Prospective Evaluation of Aspiration Needle,Cutting Needle,Transbronchial, and Open Lung Biopsy in Patients with Pulmonary Infiltrates

Twenty consecutive patients with pulmonary infiltrates undiagnosed by routine, noninvasive methods were entered into a prospective study designed to evaluate the diagnostic yield of four methods of lung biopsy. Percutaneous aspiration needle, cutting needle, transbronchial, and open (anterior thoracotomy) biopsy were performed synchronously on all patients. Specimens were evaluated by microbiological, virological, and pathological methods. The diagnostic yields of the four methods were as follows: aspiration needle, 29%; cutting needle, 53%; transbronchial, 59%; and open lung biopsy, 94%. Open lung biopsy was significantly better in yielding a diagnosis than aspiration needle (p < 0.001), cutting needle (p < 0.001), and transbronchial biopsy (p < 0.04).     

Image-guided percutaneous approach is superior to the thoracoscopic approach in the diagnosis of pulmonary nodules in children

Background/Purpose: Image-guided, percutaneous techniques are increasingly used in diagnosis of pulmonary disease in children. The aim of this study was to determine the diagnostic accuracy and clinical outcomes of thoracoscopic versus percutaneous lung biopsy in children. Methods: Sixty-three consecutive patients from January 1996 to December 2000 who had a thoracoscopic lung biopsy, a percutaneous ultrasound scan, or computed tomography (CT)-guided lung biopsy for well-defined and ill-defined lesions were analyzed. Results: Twenty-eight patients had a thoracoscopic lung biopsy (TLB), and 35 patients had a percutaneous image-guided lung biopsy (PLB). Age ranged from 6 months to 17 years (median, 8 years). There was no significant difference between groups with regard to age, depth of lung nodule biopsied, or prebiopsy diagnoses. Seventeen patients (60%) of TLB and 23 (65%) of PLB had well-defined pulmonary nodules suspicious for malignancy at the time of biopsy. Adequate tissue for pathologic diagnosis was obtained in 28 (100%) of TLB versus 26 (80%) of PLB patients. However, 8 (28%) thoracoscopic cases needed to be converted to an open procedure. In 3 (8.5%) PLB cases the percutaneous biopsy was insufficient, and a thoracoscopic or open biopsy was required. The median hospital stay was 3 days for TLB and 4 to 6 hours for PLB (P [equals] .023). There were no complications in the PLB group. Five (18%) of TLB patients suffered a persistent air leak treated with continued chest tube drainage, and one patient died of other causes with a persistent air leak. Conclusions: Percutaneous lung biopsy has a significantly shorter hospital stay and a lower complication rate than thoracoscopic lung biopsy. The authors propose that the percutaneous technique should be considered as the initial approach for children with pulmonary nodules. J Pediatr Surg 38:745-748. [copy ] 2003 Elsevier Inc. All rights reserved.     

Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: a randomised controlled trial

BACKGROUND: Some patients with diffuse lung disease require a lung biopsy for diagnosis. This study is aimed to compare the clinical results and the efficacy of video-assisted thoracoscopic lung biopsy with the open lung biopsy method for the diagnosis of interstitial lung disease. From January 1996 to December 1998, 61 patients were referred for diagnostic lung biopsy. Thirty two patients were randomly allocated to have a thoracoscopic lung biopsy and twenty nine had an open lung biopsy. Subsequently, various factors were analyzed and compared in both groups. RESULTS: There was no difference between the groups in age and pulmonary function test. Median operative time was 45 minutes for the thoracoscopic biopsies and 60 minutes for the open biopsies (P = 0.009). Median amount of analgesia (Demerol) in the first 24 hours postoperatively was 75 mg. for thoracoscopic biopsies and 150 mg. for open biopsies (P < 0.001). Median duration of insertion of a chest tube in days and 24 hours of pleural drainage was not statistically significant between the two groups. Duration of hospital stay was significantly less for the thoracoscopic biopsy (3 days) compared with an open biopsy (5 days) (P < 0.001). The diagnostic yield of each method was comparable (thoracoscopic biopsy 31/32; open biopsy 27/29) (P = 0.3). Complications occurred in 6/29 of patients undergoing open biopsies and 3/32 patients undergoing thoracoscopic lung biopsies (p = 0.28). There were 2 deaths among patients who had an open lung biopsy. CONCLUSION: Thoracoscopic lung biopsy has some clinical advantages over open biopsy. These findings suggest that thoracoscopic lung biopsy is an acceptable alternative to open lung biopsy for the diagnosis of diffuse interstitial lung diseases.     

Changing the way we think about medical technology policy

BACKGROUND: Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice. METHODS: We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day. RESULTS: Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3%+/-7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred. CONCLUSIONS: Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.     

Efficacy of video assisted thoracoscopic lung biopsy: an historical comparison with open lung biopsy.

BACKGROUND--Video assisted thoracoscopic lung biopsies were compared with historical controls undergoing open lung biopsy to determine the diagnostic accuracy, effect on length of postoperative stay, and cost effectiveness of the new thoracoscopic technique. METHODS--The first 25 video assisted thoracoscopic lung biopsies performed in the Edinburgh Thoracic Unit were compared with 25 historical controls for complications, diagnostic accuracy, and length of postoperative stay. RESULTS--Statistical comparison showed equal diagnostic accuracy in both groups (96% v 92%), but mean (SD) inpatient stay was reduced in the video assisted thoracoscopic group (1.4 (0.7) days) compared with those undergoing open lung biopsy (3.1 (1.8) days). No postoperative complications were reported in the group which underwent video assisted thoracoscopic lung biopsies but three patients had postoperative complications in the open lung biopsy group. CONCLUSIONS--Video assisted thoracoscopic lung biopsy is as effective in providing histological diagnosis as is open lung biopsy. All postoperative complications were related to post thoracotomy pain and occurred only in patients undergoing open lung biopsy. Reduced postoperative disability in the video assisted thoracoscopic group decreased hospital stay, offsetting the increased cost in disposables. The overall cost of video assisted thoracoscopic and open lung biopsy was 712 pounds and 1114 pounds, respectively.     

The role of early open lung biopsy in the diagnosis and treatment of Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonitis has increased in incidence within the population of patients receiving cytotoxic and immunosuppressive therapy. During the last seven years 12 patients with this fulminant disease have been encountered. Results of diagnosis and therapy are presented and discussed. Early open lung biopsy and the initiation of appropriate antimicrobial therapy are stressed.     

The Diagnosis and Management of Pneumocystis carinii Pneumonia

Pneumocystis carinii pneumonia is a disease of increasing clinical significance in patients with impaired cellular immunity. Twenty-seven such individuals who demonstrated the characteristic triad of progressive respiratory failure, minimal auscultatory findings, and roentgenographic hilar infiltrates progressing to consolidation are presented. In this series, open lung biopsy was more effective early in the disease when hilar infiltrates had not consolidated; when consolidation was present, needle biopsy appeared to be effective. Of the patients in whom a diagnosis was established prior to death, 6 of 7 treated with amphotericin died and 9 of 11 treated with pentamidine recovered from their pneumonia though they demonstrated transient drug toxicity. The future role of the membrane lung in supporting patients in severe respiratory failure during the course of drug therapy is suggested by the response of 2 patients.     

Prospective randomized study of open lung biopsy versus empirical antibiotic therapy for acute pneumonitis in nonneutropenic cancer patients

Diffuse pulmonary infiltrates and acute respiratory compromise frequently occur in patients with cancer who are undergoing chemotherapy, and treatment remains controversial. We initiated a prospective randomized trial in 22 nonneutropenic patients to compare the efficacy of immediate open lung biopsy with that of empirical trimethoprim-sulfamethoxazole and erythromycin therapy with delayed open lung biopsy if no clinical improvement occurred after 4 days of therapy. Diagnoses included non-Hodgkin's lymphoma (15 patients), T-cell lymphoma (2), acute lymphoblastic leukemia (3), Hodgkin's disease (1), and breast cancer (1). The median age was 40 years, and fever (18) and tachypnea (13) were the most frequent signs. Median room air arterial oxygen tension in 18 hypoxic patients was 53 mm Hg; 19 patients had diffuse pulmonary infiltrates. Eight of the 10 patients randomized to empirical antibiotic therapy showed improvement after 4 days. The 2 patients whose condition did not improve and who underwent delayed open lung biopsy had Pneumocystis carinii pneumonia. One of them did show improvement, and the other died of respiratory failure. Time to clinical resolution in the 9 surviving patients was 14 days; 4 required prolonged ventilation (longer than 24 hours). Findings for the 12 patients randomized to immediate open lung biopsy were P. carinii pneumonia in 7 and nonspecific pneumonitis in 5; there were 3 deaths related to open lung biopsy. Time to resolution in the surviving patients was 13 days for those with P. carinii pneumonia and 5 days for those with nonspecific pneumonitis; 7 required prolonged ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of open lung biopsy in diagnosing pulmonary complications of AIDS.

Over a 4-year period, 25 patients with pulmonary complications of acquired immunodeficiency syndrome underwent open lung biopsy for diagnosis. Results of the biopsy led to a change in therapy in 15, and of this group, 8 patients improved clinically and were discharged. We believe that a select group of acquired immunodeficiency syndrome patients with pulmonary disease will benefit from open lung biopsy. Our indications for open lung biopsy are (1) a nondiagnostic bronchoscopy, (2) failed medical therapy after a diagnostic bronchoscopy, (3) failed empiric medical therapy after a nondiagnostic bronchoscopy or after a second nondiagnostic bronchoscopy, and (4) when any of the forementioned are accompanied with a worsening chest roentgenogram. Patients with acquired immunodeficiency syndrome who have a deteriorating respiratory status or require mechanical ventilation should not undergo open lung biopsy.     

Open lung biopsy in patients with diffuse pulmonary shadowing.

The radiological appearances of diffuse pulmonary shadowing are not specific and frequently histological examination is necessary to provide a diagnosis or assess the activity of the disease. From July 1979 to May 1983 open lung biopsy was performed in 101 patients through a limited submammary incision. Twenty seven patients had undergone prior invasive investigations and 27 were taking corticosteroids at the time of biopsy. In 92 patients the histological appearances after open lung biopsy were sufficiently specific to permit diagnosis. Respiratory tract infection occurred in six patients and in eight there was some superficial infection of the wound. These complications were more frequent in patients taking corticosteroids but the difference was not statistically significant. The chest drain was removed usually on the first postoperative day. In three critically ill patients an air leak occurred after removal of the drain, requiring formal surgical re-exploration and drainage in two cases and a brief period of intercostal drainage in the third. Four patients in the series died. All had severe pre-existing lung disease; in three open lung biopsy was performed in the late stages of severe, rapidly progressive lung disease eluding diagnosis; the fourth patient, who had massive pulmonary fibrosis from asbestos lung disease, developed a respiratory tract infection and died from progressive respiratory failure. Open lung biopsy can be performed with minimal morbidity and a high diagnostic yield. The approach used in this series provides a safe and reliable operation with good cosmetic results.     

Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy

Background

Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication.

Methods

Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression.

Results

Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors.

Conclusions

Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.     

THE EFFICACY OF OPEN LUNG BIOPSY

Background : The morbidity and mortality of open lung biopsy was assessed, and the ability to provide a specific diagnosis in the assessment of patients with diffuse radiographic pulmonary infiltrates was determined. Methods : A retrospective analysis was undertaken from January 1990 to May 1995 of all patients undergoing open lung biopsy during the study period. A total of 127 biopsies were performed. The indications were diffuse, infiltrative or multinodular disease. Forty-two (33%) patients had previously undergone non-diagnostic trans-bronchial biopsy. Results : Open lung biopsy obtained a histological diagnosis in 121 (95.3%) patients. Postoperative in-hospital mortality was 4.7% (six patients). Three of the four patients being ventilated at the time of biopsy died. Thirty-six (28.3%) patients suffered one or more morbid events. Patients with decreased lung function, as measured by forced expiratory volume, experienced a higher risk of a morbid event (P < 0.01). There was no significant correlation between the chance of a morbid event and age, sex or the use of multiple biopsy sites. A presumptive diagnosis was made prior to biopsy in 71 patients (55.9%) and was proven correct in 43.6% of cases. Conclusions : Open lung biopsy in patients with diffuse pulmonary disease is an accurate diagnostic tool and has an acceptable morbidity and mortality associated with the procedure.     

Traumatic pulmonary pseudocysts.

From July, 1973, to June, 1977, 25 patients in an immunosuppressed state from underlying reticuloendothelial neoplasm or associated chemotherapy, underwent open biopsy of the lung at the University of Maryland Hospital for diagnosis of unilateral diffuse pulmonary infiltrates. Eight patients were in marked respiratory distress, 13 in moderate distress, and 4 in little or no distress at the time of open lung biopsy. There were 3 postoperative deaths (12%). The operation-related morbidity was 1 out of 25 (4%). Two of the patients who died were found to have irreversible pulmonary fibrosis secondary to bleomycin drug therapy. The subsequent treatment of all 25 patients was influenced by the biopsy findings as follows: upgrading the disease stage or establishing treatment failure in 11 patients; establishing the presence of inflammatory disease in 3 patients; establishing the diagnosis of fibrosis associated with drug treatment without recurrent disease or infection in 11 patients. The preferability of open lung biopsy as opposed to transbronchial or percutaneous techniques is discussed.     

Pulmonary hypertension associated with pulmonary occlusive vasculopathy after allogeneic bone marrow transplantation

BACKGROUND: Pulmonary vasculature abnormalities, including pulmonary veno-occlusive disease, have been demonstrated in marrow allograft recipients. However, it is often difficult to make a correct diagnosis of pulmonary lesions. METHODS: An open lung biopsy was performed on a patient who developed severe pulmonary hypertension after bone marrow transplantation for T-cell lymphoma. RESULTS: An open lung biopsy specimen demonstrated pulmonary arterial occlusion due to intimal fibrosis and veno-occlusion. The most striking alteration was partial to complete occlusion of the small arteries by fibrous proliferation of the intima. CONCLUSION: High-dose preparative chemotherapy and radiation before transplantation are thought to have contributed to the development of vasculopathy in this patient, because arterial occlusion by intimal fibrosis and atypical veno-occlusion are often associated with lung injury due to chemoradiation. An open lung biopsy is essential for diagnosing pulmonary vascular disease presenting signs compatible with posttransplantation pulmonary hypertension.     

Interstitial pneumonitis in the immunologically suppressed child: an urgent surgical condition.

Thirty-eight children were evaluated for interstitial pneumonia by open lung biopsy. In most instances the patients were immunosuppressed as a result of cancer chemotherapy and irradiation. Pneumocystis carinii infection was the most common cause of pneumonitis (60.4%), especially in children with leukemia (78.3%). The clinical triad of hypoxemia, tachypnea, and a diffuse interstitial infiltrate on chest x-ray, is an indication for early open lung biopsy. Survival was 91.7% in cases of acute pneumocystis pneumonia, a significant improvement over previous reports. These observations strongly support the concept of early open lung biopsy in the management of diffuse interstitial pneumonitis in patients who are immunosuppressed.     

Lung biopsy using mediastinoscope in the time of VATS

Patients with diffuse lung disease need lung biopsy for accurate diagnosis and treatment. Both traditional open lung biopsy through a thoracotomy and video assisted thoracoscopic lung biopsy are effective methods for obtaining parenchymal samples. The authors present their surgical method and experience. Thirty patients were operated on for lung biopsy using mediastinoscope between 1999-2003. Lung parenchymal samples were eligible for histological examination. No serious postoperative complications developed. The method is simple, safe and low-cost.     

Open lung biopsy in neonatal and paediatric patients referred for extracorporeal membrane oxygenation (ECMO)

BACKGROUND: This study was undertaken to determine the usefulness, safety, and most appropriate timing of open lung biopsy in infants and children considered for and on extracorporeal membrane oxygenation (ECMO) for respiratory failure. METHODS: A retrospective review of children referred for consideration of and placed on ECMO in our institution in the period 1996-2002. RESULTS: 506 patients were referred, 15 (3%) of whom underwent antemortem open lung biopsy (eight neonatal, four paediatric, and three cardiac patients). In the neonatal group open lung biopsy contributed to clinical decision making in all patients. Four neonates had a fatal lung dysplasia (three alveolar capillary dysplasia and one surfactant protein B deficiency) and treatment was withdrawn. Of the other four neonates, two had pulmonary hypoplasia, one had pulmonary lymphangiectasia, and one had meconium aspiration with mild barotrauma. Treatment was continued in these four patients and two survived. In the paediatric group the biopsies were of clinical relevance in two infants with pertussis who had lung infarction on biopsy in whom treatment was withdrawn. In the other two paediatric patients the biopsies were equivocal, treatment was continued, but both patients died. In the cardiac group, who presented perioperatively with pulmonary hypertension, the biopsies excluded a fatal lung dysplasia and severe pulmonary vascular disease but all three infants died. One patient had non-fatal bleeding complications. CONCLUSION: Open lung biopsy is clinically most useful when performed to diagnose fatal lung dysplasias in neonates and to confirm the presence of viable lung tissue in patients with acute lung injury due to pertussis infection.     

Die offene Lungenbiopsie in der Diagnostik diffuser pulmonaler Erkrankungen

Zusammenfassung Die operative Technik der offenen Lungenbiopsie wird beschrieben und über unsere Erfahrungen mit 36 Eingriffen dieser Art berichtet. Bei diffusen pulmonalen Erkrankungen erhielten wir eine histologische Diagnose in allen Fällen und beobachteten nur drei unbedeutende Komplikationen. Eine Literaturübersicht bestätigt unsere Ergebnisse. Nach ihr bietet die offene Lungenbiopsie in weniger als 3 % keine diagnostische Hilfe, und die Operationsletalität liegt unter 1%.

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Open lung biopsy in the diagnosis of diffuse pulmonary disease

Summary Our experience with open lung biopsy for diffuse pulmonary disease in 36 cases including operative techniques is described. We were able to make a histological diagnosis in all cases, and had only three minor complications. A review of the literature confirms our experience. Open lung biopsy is uncontributionary in less than 3 %. Complications are infrequent, and the mortality rate is less than 1 %. Thus, open lung biopsy is a safe procedure with a high diagnostic yield. It should be used in all cases of diffuse pulmonary disease in which a tissue diagnosis cannot be established by other means, and perhaps earlier in the course of the patient's evaluation.

     

Ultrastructural examination of broncho-alveolar lavage for diagnosis of pulmonary histiocytosis X: Preliminary report on 4 cases.

Fibreoptic broncho-alveolar lavage was used in four patients; the diagnosis of histiocytosis X had been established by lung biopsy in three and was suggested on clinical grounds in the remaining patient. Characteristic cells with an ultrastructural cytoplasmic marker (X body) were found in the washes of all four patients. In the patient without biopsy confirmation, the findings in the broncho-aleolar washes supplied the corroborating evidence for the diagnosis. From this preliminary study the technique seems able to provide a diagnosis in pulmonary histiocytosis X without the need for an open lung biopsy.     

The clinical value and risks of lung biopsy in children with congenital heart disease

A retrospective review was made of 59 open lung biopsy specimens taken between 1984 and 1988 from children with congenital heart disease who were at risk for pulmonary vascular disease. Thirty-seven patients (ranging in age from 3.5 months to 23 years; median age, 14 months) had a primary left-to-right shunt (group A) and 22 patients (ages 1 to 15 years) had palliated cyanotic heart disease (group B). Forty-five of the lung biopsy specimens were requested as frozen sections. In both groups lung biopsy specimens were graded by the Heath-Edwards classification and correlated against preoperative hemodynamic data and outcome. In group A patients, carefully measured pulmonary vascular resistance and pulmonary/systemic vascular resistance ratio were reliable indicators of the structural state of the pulmonary vascular bed, obviating the need for routine lung biopsy. Pulmonary/systemic vascular resistance ratios greater than 0.45 accurately predicted all patients with irreversible pulmonary vascular disease, and pulmonary vascular resistance greater than 7 units.m2 accurately predicted all but one case of disease. Reversibility of pulmonary vascular changes is not synonymous with immediate postoperative survival: Fatal postoperative pulmonary hypertensive crises occurred in the presence of reversible pulmonary disease. Of those considered for the Fontan procedure, a mean pulmonary artery pressure less than 30 mm Hg and pulmonary vascular resistance less than 3 units.m2 correlated with Heath-Edwards grade I or normal lung biopsy results. In 36% of group B patients, reliable assessment of pulmonary vascular resistance could not be made, indicating a possible need for open lung biopsy procedures. When lung biopsy procedures were used as an isolated procedure, they were more dangerous (20% mortality, 13% morbidity) than previously reported. Intraoperative frozen sections are not adequate to accurately assess pulmonary vascular changes (9% error); serial paraffin sections are required.