If you see a thoracic lesion that you would like to sample and cannot readily see it on ultrasound after counting rib spaces and measure in the vertical distance from the sternum and you know you are in the correct region, sedate the patient with Propofol or dexdomitor (or similar) and have your technicians apply wide spread manual pressure in the region around the lesion to collapse the lung and push the lesion to the wall (Image 4). In large dogs this may take some strength. Then perform your usual “wood pecker” FNA technique or biopsy if you have the angle. This technique often makes the inaccessible accessible. If the lesion is still not visible with an enhanced window then a CT would be in order or you may be able to go transdiapragmatically through the liver with widespread pressure under sedation or through the thoracic inlet with the lesion is in the cranial chest. This lesion could not be accessed entirely transdiaphragmatically but some peripheral alveolar consolidation was visible.
Image 1 (above): At times the lesion that we would like to sample is obscured by lung air artifact. Typically any lesion that is within 1 inch of the thoracic wall may be sampled with this described technique that just necessitates a few hands from around the room.
Image 2 (above): Shows the team effort needed to execute this compression technique.
Images 3 & 4 (below): Demonstrate a lung carcinoma that was located in the right caudal lung field approximately 1-1.5 inches from the right caudal thoracic wall at the 7-10 intercostal space with the closes radiopacity near OC 10 which was our target.
Image 3 (above)
Image 4 (above)
Below is an example of a thoracic target for FNA. The patient was sedated and while a technician applied pressure on the chest to enhance the sonographic window and get the lesion closer to the body wall, the sonographer guided the needle intercostally the same as you would for an intercostal liver FNA.
