Lung needle biopsies are among the most common and consequential procedures in interventional radiology. When a radiologist spots a suspicious nodule on a chest scan, the definitive diagnosis usually requires extracting a sliver of tissue through the chest wall, guided by computed tomography. The challenge is geometric as much as medical. The needle must reach the lesion while dodging ribs, avoiding the mediastinum and its great vessels, steering clear of pulmonary fissures, and traversing as little healthy lung parenchyma as possible. Every extra millimeter of lung crossed raises the risk of pneumothorax, the collapsed lung that occurs when air leaks through a puncture, as well as bleeding and hemoptysis. Yet despite decades of advances in imaging, the choice of trajectory still varies considerably from one radiologist to the next, a variability that AI and robotics have long been expected to tame.

The new study, led by Taylor Hoffman and Francois H. Cornelis with colleagues including Stephen B. Solomon and Debkumar Sarkar, set out to test whether a general-purpose generative AI model could shoulder part of that planning burden. The team conducted a retrospective, institutional review board-approved analysis of de-identified CT images from 30 consecutive lung biopsies performed by three interventional radiologists, each with at least a decade of experience. The cohort included 17 men and 13 women with a median age of 65 years, and the lesions ranged from 5 to 45 millimeters across, deliberately spanning technically difficult territory: five apical lesions at the top of the lung, seven subpleural nodules hugging the chest wall, three para-mediastinal lesions, and four near the lung base.

The technical setup was elegantly simple. Each axial CT image, acquired on a GE Healthcare scanner and exported in DICOM format, was cropped and magnified but not rescaled. Using the open-source image editor GIMP, the team overlaid a radial grid on the image and converted it to PNG. One author annotated the target lesion with a blue circle and outlined the sensitive structures in red, including the mediastinum and major vessels. The annotated image was then uploaded to ChatGPT-4 with a standardized prompt specifying five key parameters for an optimal entry angle: reaching the target, minimizing the distance traveled through lung tissue, and avoiding bones, fissures, and the mediastinum. The model was asked to read the radial grid and return the angle at which the needle should enter.

Before running the full analysis, the researchers validated the approach by comparing a pre-biopsy planning CT image with a procedural CT image captured during the actual biopsy, acquired at the same anatomical level and showing the needle, skin, and target in place. A separate validation dataset of 30 paired planning and procedural images was then used for data collection. Each case was processed independently in a fresh chat session, with iterations allowed whenever the model failed to incorporate all criteria. The median number of iterations needed to arrive at a complete answer was just two, with an interquartile range of one to three, suggesting the model could converge on a usable plan with minimal back-and-forth.

The results were striking. Independent reviewers, two experienced interventional radiologists who had not performed the original procedures and who assessed the AI-generated paths in blinded fashion, judged 28 of 30 paths, or 93.3 percent, safe and adequate for performing the biopsy. The two rejected paths were deemed theoretically feasible but not representative of best clinical practice: in one case the AI path crossed 20 millimeters of lung tissue, four times longer than the manual route, and in another it unnecessarily punctured lung parenchyma to reach a subpleural nodule, raising concerns about needle stability. More remarkably, the AI paths crossed a median of just 5 millimeters of lung tissue, compared with 23 millimeters for the paths the human radiologists actually chose, a difference that reached statistical significance with a p-value of 0.0063 on a Wilcoxon signed-rank test. Paths with zero lung traversal corresponded exclusively to subpleural nodules, where a direct pleural puncture enters the lesion immediately.

On the question of whether the AI simply rediscovered what the humans had already chosen, the answer was nuanced. The mean entry angle suggested by the AI was 179 degrees, against 174 degrees for the manual procedures, a difference that was not statistically significant. Using a definition of path match requiring entry angles within 10 degrees of each other and similar trajectories through tissue planes, 8 of 30 cases, or 26.7 percent, showed good concordance. The authors note that this match rate is lower than in earlier work, such as a study by Too and colleagues that used a three-dimensional convolutional neural network for lesion detection and path planning and reported 82 percent concordance with an average angular deviation of 2.30 degrees, alongside 93.5 percent sensitivity and 93.2 percent specificity in lesion detection. That earlier system, however, was purpose-built for the task rather than adapted from a general-purpose chatbot, and it defined path match more narrowly, within 5 degrees.

Why should a shorter path matter? The authors argue that reduced traversal through lung tissue could lessen tissue manipulation and lower the risk of pneumothorax and hemoptysis, potentially shortening procedure time, improving patient comfort, reducing anesthesia use, and increasing operating room efficiency. In the 30 procedures studied, no major complications occurred, and minor events were self-limiting: minimal pneumothorax in four cases, 13.3 percent, which resolved spontaneously, and mild hemoptysis in two cases, 6.7 percent. But the authors also flag a clinical caveat. With a coaxial technique, in which an outer introducer needle anchors the pathway for repeated sampling, a very short path through lung tissue might provide insufficient purchase, increasing the risk that the needle dislodges during the procedure. Shorter, in other words, is not automatically better in every scenario.

The study is candid about its limits. With only 30 cases and a retrospective design, generalizability remains unproven. The analysis was performed in two dimensions on single axial slices rather than in three dimensions, a simplification that may underestimate the true spatial complexity of biopsy planning. The prompt did not require the AI to maintain a standard 5-millimeter safety margin from the subclavian and axillary neurovascular bundles, though those structures were kept out of the imaging field because patients were scanned with their arms raised. Iterative follow-up prompts were not scripted, which limits reproducibility, and the study measured technical feasibility only, not clinical outcomes such as diagnostic yield, complication rates, or procedure time. The authors also caution that GPT-4 itself may soon be superseded, arguing that the field should move toward specialized generative models trained specifically on interventional radiology rather than adapting general-purpose systems.

Even so, the trajectory of the technology is hard to ignore. The authors envision generative AI integrated with robotic biopsy platforms to automate trajectory planning, real-time procedural guidance in which the model continuously analyzes intraoperative imaging and suggests adjustments as the patient moves or breathes, pre-procedural virtual rehearsals that let clinicians simulate multiple approaches before committing to one, and eventual three-dimensional reconstruction that would eliminate manual image annotation altogether. Combined with augmented reality, AI-recommended paths could be projected directly into the clinician’s field of view. The same logic extends beyond the lung to tumor ablation, where precise positioning determines whether the entire tumor is covered, and to vascular interventions, where AI could recommend optimal access routes based on patient-specific anatomy. For now, the message of this small feasibility study is measured but provocative: a model built to converse with humans can, with a radial grid and a well-crafted prompt, plan a needle path through the lung that is measurably less invasive than the one a seasoned specialist picked. The needle, for the moment, remains in human hands, but the map may increasingly be drawn by machines.

Subject of Research: Feasibility of using a multimodal large language model to plan entry angles for CT-guided lung needle biopsies

Article Title: Feasibility study on using multimodal large language model for CT-guided lung biopsy trajectory planning

Article References: Hoffman, T., Worthington, M., Sarkar, D., Solomon, S. B., & Cornelis, F. H. (2025). Feasibility study on using multimodal large language model for CT-guided lung biopsy trajectory planning. CVIR Oncology, 1(1), Article 5. https://doi.org/10.1007/s44343-025-00005-3

Image Credits: AI Generated

DOI: 10.1007/s44343-025-00005-3

Keywords: generative AI, ChatGPT-4, lung biopsy, CT-guided biopsy, trajectory planning, interventional radiology, pneumothorax, needle path planning, multimodal large language model, Memorial Sloan Kettering, CVIR Oncology, medical imaging

Chronic eosinophilic pneumonia, or CEP, occupies a distinctive niche in pulmonary medicine. The disease is characterized by dense infiltration of the lung parenchyma by eosinophils, the white blood cells best known for fighting parasites and driving allergic reactions. It typically strikes middle-aged adults, shows a marked female predominance, and is strongly linked to asthma and atopic disease, with up to two-thirds of patients carrying a history of asthma before the lung disease declares itself. Clinically, CEP follows a subacute to chronic course, unfolding over weeks to months with cough, progressive shortness of breath on exertion, and constitutional symptoms such as weight loss and fatigue. The classic radiological picture is equally recognizable: bilateral consolidations and ground-glass opacities clustered at the periphery of the lungs, hugging the pleural surface in a pattern that experienced radiologists can spot from across the reading room.

The diagnostic architecture of CEP rests on a tripod of findings. Because no universally accepted diagnostic criteria exist, clinicians generally require a compatible subacute clinical course, characteristic peripheral-predominant pulmonary infiltrates on imaging, and evidence of eosinophilic inflammation, either in the blood or in bronchoalveolar lavage fluid, while systematically excluding secondary causes of pulmonary eosinophilia such as drugs, parasites, and systemic autoimmune disease. In typical cases, the lavage findings are dramatic. BAL eosinophilia is usually marked, often reaching 40 percent or more of the recovered cells, and peripheral blood eosinophil counts commonly exceed 1,000 cells per microliter. When the clinical picture, the imaging, and the cellular evidence all align, lung biopsy is generally considered unnecessary, reserved for the minority of cases in which features are atypical or inconclusive. That reserve clause, as this case demonstrates, is where diagnostic danger lives.

The patient at the center of the report was a 61-year-old ex-smoker who arrived with two months of progressively worsening breathlessness on exertion and two weeks of a productive cough that would not relent, accompanied by weight loss. His medical history included asthma, managed with inhaled fluticasone furoate and vilanterol, along with type 2 diabetes treated with empagliflozin and metformin and hyperlipidaemia controlled with simvastatin for more than a decade. He reported no recent travel abroad and no consumption of raw or undercooked food, closing off the most common routes to parasitic lung infection. On examination, doctors heard bilateral fine inspiratory crackles but no wheezing, and they found none of the peripheral stigmata, purpura, mechanic’s hands, Gottron papules, Raynaud phenomenon, synovitis, or neurological deficits, that would suggest a connective tissue disease or vasculitis masquerading as lung disease.

Laboratory testing initially seemed to confirm the suspicion of CEP. The patient’s peripheral blood showed eosinophilia of 15 percent, corresponding to 1,314 cells per microliter, comfortably above the threshold commonly associated with eosinophilic lung disease. Chest radiography revealed bilateral peripheral patchy opacities with an upper-lobe predominance, and high-resolution computed tomography went further, demonstrating multifocal peripheral consolidations and ground-glass opacities with a subpleural predilection, along with traction bronchiectasis indicating that the process had been smoldering long enough to begin remodeling the lung’s architecture. Taken together, the subacute course, the blood eosinophilia, and the textbook peripheral distribution of disease made CEP the leading diagnosis on admission, and a reasonable one by any standard.

Then the bronchoscope told a different story. Bronchoalveolar lavage of the patient’s lung returned a cellular differential that was 85 percent neutrophils and only 6 percent eosinophils, a profile that belongs to bacterial pneumonia, not to eosinophilic lung disease. Autoimmune serology, including antinuclear antibody, proteinase 3-antineutrophil cytoplasmic antibody, and myeloperoxidase-antineutrophil cytoplasmic antibody, came back negative, and the total IgE level of 289 kU/L offered no signal of an allergic driver. Urinalysis showed neither haematuria nor proteinuria, and renal function was normal, further arguing against a systemic vasculitis. Confronted with neutrophil-predominant lavage fluid, the clinical team reasonably pivoted to an infectious explanation and initiated empirical treatment with amoxicillin and clavulanate. The antibiotics failed. Symptoms persisted, radiographic abnormalities did not budge, follow-up lavage microbiological cultures were negative, cytological examination identified no parasitic organisms, and stool examination for parasites was also unrevealing.

With the non-invasive pathway exhausted, the team turned to video-assisted thoracoscopic surgery, resecting a wedge of the left lower lobe for histopathological examination. What the pathologist found rewrote the case entirely. The tissue demonstrated an organizing pneumonia pattern, defined by intra-alveolar proliferation of fibroblastic foci, the plug-like clusters of immature connective tissue known as Masson bodies, accompanied by active immature fibrosis. Critically, woven through the interstitial and peribronchiolar regions was a prominent eosinophilic inflammatory infiltrate, with plasma cells and scattered lymphocytes in attendance. The alveolar architecture was relatively preserved, and, importantly, a blood vessel examined in the specimen showed an intact wall with no histological evidence of vasculitis, excluding one of the most dangerous mimics. Integrating the clinical course, the peripheral eosinophilia, the radiological findings, the histopathological features, and a thorough assessment for secondary causes, the physicians made the diagnosis of chronic eosinophilic pneumonia.

Treatment followed the established playbook for CEP. Intravenous methylprednisolone was commenced at 40 milligrams daily, a dose equivalent to prednisolone at 1 milligram per kilogram of body weight per day, then converted to oral methylprednisolone before discharge and gradually tapered over approximately two months. The response was swift and convincing. Symptoms improved progressively, and a chest radiograph obtained after roughly one month of corticosteroid therapy showed resolution of the bilateral peripheral opacities that had dominated the initial films. The trajectory underscores why making the correct diagnosis matters so much: corticosteroids, which are useless against bacterial pneumonia and potentially harmful, are precisely the right weapon against CEP, and delays in reaching the diagnosis translate directly into prolonged symptoms and unnecessary exposure to antibiotics.

The case’s most instructive twist lies in what the lavage fluid did and did not reveal. Although BAL eosinophilia is usually prominent in CEP, the authors note that considerable variability has been reported across published series, with eosinophil proportions ranging from as low as 12 percent to as high as 95 percent. There is a technical reason for this scatter: bronchoalveolar lavage samples only a limited portion of the distal airways and alveolar compartment, a tiny and possibly unrepresentative window onto a patchy disease process. A normal or atypical BAL differential, the authors emphasize, does not exclude microscopic abnormalities elsewhere in the lung tissue. The cellular profile of lavage fluid should therefore be interpreted in conjunction with the clinical and radiological findings rather than wielded in isolation, and when the lavage results clash with the broader picture, surgical lung biopsy may be justified in selected patients to establish the diagnosis definitively.

The report also untangles a second source of confusion, the relationship between CEP and cryptogenic organizing pneumonia. The two conditions share several clinical and radiological features, including subacute respiratory symptoms, pulmonary consolidation, and ground-glass opacities, which can complicate their distinction even for experienced clinicians. Histologically, however, organizing pneumonia is a non-specific pattern of lung injury that may occur in a variety of pulmonary disorders, CEP among them. Although eosinophilic infiltration of the alveolar spaces and interstitium is the characteristic histopathological hallmark of CEP, foci of organizing pneumonia with intra-alveolar fibroblastic plugs may also be present within it. The presence of an organizing pneumonia pattern on biopsy, in other words, does not automatically signify cryptogenic organizing pneumonia. In this patient, the combination of that pattern with prominent eosinophilic infiltration, alongside compatible clinical, radiological, and peripheral blood findings, anchored the diagnosis firmly in eosinophilic territory. For clinicians navigating the eosinophilic lung diseases, the message is blunt: lavage fluid is a supporting witness, not the judge, and when the evidence conflicts, the tissue still holds the final word.

Subject of Research: Diagnosis of chronic eosinophilic pneumonia with atypical bronchoalveolar lavage findings and an organizing pneumonia pattern on lung biopsy

Article Title: Chronic Eosinophilic Pneumonia: A Diagnostic Challenge With Atypical Bronchoalveolar Lavage Findings and an Organizing Pneumonia Pattern

Article References: Chronic Eosinophilic Pneumonia: A Diagnostic Challenge With Atypical Bronchoalveolar Lavage Findings and an Organizing Pneumonia Pattern. (n.d.). https://doi.org/10.1002/rcr2.70780

Image Credits: AI Generated

DOI: 10.1002/rcr2.70780

Keywords: chronic eosinophilic pneumonia, bronchoalveolar lavage, organizing pneumonia, lung biopsy, eosinophilia, interstitial lung disease, corticosteroids, high-resolution computed tomography, cryptogenic organizing pneumonia, respiratory medicine, case report, differential diagnosis

The technique at the heart of the consensus, known as US-PLNB, exploits a simple physical fact: sound waves cannot travel through air. That limitation once confined ultrasound to soft tissues like the liver and thyroid, but it becomes an unexpected advantage at the lung’s edge. When a tumor sits directly against the chest wall—the so-called subpleural position—with no aerated lung in between, ultrasound can see it with exquisite clarity, and in real time. Unlike computed tomography, which offers only static snapshots and exposes patients to ionizing radiation, ultrasound shows the needle, the lesion, and the beating, breathing anatomy between them continuously, allowing operators to adjust course millimeter by millimeter. The consensus notes that this real-time capability makes ultrasound particularly valuable for small, mobile lesions near the heart, great vessels, or the lung apex, where a misplaced needle could prove catastrophic.

The document does not pretend ultrasound is a universal solution. Because air blocks sound, the technique applies only to lesions abutting the parietal pleura or to central tumors made visible by surrounding collapse, consolidation, or fluid that creates an acoustic window. CT guidance remains superior for deep and central lesions, offering precise localization at the cost of radiation and longer procedure times. The consensus positions US-PLNB as the first-line method for subpleural lesions, citing reported complication rates of 1.1 to 32.7 percent and safety data consistently favoring ultrasound over CT guidance, including a retrospective series of 3,043 consecutive patients and comparative studies showing shorter wait times and procedure durations.

What distinguishes the new document from prior guidelines, such as those from the British Thoracic Society and the Korean Society of Thoracic Radiology, is its embrace of multimodal ultrasound. Beyond conventional gray-scale imaging, the consensus details how color Doppler imaging maps blood flow within and around a lesion, distinguishing the bidirectional, high-resistance waveform of pulmonary arteries—typical of benign lesions—from the low-resistance bronchial arterial signals and chaotic arteriovenous waveforms that betray malignancy. Elastography adds another dimension: stiff, blue-dominant lesions on strain imaging, or those with shear wave velocities above 2.47 meters per second, are highly likely to be malignant, with reported sensitivity and specificity reaching 98 percent in some series. These tools let operators target the most suspicious, viable regions of a tumor before the needle ever advances.

The most technically sophisticated section concerns contrast-enhanced ultrasound. After an intravenous injection of sulfur hexafluoride microbubbles, malignant lesions typically light up in a snowing-like or curly hair-like pattern as disorganized tumor neovessels fill from the periphery, while benign lesions enhance in a tree-like pattern radiating from the hilum, reflecting preserved pulmonary arterial supply. Because normal lung receives roughly 85 percent of its blood from pulmonary arteries and only 15 percent from bronchial arteries—and because tumors progressively destroy the pulmonary supply in favor of bronchial arteries—the timing of contrast arrival becomes a diagnostic signature. The consensus highlights an arrival-time difference ratio, comparing lesion enhancement against both adjacent lung and chest wall references, that achieved 91 percent diagnostic accuracy at a threshold of 43 percent in published studies. Contrast imaging also reveals necrotic, non-enhancing zones that would yield useless specimens, allowing operators to steer toward viable tissue and reduce false negatives.

Procedural detail in the consensus is granular to the point of being a manual. It specifies that warfarin should be bridged with low-molecular-weight heparin a week before biopsy, aspirin stopped three days ahead, clopidogrel five days ahead, platelets kept above 50 billion per liter, and the international normalized ratio below 1.5. Bevacizumab, the anti-angiogenic drug, must be withheld for roughly four weeks. The document contrasts fine-needle aspiration, which yields cytology with sensitivity of 90 to 95 percent for malignancy, against core needle biopsy, which provides intact histology essential for immunohistochemistry and molecular typing, and recommends combining both to maximize diagnostic yield. Needle selection, firing mechanisms, coaxial techniques that allow multiple samples through a single pleural puncture, and even methods to improve needle visibility on screen—jiggling the needle, injecting saline to outline its track—are all codified.

Complications receive equally rigorous treatment. Hemorrhage, the most common adverse event at 0.3 to 9.9 percent incidence, is managed with a graded protocol from bed rest for minor bleeding through vasopressin and tranexamic acid for moderate hemoptysis to emergency embolization for massive hemorrhage. Pneumothorax, occurring in 0.8 to 11.6 percent of cases, can often be resolved on the spot by aspirating air through the coaxial introducer needle—a maneuver the consensus illustrates with cases in which lesions obscured by escaped air became fully visible again after 20 milliliters were withdrawn. The rarest and deadliest complication, systemic arterial air embolism, carries a mortality of up to 26 percent; the consensus explains that as little as half a milliliter of air in the coronary circulation can be fatal and mandates avoiding aerated bronchi, upright positioning, and positive-pressure ventilation during puncture.

The methodology behind the consensus is as notable as its content. Developed according to the WHO Handbook for Guideline Development and registered on the PREPARE platform, it employed a three-tier structure—a steering committee of five senior experts, a fifteen-member writing group, and a voting panel of nearly one hundred multidisciplinary specialists. Clinical questions were gathered through surveys of more than one hundred physicians, evidence was systematically retrieved from eight Chinese and international databases through August 2025, study quality was assessed with Cochrane, Newcastle-Ottawa, and QUADAS tools, and recommendations were graded using the GRADE framework and ratified through two rounds of anonymous Delphi voting requiring at least 80 percent agreement.

The consensus also looks forward. It endorses image fusion and volume navigation technology, in which electromagnetic sensors track the ultrasound probe and biopsy needle in space, fusing real-time ultrasound with pre-acquired CT volumes to guide biopsies of lesions once considered beyond ultrasound’s reach. The authors acknowledge that large prospective randomized trials directly comparing ultrasound with other guidance modalities are still lacking, and they commit to annual literature monitoring and timely updates as new evidence emerges. For now, the document stands as both a practical manual and a statement of ambition: that a technique once dismissed as too limited for the air-filled lung has matured, with the help of contrast agents, elastography, and navigation systems, into a precise, radiation-free first-line approach for the growing population of patients whose lung lesions sit within reach of a sound wave.

Subject of Research: Development of the first Chinese expert consensus standardizing ultrasound-guided percutaneous lung needle biopsy for subpleural pulmonary lesions

Article Title: Chinese expert consensus on ultrasound-guided percutaneous lung needle biopsy (2025 Edition)

Article References: Wang, Y., Xu, H., & on behalf of Chinese Society of Ultrasound in Medicine, Interventional Physicians Branch of the Chinese Medical Doctor Association, Minimally Invasive Therapy for Oncology Committee of Chinese Anti-Cancer Association, Ultrasound Branch of the Chinese Anti-Tuberculosis Association, Tuberculosis Control and Prevention Branch of the China International Exchange and Promotive Association for Medical and Health Care, Ultrasound Equipment Technology Branch of China Association of Medical Equipment, Ultrasound Su (2026). Chinese expert consensus on ultrasound-guided percutaneous lung needle biopsy (2025 Edition). Clinical Cancer Bulletin, 5(1), Article 4. https://doi.org/10.1007/s44272-026-00055-5

Image Credits: AI Generated

DOI: 10.1007/s44272-026-00055-5

Keywords: ultrasound-guided biopsy, lung biopsy, subpleural pulmonary lesions, expert consensus, contrast-enhanced ultrasound, elastography, interventional ultrasound, pneumothorax, lung cancer diagnosis, image fusion navigation, core needle biopsy, clinical guideline