EDITORIALS
Needle Biopsy of the Lung Peter G. Herman, M.D. In this issue of the Annuls (p 399), Sage1 and co-workers report their experience with 1,211 patients who underwent aspiration needle biopsy. An accurate diagnosis was obtained in more than 90%. The only significant morbidity associated with the procedure was pneumothorax, which occurred in 24% of the patients. But only 14% of them required chest tube drainage. The results of the study are in essential agreement with those of other reports 15, 61 and with the results of a nationwide survey conducted over the 2-year period 1974 through 1975 [3]. Most of the reported series, including this one, deal primarily with suspected neoplastic diseases; the diagnostic yield in inflammatory conditions is not as extensively documented. The available data indicate, however, that a correct causative diagnosis for inflammatory diseases can be made in approximately 80% of patients. In the presence of cavitary lung disease, this figure is perhaps slightly higher. The radiographic detection of an unexpected pulmonary abnormality often poses a difficult diagnostic dilemma, particularly if the lung lesion cannot be related to any past or current illness. This is true both for focal lung disease and disseminated pulmonary diseases. The management of these patients depends to a large extent on a priori judgment as to the most likely causative factor. In the presence of a solitary mass or infiltrate, if primary lung cancer is clinically suspected, surgical excision of the lesion is considered both diagnostic and therapeutic. The role of needle biopsy of the lung in patients who are potentially good surgical candidates is not clearly defined. In these patients, the risks of operation have to be weighed against the risk of missing the diagnosis by closed biopsy. Other risks of needle biopsy, including the likelihood of spreading the neoplastic or inflammatory disease, are apparently From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, 25 Shattuck St, Boston, MA 02115.
almost negligible. In a yet unpublished series cited by Fraser and Pare [21 of 300 consecutive lung biopsies in patients with focal pulmonary abnormality, there were no false-negative errors. If this or a similarly high degree of accuracy can be achieved, percutaneous biopsy in most patients with suspected lung cancer can be justly advocated. Needle biopsy of the lung will not only reduce the number of unnecessary thoracotomies, but in addition advanced knowledge of cell type can change the treatment plan. The preoperative diagnosis of lung cancer can modify the extent of staging procedures. In numerous clinical situations, it is unlikely that the removal of the lung lesion will be therapeutic. In patients with advanced neoplastic disease or an infectious disease as well as in a rather sizable group with interstitial lung disease of obscure etiology, thoracotomy serves a diagnostic purpose only. In these patients, closed lung biopsy may play an important role provided it is accurate and carries a low risk. A clear consensus concerning the relative merits of tissue-core needle biopsy and aspiration lung biopsy has not evolved. Often aspiration biopsy specimens contain small tissue fragments that can be used for histological examination. Even with tissue fragments, the cellular aspirates have the same diagnostic yield as the tissue samples [31. The histological categorization, however, is much easier if a tissue core is available. A special type of core biopsy that utilizes a high-speed drill (trephine) has the advantage of providing a fairly large and nondistorted tissue sample. The morbidity and the mortality of the drill biopsy, however, is probably higher than that of other needle biopsy methods. In general, cutting needle core biopsies will have higher morbidity and mortality but essentially the same diagnostic accuracy as aspiration biopsies; therefore, the former have a competitive advantage. A successful needle biopsy program requires close cooperation between the physician who performs the procedure and the cytologist and
395 0003-4975/78/0026-0501$01.00 @ 1978 by Peter G. Herman
396 The Annals of Thoracic Surgery Vol 26
No 5 November 1978
microbiologist who make the definitive diag- emphasize, however, that closed lung biopsy procedures must be tailored to the specific nosis. In disseminated pulmonary diseases, aspira- clinical problem, taking into consideration the tion biopsy plays no notable role. Transbron- institutional resources and experience. chial biopsy, on the other hand, is reported to be quite accurate primarily in the diagnosis of References sarcoidosis [4]. In disseminated lung diseases, 1. Carrington CB, Gaensler EA, Coutu RE, et al: Natural history and treated course of usual and however, open lung biopsy permits more predesquamative interstitial pneumonia. N Engl J cise pathological classification. Apparently, Med 298:801, 1978 histological distinction among various intersti- 2. Fraser RG, Pare PJA: Diagnosis of Diseases of the Chest. Second edition. Philadelphia, Saunders, tial pneumonias, important for both prognosis 1977, vol 1, p 247 and treatment, is not feasible from a small tis3. Herman PG, Hessel SJ: The diagnostic accuracy sue sample [ll. and complications of closed lung biopsies. Because of the high diagnostic accuracy and Radiology 125:11, 1977 rather low morbidity, fluoroscopically-guided 4. Koemer SK, Sakowitz AJ, Appelman RI, et al: Transbronchial lung biopsy for the diagnosis of needle aspiration biopsy of the lung seems to sarcoidosis. N Engl J Med 293:268, 1975 be the procedure of choice for the diagnosis of 5. Lalli AI, McCormack LJ, Zelch M, et al: Aspiration focal pulmonary disease. Tissue-core needle bibiopsies of chest lesions. Radiology 127:35, 1978 opsy will have a similar accuracy and only a 6. Sinner WN: Transthoracic needle biopsy of small slightly increased morbidity if performed with peripheral malignant lung lesions. Invest Radio1 8:305, 1973 small-caliber cutting needles. It is important to
Needle Biopsy of the Lung Peter G. Herman, M.D. In this issue of the Annuls (p 399), Sage1 and co-workers report their experience with 1,211 patients who underwent aspiration needle biopsy. An accurate diagnosis was obtained in more than 90%. The only significant morbidity associated with the procedure was pneumothorax, which occurred in 24% of the patients. But only 14% of them required chest tube drainage. The results of the study are in essential agreement with those of other reports 15, 61 and with the results of a nationwide survey conducted over the 2-year period 1974 through 1975 [3]. Most of the reported series, including this one, deal primarily with suspected neoplastic diseases; the diagnostic yield in inflammatory conditions is not as extensively documented. The available data indicate, however, that a correct causative diagnosis for inflammatory diseases can be made in approximately 80% of patients. In the presence of cavitary lung disease, this figure is perhaps slightly higher. The radiographic detection of an unexpected pulmonary abnormality often poses a difficult diagnostic dilemma, particularly if the lung lesion cannot be related to any past or current illness. This is true both for focal lung disease and disseminated pulmonary diseases. The management of these patients depends to a large extent on a priori judgment as to the most likely causative factor. In the presence of a solitary mass or infiltrate, if primary lung cancer is clinically suspected, surgical excision of the lesion is considered both diagnostic and therapeutic. The role of needle biopsy of the lung in patients who are potentially good surgical candidates is not clearly defined. In these patients, the risks of operation have to be weighed against the risk of missing the diagnosis by closed biopsy. Other risks of needle biopsy, including the likelihood of spreading the neoplastic or inflammatory disease, are apparently From the Department of Radiology, Harvard Medical School and Peter Bent Brigham Hospital, 25 Shattuck St, Boston, MA 02115.
almost negligible. In a yet unpublished series cited by Fraser and Pare [21 of 300 consecutive lung biopsies in patients with focal pulmonary abnormality, there were no false-negative errors. If this or a similarly high degree of accuracy can be achieved, percutaneous biopsy in most patients with suspected lung cancer can be justly advocated. Needle biopsy of the lung will not only reduce the number of unnecessary thoracotomies, but in addition advanced knowledge of cell type can change the treatment plan. The preoperative diagnosis of lung cancer can modify the extent of staging procedures. In numerous clinical situations, it is unlikely that the removal of the lung lesion will be therapeutic. In patients with advanced neoplastic disease or an infectious disease as well as in a rather sizable group with interstitial lung disease of obscure etiology, thoracotomy serves a diagnostic purpose only. In these patients, closed lung biopsy may play an important role provided it is accurate and carries a low risk. A clear consensus concerning the relative merits of tissue-core needle biopsy and aspiration lung biopsy has not evolved. Often aspiration biopsy specimens contain small tissue fragments that can be used for histological examination. Even with tissue fragments, the cellular aspirates have the same diagnostic yield as the tissue samples [31. The histological categorization, however, is much easier if a tissue core is available. A special type of core biopsy that utilizes a high-speed drill (trephine) has the advantage of providing a fairly large and nondistorted tissue sample. The morbidity and the mortality of the drill biopsy, however, is probably higher than that of other needle biopsy methods. In general, cutting needle core biopsies will have higher morbidity and mortality but essentially the same diagnostic accuracy as aspiration biopsies; therefore, the former have a competitive advantage. A successful needle biopsy program requires close cooperation between the physician who performs the procedure and the cytologist and
395 0003-4975/78/0026-0501$01.00 @ 1978 by Peter G. Herman
396 The Annals of Thoracic Surgery Vol 26
No 5 November 1978
microbiologist who make the definitive diag- emphasize, however, that closed lung biopsy procedures must be tailored to the specific nosis. In disseminated pulmonary diseases, aspira- clinical problem, taking into consideration the tion biopsy plays no notable role. Transbron- institutional resources and experience. chial biopsy, on the other hand, is reported to be quite accurate primarily in the diagnosis of References sarcoidosis [4]. In disseminated lung diseases, 1. Carrington CB, Gaensler EA, Coutu RE, et al: Natural history and treated course of usual and however, open lung biopsy permits more predesquamative interstitial pneumonia. N Engl J cise pathological classification. Apparently, Med 298:801, 1978 histological distinction among various intersti- 2. Fraser RG, Pare PJA: Diagnosis of Diseases of the Chest. Second edition. Philadelphia, Saunders, tial pneumonias, important for both prognosis 1977, vol 1, p 247 and treatment, is not feasible from a small tis3. Herman PG, Hessel SJ: The diagnostic accuracy sue sample [ll. and complications of closed lung biopsies. Because of the high diagnostic accuracy and Radiology 125:11, 1977 rather low morbidity, fluoroscopically-guided 4. Koemer SK, Sakowitz AJ, Appelman RI, et al: Transbronchial lung biopsy for the diagnosis of needle aspiration biopsy of the lung seems to sarcoidosis. N Engl J Med 293:268, 1975 be the procedure of choice for the diagnosis of 5. Lalli AI, McCormack LJ, Zelch M, et al: Aspiration focal pulmonary disease. Tissue-core needle bibiopsies of chest lesions. Radiology 127:35, 1978 opsy will have a similar accuracy and only a 6. Sinner WN: Transthoracic needle biopsy of small slightly increased morbidity if performed with peripheral malignant lung lesions. Invest Radio1 8:305, 1973 small-caliber cutting needles. It is important to
