A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

Published: November 03, 2023

doi:

Christian B. Laursen², Rahul Bhatnagar^3,4, Amanda Dandanell Juul²

¹Department of Respiratory Medicine,Odense University Hospital, ²Odense Respiratory Research Unit (ODIN), Department of Clinical Research,University of Southern Denmark, ³Respiratory Medicine Department, North Bristol NHS Trust,Southmead Hospital, ⁴Academic Respiratory Unit,University of Bristol

Summary

Transthoracic ultrasound-guided lung biopsy represents a safe, cost-effective, and efficient approach for patients presenting with subpleural lung lesions suspected of malignancy. Employing a systematic, step-by-step process is crucial to achieve optimal patient selection, minimize complication risks, and maximize diagnostic accuracy.

Abstract

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. When selecting the most suitable invasive procedure to establish a diagnosis in these cases, a delicate balance must be struck between achieving a high diagnostic yield, providing staging information, minimizing potential complications, enhancing the patient experience, and controlling costs. The integration of thoracic ultrasound as a routine clinical tool in respiratory medicine has led to increased awareness and utilization of ultrasound-guided invasive techniques in chest procedures, including transthoracic biopsies. By following a systematic and stepwise approach, transthoracic ultrasound-guided lung biopsy emerges as a safe, cost-effective procedure with a remarkable diagnostic accuracy. These attributes collectively position it as an ideal invasive technique when technically feasible. Consequently, in patients presenting subpleural lung lesions suspected of malignancy, transthoracic ultrasound-guided lung biopsy has become a standard procedure in the realm of modern invasive pulmonology.

Introduction

Establishing a diagnosis in patients with radiological lung lesions is crucial, particularly when malignancy is suspected. Tissue sampling is essential for confirming malignancy, obtaining additional information like genotyping and staging, and diagnosing non-malignant lung lesions (e.g., infection or vasculitis)¹^,².

Several invasive procedures are available for tissue sampling in patients with lung lesions, including conventional bronchoscopy, bronchoscopy supplemented with radial endobronchial ultrasound (REBUS), electromagnetic navigation bronchoscopy (ENB), endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), computed tomography guided transthoracic biopsy (CT-TTNB), and surgical biopsy³^,⁴^,⁵^,⁶. The selection of the optimal procedure involves balancing factors like diagnostic yield, complication risks, patient comfort, and resource allocation³.

Most of these techniques have limitations. For instance, conventional bronchoscopy is less effective for peripheral lesions, CT-TTB carries a higher risk of complications (especially pneumothorax), and procedures like ENB and surgical biopsy can be costly⁴^,⁶^,⁷.

Ultrasound-guided transthoracic needle biopsy (US-TTNB) is an alternative method for obtaining tissue samples from lung lesions. The technique itself is not new, but its use has significantly increased in patients with peripheral lung lesions of unknown origin, particularly among pulmonologists, who now routinely use thoracic ultrasound (TUS) for point-of-care diagnostics and basic procedural guidance in various clinical scenarios⁸^,⁹. In addition, ultrasound equipment is now more widely available, with TUS training increasingly formalized and made more accessible to clinicians at an earlier stage⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶.

US-TTNB carries several potential advantages. Complication rates and costs related to the procedure are low, while diagnostic yields remain comparable to other approaches, especially CT-TTB¹⁷^,¹⁸^,¹⁹^,¹⁸^,¹⁹^,²⁰^,²¹. Its major limitation, however, is its suitability only for a limited proportion of lung lesions that can be appropriately visualized using TUS. Therefore, it cannot be used for lesions that do not contact the parietal pleura at the chest wall, such as any central tumor; lesions behind structures impenetrable to ultrasound waves, such as the scapula; or lesions with a meaningful air content, which also does not transmit ultrasound, such as 'ground glass' opacities seen on CT⁸^,⁹^,¹⁷^,¹⁸^,¹⁹^,²⁰^,²²^,²¹^,²²^,²³^,²⁴^,²⁵^,²⁶. US-TTNB is also unable to definitively assess the N-stage of lung cancer, meaning in some cases, the procedure must be combined with another invasive procedure to provide a full picture¹^,².

Nonetheless, US-TTNB remains an important and increasingly used front-line tool in modern invasive pulmonology practice in selected patients with suspected malignant lung lesions⁹^,¹⁸.

Indications and contraindications
US-TTNB is indicated when all of the following criteria are met: (1) subpleural lung consolidation that can be visualized using thoracic ultrasound; (2) clinically warranted lung tissue biopsy (e.g., for establishing a diagnosis, obtaining material for supplementary diagnostic analyses). US-TTNB should not be performed when one or more of the following criteria are met: (1) manifest chronic or acute respiratory failure; (2) hemorrhagic diatheses; (3) ongoing treatment with anticoagulants or platelet aggregation inhibitors; (4) another invasive method for tissue sampling can establish a diagnosis and simultaneously provide N- or M-staging (e.g., EBUS/EUS-B in patients with suspected lung cancer and suspected involvement of mediastinal lymph nodes).

It should be noted, however, that the listed contraindications are generally relative. The physician, in agreement with the patient, should consider the clinical consequences of obtaining a biopsy by US-TTNB and balance this against the risk of complications and other potential invasive or diagnostic methods that could be performed instead of US-TTNB.

Protocol

The described protocol below follows the human care guidelines of Odense University Hospital, Odense, Denmark, and the University of Southern Denmark, Odense, Denmark. The step-wise protocol described below represents a potential, systematic approach for a typical patient with suspected lung cancer for whom US-TTNB was performed in an outpatient or daycase setting. Informed written consent was obtained from the patient. We have taken into account current clinical practices at the authors' institutions, as well as des…

Representative Results

The overall diagnostic yield of US-TTNB in patients with lung lesions has been reported as 88.7% in a meta-analysis by DiBardiono et al.18. However, it should be noted that other studies have reported lower diagnostic yields of US-TTNB17,23,25. Several patient factors have been shown to affect the diagnostic yield of US-TTNB, including: (1) whether there is a malignant or non-malignant condition; (2) the …

Discussion

Appropriate patient selection and a careful initial TUS assessment are crucial steps before performing US-TTNB. If the lung lesion cannot be visualized, US-TTNB is not a viable option. Ideally, TUS should be conducted before scheduling the procedure during the clinic visit to prevent last-minute cancellations in the procedural room¹⁷. This approach also allows for more comprehensive planning and a potential shift to an alternative invasive procedure if the lesion cannot be visualized<sup class="xr…

Disclosures

The authors have nothing to disclose.

Acknowledgements

None.

Materials

Ambu BlueSensor R	Ambu	R-00-S/25	ECG patches
BD Nexiva Closed IV Catheter System (20 GA x 1.25 in)(1.1 x 32 mm)	BD	383667	Intravenous accesskit
BD PosiFlush SP Syringe 5 mL	BD	306574	Syringe with 5 mL 0.9% NaCl
Blunt Fill Needle with 5 Micron Filter (18 G x 11/2")	Sol-Millennium Medical Inc.	BN1815F	18 G needle
C1-6VN ultrasound transducer	GE Healthcare	5476279	Ultrasound transducer
C2-9D ultrasound transducer	GE Healthcare	5405253	Ultrasound transducer
CARBON STEEL SURGICAL BLADES	Swann-Morton	203	Scalpel blade
Disinfection wipe (82% ehanol + 0.5% chlorhexidine)	Vitrex Medical A/S	527297	Disinfection wipe
Disposable needle single use (0.80 mm x 80 mm)	Misawa Medical Industry Co., Ltd.	K070001	80 mm 21 G hypodermic needle
EKO GEL	Ekkomed A/S	29060008-29	Ultrasound gel
Formalin system, buffered formalin solution 450 mL	Sarstedt	5,11,703	Biopsy specimen contained and relevant fixation liquid (e.g. formaldehyde)
GAMMEX Latex	Ansell	330048075	Sterile gloves
KD-JECT 20 mL	KD Medcial GmbH	820209	20 mL syringe
Klorhexidin sprit 0.5% 500 mL	Fuckborg Pharma	212045	Disinfectant
Lidokain Mylan 10 mg/mL, 20 mL	Mylan	NO-6042A1	Local anesthetic (20 mL, 2% lidocaine)
LOGIQ E10	GE Healthcare	NA	High-end ultrasound machine
Mölnlycke BARRIER Adhesive Aperture Drape (50 x 60 cm / 6 x 8 cm)	Mölnlycke Healthcare AB	906693	Adhesive surgical drape with a central hole
Mölnlycke Gauze 10 x 10 cm	Mölnlycke Healthcare AB	158440	Swaps for applying disinfectant
Philips IntelliVue X2	Philips	NA	Patient monitoring system
Raucodrape PRO 75 x 90 cm	Lohmann & Rauscher International GmbH & Co	33 005	Sterile drape for procedure table
SEMICUT 18 G x 100 mm	MDL	PD01810	18 G x 100 mm core biopsy needle
SEMICUT 18 G x 160 mm	MDL	PD01816	18 G x 160 mm core biopsy needle
S-Monovette, 25 mL, for Formalin system, (LxØ): 97 x 25 mm, with paper label	Sarstedt	9,17,05,001	Biopsy specimen container
Sterican (0.80 x 120 mm BL/LB)	Braun	4665643	120 mm 21 G hypodermic needle
Tegaderm I.V.	3M	1633	I.V. Transparent film dressing with border
Ultra-Pro II Disposable Replacement Kits	CIVCO	610-608	For use with GE Healthcare C2-9 transducer
Ultra-Pro II In-Plane Ultrasound Needle Guides-Multi-Angle	CIVCO	H4913BA	For use with GE Healthcare C2-9 transducer
Verza Needle Guidance System for VerzaLink™ Transducers	CIVCO	610-1500-24	For use with GE Healthcare C1-6 transducer
Verza Ultrasound Needle Guidance System	CIVCO	H4917VB	For use with GE Healthcare C1-6 transducer

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