Diagnostic Dilemma of Nonresolving Lung Consolidation: Role of Percutaneous CT-Guided Transthoracic Lung Biopsy

Abstract Nonresolving consolidation (NRC) is defined as a persistent radiological abnormality despite ≥ 10 days of optimal antibiotic therapy and poses a diagnostic challenge for both clinicians and radiologists. When noninvasive tests such as sputum analysis, bronchoalveolar lavage, and bronchoscopy are inconclusive, percutaneous computed tomography (CT)-guided transthoracic lung biopsy (PCTLB) offers direct histopathological diagnosis. This retrospective single-center study included 37 patients with NRC who underwent PCTLB between January 2020 and December 2025. Patients had persistent consolidation with prior inconclusive investigations. Biopsies were deemed diagnostic when histopathology, cytology, or microbiology provided conclusive results, which were statistically analyzed. Definitive tissue diagnoses were established in 32 of 37 cases, yielding an 86.5% diagnostic rate. Of these, 19 (51.3%) were malignant (invasive nonmucinous adenocarcinoma in 13 cases, mucinous in 5, and enteric in 1) and 13 (35.1%) were benign (bacterial/community-acquired pneumonia or abscess in 3, necrotizing granulomatous process/tuberculosis in 4, organizing pneumonia in 2, and fungal in 4). The remaining 5 cases (13.5%) had nonspecific histopathological findings (chronic inflammatory process in 4, necrotizing inflammatory process in 1). Minor complications occurred in 3 patients (8.1%): pneumothorax (n = 2) and minimal hemoptysis (n = 1). No major complications or procedure-related mortality were observed. PCTLB is a safe and effective diagnostic tool for NRC, with a high diagnostic yield of 86.5% and low complication rate of 8.1%. The detection of malignancy in more than half the study population highlights the indispensable role of PCTLB in the management of NRC when other investigations fail, prompting a potential rethink of contemporary diagnostic algorithms.