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Ann Thorac Surg 2008;86:1098-1103. doi:10.1016/j.athoracsur.2008.06.021
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Needlescopic Lung Biopsy for Interstitial Lung Disease and Indeterminate Pulmonary Nodules: A Report on 65 Cases

Hyun Koo Kim, MD, PhDa, Won-Min Jo, MD, PhDb,*, Jae Ho Jung, MDb, Won Jae Chung, MDb, Jae Hoon Shim, MDa, Young Ho Choi, MD, PhDa, In Sung Lee, MD, PhDb

a Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
b Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University Ansan Hospital, Kyonggi-do, Republic of Korea

Accepted for publication June 2, 2008.

* Address correspondence to Dr Jo, Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University, Gojan-1-dong, Ansan-si, Kyonggi-do, 425-707, Rep of Korea (Email: jowonmin{at}korea.ac.kr).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: We evaluated the feasibility and accuracy of a needlescopic procedure for lung biopsies in patients with interstitial lung disease or indeterminate pulmonary nodules.

Methods: Sixty-five patients (36 women; mean age, 51.3 ± 15.6; range, 13 to 76 years) underwent a needlescopic procedure to obtain lung biopsy specimens. Forty had indeterminate pulmonary nodules, and 25 had interstitial lung disease. A 2-mm needlescope and a 2-mm MiniSite Endo Grasp (Covidien, Norwalk, CT) were inserted at the sixth intercostal space along the middle and the posterior axillary line, respectively. Biopsy specimens were obtained using endostaplers.

Results: The average number of biopsy specimens was 1.7 ± 0.6 (range, 1 to 4). For 9 patients, a frozen specimen was sent twice to pathology. Complete resection was continued after intraoperative pathology confirmation in 13 patients (lobectomy, 7; segmentectomy, 3; mass removal, 1; metastasectomy, 2). The volume of lung tissue was 8.7 ± 11.8 cm3 (range, 0.15 to 55.44 cm3). The operation time was 58.7 ± 37.5 minutes (range, 15 to 160 minutes). The final pathologic results were confirmed in all patients. No thoracoscopic procedure was converted to an open thoracotomy. Three patients (4.3%) had prolonged air leakage (> 5 days), and the chest tube remained in the pleural space for 2.3 ± 2.4 days (range, 1 to 8 days).

Conclusions: Needlescopic operation for lung biopsies in patients with interstitial lung disease and indeterminate pulmonary nodules is a minimally invasive procedure that is safe and effective for obtaining a diagnosis in selected patients.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Although the advances in noninvasive diagnostic imaging such as high-resolution computed tomography (HRCT) [1] and positron emission tomography (PET) [2] have improved the diagnosis of diffuse lung disease and indeterminate pulmonary nodules, a pathologic confirmation by a lung biopsy specimen nevertheless remains essential whenever there is any doubt regarding the diagnosis or prognosis [3]. Noninvasive or minimally invasive diagnostic procedures such as CT-guided biopsy, transbronchial biopsy, or lavage were introduced to provide pathologic confirmation. At times, however, a definitive diagnosis of some lung lesions cannot be made with these procedures; this may be due to inaccessibility of the lesion or an inadequate sample obtained [4, 5].

A surgical open lung biopsy has been considered the gold standard diagnostic modality, generally used as a final option due to its association with substantial morbidity and mortality, even with the advances in surgical techniques and respiratory care [5]. Recently, the frequency of thoracoscopic lung biopsies has increased because it is minimally invasive, results in fewer postoperative complications [6], and reduces the duration of pleural drainage and the length of the hospital stay [7, 8]. Moreover, as thoracoscopic lung biopsy techniques continue to improve, the size of the scope has gradually decreased.

More recently, a 2-mm thoracoscope—a needlescope—and accompanying instruments have been introduced for lung biopsy procedures [9]. Therefore, starting in September 2004, we have performed needlescopic procedures in all patients who have required a lung biopsy. The goal of this study was to evaluate the feasibility and accuracy of a needlescopic procedure for lung biopsies in patients with interstitial lung disease or indeterminate pulmonary nodules.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
A surgical lung biopsy was performed when the pathology report on samples from the preoperative CT-guided or transbronchial biopsy or lavage were inconclusive, or when the pulmonary lesion was inaccessible by CT-guided or transbronchial techniques.

This study was conducted from September 2004 to February 2007 at the Ansan and Guro Hospitals, Korea University Medical Center. The Ethics Committee of the Korea University Medical Center approved this retrospective study and waived the need for patient consent.

Among 98 patients who underwent lung biopsy, 25 patients with pleural adhesions were not suitable for the needlescope procedure, and 8 patients who were not candidates for single-lung ventilation during the procedure were also excluded. Finally, 65 patients with interstitial lung disease or indeterminate pulmonary nodules underwent the needlescopic procedure for lung biopsies to obtain a tissue diagnosis.

A CT-guided hookwire localization was performed just before the procedure when both the radiologists and surgeons thought it might be difficult to find the target lesion by thoracoscopy alone, in the patients with indeterminate pulmonary nodules (Fig 1).


Figure 1
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  		Fig 1. Intraoperative needlescopic image of a wedge resection of a pulmonary nodule that was preoperatively marked by hookwire positioning (arrow).

 
Two surgeons, 1 at each hospital, performed the operations using the same procedure protocol. The medical records of these patients were retrospectively reviewed. After single-lung ventilation was initiated under general anesthesia, the patient was placed in a full lateral position. Initially, a 2-mm needlescope (Hopkins II Forward Oblique-Telescope0°, Karl-Storz GmbH & Co, Tuttlingen, Germany) was introduced into the thoracic cavity through an 11.5-mm port at the fifth or sixth intercostal space along the anterior axillary line to determine whether any dense adhesions were present and to find the location of the target lesion. If there were dense adhesions in the thoracic cavity, the needlescopic procedure was abandoned.

In the patients in whom the needlescopic procedure was continued, a 2-mm needlescopic port at the fifth or sixth intercostal space along the midaxillary line and another 2-mm port for the MiniSite Endo Grasp (Covidien, Norwalk, CT) at the fifth or sixth intercostal space along the posterior axillary line, were made (Fig 2, 3). Go When there were loose or moderate pleural adhesions, or it was difficult to identify the target lesion, a 5-mm thoracoscope was used that provided better vision, which was introduced through an 11.5-mm port.


Figure 2
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  		Fig 2. The image of typical instruments used in needlescopic lung biopsy. (A) The MiniSite Endo Grasp (Covidien, Norwalk, CT). (B) The syringe-suction and irrigation (MiniSite, Covidien). (C) The 2-mm thoracoscope, needlescope, Hopkins II Forward Oblique-Telescope 0° (Karl-Storz GmbH & Co, Tuttlingen, Germany).

 

Figure 3
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  		Fig 3. Typical positioning of needlescopic instrument for lung biopsy.

 
The pleural adhesions were dissected, and the exact location of the target lesions was determined with a 2-mm MiniSite Endo Grasp or MiniSite MiniShears (Auto Suture/USSC, Norwalk, CT) through two 2-mm ports. In addition, when the intraoperative pathology report on the frozen biopsy was inconclusive, a 5-mm thoracoscope was used to look for a second biopsy site. The site and the number of lung biopsy specimens were determined by the findings of the chest roentgenograms or the CT scans.

A biopsy specimen was obtained using 1 or 2 endostaplers, through the 11.5-mm port, for securing the pulmonary margins. The entire nodule was removed, leaving a 2 cm- resection margin, especially when the pulmonary nodule was suspected to be malignant. The resected specimen was removed through the 11.5-mm port. The specimens were sent to pathology for freezing and sectioning. After confirming that there was no hemorrhage from the stapler line, the surgeon performed an air leakage test under a pressure load of 20 cm H2O.

In all cases the operation continued until there was a pathology diagnosis on the frozen biopsy specimen. When an immediate pathology result of the frozen section was not assured, another biopsy was obtained at other sites including the lung, lymph nodes, and pleura, until there was a specific diagnosis on the frozen section. Depending on the pathology results from the frozen biopsy, further procedures such as lobectomy or segmentectomy were performed, if necessary, through a standard or limited (10-cm sized) posterolateral thoracotomy. Upon completion of the operation, a drain was inserted in the 11.5-mm port. The holes for the 2-mm port were closed with surgical tape only (Fig 4).


Figure 4
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  		Fig 4. The 2-mm port site wounds at 1 week postoperatively are barely visible. Arrows indicate the wounds of the 2-mm miniport sites.

 
The clinical data evaluated included patient demographic data, adequacy of the biopsy, pathology diagnosis, number of biopsy specimens, operation time, duration of chest tube drainage, and operative morbidity and mortality. Statistical analysis was performed using SPSS 10.0 software (SPSS Inc, Chicago, IL). Values of p < 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The study population consisted of 29 men and 36 women who were a mean age of 51.3 ± 15.6 years (range, 13 to 76 years) at the time of the procedure. There were 25 patients with interstitial lung disease and 40 with indeterminate pulmonary nodules; among these, 13 patients underwent preoperative CT-guided hookwire procedures for marking the location of the lesion. A total of 100 lung specimens were obtained, and the average number of biopsy specimens was 1.7 ± 0.6 (range, 1 to 4). Frozen specimens for 9 patients were sent twice to pathology because the pathology reports were not conclusive (3 patients with interstitial lung disease) or because the resection margin was not free of pathology (3 patients with indeterminate pulmonary nodules, 3 with preoperative marked pulmonary nodules). The average number of frozen specimen was 1.1 ± 0.3 (range, 1 to 2).

The biopsy specimen was more frequently taken from the left lung (left, 54%; right, 46%), and both lower lobes were more frequently involved (left lower lobe, 34%; right lower lobe, 27%; Table 1). During the lung biopsy, 5 hilar or mediastinal lymph nodes and 3 parietal pleura specimens were also taken for pathology confirmation.


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  		Table 1 Distribution of Biopsy Sites
 
Among 13 patients, subsequent complete resection was continued after intraoperative pathology confirmation (lobectomy, 7 patients; segmentectomy, 3; mass removal, 1; metastasectomy, 2). The mean volume of the lung biopsy tissue was 87.7 ± 220.5 cm3 (range, 0.15 to 1065.90 cm3). With the exception of 13 patients who underwent complete resection after the biopsy, the volume of lung tissue was 8.7 ± 11.8 cm3 (range, 0.15 to 55.44 cm3). The operation time was 105.0 ± 86.2 minutes (range, 15 to 338 minutes). With the exception of 9 patients who required frozen biopsy specimens twice and the 13 patients who underwent complete resection, the operation time for 43 patients was 58.7 ± 37.5 minutes (range, 15 to 160 minutes). The pathology was definitively diagnosed in all patients (Table 2).


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  		Table 2 Diagnosis of the Lung Biopsy Pathology and Further Procedures
 
No thoracoscopic procedures were converted to an open thoracotomy. The chest tube drain could be removed at an average of 4.4 ± 3.2 days (range, 0 to 17 days) postoperatively. Excluding the 13 patients who underwent complete resection, the chest tube remained in the pleural cavity for an average of 2.3 ± 2.4 days (range, 1 to 8 days).

There were no surgical deaths related directly to the procedure. Three patients (4.3%) had surgical complications, including prolonged air leakage (> 5 days). However, the chest tubes of these patients were successfully removed on postoperative day 8, after talcum pleurodesis was performed. All patients, except one, survived to be discharged from the hospital. The patient who died, 29 days after surgery, had complications of respiratory failure, with the underlying diagnosis of idiopathic interstitial pneumonia.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The introduction of video technology to surgical interventions has widened the indications for thoracoscopic operations, and the indications are continuously expanding. Currently, most surgeons consider this procedure as an ideal approach to lung wedge resections for diffuse pulmonary disease and indeterminate pulmonary nodules [10, 11]. Video-assisted thoracoscopic surgery (VATS) provides good visual inspection of the entire pleural cavity and a greater selection of biopsy sites. In addition, the VATS lung biopsy reduces postoperative pain and disability, causes fewer operative scars, and is equally effective in obtaining a histologic diagnosis compared with open procedures [7, 12]. Therefore, VATS is considered the procedure of choice for surgical lung biopsies [13].

However, a randomized trial of thoracoscopic or limited thoracotomy for diagnostic lung biopsies in patients with interstitial lung disease showed no difference in postoperative pain, narcotic drug requirements, operating room time, adequacy of biopsy specimen, duration of chest tube drainage, length of hospital stay, spirometry testing, or complications [14]. Nonetheless, it is clear that the thoracoscopic procedure is less invasive and causes a smaller scar compared with a thoracotomy.

The needlescopic procedure, which uses instruments with a diameter of less than 3 mm, has been used mainly in patients requiring a cholecystectomy [15] and sporadically in urologic operations [16]. For thoracic procedures, it has been used for diagnostic thoracoscopy [17], laser ablation, or thoracic sympathectomy for palmar hyperhidrosis [18]. More recently, this technique has been applied to lung biopsy procedures for diffuse pulmonary disease [19] and bullectomy for patients with a spontaneous pneumothorax [20, 21].

We previously reported that there was no significant difference in the operation time, duration of indwelling chest tube, and pain according to the size of the thoracoscope [22]. The 11.5-mm wound for the chest tube was likely the major cause of postoperative discomfort, even with downsizing of the other 2 ports. Recently in selected patients, we have inserted a 7F catheter (ARROWgard Blue, Arrow International Inc, Reading, PA) in a 2-mm port as a drain instead of chest tube, with no specific problems during the operation. This resulted in reduced pain, and the catheter could be removed soon after, confirming that no pleural effusion or pneumothorax was present on the postoperative chest roentgenogram. It is clear that the needlescopic procedure leaves minimal scarring. In addition, it could reduce the need for postoperative analgesia and allow more rapid recovery by developing operative techniques in selected cases.

The indications for the needlescopic procedure to obtain a lung biopsy specimen are basically the same as for 5-mm or 10-mm thoracoscopic lung biopsies. The CT-guided or transbronchial biopsy cannot be replaced by the needlescopic lung biopsy, no matter how minimally invasive it is, because it requires general anesthesia. The needlescopic lung biopsy does have the clear advantage of minimal scarring and might reduce the need for postoperative analgesia as well as allow for a more rapid recovery. Compared with the conventional thoracoscopic instruments, however, the needlescopic instruments have some limitations: they do not have curved forceps for dissection, the grasping forceps have limited ability to manipulate the internal organs, some difficulty exists with fine motor control, suction and irrigation are insufficient, less light is cast on the surgical field, the viewing angle is smaller, and imaging is poor [21].

When it was not possible to grasp the target lesion with a 2-mm endograsper due to severe pulmonary fibrosis, the 2-mm port was replaced by a 5-mm port for a 5-mm endograsper. However, the 2-mm thoracoscope could still be used and did not need to be changed to a 5-mm thoracoscope. In patients in whom suction and irrigation was needed, the syringe-suction and irrigation (Auto Suture/Covidien, Norwalk, CT) was adequate for control. Better images may be acquired with better use of the 5-mm thoracoscope in the 11.5-mm port and the two 2-mm MiniSite Endo Graspers; improved use of these instruments can help resolve problems with finding target lesions or pleural adhesions. The contraindications for the needlescopic procedure for lung biopsy were therefore basically the same as for 5-mm or 10-mm thorascopic lung biopsy procedures.

The needlescopic operation for biopsy of interstitial lung disease can be relatively easily performed after careful evaluation of preoperative imaging studies. The findings of this study showed that the volume and number of specimens obtained were sufficient to confirm the diagnosis of the pathology. In all 25 patients with interstitial lung disease, a specific diagnosis could not be confirmed by the chest CT-guided biopsy, transbronchial biopsy, or lavage. For 16 patients (64%), a specific diagnosis could only be made after the needlescopic lung biopsy. Autoimmune disease and infection were among the most common specific diseases in these patients. These findings are consistent with prior reports [5, 13, 23–25].

A change in therapy was required in 6 of 25 patients (24%); this is lower than reported in another study [5]. The pathology from the preoperative CT-guided or transbronchial biopsy aided in patient management even though the diagnosis was not confirmed by these procedures.

In patients who require biopsy of a pulmonary nodule, the needlescopic surgical procedure is not easy to perform. The nodule size and distance from the pleural surface are reported to be important variables for successful identification of the lesion at thoracoscopy [26]. Instrumental palpation has been effective when the nodule was superficial or its size exceeded 20 mm and the lung was adequately deflated [27]. However, there can be difficulty with nodules sized less than 10 mm or at a distance of between 15 and 25 mm from the pleural surface [28]. In the present study, the preoperative CT-guided hookwire marking was done when the size of the pulmonary nodule was less than 10 mm or the distance from the lung surface was more than 15 mm, or when both the radiologists and the surgeons decided that it might be difficult to find the target lesion.

This procedure can be safely performed preoperatively by a radiologist; it requires a short time [28] and gives exact information about the site of the nodule. This approach aides the feasibility and accuracy of needlescopic operation for lung biopsies. For all cases, we waited for the frozen biopsy report for about 30 minutes in the operating room; therefore, the real operation time was about 30 minutes, which was relatively short. Furthermore, our diagnostic confidence for the pathology of the interstitial lung disease and pulmonary nodules was 100%.

In addition, biopsy of the parietal pleura and hilar or mediastinal lymph nodes were performed without any difficulty. Moreover, when subsequent procedures such as lobectomy or segmentectomy were necessary, the thoracotomy incision could be placed at any level without concern for the 2-mm port site; the 2-mm port incision was too small to leave a scar later.

In conclusion, the needlescopic surgical technique for lung biopsies is much less invasive compared with more conventional procedures and is technically feasible and safe. It also provides an accurate pathology diagnosis for patients with interstitial lung disease and indeterminate pulmonary nodules.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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Ann. Thorac. Surg., October 1, 2008; 86(4): 1103 - 1103.
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