Percutaneous Trephine Biopsy of the Lung

Percutaneous Trephine Biopsy of the Lung* Thomas A. Neff, MD. o O

Needle lung biopsy performed with a trephine cutting needle attached to a high speed pneumatic drill is a new technique which can be expected to yield a high quality lung specimen in 85 percent - 90 percent of attempts. This technique is especially applicable to diffuse pulmonary disease. The most frequent complication is the development of pneumothorax (in up to 65 percent of biopsies) which if handled appropriately is not dangerous and, therefore, should not be considered to outweigh the benefits of a pathologic and often etiologic diagnosis.

Needle biopsy of the lung for diagnostic purposes

needle under fluoroscopic guidance.t-"} The biopsy is done at the patient's bed side; usually in the eighth right intercostal space posteriorly with the patient sitting with his arms supported by pillows on a hospital table. An anterior approach in the second intercostal space with the patient supine may also be used (Fig lA and IB).

is recorded as early as 188.3. 1 In the early days of needle lung biopsy (l':LB) serious complications of large pneumothorax, air embolism, emphysema and hemorrhage occurred and were related to both sudden and delayed deaths." For this reason and because the spongy air-filled lung is one of the most difficult tissues from which to obtain consistently good quality pathologic specimens, NLB has not obtained wide acceptance. Over the last 88 years, however, physicians have learned how to prevent or effectively treat the above-mentioned complications so that biopsy related mortality in several recent large series has been zero,:I-;· and in a recent combined series of 766 IJiopsies, mortality was 0.78 percent. Ii In addition, the development of a new trephine biopsy technique has been developed which allows a high quality pathologic specimen with consistency (90 percent i.:' In this paper I describe our recent experience at Colorado Medical Center with the new trephine biopsy technique and demonstrate the value and safety of this procedure today. ~IETIIODS

The specific technique has previously been described by Steel and Winstanley." In brief, a hollow trephine, 7 ..'5 ern long, 3 nun in external diameter, and 2.1 mm internal bore, with a right-angled (nonlx-vcled ) sharp cutting edge is used (Fig 2). This trephine, with a fine pointed accompanying obturator in place is inserted through a 2-cm skin incision down through the parietal pleura. The obturator is removed and the trephine attached (via a Luer's fitting) to a small compressed gas-driven hand held turbine drill (Fig 3) o. When the drill is fully activated by depressing the trigger, a speed of up to 1.5,000 rpm is achieved when the pressure source is a recomme-nded 100 pounds per square inch. The patient is forewarned of the humming sound of the drill just before the biopsy, and asked to breathe quietly and not to cough or move. The trephine is advanced 3 to !5 cm at a trajectory parallel to or away from the hilum at full rpm's over three seconds. The turbine is removed and immediately replaced with a l O-ml syringe prefilled with sterile isotonic saline"" and the trephine and syringe are then rapidly withdrawn maintaining strong suction on the syringe. The specimen, dot, lung juices, etc are carefully injected into 10 to 20 ml of sterile isotonic saline in a sterile specimen cup, Petri dish, etc. The specimen is closely inspected for adequacy and after .5 to 10 minutes, it is transferred to a 10 percent formalin fixative and hand carried to the histopathology laboratory. The previously inoculated sterile, isotonic saline solution is used as the specimen for any appropriate microbiologic testing, ic routine bacterial, AFB, fungus and virus cultures, etc. (During removal of the obturator and attachment of the turbine before the "drilling procedure" and during removal of the turbine and attachment of a 1O-ml syringe after the drilling procedure, extreme care should be taken to prcccut the external orifice of the hollow trephine to be open to the atmosphere. This can be accomplished after minimal practice by simply covering

A:\'D TECH"IQUE

Any patient with a diffuse pulmonary lesion of unknown diology is a prospective candidate for :'\LB. Routine precaution, ie history and testing for bleeding diathesis, complete blood count (CBC). etc are performed as with any needle biopsy procedure. Any peripheral area of the lung, away from the hilum and large vesse-ls, which has significant involvement shown by a chest x-ray picture is satisfactory for biopsy. (Localized or more- centrally located lesion may also be suitable for needle aspiration biopsy but this should not be tried with the technique described lu-re- but rather with a noncutting "hom the Department of Mediclne. University of Colorado \Inlical Center, Denver, e e Assistant Professor of \Iedicine. Rq>rint requests: Dr . .\'elf, Dcni cr General llospital, Dcncer

e

.';02(),J

18

"Downs Surgical, Inc., Xiauaru Falls, :'\ew York 14304. e IV saline is used instead of "saline for injection" because the latter often contains bacteriostatic preservatives hinderinu further culture.

PERCUTANEOUS TREPHINE BIOPSY OF THE LUNG

19

FILI'IlE 1:\ ( Idt). Biopsy of Idt lowe-r 11I1Il! posteriorly via left posterior lateral intercostal approach witl: patie-nt sittilll! witl: arms sllpport<-d on th,· table. B (ri,l!ht). Biopsy of left uppe-r lunu alltniorly via second intercostal space at mid clavicular line. Patie-nt is supine. :\ot<-: Ste-rikt",\'(,ls or dr.qx-s hav« !wen e,e1l1ded purpose-ly to show the l!ross anatomicul n-lationships. \\'Iu'n hiopsyilll! the ldt lo\\"er luru; as in A. om- shouk] be keenly aware of the spatial relationships of tlH' lu-art wit hin this hemithorax to prevent an inadvertent myocardiul biopsy. tl", nt"rnal orific,' of tlu- hollo\\" trephine with OIll"S glo\'('d fillt:l'I" tip, If air is all",\'(·d to enter the ru-r-dlc-, thre-e unclesirabl,· n'slllts lIlay occur: I) cn-ation of an unnecessary PIU'llIlll,thoras. :2) dllrinl! rr-tr.u-tiou of the lunu, the specimen lItay re-tract out of the Ill'edle lx-fon- the specinu-n is removed via tl", aspiration t<-e1mi,!I1'" and :,) the n-moh- possibility of an air i-mlx.Iisu: is c-nhancocl. The chance of air embolism is also n·dlll'l·d by positioning tlu- patient". that the site of the biopsy is close to or lx-low the 1..\'('1 of till' heart. This \\"i11 pn'\'t'llt tilt' pulnronary vi-ins at th,· site of the hiopsy to ha\'(' slIhatnlOspheril' pn-ssurr-s, it' only the base» of the IlInl!s shollld })(' hiopsu-d with till' patient in till' sitting position as in Fil!ure 1:\),

CO:\IPLI(:ATI()~S

The potential causes of morbidity and mortality from NLB were outlined" .. in the introduction. Thirteen pneumothoraces occurred in this series of 20 separate :\ LB (().'') percent). Their degree and

HESl"LTS

The results of 20 separate biopsies on 17 patients an' reported in Table 1. Adequate tissue for pathologic e-valuation was obtained on 17 of tlu- biopsies with no tissue in three attempts. In L5 of 17 cases. tlu- hiopsy was essential or significantly helpful in deciding correct management of the case, The spectrum of help is reported under Case Reports.

FILI"IlE :3. Pic-ture of turbim- drill with trephine Ill·,>dlt· at-

Filonn, :2, eloS(' lip vir-w of pointed ohturutor. c-uttinu trr-phin« IH·,·dl", and turhim- drill. ( From aliov« down )

CHEST, VOL. 61, NO.1, JANUARY 1972

t.u-lu-d on Idt and corupressed ,gas hose runninu From tank to

ril!ht end of turbine. Any colltpn'ssed l!as at IO() Ih/s,! inch lIlay be used as power source but o'yl!en is most convenie-nt.

20

THOMAS A. NEFF Tabl.- I-Rf'sults o/l'if'f'dlf' Lung Biopsy.

.\

Ituuk-quutr- pnt hologi« uuu oriul

20 17 3

:\0. of pa I i.. n Is hn vi ng hiopsi..s :\0. of pat ic-nt s who-«. diagnosi:-:.

15

:\0. of hiops\' IU'o"('dun's .\d"'1ual .. palhologi,' Illal ..rial

B

and or lIlanag.. mr-nt ai,iPd

h~'

17' :\ LB

"Thro« pat i.. nt" had hiopsi{'s t wir-e on s(']Jarate duy»: one he":uls" of s(']larat .. IU'O('{'''S('" in (':l<'h lung, I",'.. ('a"{' example h{','aus{' first hiops.\· wax inudvort ..nt lv destroyed in the pu t hologv luhorutorv, and on .. IH"·:HIS(' t lu- first biopsy ,,;p("'illl('n vu-kk-d inudequntv mat ..rial. ,\111hn',' "as{'s yiolded ad{'quat .. "p",·illl..ns on s"('ond hiop,.;.\·. :\0.

:~J;

site of the biopsy. One patient who developed a 30 percent pneumothorax before chest tube placement had an increase of premature ventricular contraction from three per minute to eight to ten per minute. This frequency decreased back to prebiopsy level shortly after relief of his pneumothorax.

OIl<'

our use of chest tuhes is enumerated in Tahle 2. Because most of the cases have some respiratory function impairment and an increased tendency for lung collapse or hath (ie fibrosis with increased retractable forces of the lung), any significant pneumothorax was treated early with placement of a :\0. 1-4 intracath" or Clagett "5" cannula and 15 to 25 em H:!O negative pressure suction. With this approach, all lungs were completely reexpanded within 2-4 hours (usually within four to eight hours) and the chest tube or cannula removed. In our 20 biopsies no mortality occurred. Air embolism did not occur (see last paragraph under Xlethods and Technique). Only one patient had minimal blood-tinged sputum and no other type hemorrhage occurred. Three patients had pleuritic chest pain which was verv similar in degree to the pain some patients with spontaneous pneumothorax experience. This pain was accompanied hy pneumothorax (pleuritic chest pain after this procedure is an early diagnostic symptom of pneumothorax) and resolved within four to eight hours. One patient had a small amount of subcutaneous emphysema at the f

"

CASE Ih;poHTS CASE

1

A 39-year-old Spanish American man den' loped a Iiu-lik« syndrome four weeks prior to admission. Three weeks prior to admission, slight hemoptysis was noted. A chest x-ray examination on \[ay :W, W70, rewa led a miliary-like picture. By time of admission to Colorado Ceneral Hospital, the patient was asymptomatic hut acknowledged a [,')-pound weight loss in tlu- last three months. He also had a six-year occupational history of significant exposure to brick dust from kilns at a steel factory. Physical e-xamination revealed the patient to 1)(' healthy with normal vital signs and chest examination. The only positive finding was a spleen pulpable 4 em Ix-lnw the costal margin. Laboratory work was entirely normal or negative except for a gamma glohulin of 2.1 mm percent and moderate hypercalciuria (720 mg/24 hr ) without hypercalcemia (~).3 mg pe-rcent}. All skin tests were negutiv« exce-pt for 8-mm induration to mumps antigen. Spirometry and arterial hlood gases were normal. The main diagnostic conside-rations were sarcoidosis, silicosis, and miliary infectious granulomatosis. ;'I;LB (Fig -IA and 4H) n-veah-d uonc-asr-ating granuloma with no organism demonstrated hy special staining or culture. On treatment with prednisone -10 milligrams per

,.

°C H. Burdic Inc., \Iurray lIill, :\l'W Jersey 07H7-1. OOY. \[lll'1kr, Chicago, Illinois GOG-IH.

Table 2--Com"licationll.

I'nr-utnut h, irn x H x wit hout r ube H x wit h :\". ]·1 int r.u-nt h and suet ion H x wit h :\0. I·j int rnr-ut h and sur-t ion prophvlu«t ir-ullv" I Ivmopt vsis " :-; (~ (·lIlphy"..IIl:' * I'I ..urit i« pain' Ot lu-r 11'\'("s"

H5 5, 10. 10 fiO, ,')0,

:~O.

an, ao.

:lO,20, 15 2 I I

3 I

10.10 ,'i .'i is .'i

.:-;.... paragraph on ('1/11/ plil'lllimis for ,iPt ails. **l'l'oph.\'I:l<'ti,·:dly t ul n- pl:l<'('nH'nt n-fors to t ho pract i..e of ,·h,'st t ulu- pla,·('m.. nt imm..diatl'Iy h{'fOl'{' or imm..diatcly aft(,1' hiops.'· hdon' any "ignifi":lllt pnoumothorax has .k-v .. I"p('d.

FICUHE 4A (top). Photomicrograph of lung hiopsy showing normal lung on right and non-caseating grannloma on left (hematoxylin and eosin, H & E, X .'30). B (hottom). Photomicrograph of single granuloma with prominent e-pithe-lioid cells although no giant cells prese-nt in this section. (II & E, X 120).

CHEST, VOL. 61, NO.1, JANUARY 1972

21

PERCUTANEOUS TREPHINE BIOPSY OF THE LUNG day, the pulmonary infiltrates and hypercalciuria were both deereasing on July 1, 1970, CASE

2

Acute granulocytic leukemia was diagnosed in an 18-yearwhite girl in July 19G9, She was originally treated with vincristine, 6 mercaptopurine and prednisone and by October WG9 was in remission. He-lapse occurred and was treated by six separate courses of cytosine arabinoside. By July 8, 1970, tln- white hlood cell count (\\'BC) was 1,000 and hematocrit 12 percent. Two units of packed red blood cells (HBC) were gin'n and on July I I, a fe\"('r of 101 d,'grees was noted, Between July 13 and W, the "'BC had decreased to JOO and the fever was elevated to 104 deglw's. The patient's fever and course had not lx-en affected by kanamycin. On July lfith a nonproductive cough developed with infiltrates showing on clu-st x-ray examination hy July 18, 1970. She was transferred to Colorado General Hospital and on admission was acutely ill, pale, toxic, with a temperature of 102 degrees, pulse 1.'jO and respiration of 28. A flame hemorrhage was present in the left fundus hut no other evidence of bleeding was present. The chest examination revealed a decreased respiratory excursion and faint rales, Laboratory procedures ren'aled hematocrit 20 percent, \VBC 1,100, platelets 100,000, prothrombin time 44 percent, PaO~ 46 Ullll Hu and vital capacity (i6 percent of normal. An acute infectious pneumonitis was considr-n-d most likely and after two more units of packed cells, a :\LB was done. This revealed an impressive alveolitis on hemotoxylin-eosin with classic PIlCIlIlIOCf/stis clIrilli organism by Comori's methenamine-silver stains (Fig ,'5A and .'513). Pentamidine isethionatc, 4 mg/kg of body weight was administered and in four days the fever was lx-low !OO degre,'s; by seven days the x-ray picture was clearing and after ten days of pentamidine treatment, the patient was discharged. She had another hematologic remission for six months but then relapsed and died acutely of a bacterial pneumonia and pulmonary hemorrhage. CASE

3

This 72-year-old white man was referred for evaluation of a progressive left lower lobe (LLL) infiltrate which was first noted on x-ray examination on August .'5, 1969 when the patient clinically had "pneumonia." The patient's symptoms of pneumonia cleared but the LLL infiltrate not only persisted but had um-quivocally progressed by June 6, lH70 (Fig GA ). Whil« Ill' was being evaluated in another hospital, the patient developed an acute pneumonitis of the right lung the day after a negative bronchoscopy. l'\o etiology of this right pne-umonitis was established; however the possibility of aspiration was considered most likely. Progressive loss of lung volume with scarring was present by July q, lH70, although pulmonary functions were excellent (Fig (13). Further medical history revealed the patient to have had a mild exposure to ashestos from Wl.'5 to W30 and in addition, used "Ben Cay" ointment regularly in his nose for dryness. Further diagnostie work-up included fluoroscopy, lung scanning, ( perfusion and ventilation), sputum cytology and microbiology, but was nondiagnostic. A :\LB of the LLL infiltrate was done on July :30. 1970 and re-ve-aled squamous cell carcinoma with keratin pearls (Fig 7 A and 713). This biopsy was followed by mediastinoscopy which revealed no hilar involvenu-nt whic-h corre-lates well with "resectability"," therefore, a :\'LB of the right lung was done on August 10, lH70 and this n'\"('aled a chronic organizing pneumonia with no signs of acute activity. A left-lower lobectomy was performed on

CHEST, VOL. 61, NO.1, JANUARY 1972

FIGUnE .5A (top). Photomicrograph of lung biopsy reveulim; inflamed thickened alveolar septa with many alveolar spaces full of a hvaline relativolv acellular exudate (H & E X 30). 13 (bottou;). PhotomicJ'(;graph of an alveolar space packed with round and r-lipticul organisms characteristic of PIlCIlIllOeustis clIrilli (Comori nn-tlu-numine-silver X ,'5()(») ,

August 14. 1970 and no sign (gross or microscopic) of tumor spread lx-yond tlu left lower lolx- was present. The patient made- an uneve-ntful recove-ry and is presently well seve-n months after surgery with no- e-vidence of recurrent tumor. Examination of the final pathologic sections of the n'sected lobe revealed a chronic lipoid pneumonia adjacent to the cancer and in other areas of the lobe, The rare association of lung cancer with lipoid pneumonia has recently bee-n reported by others.! II 1 t DISCUSSIO:'>l

When a clinician is faced with a diffuse pulmonary infiltrate, which mayor may not be miliary in pattern, it is not surprising that the exact diagnosis often remains uncertain before lung biopsy because over l(){) diseases can cause this x-ray pattem.!" Gaensler and co-workers 1:1 reporting on 106 open lung biopsies in 10.5 patients with diffuse lung

22

THOMAS A. NEFF

MVV -144

Po02 '67

n:\ (left), Chl'st x-ray film showing tlu- Il'ft lower lohe lesion and tlu- normal right lung, B ( right I, Clu-s! x-ray film showiiu; tlu- IlI'W proCI'SS in till' right IUllg with loss of volunu-. Compan-

F'LVIII-:

with (i:\,

disease noted that specific diagnosis could he made only hv lung biopsy in :3:3 percent of their cases, An additional .51 percent of their cases could be classified in a diagnostic category "which may require lung biopsy for confirmation," In addition. it was noted that over one half of the preoperative primary diagnoses were in error. In reviewing his I."i years of experiences. Cuenslcr!" also noted the long delay (IJ2 years after an ahnormal chest x-ray film) before thoracotomy. He stated "many patients would have lx-en spared years of uncertainty. inactivity, large hospitalization costs and many unpleasant procedures by earlier hiopsy". In many acutely ill patients. it is understandable that doctors are reluctant to advise a stressful surgical procedure even though a tissue diagnosis lIlay 1)(' essential for correct diagnosis and managemc-nt, :\ ow that simple and effective needle biopsy techniques have [x-en developed, this reluctance should be overcome. (:\ote that case :2 was moderately hypoxemic at the time of biopsy and was ill respiratory Failure by definition. Aggressin- use of intrapleural suction via intrapleural tube placement may be needed to prevent further respiratory embarrassment. Some operators recommend prophylactic tube placement in all cases. 4 ) Xow that :\LB is within standing the test of time for safe-tv and effectin'lwss. the attitude in our Chest Division is for earlier biopsy so that specific diagnosis can he made before more end-stage

CHEST, VOL. 61, NO.1, JANUARY 1972

PERCUTANEOUS TREPHINE BIOPSY OF THE LUNG

irreversible pathology develops. This more aggressive and direct approach to diagnosis should save the patient much time, money, worry and inappropriate disability. Finally, the enthusiasm expressed by me in this article on NLB should not be interpreted to mean that i'\LB is essential in all cases of diffuse pulmonary disease or that NLB should replace a basic work-up with a complete medical history including an exacting occupational and "exposure" history, skin and serologic testing when appropriate, and meticulous microbiological culturing techniques. The latter cultures can be often more help if adequate material is obtained by newer techniques.t v ! H In certain cases, open lung biopsy may be an acceptable alternative to NLB. u.r :l.1 7.18 The choice between NLB and open lung biopsy often depends on the physician's personal experience and prejudices. ACKNOWLEDGMENT: I would like to thank Dr. T. L. Petty for his support of this work and his review of this paper. I would like to thank Dr. E. Garner King who coordinated all the culture testing on the lung specimens. Finally, I would like to then thank B. B. Higgins and \1. George, the two histology technicians, who so expertly prepared the majority of tissue specimens, and Dr. J. Maisel who helped with the pathologic interpretation. REFERENCES

Leuden R: Ueber Infectiose Pneumonic. Deutsch Med Wschr 9:52-54, 1883 2 Russell AE: Lung puncture. Lancet 2: 1.'539, 1909 3 Krumholz RA, Manfredi F, Weg JG, et al: Needle biopsy of the lung. Ann Intern \Ied 6.'5:293-307, 1966 4 Youmans CR [r, \Iiddleton J\I, Derrick JR, et al: Percutaneous needle biopsy of the lung for diffuse parenchy-

23

mal disease. Dis Chest 54:25-31, 1968 .'5 Steel SJ, Winstanley 01': Trephine biopsy of the lung and pleura. Thorax 24:576-584, 1969 6 Youmans CR jr: Needle hiopsy hest in diagnosis of generalized lung disease. Inter ~Ied Diau News 3:30, 1970 7 Stevens G\1, Weigen ]F, Lillington GA: Needle aspiration biopsy of localized pulmonary lesions with amplified fluoroscopic guidance. Amer J Roentgen 103:.'561-.'571, 1968 8 Fontana RS, Miller WE, Beabout JW, et al: Transthoracic needle aspiration of discrete pulmonary lesions: Experience in 100 cases. Med Clin N Amer .'54:961-971,1970 9 Ashbaugh DG: Mediastinoscopy. Arch Surg 100: .'568-573, 1970 10 Bryan CS, Boitnott JK: Adenocarcinoma of the lung with chronic mineral oil pneumonia, Amer Rev Resp Dis 99: 272-273, 1969 11 Keshishian JM, Abad J~1, Fuchs M: Lipoid pnt'umoniareview with a report of a case of carcinoma occurring within an area of lipoid pneumonia. Ann Thorac Surg 7:231-234,1969 12 Buechner HA: Differential diagnosis of miliary diseases of lung. Med Clin N Amer 43:89-112, 19.'59 13 Gaensler EA, Moister VB, Hamm J: Open-lung biopsy in diffuse pulmonary disease. New Eng J \Ied 270:13211331, 1964 14 Fennessy JJ: Bronchial brushing and transbronchial forceps biopsy in the diagnosis of pulmonary lesions. Dis Chest 53:377-389, 1962 1.'5 Pecora DV, Kohl \1: Transtracheal aspiration in thediagnosis of acute lower respiratory tract infection. Amer Rev Resp Dis 86:7.'5.'5-7.'58, 1962 16 Hahn HH, Beaty H:\': Transtracheal aspiration in tluevaluation of patients with pneumonia. Ann Intern \Ied 72: 183-183, 1970 17 Klassen KP: Open lung biopsy: A strong stand. (Editorial) Chest .'59 :2-3, HJ71 18 Aaron BL, Bellinger SB, She-pard B\I, et al: Open lung biopsy: A strong stand. Chest 59: 18-22, W71

Paradoxic Harmony Between Giants of Intellect Schiller (1759-1805) had lived in Weimar for seven years hefore having any close contact with Goethe ( 1749-1832). At their first meeting he finds him stiff and uncommunicative. It annoys him that Goethe, while charming and captivating everyone, always maintains his independence "like a god, without giving anything of himself-this appears to me a consistent and systematic method of procedure aimed entirely at satisfying to the utmost his own self-love." Schiller never frees himself entirely of this mood, even during his closest intimacy with Goethe. Friendship is an inadequate word to describe this relationship, however pleasant it may he to visualize the two poets hand in hand, in perfect unity, as

CHEST, VOL. 61, NO.1, JANUARY 1972

they are represented on their Weimar monument. The facts, however, are different; their relationship is much more like a truce between two great powers that have the deepest respect for one another and open their common frontier for purposes of communication; many of their letters read like diplomatic notes. Goethe finds Schiller physically unsympathetic; his writings strike him as confused, abstruse or, in the case of philosophical works, perverted and even dangerous. Goethe's eulogies of Schiller came after the latter's death; it was onlv then that he fully realized the magnitude of his loss. . Friedenthal, R: Goethe-His Life and Times, Cleveland, World Publishing Co, 196.'5