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Lung Biopsy

Lung biopsy

Definition

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.


Purpose

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.


Demographics

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.


Description

Overview

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 23 in (58 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.


Diagnosis/Preparation

Diagnosis

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.


Preparation

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.

Smoking cessation

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

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.


Aftercare

Needle biopsy

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.


Risks

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.


Bronchoscopic biopsy

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

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.


Open biopsy

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.

Mediastinoscopy

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

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.


Alternatives

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 technologylow-dose helical computed tomographyfor 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.


Resources

books

"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.

organizations

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>.

other

dailylung.com <http://www.dailylung.com>.

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>.


Barbara Wexler
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?

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Lung Biopsy

Lung Biopsy

Definition

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.

Purpose

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.

Precautions

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.

Description

Overview

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.

Preparation

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.

Aftercare

Needle 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.

Risks

Needle biopsy

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.

Open biopsy

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.

Mediastinoscopy

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

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

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.

KEY TERMS

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.

Resources

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org.

American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872. http://www.lungusa.org.

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.

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Lung Biopsy

Lung Biopsy

Definition

Lung biopsy is a procedure by which a small sample of lung tissue is obtained for examination. Usually, it is examined under the microscope and also may be sent to the microbiological laboratory for culture. Microscopic examination is performed by pathologists.

Purpose

A lung biopsy is usually ordered to determine the cause of abnormalities that appear on chest x rays, such as nodules or infiltrates. Lung biopsies are performed to 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 in the diagnosis of lung infections, especially tuberculosis and Pneumocystis pneumonia, drug reactions, and chronic diseases of the lung such as sarcoidosis.

A lung biopsy can be used for treatment as well as diagnosis. Bronchoscopy, 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. Today, flexible fiberoptic bronchoscopes, which are easier to use than rigid scopes, are used to perform most biopsies.

Precautions

As with any other biopsy, lung biopsies should not be performed on patients who have a tendency to bleed 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 clots. If they are prolonged, it might 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.

Description

Overview

The mediastinum separates the right and the left lungs from each other. The heart, the trachea, the lymph nodes, and the esophagus lie in the mediastinum. Lung biopsies may involve mediastinoscopy, 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 lesion identified on the x ray seems to be located in the periphery of the chest. If the suspicious area lies close to the chest wall, a needle biopsy can be done. If both these methods fail to diagnose the problem, an open lung biopsy may be performed. When there is a question about whether the lung cancer has spread to the lymph nodes in the mediastinum, a mediastinoscopy is performed.

NEEDLE BIOPSY. About an hour before the needle biopsy procedure, a sedative is administered to the patient. The patient is mildly sedated but fully awake. An X ray technician takes a computerized axial tomography (CT) scan to identify the location of the suspicious areas. 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 physician then 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. 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 do not experience severe pain.

OPEN BIOPSY. Open biopsies are performed in a hospital operating room under general anesthesia. As with needle biopsies, patients are sedated before the procedure. An intravenous line is placed to give medications or fluids as necessary. A hollow tube, called an endotracheal tube, is passed through the mouth, into the airway leading to the lungs. It is used to convey the general anesthetic.

Once the patient is anesthetized, 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. 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 a pneumothorax (lung collapse). The patient may experience some grogginess for a few hours after the procedure. Patients also may 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 endotracheal tube. The patient may also have some pain or discomfort at the incision site, which can be relieved by pain medication.

VIDEO-ASSISTED THORASCOPIC SURGERY. A new technique, video-assisted thorascopic surgery (VATS), also can be used to biopsy lung and mediastinal lesions. VATS may be performed on selected patients in place of open lung biopsy. To perform a VATS procedure, the surgeon makes several small incisions in the patient's 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 surgical instruments to retrieve tissue for biopsy.

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 are cleansed with an antiseptic solution.

After the patient is anesthetized, 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 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.

Preparation

Before scheduling a lung biopsy, the physician performs a preoperative history and physical examination. An electrocardiogram (EKG) and laboratory tests may be performed before the procedure to check for clotting problems, anemia, and blood type, in case a transfusion becomes necessary.

Patient education

Patients who will undergo surgical diagnostic and treatment procedures should be encouraged to stop smoking. Patients able to stop smoking several weeks before surgical procedures have fewer postoperative complications.

Before any procedure is performed, the patient is asked to sign a consent form. The nurse may review the procedure and answer questions about the consent form or procedure. The nurse will advise the patient preparing for general anesthesia to refrain from eating or drinking anything for at least 12 hours before the biopsy.

Aftercare

Needle biopsy

Following a needle biopsy, the patient is allowed to rest comfortably. The nurse checks the patient's status at two-hour intervals. If there are no complications after four hours, then the patient can go home.

Patient education

Prior to discharge to home, the nurse instructs the patient about resuming normal activities. 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, VATS, or mediastinoscopy

After an open biopsy, VATS, or mediastinoscopy, patients are taken to the recovery room for observation. If no complications develop, they are returned to the hospital room. Nursing care includes monitoring temperature, pulse blood pressure and respiration. Fever may indicate infection, and decreased breath sounds may be symptoms of pneumothorax. Sutures are usually removed after seven to 14 days.

If the patient has extreme pain, light-headedness, or difficulty breathing after an open biopsy, the physician should be notified immediately. The sputum may be slightly bloody for a day or two after the procedure. Heavy or persistent bleeding requires evaluation by the physician.

Complications

Needle biopsy

Needle biopsy is associated with fewer risks than open biopsy, because it does not involve general anesthesia. Rarely, the lung may collapse because of air that leaks in through the hole made by the biopsy needle. If a pneumothorax (lung collapse) occurs, a chest tube is inserted into the pleural cavity to re-expand the lung. Some hemoptysis (coughing up of blood) occurs in 5% of needle biopsies. Prolonged bleeding or infection may also occur, although these are very rare.

Open biopsy

Possible complications of an open biopsy include infection or pneumothorax. Death occurs in about one in 3000 cases. If the patient has very severe breathing problems before the biopsy, then breathing may be further impaired following the operation. For patients with normal lung function before the biopsy, the risk of respiratory problems resulting from or following the procedure is very small.

Mediastinoscopy

Complications due to mediastinoscopy are rare; death occurs in fewer than one in 3000 cases. More common 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.

Results

Abnormal results of needle biopsy, VATS, and open biopsy may be associated with diseases other than cancer. Nodular lesions, while frequently cancerous, can also be the result of active infections such as tuberculosis, or may be healed scars from a previous infection. 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 definitive diagnosis is made.

Health care team roles

Fiberoptic bronchoscopy is performed by pulmonologists, physician specialists in pulmonary medicine. CT guided needle biopsy is done by interventional radiologists, physician specialists in radiological procedures. Thoracic surgeons perform open biopsy and VATS. Specially trained nurses, x ray, and laboratory technicians assist during the procedures and provide pre and postoperative education and supportive care.

KEY TERMS

Bronchoscopy— A medical test that enables the physician 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 trap bacteria or cancer cells that are traveling through the lymphatic system.

Mediastinoscopy— A procedure that allows the physician 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.

Pneumothorax— A condition in which air or gas enters the pleura (area around the lungs) and causes a collapse of the lung.

Sputum— A mucus-rich secretion that is coughed up from the passageways (bronchial tubes) and the lungs.

Resources

BOOKS

"Bronchoscopy." In The Merck Manual of Diagnosis and Therapy, edited by Robert Berkow, et al. Rahway, NJ: Merck Research Laboratories, 2005.

Groenwald, S.L. et al. Cancer Nursing Principles and Practice. Sudbury, MA: Jones and Bartlett Publishers, 1997, pp.1273-1275.

Murphy, Gerald P., et al. American Cancer Society Textbook of Clinical Oncology Second Edition Atlanta, GA: The American Cancer Society, Inc., 1995, pp.223-234.

Otto, S.E. Oncology Nursing. St. Louis, MO: Mosby, 1997, pp. 317-318.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Road, N.E., Atlanta, GA 30329. (800)227-2345.

American Lung Association. 1740 Broadway, New York, NY 10019-4374. (800)586-4872.

Cancer Research Institute. 681 Fifth Avenue, New York, NY 10022. (800)992-2623.

National Cancer Institute (National Institutes of Health).9000 Rockville Pike, Bethesda, MD 20892. (800) 422-6237.

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Lung Biopsy

Lung biopsy

Definition

A lung biopsy is a procedure that removes a small piece of lung tissue for examination. The tissue will be examined under a microscope to look for certain diseases.

Purpose

A lung biopsy may be used to diagnose or confirm a diagnosis of lung cancer . Patients sometimes have symptoms in the lungs such as wheezing, coughing up bloody sputum, or lumps (nodules). A biopsy may help determine the cause or rule out a cause such as cancer . A lung biopsy also can be used to diagnose lung infections or lung conditions such as sarcoidosis , in which the lungs inflame for unknown reasons, or for pulmonary fibrosis , or thickening of the tissues in the lungs. Often, the lung biopsy is performed when other tests, such as x-ray examinations, cannot identify the cause of a lung problem or nodule. In cancer diagnoses, a biopsy usually is the authoritative test to determine if cancer is present and to stage the cancer.

Precautions

As of 2008, lung biopsies had become less invasive than before. Although some patients still require open biopsies, which involve surgery, many can have tissue removed with no incision or through a small needle. Of course, any time a physician must take tissue from a patient's lungs, there are risks. Patients may have to take certain precautions to prevent reactions to anesthesia if they will require it for their biopsy. Patients with blood clotting problems will need to discuss their conditions with the physician. In general, older patients who may have other illnesses such as heart or lung diseases may need to take special precautions before having a lung biopsy. They should discuss preparation, precautions, and risks with their physician.

Description

There are several types of lung biopsy procedures. The one chosen for a particular patient may depend on the location of the sample and the patient's overall health. In all types of biopsies, the small piece of lung tissue that is removed is sent to a laboratory, where a pathologist examines the results. Pathologists are physicians who are specially trained and certified in the microscopic evaluation of cells, tissues, blood, and other body fluids. The tissue for examination may be collected by one of several biopsy methods, including the following.

Fine needle aspiration

By inserting a long needle through the chest wall and into the sample tissue, such as the nodule or inflamed area of the lung, the physician can lessen damage to healthy lung tissue. Many of these procedures are performed by radiologists or interventional radiologists, who use computed tomography, ultrasound, or other imaging to guide them to the correct site for needle placement. Once the needle location is confirmed, the doctor marks the entry site on the skin, disinfects the site, and numbs it with a local anesthetic. The needle requires an incision of only about one-eighth inch. The patient will be asked to hold his or her breath several times during the procedure. The entire needle biopsy procedure lasts about one hour.

Bronchoscopy

A bronchoscope is a long, slender, lighted instrument that is inserted through the mouth or nose. The tool often is used to clear a patient's air passages when they get blocked. In a bronchoscope biopsy, a pulmonologist or other trained clinician can observe the lungs to look for nodules. Instruments can be passed through the bronchoscope that are used to collect tissue or fluid samples for the pathologist. The patient's mouth and throat are sprayed with a solution to numb them before placing the bronchoscope. Some patients also receive medications through an intravenous (IV) line to help them relax during the procedure.

Thorascopy

In thorascopy or video-assisted thorascopic surgery (VATS), a thoracic surgeon, or a physician who specializes in operating on the chest, passes a slender tube called a thorascope through a small incision in the chest. This type of biopsy is more invasive than a needle biopsy or bronchoscopy but requires a few tiny incisions through which instruments pass, instead of a large incision, as in typical chest surgery. The surgeon watches a television monitor to guide the procedure.

Open biopsy

In open biopsy, a surgeon makes an incision over the patient's lung area. The surgeon removes a small piece of tissue from the problem area of the lung and visually examines the area. The procedure usually takes about one hour and is performed in an operating room. The patient receives anesthesia before surgery begins. The area of the incision is sutured, or stitched, at the end of the procedure. Sometimes, a chest tube is placed inside one end of the lung, with the other end of the tube through the incision, which helps prevent the lung from collapsing.

QUESTIONS TO ASK YOUR DOCTOR

  • What are the risks of the procedure?
  • Is there a biopsy procedure that is less invasive or less risky?
  • What if I have breathing problems?
  • Should I avoid coughing after the biopsy?

Preparation

Preparation depends on the procedure. Most biopsy procedures require that the patient have no food or drink for at least eight hours prior to the procedure in case the patient needs general anesthesia . When preparing for a biopsy, patients should discuss all medications, including herbal supplements, that they are taking. Some medications, such as aspirin or blood thinners, can cause bleeding. It also is important for them to check for allergies and possible clotting problems. Patients may be asked to sign an informed consent form, in which the risks and benefits of the procedure are discussed. It is helpful for patients to arrange for someone to come along during the biopsy procedure. Often, patients cannot drive for some time following anesthesia or may suffer some discomfort. For an open biopsy, the patient may require hospitalization and should prepare for hospital admission.

Aftercare

After a fine needle biopsy, little care is needed, except removal of a bandage about one day following the procedure. There may be some soreness and patients should not exert themselves, such as lifting heavy objects, for at least one day following the procedure. After bronchoscopy, patients are observed to make sure that normal breathing has been achieved. Following thorascopic lung biopsy, patients usually recovers for a while under the watch of the surgery team. A visit is made to the surgeon in about one week to check for healing of the small entry wounds. After an open biopsy, patients go to the surgical recovery room for care and observation. Hospital stays after thorascopy and open biopsy vary but should be minimal if there are no complications.

KEY TERMS

Bronchoscopy —A medical test that allows a physician to see the breathing passages and lungs through a long, hollow, lighted tube passed through the nose or throat.

Invasive —Involving entry to a patient's body by an instrument or incision.

Thorascopy —A medical test that allows a physician to see the breathing passages and lungs through a special scope passed through small incisions in the chest. The physician guides the examination by video monitor.

Complications

Many patients receive a chest x ray following a lung biopsy to check for possible complications. Very few complications occur from bronchosopies. Signs include shortness of breath, difficulty catching one's breath, rapid pulse, sharp chest or shoulder pain when breathing, and blue skin. Any time patients receive anesthesia, there is some risk of complication from the anesthesia. Complications are less for needle biopsies than for open biopsies, but patients may experience bleeding, coughing up blood, infection, or collapsed lung. After open biopsy, infection, lung collapse, and anesthesia complications may occur.

Results

Typically, the pathologist sends a report with results to the primary care physician within a few days. If the results are normal, there is no lung cancer, infection, or inflammation in the lungs. Abnormal results may indicate that there is an active infection. Results also may show the possibility of certain lung diseases, lung cancer, or cancer from another organ that has spread to the lung. The physician combines the information from the biopsy with other information from the patient's medical history and clinical examination.

Caregiver concerns

Most lung biopsies are ordered by a primary care physician, such as a family practice physician, internal medicine physician, or a certified nurse practitioner, or physician assistant. Many different physician specialists perform lung biopsies, depending on the type that best suits the patient. If the biopsy requires surgery, an anesthesiologist and/or certified registered nurse anesthetist may be involved in making the patient more comfortable during the procedure. Other surgical staff, such as nurses or assistants may be involved as well. A respiratory therapist may assist with aftercare if a patient has trouble breathing. A pathologist examines the tissue sample and determines results, which go back to the physician who ordered the biopsy for evaluation and determination of treatment or referrals to specialists if needed.

Resources

OTHER

“Needle Biopsy of Lung (Chest) Nodules.” RadiologyInfo [cited February 7, 2008]. http://www.radiologyinfo.org/en/info.cfm?PG=nlungbiop&bhcp=1

ORGANIZATIONS

American Lung Association, 61 Broadway, 6th Floor, New York, NY, 10006, (800)548-8252, (212) 315-8700, http://www.lungusa.org.

National Heart, Lung, and Blood Institute, PO Box 30105, Bethesda, MD, 20824-0105, (301)592-8573, (240)629-3246, [email protected], http://www.nhlbi.nih.gov.

Teresa G. Odle

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Lung Biopsy

Lung Biopsy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

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.

Purpose

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.

Demographics

Lung cancer is the leading cause of cancer-related deaths in the United States. About 213,380 patients were newly diagnosed with lung cancer in 2007 (about 114,760 in men and 98,620 in women). It is expected to claim nearly 160,390 lives in 2007 (89,510 in men and 70,880 in women). Lung cancer kills more people than cancers of the breast, prostate, colon, and pancreas combined. Cigarette smoking accounts for nearly 90% of cases of lung cancer in the United States.

Description

Overview

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.

KEY TERMS

Bronchoscopy— A medical test that enables the physician to see the breathing passages and the lungs through a hollow, lighted tube.

Chest x ray— Brief exposure of the chest to radiation to produce an image of the chest and its internal structures.

Endotracheal tube— A hollow tube that is inserted into the windpipe to administer anesthesia.

Lung nodule— See pulmonary nodule.

Lymph nodes— Small, bean-shaped structures that serve as filters, scattered along the lymphatic vessels. Lymph nodes trap bacteria or cancer cells that are traveling through the lymphatic system.

Malignant— Cancerous.

Mediastinoscopy— A procedure that allows the physician 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.

Pleural cavity— The space between the lungs and the chest wall.

Pneumothorax— A condition in which air or gas enters the pleura (area around the lungs) and causes a collapse of the lung.

Pulmonary nodule— A lesion surrounded by normal lung tissue. Nodules may be caused by bacteria, fungi, or a tumor (benign or cancerous).

Sputum— A mucus-rich secretion that is coughed up from the passageways (bronchial tubes) and the lungs.

Sputum cytology— A lab test in which a microscope is used to check for cancer cells in the sputum.

Thoracentesis— Removal of fluid from the pleural cavity.

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 30-60 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. Aminimally-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 inch (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.

Diagnosis/Preparation

Diagnosis

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.

Preparation

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.

Smoking cessation

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

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.

Aftercare

Needle biopsy

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.

Risks

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.

Bronchoscopic biopsy

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

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.

Open biopsy

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.

Mediastinoscopy

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

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 media-stinoscope, 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.

Alternatives

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

WHO PERFORMS THIS 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.

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.

Resources

BOOKS

Abeloff, MD et al. Clinical Oncology. 3rd ed. Philadelphia: Elsevier, 2004.

Mason, RJ et al. Murray & Nadel’s Textbook of Respiratory Medicine. 4th ed. Philadelphia: Saunders, 2007.

ORGANIZATIONS

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.organdhttp://www.thoracic.org.

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?

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.

OTHER

Dailylung.com. http://www.dailylung.com.

Chest Medicine On-Line. http://www.priory.com/chest.htm.

National Lung Health Education Program. http://www.nlhep.com.

Pulmonary Forum. http://www.pulmonarychannel.com.

Pulmonarypaper.org. P.O. Box 877, Ormond Beach, FL 32175. (800) 950- 3698. http://www.pulmonarypaper.org.

Barbara Wexler

Angela M. Costello

Rosalyn Carson-DeWitt, MD

Lung surgery seeLobectomy, pulmonary

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