A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy

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 ultraso....

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 descriptions from previously published papers^{9,13,17,<....}

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-TTNB^17,23,25. 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

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Ambu BlueSensor R	Ambu	R-00-S/25	ECG patches
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