Lung Biopsy

The discovery of a lung nodule, mass, or other abnormality on a chest X-ray or CT scan can raise important questions about its cause and whether further evaluation is necessary. While many lung nodules are benign, others may represent an early lung cancer or another pulmonary disorder. When imaging alone cannot establish a definitive diagnosis, a lung biopsy may be recommended to obtain tissue for microscopic and molecular evaluation.

At the Institute for Thoracic Surgery in Miami, Florida, Mark R. Dylewski, M.D., provides specialized evaluation and minimally invasive surgical approaches for patients requiring tissue diagnosis of pulmonary abnormalities. The appropriate biopsy technique is determined by the location, size, appearance, and accessibility of the abnormality, as well as the patient's overall health and the information required to guide treatment.

 

When Is a Lung Biopsy Necessary?

Not every lung nodule requires a biopsy. Some abnormalities can be safely monitored with interval imaging when their appearance and clinical circumstances suggest a low likelihood of malignancy. A biopsy may become appropriate when a nodule or mass:

• Has imaging characteristics concerning for malignancy
• Demonstrates growth or changes over time
• Is large or sufficiently suspicious to require definitive diagnosis
• Has an uncertain diagnosis that would change treatment
• Requires tissue for specialized pathologic or molecular testing
• Cannot be adequately characterized through imaging alone

The decision to biopsy is based on the patient's individual risk factors, imaging findings, previous medical history, and the potential impact of a tissue diagnosis on treatment.

Different Approaches to Lung Biopsy

There is no single biopsy technique that is appropriate for every pulmonary lesion. Depending on the location and characteristics of the abnormality, tissue may be obtained using several different approaches.

CT-Guided Needle Biopsy

A CT-guided percutaneous biopsy uses real-time or sequential CT imaging to guide a needle through the chest wall directly into a pulmonary nodule or mass. This technique can be particularly useful for lesions located near the outer portion of the lung.

Bronchoscopic Biopsy

A bronchoscopic biopsy is performed by advancing a flexible or specialized bronchoscope through the airways to reach an abnormality. Advanced bronchoscopic techniques, including navigational and robotic-assisted bronchoscopy, may allow physicians to access selected peripheral pulmonary nodules that are difficult to reach with conventional bronchoscopy.

Surgical Lung Biopsy

When a lesion cannot be safely or reliably diagnosed with a needle or bronchoscopic approach—or when definitive surgical removal is appropriate—a surgical biopsy may be recommended.

Surgical biopsy is commonly performed using video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracic surgery through small incisions. In selected circumstances, the abnormality can be removed completely during the same procedure, providing both a definitive diagnosis and definitive treatment.

Choosing the Right Biopsy Strategy

The choice of biopsy technique requires careful consideration of the patient's imaging studies and the characteristics of the lesion. Important factors include its size, location within the lung, relationship to blood vessels and airways, accessibility, and the likelihood that the procedure will provide sufficient tissue for diagnosis.

At the Institute for Thoracic Surgery, Dr. Dylewski works in coordination with pulmonology, radiology, pathology, and oncology specialists when appropriate to determine the most appropriate diagnostic strategy for each patient.

When a pulmonary lesion is highly suspicious for cancer and technically suitable for removal, surgical biopsy may offer an additional advantage: the lesion can sometimes be completely removed at the time the diagnosis is established, potentially avoiding the need for a separate procedure.

Minimally Invasive Surgical Biopsy

When surgical biopsy is indicated, our practice emphasizes minimally invasive techniques whenever they can be safely performed. VATS and robotic-assisted approaches allow the surgeon to access the chest through small incisions rather than a traditional open thoracotomy.

Robotic-assisted surgery provides three-dimensional visualization, magnification, and articulated instruments that can facilitate precise dissection and removal of selected pulmonary lesions.

The objective is not simply to obtain a tissue sample. Our goal is to establish an accurate diagnosis using the least invasive approach appropriate for the individual patient—and, when appropriate, to proceed directly from diagnosis to definitive treatment.

Robotic-Assisted Bronchoscopy for Lung Nodules

Advances in bronchoscopic technology have created new options for diagnosing lung nodules that previously could be difficult to reach without a needle biopsy or surgical procedure. Robotic-assisted bronchoscopy uses computer-assisted navigation and highly maneuverable bronchoscopic instruments to guide the physician through the natural airway passages deep into the lung, allowing tissue to be obtained from selected peripheral pulmonary nodules through the airways.

At the Institute for Thoracic Surgery, robotic-assisted bronchoscopy represents an important addition to the minimally invasive evaluation of suspicious lung nodules. The Ion™ Endoluminal System and MONARCH™ Platform are two advanced robotic bronchoscopy technologies designed to facilitate access to peripheral lung lesions. Both systems allow physicians to navigate beyond the reach of conventional bronchoscopes and obtain tissue samples while avoiding an incision through the chest wall.

Ion Robotic Bronchoscopy

The Ion system, developed by Intuitive, uses an ultra-thin, flexible catheter that can navigate the branching airways of the lung. Pre-procedure CT imaging is used to create a three-dimensional map of the airways and plan a pathway toward the target lesion. The system incorporates shape-sensing technology to help the physician maintain precise control and stability as the catheter advances toward small, peripheral nodules.

Ion is particularly useful when a suspicious nodule is small, located toward the outer portions of the lung, or positioned in an area that may be difficult to reach with conventional bronchoscopy. Once the catheter reaches the target, multiple tissue samples can be obtained for pathologic and, when appropriate, molecular testing.

MONARCH Robotic Bronchoscopy

The MONARCH Platform, developed by Johnson & Johnson MedTech, is another advanced robotic-assisted bronchoscopy system designed to provide access to peripheral pulmonary lesions. Its flexible, articulating bronchoscope and sheath allow the physician to navigate through progressively smaller airways while maintaining visualization during the procedure.

The platform incorporates advanced navigation and imaging capabilities to assist with localization of peripheral lung nodules. The recently introduced MONARCH QUEST 3 software includes updated 3D modeling and navigation capabilities designed to improve targeting and account for changes between the preoperative CT scan and the patient's anatomy during the procedure.

Who May Be a Candidate?

Robotic-assisted bronchoscopy is generally considered when a patient has a pulmonary nodule or mass that requires tissue diagnosis and the lesion can reasonably be accessed through the bronchial tree.

Patients who may benefit include those with:

• A suspicious pulmonary nodule identified on CT or other imaging
• A small or peripheral lesion that is difficult to reach with conventional bronchoscopy
• A lesion for which obtaining tissue is important before determining treatment
• Multiple or bilateral nodules requiring careful diagnostic evaluation
• A need for tissue for molecular or biomarker testing when cancer is suspected
• A clinical situation in which a bronchoscopic approach may be preferable to a percutaneous needle biopsy or surgical biopsy

Patient selection is individualized. The location, size, shape, and appearance of the nodule; its relationship to the airways; the presence of a bronchus sign; prior imaging; PET findings when available; pulmonary function; and the patient's overall medical condition all influence whether robotic bronchoscopy is appropriate.

Importantly, not every lung nodule requires a biopsy. Some nodules can appropriately be monitored with serial imaging, while others may be better evaluated with CT-guided needle biopsy or surgical biopsy. The appropriate approach depends on the clinical and radiographic characteristics of the individual lesion.

What Are the Advantages?

Robotic-assisted bronchoscopy is designed to improve the physician's ability to reach and stabilize within the smaller airways of the peripheral lung. Contemporary studies have demonstrated the ability to localize and biopsy many small peripheral lesions, with generally favorable safety profiles. For example, the prospective multicenter TARGET study of the MONARCH platform included 679 patients and reported successful lesion localization in more than 98% of cases.

The potential advantages of a bronchoscopic approach include:

• Access to peripheral lung nodules through the natural airways
• No incision through the chest wall
• Ability to obtain multiple tissue samples
• Potentially lower pneumothorax risk than a transthoracic needle approach
• The opportunity to combine diagnosis with additional bronchoscopic procedures when appropriate
• Tissue acquisition that may permit molecular and biomarker testing when lung cancer is suspected

Robotic bronchoscopy does, however, carry potential risks, including bleeding, infection, low oxygen levels, and pneumothorax. A small number of patients may also have a nondiagnostic procedure and require another method of obtaining tissue.

Robotic Bronchoscopy as Part of a Comprehensive Lung Nodule Program

The decision to perform robotic bronchoscopy should be based on the entire clinical picture rather than the technology alone. At the Institute for Thoracic Surgery, evaluation of a lung nodule may incorporate CT imaging, PET imaging when appropriate, pulmonary evaluation, bronchoscopic assessment, and multidisciplinary review.

For selected patients, robotic-assisted bronchoscopy can provide a minimally invasive pathway to diagnosis. If the biopsy demonstrates lung cancer, the results can then be integrated with staging studies, molecular testing, and the patient's overall health to determine the most appropriate treatment strategy.

Our goal is to obtain an accurate diagnosis using the least invasive approach appropriate for each patient, while ensuring that the diagnostic process leads efficiently to definitive treatment when treatment is required.

If you have been referred for evaluation of a lung nodule or mass, a comprehensive review of your imaging and medical history can help determine whether observation, bronchoscopic biopsy, needle biopsy, or minimally invasive surgical biopsy is the most appropriate next step.