Biopsy Procedures of the Lung, Mediastinum, and Chest Wall

Matthew D. Cham

Claudia I. Henschke

David F. Yankelevitz

Indications

1. Evaluation of a solitary pulmonary nodule (solid, part-solid, and nonsolid nodules) with features suspicious for primary lung cancer and lacking benign features such as fat composition or calcification in a benign pattern (1,2)

2. Evaluation of pulmonary nodules with documented growth at a malignant rate

3. Evaluation of positron emission tomography (PET)-positive pulmonary lesions that are suspicious for malignancy

4. Evaluation of pulmonary nodules as part of a staging strategy in patients with known malignancies (lung cancer and extrathoracic malignancies)

5. Obtaining tissue for molecular characterization to guide therapy

6. Evaluation of focal pulmonary infections that are refractory to standard therapy

7. Evaluation of pleural masses, pleural thickening, or pleural fluid collections

8. Evaluation of mediastinal masses, hilar masses, and lymphadenopathy

9. Evaluation of chest wall masses and lytic rib lesions

Contraindications

1. An uncooperative patient (considered by some as the sole absolute contraindication)

2. Bleeding diathesis (international normalized ratio [INR] >1.3, platelet count <50,000 per µL)

3. Medications associated with increased risk of bleeding (relative risk, some or all can be discontinued prior to procedure; consideration also as to location of the lesion)

4. Severe bullous emphysema

5. Contralateral pneumonectomy or severely limited function in the contralateral lung

6. Intractable cough

7. Suspected hydatid cyst (due to risk of an anaphylactic reaction)

8. Possible pulmonary arteriovenous malformation (AVM), vascular aneurysm, or pulmonary sequestration (intralobar or extralobar)

9. Pulmonary hypertension (especially when biopsy of a central lesion is considered) (3)

10. Patients on positive pressure ventilation

Preprocedure Preparation

1. Explain the procedure and its possible complications to the patient 1 week prior to the biopsy if performed in the outpatient setting. Referring clinicians can also provide suitable information about the procedure at that time which can be reviewed prior to the procedure when obtaining consent.

2. Discontinue aspirin 5 days before biopsy. Discontinue other nonsteroidal antiinflammatory drugs (NSAIDs) 2 days prior to the procedure. Patients on oral anticoagulants should be switched to heparin for 2 to 3 days, which in turn should be discontinued several hours before the procedure.

3. Obtain INR, prothrombin time, partial thromboplastin time, and platelet count 1 day prior to biopsy.

4. Correct any bleeding disorders with fresh frozen plasma, platelets, or vitamin K.

5. Patient instructed to not eat or drink 8 hours prior to the biopsy.

6. Choose the appropriate image guidance for the procedure.

a. Computed tomography (CT) guidance is used for most transthoracic needle biopsies (TNB) (4). CT may allow planning of a trajectory that avoids traversing aerated lung. If this is impossible, CT can help plan a needle path that bypasses potential obstacles such as interlobar fissures, bullae, large vascular structures, and bone. In addition, CT may help to differentiate necrotic from viable areas within tumor.

b. CT fluoroscopy offers the advantages of CT combined with real-time imaging but is not as widely available as CT. There is also the potential risk of increased radiation exposure for radiologists performing this procedure frequently.

c. Fluoroscopic guidance offers real-time imaging for lesions visualized in two projections. Although previously the standard of care, currently this modality is less useful for smaller pulmonary nodules and has been largely replaced by CT guidance.

d. Ultrasound guidance is useful for biopsy of chest wall, pleural, anterior mediastinal, and peripheral lung lesions (5).

7. Choose the appropriate needle for the procedure (Table 46.1).

a. There are two main types of biopsy needles: aspiratingneedles, which provide a cellular aspirate for cytologic examination, and cutting needles, by which a core of tissue for histologic examination is obtained. Some needles, such as Turner needles and Westcott needles, yield small fragments as well as a cellular aspirate. Most biopsy needles are available in diameters ranging from 16 to 22 gauge; 25-gauge needles have also been developed.

b. When a single-needle technique is used, multiple pleural punctures are required to obtain multiple samples. Alternatively, a coaxial needle system can be used to obtain multiple samples using a single pleural puncture. In this type of needle system, a thinner inner needle is inserted through a larger outer needle called an introducer. Therefore, the pleura will be punctured by a needle that is larger than the one used to obtain the sample. Tru-Cut-type cutting needles powered by spring-activated handles can be used to obtain a large core of tissue, which is of particular value in the diagnosis of benign lesions (e.g., hamartomas, granulomas) and lymphoma (6).

Table 46.1 Needles Used for Transthoracic Needle Biopsy

Type of Needle	Brand and Manufacturer	Commonly Used Gauge
Aspiration needle	Chiba (Cook Catheter, Bloomington, IN)	20-25
Aspiration needle that also yields tissue fragments	Westcott (BD Medical, Franklin Lakes, NJ) Turner (Cook Catheter)	20-22 18-22
Coaxial needle system	Greene (Cook Catheter)	Outer needle: 19 Inner needle: 22
Cutting needle with springactivated handle	Biopty (USCI Bard, Billerica, MA) Temno (BD Medical)	18-20

c. No single type of needle design has been shown to be consistently superior to other types in terms of higher diagnostic yield and lower complication rate. Choice is often a matter of preference (7).

8. Review the procedure, possible complications, and alternatives with the patient. Obtain signed informed consent minutes prior to the biopsy.

Procedure

1. Position the patient on the biopsy table so that the skin entry site is placed upright. When ease of performance and risk of complications are not substantially affected by the patient’s position, prone position is preferred to minimize chest wall motion and to minimize patient anxiety from seeing the needle. Biopsy side down post procedure is also facilitated.

2. Perform preliminary examination.

a. For CT-guided biopsies, a scout view is obtained followed by localizing transaxial images through the lesion. Upper lobe lesions generally do not require any special breathing instructions. When nodule motion is observed near the diaphragm, breath-holding instructions are given. A small inspiration is requested so that there will be minimal amount of motion once the needle has passed through the pleura and less chance of a pneumothorax, as with deeper breath holds there will be greater motion and more chance of tearing the pleural surface. The patient is requested to maintain the same degree of inspiration each time he or she is asked to breath-hold (whenever the lesion is scanned or the biopsy needle is advanced). It is often useful to practice breath-holding with the patient before beginning the procedure.

b. When ultrasound guidance is used, a preliminary examination is performed to confirm visibility of the lesion.

3. When CT is used for guidance. The dose should be reduced to the minimal amount necessary for monitoring of the procedure as it is not being performed for diagnostic purposes. Typically, this can be less than the range of exposure factors used in lung cancer screening CT. Both kVp and mAs should be lowered to achieve an estimated dose of less than 1.0 mSv for the entire procedure.

4. Plan the desirable needle path and mark the skin entry site.

a. Whenever possible, a needle path that avoids aerated lung should be chosen to reduce the likelihood of developing a pneumothorax. A technique that can be used in selected cases to avoid puncture of aerated lung is expansion of the extrapleural space by injecting a lidocaine-saline mixture (8

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