- Email: [email protected]
Open versus needle biopsy of the lung
Open versus needle biopsy of the lung How valuable to the patient? Open or needle biopsy of the lung was performed in 31 patients with diffuse, undiagnosed pulmonary lesions. Although needle biopsy resulted in less morbidity and no deaths, an adequate specimen was obtained in only 67 per cent of the patients, compared to 100 per cent of those subjected to open biopsy. The preoperative diagnosis was changed in only 46 per cent of all patients, and the biopsy results altered therapy in a disappointing 29 per cent. Thus in 22 of the 31 cases (71 per cent}, lung biopsy was of no therapeutic value to the patient and merely served physician curiosity.
Charles P. Lincoln, M.D., Ph.D., Frederick L. Grover, M.D., and J. Kent Trinkle, M.D., San Antonio, Texas
i \ retrospective study is presented concerning open versus needle biospy of the lung in patients with undiagnosed, diffuse pulmonary lesions. Morbidity, deaths, diagnostic yield, and therapeutic implications were examined. We specifically tried to determine whether treatment was changed by the results of the biopsy or whether biopsy merely served physician curiosity rather than patient welfare. Materials Lung biopsy was performed at the Bexar County Hospital in 31 consecutive patients with diffuse, undiagnosed pulmonary lesions during the IVi year period from Jan. 1, 1967, to May 30, 1974. For purposes of comparison, the patients were grouped according to whether they had open or needle biopsy. There were nineteen open and twelve needle procedures. Technique Open biopsy. The operation was carried out under general anesthesia with endoFrom the Division of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Received for publication July 11, 1974.
tracheal intubation and controlled ventilation. A small anterior thoracotomy was performed over the fourth or fifth intercostal space on either the right or left side. A section of the free margin of the lung was excluded with a vascular clamp and excised. The clamp was undersewn with a running 3-0 nonadsorbable suture, which was doubled back upon itself to provide a two-layer closure. A chest tube was placed and the chest wall closed in layers. The procedure lasted an average of 45 minutes. Needle biopsy. The needle biopsies were performed by members of the medicine, surgery, and pediatric staffs. Their techniques varied slightly but in general conformed to that which will be described. If the patient had adequate pulmonary function and was cooperative, the procedure was done with local anesthesia; otherwise a general anesthetic was used. A biopsy needle was inserted through an intercostal space immediately above the rib, and a small amount of tissue was removed. This was usually done with a Vim-Silverman or Cope needle. After the procedure, a chest x-ray film was taken to check for evidence of pneumothorax, and if necessary a chest tube was inserted into the pleural cavity. 507
The Journal of
508
Lincoln, Grover, Trinkle
Thoracic and Cardiovascular
Surgery
Table I. Signs and symptoms in 31 patients undergoing lung biopsy
Table III. Morbidity, deaths, diagnostic yield, and therapeutic implications of biopsy '""«
Type of biopsy * (Open
Type of
Needle
Symptoms Cough Dyspnea Hemoptysis Wheeze Weight loss Average weeks' duration of symptoms (range) Signs Cachexia Pulmonary findings Rales and/or rhonchi. Wheeze Peripheral findings Clubbing Cyanosis
biopsy* Aleedle
Open
No. Per cent No. Per cent
uiuyjj-
No \Per cent No. Per cent 12 11 3 1 7
7 4 1 0 3
65 60 16 5 35
58 33 8 25
45
0-250)
31 (0-150)
1 12
5 60
2 7
17 56
12 6 3 1 I
60 30 15 5 10
7 0 2 1 1
56
Mortality Morbidity Pneumothorax Chest tube duration (avg. days) Hemoptysis Wound infection Diagnostic yield Inadequate specimen Nonspecific Infection Neoplasia Sarcoidosis Diagnostic change Therapeutic change
2
11
_
5
40
3
2.7 1
8
-
1 0 15 1 2 1 9 6
5
79 5 11 5 49 32 ♦Nineteen open and 12 needle biopsies were
16 8 8
0
— 4 5 2 1
33 42 17 18
5 3
42 25
—
performed.
♦Nineteen open and 12 needle biopsies were performed.
Table II. Roentgenologic findings in 31 patients at the time of lung biopsy Type of
biopsy*
Open Findings Interstitial fibrosis Alveolar consolidation Mass lesion
Needle
ing "diagnostic yield," the category "nonspecific" includes pulmonary fibrosis, interstitial fibrosis, amyloidosis, or interstitial pneumonitis, for which there was a nonspecific etiology and/or treatment.
No. Per cent No. Per cent
Discussion
14 4 1
The results given in Table III show a mortality rate of 11 per cent (two deaths) for open biopsy, compared with reported mortality rates of from 2 to 7 per cent in the literature.1- -•" Neither was an operative death, but both occurred within 30 days of the biopsy. One patient died of an intracranial hemorrhage, and the other died of respiratory insufficiency which was probably not attributable to the biopsy. There were no hospital deaths in the group of patients with needle biopsies. The incidence of pneumothorax was 100 per cent for open biopsy and 40 per cent for needle biopsy, compared with a reported incidence of from 10 to 50 per cent for needle biopsy.'• "• 10 The only other morbidity associated with needle biopsy was an 8 per cent incidence of hemoptysis, compared with a reported incidence of 8 to 15
73 21 5
7 2 3
56 17 25
♦Nineteen open and 12 needle biopsies were performed.
Results The patients' presenting signs and symptoms are summarized in Table I, and the chest x-ray findings are given in Table II. Roentgenologic diagnoses are subdivided into three categories: (1) a fibrotic, interstitial pattern, (2) a consolidated, alveolar pattern, or (3) a mass lesion. A summary of the morbidity, deaths, diagnostic yield, and therapeutic implications is found in Table III. There were no operative deaths. Two of the patients upon whom open biopsy was performed died within 30 days of the procedure, although neither of the deaths was related to the operation. Under the head-
Volume 69 Number 4
Open versus needle biopsy of lung
509
April, 1975
per cent."' '" There were no other complications. The diagnostic yield was disappointing. Adequate tissue specimens were obtained in 100 per cent of open biopsies but in only 67 per cent of needle biopsies. The latter figure may be compared with a reported yield of 79 to 87 per cent."- "' Of the open biopsies, only 21 per cent yielded a specific etiologic diagnosis. The remaining 79 per cent provided purely nonspecific histologic diagnoses such as interstitial fibrosis, interstitial pneumonitis, or pulmonary fibrosis. Other series report these nonspecific diagnoses in 20 to 60 per cent.1, -• 4 S Of the needle biopsies, 42 per cent yielded a nonspecific diagnosis (63 per cent of those from which adequate specimens were obtained) versus 20 to 45 per cent in other reports."• "' These differences may be due to patient population. Specific diagnoses in the literature usually include many cases of sarcoidosis and various pneumoconioses which are infrequent in southern Texas. 11 " In our 31 patients there was only 1 case of sarcoidosis and none of pneumoconiosis. The results of biopsy changed the pre-procedure diagnosis in 49 per cent of open biopsies and 42 per cent of needle biopsies. However, results of biopsy had therapeutic implications for the patient in only 32 per cent of the open biopsy cases and 25 per cent of needle biopsies. This difference is not statistically significant. Patients undergoing open biopsy had more discomfort, longer immobilization, and greater cost than those with needle biopsy, besides requiring a general anesthetic. Conclusions A retrospective study of 31 patients with diffuse, undiagnosed pulmonary lesions undergoing lung biopsy revealed the following: 1. Needle biopsy resulted in lower mor-
bidity and mortality rates than open biopsy. 2. An adequate tissue specimen was obtained in 100 per cent of open biopsies but only 67 per cent of needle biopsies. 3. A change in the preoperative diagnosis occurred in less than 50 per cent of cases with either technique. 4. Therapy was altered by the biopsy results in only 32 per cent of open biopsies and 25 per cent of needle biopsies. These figures are disappointing but might be higher in a population with a greater incidence of sarcoidosis and/or pneumoconiosis. In 22 of 31 (71 per cent), the biopsy was of no benefit to the patient and served only physician curiosity. REFERENCES 1 Aaron, B. L., Bellinger, S. B., Shepard, B. M., and Dooher, D. J.: Open Lung Biopsy: A Strong Stand, Chest 59: 18, 1971. 2 Baker, R. R., Lee, J. M., and Carter, D.: An Evaluation of Open Lung Biopsy, Johns Hopkins Med. J. 132: 103, 1973. 3 Datia, F. R., and Geraci, C. L.: Needle Biopsy of the Lung, J. A. M. A. 155: 2 1 , 1954. 4 Gaensler, E. A., Moisten, M. V. B., and Hamm, J.: Open Lung Biopsy in Diffuse Pulmonary Disease, N. Engl. J. Med. 270: 1319, 1964. 5 Klassen, K. P., and Andrews, N. C : Biopsy of Diffuse Pulmonary Lesions: A Seventeen Year Experience, Ann. Thorac. Surg. 4: 117, 1967. 6 Klassen, K. P., Anlyan, A. J., and Curtis, G. M.: Biospy of Diffuse Pulmonary Lesions, Arch. Surg. 59: 694, 1949. 7 Rubin, E. H., and Rubin, M.: Lung Biopsy for Diffuse Pulmonary Lesions: Value and Limitations, Chest 46: 635, 1964. 8 Scadding, J. G.: Lung Biopsy in the Diagnosis of Diffuse Lung Disease, Br. Med. J. 2: 557, 1970. 9 Smith, W. G.: Needle Biopsy of the Lung, Thorax 19: 68, 1964. 10 Youmans, C. R., deGroot, W. J., Marshall, R., Morettin, L. B., and Derrick, J. R.: Needle Biopsy of the Lung in Diffuse Parenchymal Disease, Am. J. Surg. 120: 637, 1970.
Charles P. Lincoln, M.D., Ph.D., Frederick L. Grover, M.D., and J. Kent Trinkle, M.D., San Antonio, Texas
i \ retrospective study is presented concerning open versus needle biospy of the lung in patients with undiagnosed, diffuse pulmonary lesions. Morbidity, deaths, diagnostic yield, and therapeutic implications were examined. We specifically tried to determine whether treatment was changed by the results of the biopsy or whether biopsy merely served physician curiosity rather than patient welfare. Materials Lung biopsy was performed at the Bexar County Hospital in 31 consecutive patients with diffuse, undiagnosed pulmonary lesions during the IVi year period from Jan. 1, 1967, to May 30, 1974. For purposes of comparison, the patients were grouped according to whether they had open or needle biopsy. There were nineteen open and twelve needle procedures. Technique Open biopsy. The operation was carried out under general anesthesia with endoFrom the Division of Cardiothoracic Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284. Received for publication July 11, 1974.
tracheal intubation and controlled ventilation. A small anterior thoracotomy was performed over the fourth or fifth intercostal space on either the right or left side. A section of the free margin of the lung was excluded with a vascular clamp and excised. The clamp was undersewn with a running 3-0 nonadsorbable suture, which was doubled back upon itself to provide a two-layer closure. A chest tube was placed and the chest wall closed in layers. The procedure lasted an average of 45 minutes. Needle biopsy. The needle biopsies were performed by members of the medicine, surgery, and pediatric staffs. Their techniques varied slightly but in general conformed to that which will be described. If the patient had adequate pulmonary function and was cooperative, the procedure was done with local anesthesia; otherwise a general anesthetic was used. A biopsy needle was inserted through an intercostal space immediately above the rib, and a small amount of tissue was removed. This was usually done with a Vim-Silverman or Cope needle. After the procedure, a chest x-ray film was taken to check for evidence of pneumothorax, and if necessary a chest tube was inserted into the pleural cavity. 507
The Journal of
508
Lincoln, Grover, Trinkle
Thoracic and Cardiovascular
Surgery
Table I. Signs and symptoms in 31 patients undergoing lung biopsy
Table III. Morbidity, deaths, diagnostic yield, and therapeutic implications of biopsy '""«
Type of biopsy * (Open
Type of
Needle
Symptoms Cough Dyspnea Hemoptysis Wheeze Weight loss Average weeks' duration of symptoms (range) Signs Cachexia Pulmonary findings Rales and/or rhonchi. Wheeze Peripheral findings Clubbing Cyanosis
biopsy* Aleedle
Open
No. Per cent No. Per cent
uiuyjj-
No \Per cent No. Per cent 12 11 3 1 7
7 4 1 0 3
65 60 16 5 35
58 33 8 25
45
0-250)
31 (0-150)
1 12
5 60
2 7
17 56
12 6 3 1 I
60 30 15 5 10
7 0 2 1 1
56
Mortality Morbidity Pneumothorax Chest tube duration (avg. days) Hemoptysis Wound infection Diagnostic yield Inadequate specimen Nonspecific Infection Neoplasia Sarcoidosis Diagnostic change Therapeutic change
2
11
_
5
40
3
2.7 1
8
-
1 0 15 1 2 1 9 6
5
79 5 11 5 49 32 ♦Nineteen open and 12 needle biopsies were
16 8 8
0
— 4 5 2 1
33 42 17 18
5 3
42 25
—
performed.
♦Nineteen open and 12 needle biopsies were performed.
Table II. Roentgenologic findings in 31 patients at the time of lung biopsy Type of
biopsy*
Open Findings Interstitial fibrosis Alveolar consolidation Mass lesion
Needle
ing "diagnostic yield," the category "nonspecific" includes pulmonary fibrosis, interstitial fibrosis, amyloidosis, or interstitial pneumonitis, for which there was a nonspecific etiology and/or treatment.
No. Per cent No. Per cent
Discussion
14 4 1
The results given in Table III show a mortality rate of 11 per cent (two deaths) for open biopsy, compared with reported mortality rates of from 2 to 7 per cent in the literature.1- -•" Neither was an operative death, but both occurred within 30 days of the biopsy. One patient died of an intracranial hemorrhage, and the other died of respiratory insufficiency which was probably not attributable to the biopsy. There were no hospital deaths in the group of patients with needle biopsies. The incidence of pneumothorax was 100 per cent for open biopsy and 40 per cent for needle biopsy, compared with a reported incidence of from 10 to 50 per cent for needle biopsy.'• "• 10 The only other morbidity associated with needle biopsy was an 8 per cent incidence of hemoptysis, compared with a reported incidence of 8 to 15
73 21 5
7 2 3
56 17 25
♦Nineteen open and 12 needle biopsies were performed.
Results The patients' presenting signs and symptoms are summarized in Table I, and the chest x-ray findings are given in Table II. Roentgenologic diagnoses are subdivided into three categories: (1) a fibrotic, interstitial pattern, (2) a consolidated, alveolar pattern, or (3) a mass lesion. A summary of the morbidity, deaths, diagnostic yield, and therapeutic implications is found in Table III. There were no operative deaths. Two of the patients upon whom open biopsy was performed died within 30 days of the procedure, although neither of the deaths was related to the operation. Under the head-
Volume 69 Number 4
Open versus needle biopsy of lung
509
April, 1975
per cent."' '" There were no other complications. The diagnostic yield was disappointing. Adequate tissue specimens were obtained in 100 per cent of open biopsies but in only 67 per cent of needle biopsies. The latter figure may be compared with a reported yield of 79 to 87 per cent."- "' Of the open biopsies, only 21 per cent yielded a specific etiologic diagnosis. The remaining 79 per cent provided purely nonspecific histologic diagnoses such as interstitial fibrosis, interstitial pneumonitis, or pulmonary fibrosis. Other series report these nonspecific diagnoses in 20 to 60 per cent.1, -• 4 S Of the needle biopsies, 42 per cent yielded a nonspecific diagnosis (63 per cent of those from which adequate specimens were obtained) versus 20 to 45 per cent in other reports."• "' These differences may be due to patient population. Specific diagnoses in the literature usually include many cases of sarcoidosis and various pneumoconioses which are infrequent in southern Texas. 11 " In our 31 patients there was only 1 case of sarcoidosis and none of pneumoconiosis. The results of biopsy changed the pre-procedure diagnosis in 49 per cent of open biopsies and 42 per cent of needle biopsies. However, results of biopsy had therapeutic implications for the patient in only 32 per cent of the open biopsy cases and 25 per cent of needle biopsies. This difference is not statistically significant. Patients undergoing open biopsy had more discomfort, longer immobilization, and greater cost than those with needle biopsy, besides requiring a general anesthetic. Conclusions A retrospective study of 31 patients with diffuse, undiagnosed pulmonary lesions undergoing lung biopsy revealed the following: 1. Needle biopsy resulted in lower mor-
bidity and mortality rates than open biopsy. 2. An adequate tissue specimen was obtained in 100 per cent of open biopsies but only 67 per cent of needle biopsies. 3. A change in the preoperative diagnosis occurred in less than 50 per cent of cases with either technique. 4. Therapy was altered by the biopsy results in only 32 per cent of open biopsies and 25 per cent of needle biopsies. These figures are disappointing but might be higher in a population with a greater incidence of sarcoidosis and/or pneumoconiosis. In 22 of 31 (71 per cent), the biopsy was of no benefit to the patient and served only physician curiosity. REFERENCES 1 Aaron, B. L., Bellinger, S. B., Shepard, B. M., and Dooher, D. J.: Open Lung Biopsy: A Strong Stand, Chest 59: 18, 1971. 2 Baker, R. R., Lee, J. M., and Carter, D.: An Evaluation of Open Lung Biopsy, Johns Hopkins Med. J. 132: 103, 1973. 3 Datia, F. R., and Geraci, C. L.: Needle Biopsy of the Lung, J. A. M. A. 155: 2 1 , 1954. 4 Gaensler, E. A., Moisten, M. V. B., and Hamm, J.: Open Lung Biopsy in Diffuse Pulmonary Disease, N. Engl. J. Med. 270: 1319, 1964. 5 Klassen, K. P., and Andrews, N. C : Biopsy of Diffuse Pulmonary Lesions: A Seventeen Year Experience, Ann. Thorac. Surg. 4: 117, 1967. 6 Klassen, K. P., Anlyan, A. J., and Curtis, G. M.: Biospy of Diffuse Pulmonary Lesions, Arch. Surg. 59: 694, 1949. 7 Rubin, E. H., and Rubin, M.: Lung Biopsy for Diffuse Pulmonary Lesions: Value and Limitations, Chest 46: 635, 1964. 8 Scadding, J. G.: Lung Biopsy in the Diagnosis of Diffuse Lung Disease, Br. Med. J. 2: 557, 1970. 9 Smith, W. G.: Needle Biopsy of the Lung, Thorax 19: 68, 1964. 10 Youmans, C. R., deGroot, W. J., Marshall, R., Morettin, L. B., and Derrick, J. R.: Needle Biopsy of the Lung in Diffuse Parenchymal Disease, Am. J. Surg. 120: 637, 1970.