Surgical Lung Biopsy for Diffuse Lung Disease

When I started training I found out that some patients that had lung biopsy for diffuse lung disease had a complicated postoperative course and there was even some mortality associated with the procedure. The ATS/ERS guidelines recommend doing surgical lung biopsy when the clinical picture and high resolution CT scan are not characteristic of idiopathic pulmonary fibrosis. I wondered how useful was the lung biopsy affecting treatment, prognosis and survival. To answer some of these questions, we did a retrospective revision of the surgical lung biopsies we did at my Institution and try to figure out how many times we found results that changed the treatment of the patient or improve outcome. As a significant part of the practice at my Institution is transplant surgery, among these patients there was a significant number with transplants. We thought it was going to be interesting to compare patients with and without transplants having diffuse lung disease that had lung biopsies. As it is usual to find weird causes of diffuse lung disease in transplant patients, we expected to find out that lung biopsies were very useful in this group. We presented our work at the STS annual meeting and latter published in the Annals of Thoracic Surgery. We found among 60 patients that lung biopsy affected the treatment in 33 of them, and to our surprise we found no significant differences between the ones that had transplant and those without transplants.

We found that patients on the ventilator at the time of the biopsy and especially if transplant had an important in-hospital mortality. The probability of affecting the treatment was higher when biopsing a lung with nodules. Biopsing a consolidation was associated with increased mortality. On multivariate analysis, being on the vent, having a solid organ transplant and a diagnosis of cancer from the biopsy were associated with mortality.

Diffuse lung disease requiring surgical lung biopsy for diagnosis is a very serious condition just by itself. I try to make sure that all other less invasive methods of having lung tissue for diagnosis have been tried (bronchoscopy), before taking a patient to the OR for surgical lung biopsy. However, there are times that the patient is deteriorating fast and there is no time for multiple procedures; in this situation, the procedure that you believe will give you the best chance of finding out what going on is the one that should be done first. This method is a surgical biopsy most of the times. It should always be clear about what are the possibilities of finding something useful in the lung biopsy. This is especially true when taking with the patient and family. Despite surgery is probably the most accurate method, many times is not useful for affecting treatment (in our experience change treatment 30% of the times) and has a considerable risk of complications and even mortality, especially in the sicker patients.

It’d be great to hear your thoughts,