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Guidelines for Radiologically Guided Lung Biopsy a Manhire, Chairman, M Charig, C Clelland, F Gleeson, R Miller, H Moss, K Pointon, C Richardson, E Sawicka

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Guidelines for Radiologically Guided Lung Biopsy a Manhire, Chairman, M Charig, C Clelland, F Gleeson, R Miller, H Moss, K Pointon, C Richardson, E Sawicka 920 Thorax: first published as 10.1136/thorax.58.11.920 on 29 October 2003. Downloaded from BTS GUIDELINES Guidelines for radiologically guided lung biopsy A Manhire, Chairman, M Charig, C Clelland, F Gleeson, R Miller, H Moss, K Pointon, C Richardson, E Sawicka ............................................................................................................................... Thorax 2003;58:920–936 hese guidelines have been developed at the working group and decisions on levels of request of the Standards of Care Committee evidence for each paper were made by two or Tof the British Thoracic Society (BTS) and more members. The guidelines were sent for with the agreement of the Royal College of comment to the Royal College of Radiologists, Radiologists and the British Society of the British Thoracic Society, the British Society of Interventional Radiology, and approval of the Interventional Radiology, the Royal College of Royal College of Pathologists in respect of the Pathologists, and the Society of Cardiothoracic pathology recommendations and the Society of Surgeons. Cardiothoracic Surgeons of Great Britain and Ireland. Scheduled review of guidelines Lung biopsy is a relatively frequently per- As methods of diagnosis and tissue sampling formed procedure with considerable benefit for change and new evidence comes to light, the patient management but it may, on rare occa- content and evidence base for these guidelines sions, result in the death of the patient. It is a will be reviewed. multidisciplinary procedure involving respiratory physicians, surgeons, and radiologists with an interest in chest diseases. TYPES OF LUNG BIOPSY The aim of the group was to produce formal Lung biopsies may be classified according to the evidence based guidelines for subsequent use by method of access (percutaneously, bronchosco- those referring patients for the procedure and for pically, open operation) or by the reason for those performing it. biopsy (sampling of diffuse lung disease or The areas covered by these guidelines are as obtaining tissue from a mass when malignancy follows: is suspected). Sometimes percutaneous biopsy is also defined by the tissue type obtained (cytolo- N Indications gical or histological). The indications for each N Complications, contraindications and precau- will be discussed later. http://thorax.bmj.com/ tions Fine needle aspiration biopsy (FNA, FNAB) gives cytological specimens and, although these N Consent needles tend to be of narrow bore, cutting N Technique needles (CNB) that produce histological speci- N Staffing issues mens can also be of similar gauge. For that N Patient information reason, lung biopsy in general is referred to as percutaneous transthoracic lung biopsy (PTLB) The following areas are not covered by these in these guidelines. guidelines: on October 1, 2021 by guest. Protected copyright. Percutaneous transthoracic lung biopsy N Lesions of the chest wall, pleura and medias- PTLB is performed with imaging guidance and tinum most frequently by a radiologist. Usually the aim N Bronchoscopic and open lung biopsy is to diagnose a defined mass. Imaging mod- alities are fluoroscopy, computed tomography (CT), and ultrasound. Ultrasound is useful only FORMULATION OF GUIDELINES where the tissue mass is in contact with the chest Validity and grading of recommendations wall since the ultrasound beam does not pass The criteria for assessing the levels of evidence through air and, hence, the aerated lung. and grading of recommendations were based on Magnetic resonance imaging (MRI) currently those recommended in the Scottish Inter- has a limited use because of expense, difficulty collegiate Guidelines Network in 19951 using accessing the patient within the magnet, the the Agency of Health Care Policy and Research relatively poor visualisation of lung lesions, and model used in some other BTS guidelines (tables difficulties with ferromagnetic instruments See end of article for 1 and 2). within the magnetic field. authors’ affiliations It should be noted that there are very few ....................... randomised trials comparing the various aspects ................................................... Correspondence to: of lung biopsy and, for that reason, more detailed Dr A R Manhire, systems of categorisation such as that of the Abbreviations: CNB, core needle biopsy; CT, computed Department of Radiology, Scottish Intercollegiate Guidelines Network pub- tomography; FNA, FNAB, fine needle aspiration biopsy; MRI, magnetic resonance imaging; NSCLC, non-small cell Nottingham City Hospital, lished in 2001 were not used.2 Nottingham NG5 1PB, UK; lung cancer; PET, positron emission tomography; PTLB, [email protected] The papers selected by searching PubMed and percutaneous transthoracic lung biopsy; SCLC, small cell ....................... Medline were assessed by the members of the lung cancer Guidelines for radiologically guided lung biopsy 921 Thorax: first published as 10.1136/thorax.58.11.920 on 29 October 2003. Downloaded from 3 185 reports. Sinner in 1975 reported no deaths in his series of Table 1 Categories of evidence 5300 biopsies but, from his knowledge, he estimated a Level Type of evidence mortality rate of 0.07%. A further series by Berquist et al reported two deaths in 430 procedures, a rate of 0.47%.4 Ia Evidence obtained from meta-analysis of randomised 5 controlled trials Richardson et al performed a postal survey of the UK practice Ib Evidence obtained from at least one randomised controlled of lung biopsies which achieved a 61% response rate. Based trial on 5444 biopsies, the mortality rate was estimated at 0.15%. IIa Evidence obtained from at least one well designed controlled There is probably a tendency to under-report patient death. study without randomisation IIb Evidence obtained from at least one other type of well designed quasi-experimental study Causes of mortality III Evidence obtained from well designed non-experimental Mortality from PTLB is generally an early event. The causes of descriptive studies such as comparative studies, correlation mortality include acute massive haemoptysis or pulmonary studies, and case controlled studies IV Evidence obtained from expert committee reports and/or haemorrhage, pulmonary venous air embolism leading to air clinical experiences of respected authorities within the intracerebral or coronary circulation, and large haemothorax.4 6–8 Morbidity Bronchoscopic lung biopsy Pneumothorax Biopsy via a bronchoscope is useful for proximal endobron- The most common complication is pneumothorax which chial lesions but is unable to access more peripheral lesions. occurs in 0–61% of lung biopsies. Between 3.3% and 15% of 9–15 Transbronchial biopsy of diffuse lung disease may be assisted all patients will require a chest drain. This large range for by some imaging guidance. It is most commonly performed pneumothorax reflects both altered risk from the location of by a respiratory physician. Because it does not cross the the lesion and the increased sensitivity of CT, and potentially pleura, pneumothorax is much less common than in ultrasound, to detect very small pneumothoraces which may percutaneous biopsy. be overlooked on the chest radiograph. The risk of pneumothorax is related to the needle passing Open lung biopsy and video assisted thoracoscopic through aerated lung and increases significantly if the lesion 14 surgery (VATS) is not abutting the pleura. In one series using CT guided Although these surgical procedures are able to provide larger coaxial cutting needle biopsy, the highest number of samples of tissue with improved accuracy and specificity, the pneumothoraces occurred when the lesions were subpleural, morbidity and length of stay are greater than with the other and were 2 cm or less in depth from the chest wall.16 Other two methods of biopsy. work has shown that perihilar biopsy is also more likely to cause pneumothoraces because of the distance of lung 4 BACKGROUND crossed. Post biopsy positioning has not been found to decrease the The indications and methods for lung biopsy have changed 17 18 over the years with increased access to CT and more rate of pneumothorax. Injection of autologous blood through a coaxial needle is not commonly practised and is http://thorax.bmj.com/ therapeutic options. The total number of lung biopsies 19 performed has also increased. All invasive procedures have of uncertain benefit. a morbidity and mortality rate associated with them and Bilateral pneumothoraces have been reported in occasional patients with either unexpected lung herniation across the these are important in considering whether to subject the 20 patient to a procedure. midline or incomplete fusion of the pleura, as well as A multidisciplinary meeting will ensure the most appro- following heart lung transplantion where there is a single priate approach to biopsy and should include at least a pleural cavity. respiratory physician and radiologist with an interest in chest Pulmonary haemorrhage disease. Depending on the local circumstances, referral for on October 1, 2021 by guest. Protected copyright. biopsy by another specialist clinician such as an oncologist Intrapulmonary haemorrhage may occur with or without may be acceptable, but proper assessment of lung function haemoptysis. Intrapulmonary haemorrhage is recorded in 5– 35 before the procedure is essential (see later). 16.9% of patients and haemoptysis in 1.25–5%. Lesion depth has been identified as the most important risk factor for haemorrhage, with an increased risk of bleeding
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