy
3
.
.
.50,F
4
.
.
.52,M
Dyspnea, superior drome Cough, pain
5
.
.
.62,M
6
.
.
.28,M
7
.
.
.72,F
Dyspnea; drome
8
.
.
.55,M
Back pain
9
. .
.17,M
10
.
.
.28,M
Cough
ii
.
,
.32,M
Cough
vena
cava
Larynx carcinoma, dyspnea, nor vena cava syndrome
superior
vena
syn-
supe-
cava
syn-
Widened left anterosuperior mediastinum Widened left anterosuperior mediastinum Widened right posterosuperior mediastinum Lobulated right anterosuperior tumor Widened right anterosuperior mediastinum Polycyclic right anterosuperior tumor Widened right anterosuperior mediastinum, pleural effusion Round left posterosuperior mass, destruction body T8 Bilateral anterosuperiorwidening of mediastinum Round right anterosuperior tumor Polycyclic right anterosuperior
12
. .
.18,M
Fever
13
.
.
.34,F
Fever
14
.
.
.52,M
Superior
15
.
.
.69,M
Cough,
pain
16
.
.
.70,M
Weight
loss, cough
17
.
.
.27,M
18
.
.
.60,M
Superior
mass
vena cava syndrome
squamous
cell
.
.
anaplastic
car-
.
.
anaplastic
car-
Metastasis noma Lymphoma
oat
Metastasis noma
oat
cell
Pneumothorax Surgery
carci-
.
.
.
.
.
.
Myeloma
.
.
Lymphoma
.
.
Benign
cell
carci-
teratoma
Metastasis
squamous
Surgery cell
.
.
carcinoma
Bilaterally widened anterosuperior mediastinum Bilaterally widened anterosuperior mediastinum Widened right anterosuperior mediastinum Huge mass right anterosuperior mediastinum Huge mass left anterosuperor mediastinum Bilaterally widened anterosuperior mediastinum; right pleural fluid Widened right anterosuperior
vena cava syndrome
Metastasis, carcinoma Metastasis, cinoma Metastasis, cinoma Thymoma
Insufficient
material
Insufficient
material
Squamous
cell carcinoma
.
Squamous
cell carcinoma
.
.
Squamous
cell carcinoma
.
.
Insufficient
material
Oat cell carcinoma
Surgery, Hodgkin’s Surgery, Hodgkin’s .
Surgery, Hodgkin’s .
.
mediastinum .
No signs or sym ptoms;
incidental
finding.
adjacent to the spine, and displaced the posterior paravertebral line laterally (fig. 3C). In the chest radiograph it protruded beyond the left hilum (fig. 3A). The intervertebral foramina of the dorsal vertebrae were normal in size, but the structure of the T8 vertebral body was osteoporotic; on tomography a motheaten type osteolytic lesion could be observed within it. Laboratory examinations were negative. Cytologic examination by fine needle aspiration biopsy showed cells characteristic of myeloma. A thorough examination for other sites of involvement was
ment, sion.
unrewarding,
the mass
and
bone
disappeared
marrow
was
normal.
and the patient
After
treat-
is now in remis-
Discussion
The diagnosis of mediastinal lesions may be based on radiologic examinations, bronchoscopy, mediastinoscopy, and sometimes thoracotomy. While most radiologic examinations are unable to provide histologic or cytologic diagnosis, bronchoscopy has a limited value in mediastinal lesions. Mediastinoscopy allows direct visualization and biopsy of the upper mediastinum and allows histologic diagnosis. However, the posterior me-
diastinum is inaccessible by this method. These procedures all require anesthesia. Nordenstr#{228}m introduced a paraxyphoid [5] and transjugular [6] approach to the anterior mediastinum and a paravertebral approach [7] to the posterior mediastinum; his method requires a cannula, guide wire, and catheter and enables biopsy, catheterization, and contrast examination of mediastinal structures. These methods have not gained widespread acceptance. In 1972 Klatte and Yune [8] reported two cases of pericardial cysts situated in the right anterior cardiophrenic angle which were punctured with a 20 gauge needle by an anterior approach through the fifth and seventh intercostal spaces and in 1970 Dahlgren and Ovenfors [9] reported biopsy of the posterior mediastinum to diagnose neu rogenous tumors. Our method is essentially the application of fine needle aspiration biopsy technique to the mediastinum. We have limited ourselves to masses situated in the anteriorsuperior or posterior mediastinum, and we have avoided puncturing lesions situated in the middle mediastinum which contain the large arteries and veins.
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
FINE
Fig. 2.-Case Right
lateral
chest
6. A, Posteroanterior radiograph showing
NEEDLE
BIOPSY
chest radiograph poorly defined
OF
MEDIASTINUM
241
showing small bulge protruding from right superior mass density in anterosuperior mediastinum (arrows).
____
Fig. 3.-Case situated
posteriorly.
8. Posteroanterior C, Anteroposterior
mediastinum.
B,
‘1
chest radiograph tomograph
showing of thoracic
well delineated spine
mass protruding
at T8 level.
Before biopsy, we make every effort to exclude the presence of a vascular lesion like an aortic aneurysm which could appear as a mediastinal mass. In the supenor vena cava syndrome a rich collateral circulation may be present and an incidental puncture of such a vessel
Posterior
beyond
left paravertebral
left hilar region. line is pushed
B, Lateral view showing away
from
spine
mass
by mass.
could occur. In our cases of superior vena cava obstruction, we believed fine needle aspiration biopsy of the mediastinum to be the most convenient and least traumatic procedure for the patient. There were no complications. In patients who underwent thoracotomy, no
Downloaded from www.ajronline.org by 41.162.159.102 on 10/12/15 from IP address 41.162.159.102. Copyright ARRS. For personal use only; all rights reserved
242
ROSENBERGER
.hematoma or other traces of the puncture were detected by the surgeon following the procedure (H. Pelleg, personal communication). In our case material the only complication encountered was a small pneumothorax (case 3). In this patient three attempts were made to obtain sufficient aspirate for examination. In most of our patients one (and rarely two) punctures yielded enough material for cytology. In patients for whom fine needle aspiration biopsy failed to yield representative cell material (cases 12, 13, 17), the definitive diagnosis at surgery was Hodgkin’s disease, scleronodular type. In each case a stonelike resistance was felt as the needle was advanced. A similar experience has been de.cribed in percutaneous transabdominal fine needle aspiration biopsies of lymph nodes in Hodgkin’s disease, especially of the nodularsclerosing type [10]. REFERENCES 1. Fennessy JJ: Bronchographic criteria of inflammatory disease and radiologic lung biopsy techniques. Radiol C/in North Am 11:371-392,1973 2. Sinner WN: Transthoracic needle biopsy of small peripheral
AND
ADLER
malignant 3. Sinner
lung lesions. WN:
Wert
und
InvestRadiol 8:305-314, Bedeutung der perkutanen
1973 transtho-
rakalen Nadelbiopsien f#{252}r die Diagnose intrathorakaler Krankheitsprozesse Fortschr Gab R#{246}ntgenstr Nuk/earmed 123:203-206, 1975 .
4. Stevens
M,
Weigen
biopsy of localized roscopic guidance.
JF,
Lillington
pulmonary
Am J Roentgenol 5. Nordenstr#{228}m B: Paraxyphoid approach for mediastinography and mediastinal Radiol
2:i4i-i46,
8. 9.
10.
Needle
aspiration
with amplified fluo103 : 561-571 1968 ,
to the mediastinum needle biopsy. Invest
1967
6. Nordenstr#{244}m B: Transjugular
7.
GA:
lesions
approach
to the mediastinum
for mediastinal needle biopsy. Invest Radiol 2: 134-140, 1967 Nordenstr#{244}m B: Paravertebral approach to the posterior med iastinum for mediastinography and needle biopsy. Acta Radiol [Diagn] (Stockh) 13:298-304, 1972 Klatte EC, Yune HY: Diagnosis and treatment of pericardial cysts. Radiology 104: 541-544, 1972 Dahlgren SE, Ovenfors CO: Aspiration biopsy diagnosis of neurogenous mediastinum tumors. Acta Radiol [Diagn] (Stockh) 10:289-296, 1970 G#{244}thlinJH: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy. Radiology 120:205-207, 1976
