PURPOSE: We evaluated the usefulness of a CT guided percutaneous transthoracic cutting needle biopsy (PCNB) using a 20 gauge (G) needle for pulmonary lesions after a comparison with the use of an 18 G needle for diagnostic accuracy and complications. MATERIALS AND METHODS: From August 2005 to July 2007, 433 patients underwent a CT guided PCNB. A total of 191 patients were excluded from the study as these patients had benign lesions seen after PCNB, but did not receive a confirmation biopsy or undergo follow-up (> 1 year). We evaluated the diagnostic accuracy for the use of PCNB using the Chi-squared test and analyzed which factors (location and size of lesions, diameter of the needle, distance between the pleura and lesions, presence or not of emphysema) were related to occurrence of a pneumothorax after PCNB using a multi-variant regression test. RESULTS: The diagnostic accuracy for malignant lesions with the use of an 18 G and a 20 G needle were 95.4% and 97%, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the use of an 18 G needle were 95.7 %, 100%, 100%, and 91.6%. The sensitivity, specificity, PPV, and NPV were 97.8%, 100%, 100%, and 95.0% for the use of a 20 G needle. A pneumothorax occurred in 5.5% (24/433) of the cases and was closely related to the distance from the pleura to the lesions. CONCLUSION: CT guided PCNB with the use of a 20 gauge needle provided good diagnostic accuracy and the procedure is safe to perform.