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Trephine lung biopsy with a high-speed air drill
Trephine lung biopsy with a high-speed air drill Results of 50 biopsies in 47 patients Donald C. Zavala, M.D., George N. Bedell, M.D., and Nicholas P. Rossi, M.D., Iowa City, Iowa
x. issue biopsy with an electrical drill and rotating needle was described by Kirschner1 in 1935. Technique modifications and results were reported by Christiansen2 in 1940, by Ellis3 in 1947, and by Deeley4 in 1960. The trephine described by Deeley provided satisfactory specimens from peripheral lung tumors but failed to give adequate tissue in diffuse pulmonary diseases because of its small internal diameter. Steel designed a larger trephine with which he and Winstanley5' ° reported great success in obtaining specimens from the lung and pleura in patients with diffuse or localized lesions. The present study was designed to determine the diagnostic value and safety of trephine lung biopsy in patients with a variety of chest diseases. Materials and methods Forty-seven patients were studied, consisting of 30 men and 17 women with ages ranging from 19 to 79 years. Thirty-six of From the Division of Pulmonary Diseases, Department of Medicine, and the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Iowa College of Medicine, Iowa City, Iowa 52240. Supported by a Grant-in-Aid from the Iowa Tuberculosis and Respiratory Disease Association. Received for publication March 24, 1972. Address reprint requests to Dr. Zavala at the University of Iowa Hospitals, Iowa City, Iowa 52240.
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the patients had diffuse parenchymal disease and 11 had localized lesions. The biopsies were done in a room equipped with resuscitation facilities, a chest tube set, and a television fluoroscope with an image amplifier. Selection and preparation of the patient and the biopsy site, handling of the specimen, and post-biopsy orders were identical to those that we7 used in performing a previous study of percutaneous lung biopsies with the aid of a cutting needle. The equipment* consists of a handoperated pneumatic drill driven by compressed gas from a cylinder fitted with a reducing valve (Fig. 1). At a pressure of 100 p.s.i. the drill attains a speed of up to 15,000 revolutions per minute. A hollow trephine is connected to the central shaft of the drill by a Leur fitting. The trephine has a length of 7.5 cm., an external diameter of 3 mm., an internal diameter of 2.1 mm. There is a sharp cutting edge with internal rifling and a sharp pointed stylet which projects just beyond the cutting end (Fig. 2). Each trephine can be used for 15 to 20 biopsies but then should be returned to the manufacturer for resharpening and realignment. A ♦Made by Down Bros, and Mayer & Phelps Ltd., England. Distributed by Downs Surgical, Inc., Niagara Falls, N. Y.
Volume 64 Number 2 August, 1972
dull cutting edge will result in biopsy failures and increased complications. In bilateral diffuse disease the biopsy routinely is taken at the seventh or eighth intercostal space of the right posterior chest, near the tip of the scapula. In obese or short patients, the level of the diaphragm may be accurately determined by fluoroscopy to prevent biopsying the liver. An axillary or anterior approach also may be used, but cardiac and mediastinal areas are to be scrupulously avoided. In localized, peripheral lesions the site of trephine entry is determined by viewing the chest x-ray films, taking tomograms (when indicated), and using fluoroscopy with the aid of a metal rod pointer and skin marker. In 19 patients, the biopsies were taken with the patient in the sitting position, leaning forward. Otherwise, the patient was supine or prone. Drugs may be given before the procedure for the suppression of apprehension and the vagovagal reflex. The patient should be familiarized with the noise produced by the air drill before hand, so that he will not be startled when the biopsy is taken. The new drill model now in use is much more quiet. Instructions are given not to move or cough, but breathholding is not necessary. Specific contraindications to performing a drill biopsy include the following: (1) blebs, bullae, or cysts in the area to be biopsied, (2) a suspicion that the lesion may be vascular, (3) the presence of a bleeding diathesis, and (4) an uncooperative patient. Individual evaluation should be made on subjects with pulmonary hypertension, respiratory insufficiency, or poor cardiopulmonary reserve. Five of our patients were receiving oxygen at the time of biopsy. The physician operates from a sterile table. The skin is prepared, and the tissue to the pleura is infiltrated with a local anesthetic. The drill, which is not sterile, is not handled until the trephine has been introduced into the patient's chest. An incision, made just above the superior margin of the rib, is spread with a hemostat to allow the trephine to rotate with minimum impedence. The trephine, with the stylet in posi-
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Fig. 1. Trephine attached to air drill. Note compressed gas cylinder with reducing valve set at 100 p.s.i.
tion, is inserted into the incisional opening and pushed through the parietal pleura but not into the lung. The stylet is removed, the drill is firmly attached to the trephine and the trigger is pressed. The trephine, which reaches top speed almost instantaneously, is steadily pushed into the lung to an estimated depth of 3 cm. subpleurally. The entire maneuver takes only a few seconds. The drill is then disconnected and replaced by a 20 ml. syringe containing 5 ml. of normal saline solution. The trephine is withdrawn as suction is applied by the syringe to retain the specimen. The incision is covered with a dry, sterile dressing. Sutures are not necessary. If difficulty is encountered in detaching the drill from the trephine, then the ridged end of the trephine may be held and the drill turned on, thus effecting an easy separation. During any change-over, the operator should place his gloved thumb over the exposed end of the trephine to prevent air from entering the patient's chest. If no specimen is obtained on the first trial, the procedure may be repeated provided there has been no pneumothorax or hemoptysis.
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The Journal of
Zavala, Bedell, Rossi
Thoracic and Cardiovascular Surgery
Fig. 2. Air drill and lung biopsy trephine with stylet in place.
Before leaving the room the patient is examined fluoroscopically to check for pneumothorax and intrapulmonary bleeding. Routine post-biopsy orders include a check of vital signs every 30 minutes for 4 hours, a chest x-ray film in 2 to 4 hours, and close observation for hemoptysis and shortness of breath. The biopsy tissue is discharged into a sterile Petri dish containing 0.9 per cent saline. Subsequently, all or a major portion of the tissue is transferred by eye dropper to a clean glass slide. There a few drops of plasma and thrombin are added to form a fibrin clot around the specimen, which is immersed in a fixative solution and sent to pathology for hematoxylin and eosin stain. Acid-fast and Grocott (silver methenemine) stains are done when indicated. Fibrotic tissue should be examined under polarized light for birefringent silica particles. The saline and smaller tissue fragments remaining in the Petri dish may be put into a culture tube for bacteriologic and fungal studies. Case reports C A S E 1. A 67-year-old farmer's wife was admitted to the University of Iowa Hospitals in
September, 1970, complaining of increasing shortness of breath, intermittent fever, and dry cough for the previous 4 months. Her symptoms began shortly after her husband died, when she took over daily feeding of the cattle, hogs, and chickens. Because of cold weather, the animals were fed inside the barn where the patient was exposed to a great deal of dust from various grains and stored hay. Physical examination was not remarkable except for fine, crepitant rales in both lung bases. The pulmonary function studies revealed the following results: functional vital capacity, 2,380 ml. (89 per cent); mean expiratory flow rate, 320 L. per minute, forced expiratory volume in 1 second ( F E V , ) , 1.97 L., SbN 2 , 1.5 per cent nitrogen; and diffusing capacity of the lungs for carbon dioxide ( D L C O ) , 8 ml. per minute per mm. Hg (39 per cent). T h e Pa 0 , was 50 mm. Hg, the Paca, was 34 mm. Hg, and the p H was 7.51. A chest x-ray film revealed minimal diffuse infiltrates in the lower lung fields. Trephine lung biopsy from the right posterior chest revealed a noncaseating granulomatous reaction with interstitial pneumonia (Fig. 3 ) . Immunodiffusion studies were positive for Mycobacterium faeni, confirming the diagnosis of farmer's lung. The patient made an uneventful recovery when she was permanently removed from the contaminated atmosphere of the barn. The feeding operation of the animals was changed, and the barn was thoroughly cleaned. C A S E 2. A 42-year-old railroad switchman was admitted to the University Hospitals in January, 1971, with a chief complaint of exertional shortness of breath and dry cough. Physical examina-
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Fig. 3. Case 1. Noncaseating granulomatous reaction with interstitial pneumonia. (Hematoxylin and eosin; original magnification xlOO.) tion revealed a somewhat anxious patient with a respiration rate of 24 breaths per minute, sinus tachycardia of 120 beats per minute, and moist rales in both lung bases. The neck veins were not distended, the liver was not enlarged, and there was no peripheral edema. Two months previously he had had a craniotomy for a brain abscess secondary to Nocardia asteroides. Drug therapy consisted of sulfadiazine and tetracycline. The hemoglobin was 15.7 Gm. per 100 ml., the hematocrit value was 46 per cent, and the white blood cell count was 9,700 per cubic millimeter with a normal differential. An x-ray film of the chest revealed bilateral, fine pulmonary infiltrates extending from the hilar areas, predominantly involving the lower lobes. The chest films taken at the time of the craniotomy were reviewed and showed a vague, ground-glass infiltrate near the left hilum, which had not been reported initially. Skin and sputum studies were negative for tuberculosis and histoplasmosis. Fungal blood titers were negative. Sputum cultures grew normal flora. The major defect on pulmonary function studies was a reduction of the D L C O to 9 ml. per minute per mm. Hg (34 per cent of n o r m a l ) . The Pa 0 , was 42 mm. Hg, the Paco. was 31 mm. Hg, and the p H was 7.45. Trephine lung biopsy from the right posterior chest revealed pulmonary alveolar proteinosis (Fig. 4 ) . Bronchopulmonary lavage with heparinized saline produced an excellent response. Subsequently, the patient returned to work and has had no recurrence of symptoms to date. C A S E 3. A 21-year-old mentally retarded woman with a seizure disorder was admitted to the Oakdale Chest Hospital in June, 1971, with a 1 month history of fever, weight loss, and lung lesions not affected by antibiotics. Toxicity was
evident. The patient was febrile and unable to give a history. Physical examination revealed a cachectic, obtunded patient whose lungs were normal on inspection and palpation, resonant to percussion, and entirely clear on auscultation. The hemoglobin was 14.1 Gm. per 100 ml., the hematocrit value was 39 per cent, and the white blood cell count was 7,000 per cubic millimeter with 79 per cent segmented neutrophils, 17 per cent lymphocytes, and 4 per cent monocytes. Chest x-ray study showed numerous bilateral micronodular infiltrates scattered throughout the lung fields without cavitation, pleural effusion, hilar node enlargement, or cardiomegaly. A work-up for tuberculosis and fungal infections was negative, including skin tests and sputum studies. Gastric washings were inconclusive. Lymphangitic spread of a malignancy was considered, but there was no evidence of a primary tumor. Trephine lung biopsy from the right posterior chest revealed a small caseating granuloma, most likely representative of miliary tuberculosis (Fig. 5 ) , although acid-fast stains were negative. Antituberculosis therapy was started with isoniazid, streptomycin, and ethambutol plus an initial course of prednisone. The patient had an excellent clinical response and made a good recovery. Cultures of the gastric washings subsequently grew out Mycobacterium tuberculosis. C A S E 4. A 69-year-old retired farmer entered the University of Iowa Hospitals in February, 1971, complaining of extreme fatigue, anorexia, weight loss, and chronic cough with sputum production. He gave a history of having had polycythemia vera for 10 years. Therapy consisted of repeated phlebotomies, a 1 year course of busulfan (Myleran) in 1963, and a 2 year course in 1968 and 1969. Busulfan was restarted in December,
224
The Journal of
Zavala, Bedell, Rossi
Thoracic and Cardiovascular Surgery
Fig. 4. Case 2. Pulmonary alveolar proteinosis. (Hematoxylin and eosin; original magnification xlOO.)
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• .:^J;^««M^JW
Fig. 5. Case 3. Small tubercle with a central zone of caseating necrosis. (Hematoxylin and eosin; original magnification x40.) 1970, followed by rapidly increasing bilateral pulmonary infiltrates. Physical examination revealed a chronically ill patient who had bilateral pulmonary rales and rhonchi. The white blood cell count rose from 7,000 to 18,000 per cubic millimeter. The Pao2 decreased from 59 mm. Hg on hospital admission to 38 mm. Hg 9 days later. The Paco3 was 36 mm. Hg, and the pH was 7.50. Pneumocystis carinii pneumonia, cytomegalic inclusion disease, and carcinoma were considered. Studies were negative for tuberculosis and fungal infections. Trephine lung biopsy from the right posterior chest revealed large, abnormal alveolar lining cells, compatible with busulfan lung disease (Fig.
6). Immediately after the biopsy the patient had a 30 per cent pneumothorax which required the insertion of a chest tube for 48 hours. Busulfan was discontinued, and broad-spectrum antibiotics plus prednisone were given. The patient's condition improved symptomatically for several days but then worsened. He died suddenly 2 weeks later. Autopsy substantiated the diagnosis of busulfan lung disease. Death was caused by a large embolus to the main pulmonary artery trunk. CASE 5. A 37-year-old female nurse entered the University of Iowa Hospitals in January, 1971, with a history of fatigue and enlarged right inguinal nodes for 3 months. Physical examination
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Trephine lung biopsy
Fig. 6. Case 4. Large, abnormal alveolar lining cells, compatible with busulfan lung disease. (Hematoxylin and eosin; original magnification x450.) was not remarkable except for the right inguinal adenopathy. The liver and spleen were not enlarged. Chest x-ray films showed bilateral diffuse pulmonary infiltrates. A routine chest work-up was negative for tuberculosis and fungal infections. Biopsy of several right inguinal nodes was positive for mixed-type lymphoma. The patient was reluctant to have an operative staging procedure but agreed to a trephine lung biopsy. A percutaneous drill biopsy from the right posterior chest revealed a mixed lymphoma, similar to the inguinal node biopsy (Fig. 7). A standard MOPP* therapy program was started, resulting in rapid clearing of the pulmonary infiltrates.
Results The results of 50 trephine biopsies of the lung on 47 patients are recorded in Table I, and the histologic analysis is shown in Table II. Forty-six (92 per cent) of the biopsies yielded adequate material for histologic examination. Forty-two (84 per cent) were diagnostically significant. No diagnosis was reached initially in 8 patients, but a second biopsy on 3 of these patients established the diagnosis. Two of the patients were extremely obese and had chest walls which were too thick for the trephine to penetrate. Three patients had small lesions which were missed. Tissue diagnosis was confirmed by au•This regimen consists of vincristine, nitrogen mustard, prednisone, and procarbazine,
Table I. Results and complications trephine lung biopsy
of Steel6
Zavala No. No. of cases No. of biopsies Adequate biopsies Diagnostic Pneumothorax Hemoptysis
47 50 46 42 16 4
Per cent
No.
92 84 32 8
119 111 101 31 14
Per cent
93 85 26 12
topsy in 6 cases, by thoracotomy in 2 cases, and by clinical follow-up of 4 to 14 months in the remaining 39 cases. Ten of these 39 patients subsequently died without autopsies, 9 of them having been diagnosed by trephine biopsy as unequivocally having lung cancer. One patient, correctly diagnosed by trephine lung biopsy as having squamous cell carcinoma, had an open chest biopsy elsewhere 4 months previously which showed only scar tissue. Complications were not serious and are listed in Table I. Pneumothorax occurred in 32 per cent of the lung biopsies but often represented only a thin rim of air in the pleural space. A chest tube* connected to *A disposable, plastic trocar catheter made by Health and Science Division, Brunswick Corp., and distributed by Aloe Medical, St. Louis, Mo.
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The Journal of
Zavala, Bedell, Rossi
Thoracic and Cardiovascular Surgery
^2*»'5b!,*.*!^ *■ 2**?' "•'
* t £ ft* •jjr*-1*"
Fig. 7. Case 5. Lymphoma involving lung parenchyma. (Hematoxylin and eosin; original magnification x40.)
Table II. Histologic analysis of 50 trephine lung biopsies Usual interstitial pneumonia Carcinoma Undifferentiated Adenocarcinoma Squamous cell Sarcoidosis Hypersensitivity lung disease Radiation fibrosis Rheumatoid lung Miscellaneous Bulsulfan lung Chronic heart failure Lupus erythematosis Lymphoma Pulmonary alveolar proteinosis Miliary tuberculosis Viral pneumonia
16 9
Abnormal histology (total) Inadequate tissue Normal lung with abnormal x-ray films
42 4 4
Total
50
3 patients. However, 1 patient coughed up 50 ml. of blood over a half hour period. No therapy was required. There were no complications of air embolus, tumor implants, or empyema. Discussion
water-sealed drainage was used in treating 7 symptomatic patients. It was left in place until 24 hours after all evidence of air leak had ceased. In case of doubt, a chest tube was always employed, especially if the patient's respiratory function was compromised prior to the biopsy. Hemoptysis consisted of transient staining of the sputum in
From the first recorded percutaneous lung biopsy in 1883 s until the present date, three biopsy methods have evolved, namely, aspiration, cutting needle, and trephine. Aspiration of lung tumors has become a wellestablished procedure, 010 but the technique is not useful in diffuse parenchymal disease. Lung biopsy in which a cutting needle is used in cases of diffuse parenchymal disease has been controversial because of difficulty in obtaining adequate tissue (15 to 20 per cent failures) and a significantly high complication rate of 20 to 35 per cent.7'1X Pneumothorax is easy to remedy or prevent by insertion of a chest tube, but pulmonary bleeding can be life threatening. Many surgeons feel that needle biopsy on a potentially operable neoplasm runs the risk of spreading malignancy, although this had not been the experience of Lauby and co-workers9 or Dahlgren and Nordenstrom,10 who collectively have performed 1,145 needle aspiration biopsies of lung tumors. Some pathologists have pointed out that the tissue
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August, 1972
METRIC 1
II
Mil llll
51
nnLim
mill i HI Ili 11llll
Fig. 8. Gross specimen of lung obtained by trephine biopsy.
obtained may not be representative of the disease process. For these reasons, open thoracotomy has been preferred by many.12-13 The new technique of trephine lung biopsy with a high-speed air drill has proved to be the most promising of any percutaneous method of obtaining lung tissue from patients with diffuse disease. Furthermore, localized lesions may be biopsied, so long as they are at or very near the pleural surface and are large enough for the operator to hit with an acceptable degree of accuracy. The cutting edge of the trephine, moving at 15,000 r.p.m. bores cleanly through tough, elastic lung tissue with minimal tearing of the parenchyma or disruption of blood vessels. A good core of tissue without crush artifact, 2 mm. in diameter and often 2 to 3 cm. long, is usually obtained in a rapid, painless fashion with minimal complications (Fig. 8). Our results (Table I) are almost identical to those of Steel and Winstanley,5-6 except for a 6 per cent higher rate of pneumothorax. Success in obtaining adequate tissue has been increased to 92 or 93 per cent, and an accurate diagnosis has been achieved in 84 to 85 per cent of the biopsies, accompanied by an excellent safety record. No deaths have been reported to date. Trephine lung biopsy offers a relatively simple, nontraumatic method not only to diagnose but also to study various pulmonary diseases early in their onset and to
observe the response of lung tissue to therapy. Electron microscopy, light microscopy, and immunofluorescent and microbiologic studies can be carried out. Summary
By means of a unique trephine attached to a high-speed air drill, 50 percutaneous lung biopsies were performed on 47 patients, 36 having diffuse parenchymal disease and 11 having localized lesions. Fortysix (92 per cent) of the biopsies yielded adequate tissue for histologic examination. Forty-two (84 per cent) of the biopsies were diagnostically significant. Conditions such as usual interstitial pneumonia, carcinoma, sarcoidosis, hypersitivity lung disease, busulfan lung, lymphoma, pulmonary alveolar proteinosis, miliary tuberculosis, and others were conclusively diagnosed. Complications were not serious. Pneumothorax occurred in 16 (32 per cent) of the biopsies. A chest tube was required in 7 patients. Mild hemoptysis occurred in 4 (8 per cent) of the biopsies but did not necessitate therapy. It was concluded that trephine lung biopsy is a valuable and safe procedure for diagnosing localized and diffuse pulmonary diseases. REFERENCES 1 Kirschner: Die Probebohrung, Schweiz. Med. Wochenschr. 65: 28, 1935. 2 Christiansen, H.: An Aspiration Trepan for Tissue Biopsy, Acta Radiol. 21: 349, 1940. 3 Ellis, F.: Needle Biopsy in the Clinical Diag-
The Journal of
2 2 8 Zavala, Bedell, Rossi
nosis of Tumors, Br. J. Surg. 34: 240, 1947. 4 Deeley, T. J.: Drill Biopsy: Results With a High Speed Pneumatic Drill, Acta Un. Int. Cancer 16: 338, 1960. 5 Steel, S. J., and Winstanley, D. P.: Trephine Biopsy for Diffuse Lung Lesions, Br. Med. J. 3: 30, 1967. 6 Steel, S. J., and Winstanley, D. P.: Trephine Biopsy of the Lung and Pleura, Thorax 24: 576, 1969. 7 Zavala, D. C , and Bedell, G. N.: Percutaneous Lung Biopsy With a Cutting Needle: An Analysis of 40 Cases and Comparison With Other Biopsy Techniques, Am. Rev. Resp. Dis. In press. 8 Leyden, H.: Ueber infectiose Pneumonie, Dtsch. Med. Wochenschr. 9: 52, 1883. 9 Lauby, V. W., and Burnett, W. E., Rosemond,
Thoracic and Cardiovascular Surgery
G. P., and Tyson, R. R.: Value and Risk of Biopsy of Pulmonary Lesions by Needle Aspiration, J. THORAC. CARDIOVASC. SURG. 49:
10 11
12 13
159,
1965. Dahlgren, S., Nordenstrom, B.: Transthoracic Needle Biopsy, Chicago, Illinois, 1966, Year Book Medical Publishers, Inc. Youmans, C. R., Jr., deGroot, W. J., Marshall, R., et al.: Needle Biopsy of the Lung in Diffuse Parenchymal Disease: An Analysis of 151 Cases, Am. J. Surg. 120: 637, 1970. Gaensler, E. A., Moister, M. V. B., and Hamm, J.: Open-Lung Biopsy in Diffuse Pulmonary Disease, N. Engl. J. Med. 270: 1319, 1964. Klassen, K. P., and Andrews, N. C : Biopsy of Diffuse Pulmonary Lesions: A Seventeen-Year Experience, Ann. Thorac. Surg. 4: 117, 1967.
x. issue biopsy with an electrical drill and rotating needle was described by Kirschner1 in 1935. Technique modifications and results were reported by Christiansen2 in 1940, by Ellis3 in 1947, and by Deeley4 in 1960. The trephine described by Deeley provided satisfactory specimens from peripheral lung tumors but failed to give adequate tissue in diffuse pulmonary diseases because of its small internal diameter. Steel designed a larger trephine with which he and Winstanley5' ° reported great success in obtaining specimens from the lung and pleura in patients with diffuse or localized lesions. The present study was designed to determine the diagnostic value and safety of trephine lung biopsy in patients with a variety of chest diseases. Materials and methods Forty-seven patients were studied, consisting of 30 men and 17 women with ages ranging from 19 to 79 years. Thirty-six of From the Division of Pulmonary Diseases, Department of Medicine, and the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Iowa College of Medicine, Iowa City, Iowa 52240. Supported by a Grant-in-Aid from the Iowa Tuberculosis and Respiratory Disease Association. Received for publication March 24, 1972. Address reprint requests to Dr. Zavala at the University of Iowa Hospitals, Iowa City, Iowa 52240.
220
the patients had diffuse parenchymal disease and 11 had localized lesions. The biopsies were done in a room equipped with resuscitation facilities, a chest tube set, and a television fluoroscope with an image amplifier. Selection and preparation of the patient and the biopsy site, handling of the specimen, and post-biopsy orders were identical to those that we7 used in performing a previous study of percutaneous lung biopsies with the aid of a cutting needle. The equipment* consists of a handoperated pneumatic drill driven by compressed gas from a cylinder fitted with a reducing valve (Fig. 1). At a pressure of 100 p.s.i. the drill attains a speed of up to 15,000 revolutions per minute. A hollow trephine is connected to the central shaft of the drill by a Leur fitting. The trephine has a length of 7.5 cm., an external diameter of 3 mm., an internal diameter of 2.1 mm. There is a sharp cutting edge with internal rifling and a sharp pointed stylet which projects just beyond the cutting end (Fig. 2). Each trephine can be used for 15 to 20 biopsies but then should be returned to the manufacturer for resharpening and realignment. A ♦Made by Down Bros, and Mayer & Phelps Ltd., England. Distributed by Downs Surgical, Inc., Niagara Falls, N. Y.
Volume 64 Number 2 August, 1972
dull cutting edge will result in biopsy failures and increased complications. In bilateral diffuse disease the biopsy routinely is taken at the seventh or eighth intercostal space of the right posterior chest, near the tip of the scapula. In obese or short patients, the level of the diaphragm may be accurately determined by fluoroscopy to prevent biopsying the liver. An axillary or anterior approach also may be used, but cardiac and mediastinal areas are to be scrupulously avoided. In localized, peripheral lesions the site of trephine entry is determined by viewing the chest x-ray films, taking tomograms (when indicated), and using fluoroscopy with the aid of a metal rod pointer and skin marker. In 19 patients, the biopsies were taken with the patient in the sitting position, leaning forward. Otherwise, the patient was supine or prone. Drugs may be given before the procedure for the suppression of apprehension and the vagovagal reflex. The patient should be familiarized with the noise produced by the air drill before hand, so that he will not be startled when the biopsy is taken. The new drill model now in use is much more quiet. Instructions are given not to move or cough, but breathholding is not necessary. Specific contraindications to performing a drill biopsy include the following: (1) blebs, bullae, or cysts in the area to be biopsied, (2) a suspicion that the lesion may be vascular, (3) the presence of a bleeding diathesis, and (4) an uncooperative patient. Individual evaluation should be made on subjects with pulmonary hypertension, respiratory insufficiency, or poor cardiopulmonary reserve. Five of our patients were receiving oxygen at the time of biopsy. The physician operates from a sterile table. The skin is prepared, and the tissue to the pleura is infiltrated with a local anesthetic. The drill, which is not sterile, is not handled until the trephine has been introduced into the patient's chest. An incision, made just above the superior margin of the rib, is spread with a hemostat to allow the trephine to rotate with minimum impedence. The trephine, with the stylet in posi-
Trephine lung biopsy
221
Fig. 1. Trephine attached to air drill. Note compressed gas cylinder with reducing valve set at 100 p.s.i.
tion, is inserted into the incisional opening and pushed through the parietal pleura but not into the lung. The stylet is removed, the drill is firmly attached to the trephine and the trigger is pressed. The trephine, which reaches top speed almost instantaneously, is steadily pushed into the lung to an estimated depth of 3 cm. subpleurally. The entire maneuver takes only a few seconds. The drill is then disconnected and replaced by a 20 ml. syringe containing 5 ml. of normal saline solution. The trephine is withdrawn as suction is applied by the syringe to retain the specimen. The incision is covered with a dry, sterile dressing. Sutures are not necessary. If difficulty is encountered in detaching the drill from the trephine, then the ridged end of the trephine may be held and the drill turned on, thus effecting an easy separation. During any change-over, the operator should place his gloved thumb over the exposed end of the trephine to prevent air from entering the patient's chest. If no specimen is obtained on the first trial, the procedure may be repeated provided there has been no pneumothorax or hemoptysis.
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The Journal of
Zavala, Bedell, Rossi
Thoracic and Cardiovascular Surgery
Fig. 2. Air drill and lung biopsy trephine with stylet in place.
Before leaving the room the patient is examined fluoroscopically to check for pneumothorax and intrapulmonary bleeding. Routine post-biopsy orders include a check of vital signs every 30 minutes for 4 hours, a chest x-ray film in 2 to 4 hours, and close observation for hemoptysis and shortness of breath. The biopsy tissue is discharged into a sterile Petri dish containing 0.9 per cent saline. Subsequently, all or a major portion of the tissue is transferred by eye dropper to a clean glass slide. There a few drops of plasma and thrombin are added to form a fibrin clot around the specimen, which is immersed in a fixative solution and sent to pathology for hematoxylin and eosin stain. Acid-fast and Grocott (silver methenemine) stains are done when indicated. Fibrotic tissue should be examined under polarized light for birefringent silica particles. The saline and smaller tissue fragments remaining in the Petri dish may be put into a culture tube for bacteriologic and fungal studies. Case reports C A S E 1. A 67-year-old farmer's wife was admitted to the University of Iowa Hospitals in
September, 1970, complaining of increasing shortness of breath, intermittent fever, and dry cough for the previous 4 months. Her symptoms began shortly after her husband died, when she took over daily feeding of the cattle, hogs, and chickens. Because of cold weather, the animals were fed inside the barn where the patient was exposed to a great deal of dust from various grains and stored hay. Physical examination was not remarkable except for fine, crepitant rales in both lung bases. The pulmonary function studies revealed the following results: functional vital capacity, 2,380 ml. (89 per cent); mean expiratory flow rate, 320 L. per minute, forced expiratory volume in 1 second ( F E V , ) , 1.97 L., SbN 2 , 1.5 per cent nitrogen; and diffusing capacity of the lungs for carbon dioxide ( D L C O ) , 8 ml. per minute per mm. Hg (39 per cent). T h e Pa 0 , was 50 mm. Hg, the Paca, was 34 mm. Hg, and the p H was 7.51. A chest x-ray film revealed minimal diffuse infiltrates in the lower lung fields. Trephine lung biopsy from the right posterior chest revealed a noncaseating granulomatous reaction with interstitial pneumonia (Fig. 3 ) . Immunodiffusion studies were positive for Mycobacterium faeni, confirming the diagnosis of farmer's lung. The patient made an uneventful recovery when she was permanently removed from the contaminated atmosphere of the barn. The feeding operation of the animals was changed, and the barn was thoroughly cleaned. C A S E 2. A 42-year-old railroad switchman was admitted to the University Hospitals in January, 1971, with a chief complaint of exertional shortness of breath and dry cough. Physical examina-
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Trephine lung biopsy
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Fig. 3. Case 1. Noncaseating granulomatous reaction with interstitial pneumonia. (Hematoxylin and eosin; original magnification xlOO.) tion revealed a somewhat anxious patient with a respiration rate of 24 breaths per minute, sinus tachycardia of 120 beats per minute, and moist rales in both lung bases. The neck veins were not distended, the liver was not enlarged, and there was no peripheral edema. Two months previously he had had a craniotomy for a brain abscess secondary to Nocardia asteroides. Drug therapy consisted of sulfadiazine and tetracycline. The hemoglobin was 15.7 Gm. per 100 ml., the hematocrit value was 46 per cent, and the white blood cell count was 9,700 per cubic millimeter with a normal differential. An x-ray film of the chest revealed bilateral, fine pulmonary infiltrates extending from the hilar areas, predominantly involving the lower lobes. The chest films taken at the time of the craniotomy were reviewed and showed a vague, ground-glass infiltrate near the left hilum, which had not been reported initially. Skin and sputum studies were negative for tuberculosis and histoplasmosis. Fungal blood titers were negative. Sputum cultures grew normal flora. The major defect on pulmonary function studies was a reduction of the D L C O to 9 ml. per minute per mm. Hg (34 per cent of n o r m a l ) . The Pa 0 , was 42 mm. Hg, the Paco. was 31 mm. Hg, and the p H was 7.45. Trephine lung biopsy from the right posterior chest revealed pulmonary alveolar proteinosis (Fig. 4 ) . Bronchopulmonary lavage with heparinized saline produced an excellent response. Subsequently, the patient returned to work and has had no recurrence of symptoms to date. C A S E 3. A 21-year-old mentally retarded woman with a seizure disorder was admitted to the Oakdale Chest Hospital in June, 1971, with a 1 month history of fever, weight loss, and lung lesions not affected by antibiotics. Toxicity was
evident. The patient was febrile and unable to give a history. Physical examination revealed a cachectic, obtunded patient whose lungs were normal on inspection and palpation, resonant to percussion, and entirely clear on auscultation. The hemoglobin was 14.1 Gm. per 100 ml., the hematocrit value was 39 per cent, and the white blood cell count was 7,000 per cubic millimeter with 79 per cent segmented neutrophils, 17 per cent lymphocytes, and 4 per cent monocytes. Chest x-ray study showed numerous bilateral micronodular infiltrates scattered throughout the lung fields without cavitation, pleural effusion, hilar node enlargement, or cardiomegaly. A work-up for tuberculosis and fungal infections was negative, including skin tests and sputum studies. Gastric washings were inconclusive. Lymphangitic spread of a malignancy was considered, but there was no evidence of a primary tumor. Trephine lung biopsy from the right posterior chest revealed a small caseating granuloma, most likely representative of miliary tuberculosis (Fig. 5 ) , although acid-fast stains were negative. Antituberculosis therapy was started with isoniazid, streptomycin, and ethambutol plus an initial course of prednisone. The patient had an excellent clinical response and made a good recovery. Cultures of the gastric washings subsequently grew out Mycobacterium tuberculosis. C A S E 4. A 69-year-old retired farmer entered the University of Iowa Hospitals in February, 1971, complaining of extreme fatigue, anorexia, weight loss, and chronic cough with sputum production. He gave a history of having had polycythemia vera for 10 years. Therapy consisted of repeated phlebotomies, a 1 year course of busulfan (Myleran) in 1963, and a 2 year course in 1968 and 1969. Busulfan was restarted in December,
224
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Thoracic and Cardiovascular Surgery
Fig. 4. Case 2. Pulmonary alveolar proteinosis. (Hematoxylin and eosin; original magnification xlOO.)
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Fig. 5. Case 3. Small tubercle with a central zone of caseating necrosis. (Hematoxylin and eosin; original magnification x40.) 1970, followed by rapidly increasing bilateral pulmonary infiltrates. Physical examination revealed a chronically ill patient who had bilateral pulmonary rales and rhonchi. The white blood cell count rose from 7,000 to 18,000 per cubic millimeter. The Pao2 decreased from 59 mm. Hg on hospital admission to 38 mm. Hg 9 days later. The Paco3 was 36 mm. Hg, and the pH was 7.50. Pneumocystis carinii pneumonia, cytomegalic inclusion disease, and carcinoma were considered. Studies were negative for tuberculosis and fungal infections. Trephine lung biopsy from the right posterior chest revealed large, abnormal alveolar lining cells, compatible with busulfan lung disease (Fig.
6). Immediately after the biopsy the patient had a 30 per cent pneumothorax which required the insertion of a chest tube for 48 hours. Busulfan was discontinued, and broad-spectrum antibiotics plus prednisone were given. The patient's condition improved symptomatically for several days but then worsened. He died suddenly 2 weeks later. Autopsy substantiated the diagnosis of busulfan lung disease. Death was caused by a large embolus to the main pulmonary artery trunk. CASE 5. A 37-year-old female nurse entered the University of Iowa Hospitals in January, 1971, with a history of fatigue and enlarged right inguinal nodes for 3 months. Physical examination
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Trephine lung biopsy
Fig. 6. Case 4. Large, abnormal alveolar lining cells, compatible with busulfan lung disease. (Hematoxylin and eosin; original magnification x450.) was not remarkable except for the right inguinal adenopathy. The liver and spleen were not enlarged. Chest x-ray films showed bilateral diffuse pulmonary infiltrates. A routine chest work-up was negative for tuberculosis and fungal infections. Biopsy of several right inguinal nodes was positive for mixed-type lymphoma. The patient was reluctant to have an operative staging procedure but agreed to a trephine lung biopsy. A percutaneous drill biopsy from the right posterior chest revealed a mixed lymphoma, similar to the inguinal node biopsy (Fig. 7). A standard MOPP* therapy program was started, resulting in rapid clearing of the pulmonary infiltrates.
Results The results of 50 trephine biopsies of the lung on 47 patients are recorded in Table I, and the histologic analysis is shown in Table II. Forty-six (92 per cent) of the biopsies yielded adequate material for histologic examination. Forty-two (84 per cent) were diagnostically significant. No diagnosis was reached initially in 8 patients, but a second biopsy on 3 of these patients established the diagnosis. Two of the patients were extremely obese and had chest walls which were too thick for the trephine to penetrate. Three patients had small lesions which were missed. Tissue diagnosis was confirmed by au•This regimen consists of vincristine, nitrogen mustard, prednisone, and procarbazine,
Table I. Results and complications trephine lung biopsy
of Steel6
Zavala No. No. of cases No. of biopsies Adequate biopsies Diagnostic Pneumothorax Hemoptysis
47 50 46 42 16 4
Per cent
No.
92 84 32 8
119 111 101 31 14
Per cent
93 85 26 12
topsy in 6 cases, by thoracotomy in 2 cases, and by clinical follow-up of 4 to 14 months in the remaining 39 cases. Ten of these 39 patients subsequently died without autopsies, 9 of them having been diagnosed by trephine biopsy as unequivocally having lung cancer. One patient, correctly diagnosed by trephine lung biopsy as having squamous cell carcinoma, had an open chest biopsy elsewhere 4 months previously which showed only scar tissue. Complications were not serious and are listed in Table I. Pneumothorax occurred in 32 per cent of the lung biopsies but often represented only a thin rim of air in the pleural space. A chest tube* connected to *A disposable, plastic trocar catheter made by Health and Science Division, Brunswick Corp., and distributed by Aloe Medical, St. Louis, Mo.
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Zavala, Bedell, Rossi
Thoracic and Cardiovascular Surgery
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Fig. 7. Case 5. Lymphoma involving lung parenchyma. (Hematoxylin and eosin; original magnification x40.)
Table II. Histologic analysis of 50 trephine lung biopsies Usual interstitial pneumonia Carcinoma Undifferentiated Adenocarcinoma Squamous cell Sarcoidosis Hypersensitivity lung disease Radiation fibrosis Rheumatoid lung Miscellaneous Bulsulfan lung Chronic heart failure Lupus erythematosis Lymphoma Pulmonary alveolar proteinosis Miliary tuberculosis Viral pneumonia
16 9
Abnormal histology (total) Inadequate tissue Normal lung with abnormal x-ray films
42 4 4
Total
50
3 patients. However, 1 patient coughed up 50 ml. of blood over a half hour period. No therapy was required. There were no complications of air embolus, tumor implants, or empyema. Discussion
water-sealed drainage was used in treating 7 symptomatic patients. It was left in place until 24 hours after all evidence of air leak had ceased. In case of doubt, a chest tube was always employed, especially if the patient's respiratory function was compromised prior to the biopsy. Hemoptysis consisted of transient staining of the sputum in
From the first recorded percutaneous lung biopsy in 1883 s until the present date, three biopsy methods have evolved, namely, aspiration, cutting needle, and trephine. Aspiration of lung tumors has become a wellestablished procedure, 010 but the technique is not useful in diffuse parenchymal disease. Lung biopsy in which a cutting needle is used in cases of diffuse parenchymal disease has been controversial because of difficulty in obtaining adequate tissue (15 to 20 per cent failures) and a significantly high complication rate of 20 to 35 per cent.7'1X Pneumothorax is easy to remedy or prevent by insertion of a chest tube, but pulmonary bleeding can be life threatening. Many surgeons feel that needle biopsy on a potentially operable neoplasm runs the risk of spreading malignancy, although this had not been the experience of Lauby and co-workers9 or Dahlgren and Nordenstrom,10 who collectively have performed 1,145 needle aspiration biopsies of lung tumors. Some pathologists have pointed out that the tissue
Volume 64
Trephine lung biopsy
Number 2
111
August, 1972
METRIC 1
II
Mil llll
51
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Fig. 8. Gross specimen of lung obtained by trephine biopsy.
obtained may not be representative of the disease process. For these reasons, open thoracotomy has been preferred by many.12-13 The new technique of trephine lung biopsy with a high-speed air drill has proved to be the most promising of any percutaneous method of obtaining lung tissue from patients with diffuse disease. Furthermore, localized lesions may be biopsied, so long as they are at or very near the pleural surface and are large enough for the operator to hit with an acceptable degree of accuracy. The cutting edge of the trephine, moving at 15,000 r.p.m. bores cleanly through tough, elastic lung tissue with minimal tearing of the parenchyma or disruption of blood vessels. A good core of tissue without crush artifact, 2 mm. in diameter and often 2 to 3 cm. long, is usually obtained in a rapid, painless fashion with minimal complications (Fig. 8). Our results (Table I) are almost identical to those of Steel and Winstanley,5-6 except for a 6 per cent higher rate of pneumothorax. Success in obtaining adequate tissue has been increased to 92 or 93 per cent, and an accurate diagnosis has been achieved in 84 to 85 per cent of the biopsies, accompanied by an excellent safety record. No deaths have been reported to date. Trephine lung biopsy offers a relatively simple, nontraumatic method not only to diagnose but also to study various pulmonary diseases early in their onset and to
observe the response of lung tissue to therapy. Electron microscopy, light microscopy, and immunofluorescent and microbiologic studies can be carried out. Summary
By means of a unique trephine attached to a high-speed air drill, 50 percutaneous lung biopsies were performed on 47 patients, 36 having diffuse parenchymal disease and 11 having localized lesions. Fortysix (92 per cent) of the biopsies yielded adequate tissue for histologic examination. Forty-two (84 per cent) of the biopsies were diagnostically significant. Conditions such as usual interstitial pneumonia, carcinoma, sarcoidosis, hypersitivity lung disease, busulfan lung, lymphoma, pulmonary alveolar proteinosis, miliary tuberculosis, and others were conclusively diagnosed. Complications were not serious. Pneumothorax occurred in 16 (32 per cent) of the biopsies. A chest tube was required in 7 patients. Mild hemoptysis occurred in 4 (8 per cent) of the biopsies but did not necessitate therapy. It was concluded that trephine lung biopsy is a valuable and safe procedure for diagnosing localized and diffuse pulmonary diseases. REFERENCES 1 Kirschner: Die Probebohrung, Schweiz. Med. Wochenschr. 65: 28, 1935. 2 Christiansen, H.: An Aspiration Trepan for Tissue Biopsy, Acta Radiol. 21: 349, 1940. 3 Ellis, F.: Needle Biopsy in the Clinical Diag-
The Journal of
2 2 8 Zavala, Bedell, Rossi
nosis of Tumors, Br. J. Surg. 34: 240, 1947. 4 Deeley, T. J.: Drill Biopsy: Results With a High Speed Pneumatic Drill, Acta Un. Int. Cancer 16: 338, 1960. 5 Steel, S. J., and Winstanley, D. P.: Trephine Biopsy for Diffuse Lung Lesions, Br. Med. J. 3: 30, 1967. 6 Steel, S. J., and Winstanley, D. P.: Trephine Biopsy of the Lung and Pleura, Thorax 24: 576, 1969. 7 Zavala, D. C , and Bedell, G. N.: Percutaneous Lung Biopsy With a Cutting Needle: An Analysis of 40 Cases and Comparison With Other Biopsy Techniques, Am. Rev. Resp. Dis. In press. 8 Leyden, H.: Ueber infectiose Pneumonie, Dtsch. Med. Wochenschr. 9: 52, 1883. 9 Lauby, V. W., and Burnett, W. E., Rosemond,
Thoracic and Cardiovascular Surgery
G. P., and Tyson, R. R.: Value and Risk of Biopsy of Pulmonary Lesions by Needle Aspiration, J. THORAC. CARDIOVASC. SURG. 49:
10 11
12 13
159,
1965. Dahlgren, S., Nordenstrom, B.: Transthoracic Needle Biopsy, Chicago, Illinois, 1966, Year Book Medical Publishers, Inc. Youmans, C. R., Jr., deGroot, W. J., Marshall, R., et al.: Needle Biopsy of the Lung in Diffuse Parenchymal Disease: An Analysis of 151 Cases, Am. J. Surg. 120: 637, 1970. Gaensler, E. A., Moister, M. V. B., and Hamm, J.: Open-Lung Biopsy in Diffuse Pulmonary Disease, N. Engl. J. Med. 270: 1319, 1964. Klassen, K. P., and Andrews, N. C : Biopsy of Diffuse Pulmonary Lesions: A Seventeen-Year Experience, Ann. Thorac. Surg. 4: 117, 1967.