Lung biopsy is a procedure for obtaining a small sample of lung tissue for examination. The tissue is usually examined under a microscope, and may be sent to a microbiological laboratory for culture. Microscopic examination is performed by a pathologist.
A lung biopsy is usually performed to determine the cause of abnormalities, such as nodules that appear on chest x rays. It can confirm a diagnosis of cancer, especially if malignant cells are detected in the patient's sputum or bronchial washing. In addition to evaluating lung tumors and their associated symptoms, lung biopsies may be used to diagnose lung infections, especially tuberculosis and Pneumocystis pneumonia, drug reactions, and chronic diseases of the lungs such as sarcoidosis and pulmonary fibrosis.
A lung biopsy can be used for treatment as well as diagnosis. Bronchoscopy , a type of lung biopsy performed with a long, flexible slender instrument called a bronchoscope, can be used to clear a patient's air passages of secretions and to remove airway blockages.
According to the American Cancer Society, approximately 77% of all cancers are diagnosed in people ages 55 and older. Lung cancer is the leading cause of cancer deaths in the United States. Each year, about 170,000 Americans are diagnosed with lung cancer. It is much more prevalent among African Americans than the general population. Nine out of 10 cases of lung cancer are caused by smoking cigarettes, pipes, or cigars.
The right and left lungs are separated by the mediastinum, which contains the heart, trachea, lymph nodes, and esophagus. Lung biopsies sometimes involve mediastinoscopy .
Types of lung biopsies
Lung biopsies are performed using a variety of techniques, depending on where the abnormal tissue is located in the lung, the health and age of the patient, and the presence of lung disease. A bronchoscopy is ordered if a lesion identified on the x ray seems to be located on the wall (periphery) of the chest. If the suspicious area lies close to the chest wall, a needle biopsy can be done. If both methods fail to diagnose the problem, an open lung biopsy may be performed. When there is a question about whether the lung cancer or suspicious mass has spread to the lymph nodes in the mediastinum, a mediastinoscopy is performed.
bronchoscopic biopsy. During the bronchoscopy, a thin, lighted tube (bronchoscope) is passed from the nose or mouth, down the windpipe (trachea) to the air passages (bronchi) leading to the lungs. Through the bronchoscope, the physician views the airways, and is able to clear mucus from blocked airways, and collect cells or tissue samples for laboratory analysis.
needle biopsy. The patient is mildly sedated, but awake during the needle biopsy procedure. He or she sits in a chair with arms folded in front on a table. An x ray technician uses a computerized axial tomography (CAT) scanner or a fluoroscope to identify the precise location of the suspicious areas. Markers are placed on the overlying skin to identify the biopsy site. The skin is thoroughly cleansed with an antiseptic solution, and a local anesthetic is injected to numb the area. The patient will feel a brief stinging sensation when the anesthetic is injected.
The physician makes a small incision, about half an inch (1.25 cm) in length. The patient is asked to take a deep breath and hold it while the physician inserts the biopsy needle through the incision into the lung tissue to be biopsied. The patient may feel pressure, and a brief sharp pain when the needle touches the lung tissue. Most patients do not experience severe pain. The patient should refrain from coughing during the procedure. The needle is withdrawn when enough tissue has been obtained. Pressure is applied at the biopsy site and a sterile bandage is placed over the incision. A chest x ray is performed immediately after the procedure to check for potential complications. The entire procedure takes 30 to 60 minutes.
open biopsy. Open biopsies are performed in a hospital operating room under general anesthesia. Once the anesthesia has taken effect, the surgeon makes an incision over the lung area, a procedure called a thoracotomy . Some lung tissue is removed and the incision is closed with sutures. Chest tubes are placed with one end inside the lung and the other end protruding through the closed incision. Chest tubes are used to drain fluid and blood, and re-expand the lungs. They are usually removed the day after the procedure. The entire procedure normally takes about an hour. A chest x ray is performed immediately after the procedure to check for potential complications.
video-assisted thoracoscopic surgery. A minimally invasive technique, video-assisted thoracoscopic surgery (VATS) can be used to biopsy lung and mediastinal lesions. VATS may be performed on selected patients in place of open lung biopsy. While the patient is under general anesthetia, the surgeon makes several small incisions in the his or her chest wall. A thorascope, a thin, hollow, lighted tube with a tiny video camera mounted on it, is inserted through one of the small incisions. The other incisions allow the surgeon to insert special instruments to retrieve tissue for biopsy.
mediastinoscopy. This procedure is performed under general anesthesia. A 2–3 in (5–8 cm) incision is made at the base of the neck. A thin, hollow, lighted tube, called a mediastinoscope, is inserted through the incision into the space between the right and the left lungs. The surgeon removes any lymph nodes or tissues that look abnormal. The mediastinoscope is then removed, and the incision is sutured and bandaged. A mediastinoscopy takes about an hour.
Before scheduling a lung biopsy, the physician performs a careful evaluation of the patient's medical history and symptoms, and performs a physical examination . Chest x rays and sputum cytology (examination of cells obtained from a deep-cough mucus sample) are other diagnostic tests that may be performed. An electrocardiogram (EKG) and laboratory tests may be performed before the procedure to check for blood clotting problems, anemia, and blood type, should a transfusion become necessary.
During a preoperative appointment, usually scheduled within one to two weeks before the procedure, the patient receives information about what to expect during the procedure and the recovery period. During this appointment or just before the procedure, the patient usually meets with the physician (or physicians) performing the procedure (the pulmonologist, interventional radiologist, or thoracic surgeon).
A chest x ray or CAT scan of the chest is used to identify the area to be biopsied.
About an hour before the biopsy procedure, the patient receives a sedative. Medication may also be given to dry up airway secretions. General anesthesia is not used for this procedure.
For at least 12 hours before the open biopsy, VATS, or mediastinoscopy procedures, the patient should not eat or drink anything. Prior to these procedures, an intravenous line is placed in a vein in the patient's arm to deliver medications or fluids as necessary. A hollow tube, called an endotracheal tube, is passed through the patient's mouth into the airway leading to the lungs. Its purpose is to deliver the general anesthetic. The chest area is cleansed with an antiseptic solution. In the mediastinoscopy procedure, the neck is also cleansed to prepare for the incision.
Patients who will undergo surgical diagnostic and treatment procedures should be encouraged to stop smoking and stop using tobacco products. The patient needs to make the commitment to be a nonsmoker after the procedure. Patients able to stop smoking several weeks before surgical procedures have fewer postoperative complications. Smoking cessation programs are available in many communities. The patient should ask a health care provider for more information if he or she needs help with smoking cessation.
Informed consent is an educational process between health care providers and patients. Before any procedure is performed, the patient is asked to sign a consent form. Prior to signing the form, the patient should understand the nature and purpose of the diagnostic procedure or treatment, its risks and benefits, and alternatives, including the option of not proceeding with the test or treatment. During the discussions, the health care providers are available to answer the patient's questions about the consent form or procedure.
Following a needle biopsy, the patient is allowed to rest comfortably. He or she may be required to lie flat for two hours following the procedure to prevent the risk of bleeding. The nurse checks the patient's status at two-hour intervals. If there are no complications after four hours, the patient can go home once he or she has received instructions about resuming normal activities. The patient should rest at home for a day or two before returning to regular activities, and should avoid strenuous activities for one week after the biopsy.
Open biopsy, VATS, or mediastinoscopy
After an open biopsy, VATS, or mediastinoscopy, the patient is taken to the recovery room for observation. The patient receives oxygen via a face mask or nasal cannula. If no complications develop, the patient is taken to a hospital room. Temperature, blood oxygen level, pulse, blood pressure, and respiration are monitored. Chest tubes remain in place after surgery to prevent the lungs from collapsing, and to remove blood and fluids. The tubes are usually removed the day after the procedure.
The patient may experience some grogginess for a few hours after the procedure. He or she may have a sore throat from the endotracheal tube. The patient may also have some pain or discomfort at the incision site, which can be relieved by pain medication. It is common for patients to require some pain medication for up to two weeks following the procedure.
After receiving instructions about resuming normal activities and caring for the incision, the patient usually goes home the day after surgery. The patient should not drive while taking narcotic pain medication.
Patients may experience fatigue and muscle aches for a day or two because of the general anesthesia. The patient can gradually increase activities, as tolerated. Walking is recommended. Sutures are usually removed after one to two weeks.
The physician should be notified immediately if the patient experiences extreme pain, light-headedness, or difficulty breathing after the procedure. Sputum may be slightly bloody for a day or two after the procedure. Heavy or persistent bleeding requires evaluation by the physician.
Lung biopsies should not be performed on patients who have a bleeding disorder or abnormal blood clotting because of low platelet counts, or prolonged prothrombin time (PT) or partial thromboplastin time (PTT). Platelets are small blood cells that play a role in the blood clotting process. PT and PTT measure how well blood is clotting. If clotting times are prolonged, it may be unsafe to perform a biopsy because of the risk of bleeding. If the platelet count is lower than 50,000/cubic mm, the patient may be given a platelet transfusion as a temporary relief measure, and a biopsy can then be performed.
In addition, lung biopsies should not be performed if other tests indicate the patient has enlarged alveoli associated with emphysema, pulmonary hypertension, or enlargement of the right ventricle of the heart (cor pulmonale).
The normal risks of any surgical procedure include bleeding, infection, or pneumonia. The risk of these complications is higher in patients undergoing open biopsy procedures, as is the risk of pneumothorax (lung collapse). In rare cases, the lung collapses because of air that leaks in through the hole made by the biopsy needle. A chest x ray is done immediately after the biopsy to detect the development of this potential complication. If a pneumothorax occurs, a chest tube is inserted into the pleural cavity to re-expand the lung. Signs of pneumothorax include shortness of breath, rapid heart rate, or blueness of the skin (a late sign). If the patient has any of these symptoms after being discharged from the hospital, it is important to call the health care provider or emergency services immediately.
Bronchoscopy is generally safe, and complications are rare. If they do occur, complications may include spasms of the bronchial tubes that can impair breathing, irregular heart rhythms, or infections such as pneumonia.
Needle biopsy is associated with fewer risks than open biopsy because it does not involve general anesthesia. Some hemoptysis (coughing up blood) occurs in 5% of needle biopsies. Prolonged bleeding or infection may also occur, although these are very rare complications.
Possible complications of an open biopsy include infection or pneumothorax. If the patient has very severe breathing problems before the biopsy, breathing may be further impaired following the operation. Patients with normal lung function prior to the biopsy have a very small risk of respiratory problems resulting from or following the procedure.
Complications due to mediastinoscopy are rare. Possible complications include pneumothorax or bleeding caused by damage to the blood vessels near the heart. Mediastinitis, infection of the mediastinum, may develop. Injury to the esophagus or larynx may occur. If the nerves leading to the larynx are injured, the patient may be left with a permanently hoarse voice. All of these complications are rare.
Normal results indicate no evidence of infection in the lungs, no detection of lumps or nodules, and cells that are free from cancerous abnormalities.
Abnormal results of needle biopsy, VATS, and open biopsy may be associated with diseases other than cancer. Nodules in the lungs may be due to active infections such as tuberculosis, or may be scars from a previous infection. In 33% of biopsies using a mediastinoscope, the biopsied lymph nodes prove to be cancerous. Abnormal results should always be considered in the context of the patient's medical history, physical examination, and other tests such as sputum examination, and chest x rays before a final diagnosis is made.
Morbidity and mortality rates
The risk of death from needle biopsy is rare. The risk of death from open biopsy is one in 3,000 cases. In mediastinoscopy, death occurs in fewer than one in 3,000 cases.
The type of alternative diagnostic procedures available depend upon each patient's diagnosis.
Some people may be eligible to participate in clinical trials, research programs conducted with patients to evaluate a new medical treatment, drug, or device. The purpose of clinical trials is to find new and improved methods of treating different diseases and special conditions. For more information on current clinical trials, visit the National Institutes of Health's ClinicalTrials.gov at <http://www.clinicaltrials.gov> or call (888) FIND-NLM [(888) 346-3656] or (301) 594-5983.
The National Cancer Institute (NCI) has conducted a clinical trial to evaluate a technology—low-dose helical computed tomography—for its effectiveness in screening for lung cancer. One study concluded that this test is more sensitive in detecting specific conditions related to lung cancer than other screening tests.
"bronchoscopy." in the merck manual of diagnosis and therapy, seventeenth edition. edited by beers, m.d., mark h., and robert berkow, m.d. whitehouse station, nj: merck & co., inc., 1999.
groenwald, s.l. et al. cancer nursing principles and practice. fifth edition. sudbury, ma: jones and bartlett publishers, 2000.
american association for respiratory care (aarc). 11030 ables lane, dallas, tx 75229. e-mail: [email protected] <http://www.aarc.org>.
american cancer society. 1599 clifton road, n.e., atlanta, ga 30329. (800) 227-2345 or (404) 320-3333. <http://www.cancer.org>.
american college of chest physicians. 3300 dundee road, northbrook, il 60062-2348. (847) 498-1400. <http://www.chestnet.org>.
american lung association and american thoracic society. 1740 broadway, new york, ny 10019-4374. (800) 586-4872 or (212) 315-8700. <http://www.lungusa.org> and <http://www.thoracic.org>.
cancer research institute. 681 fifth avenue, new york, ny 10022. (800) 992-2623. <http://www.cancerresearch.org>.
lung line national jewish medical and research center. 14090 jackson street, denver, co 80206. (800) 222-5864. e-mail: [email protected] <http://www.nationaljewish.org>.
national cancer institute (national institutes of health). 9000 rockville pike, bethesda, md 20892. (800) 422-6237. <http://www.nci.nih.gov>.
national heart, lung and blood institute. information center. p.o. box 30105, bethesda, md 20824-0105. (301) 251-2222. <http://www.nhlbi.nih.gov>.
chest medicine on-line <http://www.priory.com/chest.htm>.
national lung health education program. <http://www.nlhep.com>.
pulmonarypaper.org p.o. box 877, ormond beach, fl 32175. (800) 950-3698. <http://www.pulmonarypaper.org>.
pulmonary forum <http://www.pulmonarychannel.com>.
Angela M. Costello
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Fiberoptic bronchoscopy is performed by pulmonologists, physician specialists in pulmonary medicine. CAT guided needle biopsy is done by interventional radiologists, physician specialists in radiological procedures. Thoracic surgeons perform open biopsies and VATS. Specially trained nurses, x ray, and laboratory technicians assist during the procedures and provide pre- and postoperative education and supportive care.
The procedures are performed in an operating or procedure room in a hospital.
QUESTIONS TO ASK THE DOCTOR
- Why is this procedure being performed?
- Are there any alternative options to having this procedure?
- What type of lung biopsy procedure is recommended?
- Is minimally invasive surgery an option?
- Will the patient be awake during the procedure?
- Who will be performing the procedure? How many years of experience does this physician have? How many other lung biopsies has the physician performed?
- Can medications be taken the day of the procedure?
- Can the patient have food or drink before the procedure? If not, how long before the procedure should these activities be stopped?
- How long is the hospitalization?
- After discharge, how long will it take to recover from the procedure?
- How is pain or discomfort relieved after the procedure?
- What types of symptoms should be reported to the physician?
- When can normal activities be resumed?
- When cam driving be resumed?
- When can the patient return to work?
- When will the results of the procedure be given to the patient?
- How often are follow-up physician visits needed after the procedure?
"Lung Biopsy." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Encyclopedia.com. (April 18, 2018). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/lung-biopsy-2
"Lung Biopsy." Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. . Retrieved April 18, 2018 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/lung-biopsy-2
Modern Language Association
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Lung biopsy is a medical procedure performed to obtain a small piece of lung tissue for examination under a microscope. Biopsy examinations are usually performed by pathologists, who are doctors with special training in tissue abnormalities and other signs of disease.
Lung biopsies are useful, first of all, in confirming a diagnosis of cancer, especially if malignant cells are detected in the patient's sputum. A lung biopsy may be ordered to examine other abnormalities that appear on chest x rays, such as lumps (nodules). It is also helpful in diagnosing symptoms such as coughing up bloody sputum, wheezing in the chest, or difficult breathing. In addition to evaluating lung tumors and their associated symptoms, lung biopsies can be used in the diagnosis of lung infections, especially tuberculosis, drug reactions, and such chronic diseases of the lung as sarcoidosis.
A lung biopsy can be used for treatment as well as diagnosis. Bronchoscopy, which is a type of lung biopsy performed with a long slender instrument called a bronchoscope, can be used to clear a patient's air passages of secretions and to remove blockages from the airways.
As with any other biopsy, lung biopsies should not be performed on patients who have problems with blood clotting because of low platelet counts. Platelets are small blood cells that play a role in the blood clotting process. If the patient has a platelet count lower than 50,000/cubic mm, he or she can be given a platelet transfusion as a temporary relief measure, and a biopsy can then be performed.
The lungs are a pair of cone-shaped organs that lie in the chest cavity. An area known as the mediastinum separates the right and the left lungs from each other. The heart, the windpipe (trachea), the lymph nodes, and the tube that brings the food to the stomach (the esophagus) lie in this mediastinal cavity. Lung biopsies may involve entering the mediastinum, as well as the lungs themselves.
Types of lung biopsies
Lung biopsies can be performed using a variety of techniques. A bronchoscopy is ordered if a patch that looks suspicious on the x ray seems to be located deep in the chest. If the area lies close to the chest wall, a needle biopsy is often done. If both these methods fail to diagnose the problem, an open surgical biopsy may be carried out. If there are indications that the lung cancer has spread to the lymph nodes in the mediastinum, a mediastinoscopy is performed.
NEEDLE BIOPSY. When a needle biopsy is to be done, the patient will be given a sedative about an hour before the procedure, to help relaxation. The patient sits in a chair with arms folded on a table in front of him or her. X rays are then taken to identify the location of the suspicious areas. Small metal markers are placed on the overlying skin to mark the biopsy site. The skin is thoroughly cleansed with an antiseptic solution, and a local anesthetic is injected to numb the area.
The doctor then makes a small cut (incision) about half an inch in length. The patient is asked to take a deep breath and hold it while the doctor inserts the special biopsy needle through the incision into the lung. When enough tissue has been obtained, the needle is withdrawn. Pressure is applied at the biopsy site and a sterile bandage is placed over the cut. The entire procedure takes between 30 and 45 minutes.
The patient may feel a brief sharp pain or some pressure as the biopsy needle is inserted. Most patients, however, do not experience severe pain.
OPEN BIOPSY. Open biopsies are performed in a hospital under general anesthesia. As with needle biopsies, patients are given sedatives before the procedure. An intravenous line is placed in the arm to give medications or fluids as necessary. A hollow tube, called an endotracheal tube, is passed through the throat, into the airway leading to the lungs. It is used to convey the general anesthetic.
Once the patient is under the influence of the anesthesia, the surgeon makes an incision over the lung area. Some lung tissue is removed and the cut closed with stitches. The entire procedure usually takes about an hour. A chest tube is sometimes placed with one end inside the lung and the other end protruding through the closed incision. Chest tube placement is done to prevent the lungs from collapsing by removing the air from the lungs. The tube is removed a few days after the biopsy.
A chest x ray is done following an open biopsy, to check for lung collapse. The patient may experience some grogginess for a few hours after the procedure. He or she may also experience tiredness and muscle aches for a day or two, because of the general anesthesia. The throat may be sore because of the placement of the hollow endotracheal tube. The patient may also have some pain or discomfort at the incision site, which can be relieved by medication.
MEDIASTINOSCOPY. The preparation for a mediastinoscopy is similar to that for an open biopsy. The patient is sedated and prepared for general anesthesia. The neck and the chest will be cleansed with an antiseptic solution.
After the patient has been put to sleep, an incision about two or three inches long is made at the base of the neck. A thin, hollow, lighted tube, called a mediastinoscope, is inserted through the cut into the space between the right and the left lungs. The doctor examines the space thoroughly and removes any lymph nodes or tissues that look abnormal. The mediastinoscope is then removed, and the incision stitched up and bandaged. A mediastinoscopy takes about an hour.
Before scheduling any lung biopsy, the doctor will check to see if the patient is taking any prescription medications, if he or she has any medication allergies, and if there is a history of bleeding problems. Blood tests may be performed before the procedure to check for clotting problems and blood type, in case a transfusion becomes necessary.
If an open biopsy or a mediastinoscopy is being performed, the patient will be asked to sign a consent form. Since these procedures are done under general anesthesia, the patient will be asked to refrain from eating or drinking anything for at least 12 hours before the biopsy.
Following a needle biopsy, the patient is allowed to rest comfortably. He or she will be checked by a nurse at two-hour intervals. If there are no complications after four hours, the patient can go home. Patients are advised to rest at home for a day or two before resuming regular activities, and to avoid strenuous activities for a week after the biopsy.
Open biopsy or mediastinoscopy
After an open biopsy or a mediastinoscopy, patients are taken to a recovery room for observation. If no other complications develop, they are taken back to the hospital room. Stitches are usually removed after seven to 14 days.
If the patient has extreme pain, light-headedness, difficulty breathing, or develops a blue tinge to the skin after an open biopsy, the doctor should be notified immediately. The sputum may be slightly bloody for a day or two after the procedure. If, however, the bleeding is heavy or persistent, it should be brought to the attention of the doctor.
Needle biopsy is a less risky procedure than an open biopsy, because it does not involve general anesthesia. Very rarely, the lung may collapse because of air that leaks in through the hole made by the biopsy needle. If the lung collapses, a tube will have to be inserted into the chest to remove the air. Some coughing up of blood occurs in 5% of needle biopsies. Prolonged bleeding or infection may also occur, although these are very rare.
Possible complications of an open biopsy include infection or lung collapse. Death occurs in about 1 in 3000 cases. If the patient has very severe breathing problems before the biopsy, breathing may be slightly impaired following the operation. If the person's lungs were functioning normally before the biopsy, the chances of any respiratory problems are very small.
Complications due to mediastinoscopy are rare; death occurs in fewer than 1 in 3000 cases. More common complications include lung collapse or bleeding caused by damage to the blood vessels near the heart. Injury to the esophagus or voice box (larynx) may sometimes occur. If the nerves leading to the larynx are injured, the patient may be left with a permanently hoarse voice. All of these complications are very rare.
Normal results of a needle biopsy and an open biopsy include the absence of any evidence of infection in the lungs. No lumps or nodules will be detected in the lungs and the cells will not show any cancerous abnormalities. Normal results from the mediastinoscopy will show the lymph nodes to be free of cancer.
Abnormal results may be associated with diseases other than cancer. Nodules in the lungs may be due to active infections such as tuberculosis, or may be scars from a previous infection. The lung cells on microscopic examination do not resemble normal cells, and show certain abnormalities that point to cancer. In a third of biopsies using a mediastinoscope, the lymph nodes that are biopsied prove to be cancerous. Abnormal results should always be considered in the context of the patient's medical history, physical examination, and other tests such as sputum examination, chest x rays, etc. before a final diagnosis is made.
Bronchoscopy— A medical test that enables the doctor to see the breathing passages and the lungs through a hollow, lighted tube.
Endotracheal tube— A hollow tube that is inserted into the windpipe to administer anesthesia.
Lymph nodes— Small, bean-shaped structures scattered along the lymphatic vessels which serve as filters. Lymph nodes retain any bacteria or cancer cells that are traveling through the system.
Mediastinoscopy— A medical procedure that allows the doctor to see the organs in the mediastinal space using a thin, lighted, hollow tube (a mediastinoscope).
Mediastinum— The area between the lungs, bounded by the spine, breastbone, and diaphragm.
Sputum— Mucus or phlegm that is coughed up from the passageways (bronchial tubes) in the lungs.
Cancer Research Institute. 681 Fifth Ave., New York, N.Y. 10022. (800) 992-2623. 〈http://www.cancerresearch.org〉.
National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. 〈http://www.nci.nih.gov〉.
"Lung Biopsy." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (April 18, 2018). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/lung-biopsy
"Lung Biopsy." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved April 18, 2018 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/lung-biopsy