|Year : 2020 | Volume
| Issue : 2 | Page : 34-37
Nonimage-guided tru-cut biopsy of lung masses in adult Nigerians in a limited-resource setting
Kelechi E Okonta1, Sandra N Ofori2, Chukwuemeka C Agugua1, Paula Osademe3
1 Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Department of Internal Medicine, Cardiology Unit, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
3 Department of Anatomical Pathology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||28-Jan-2021|
|Date of Decision||09-May-2021|
|Date of Acceptance||04-Jul-2021|
|Date of Web Publication||29-Jan-2022|
Dr. Kelechi E Okonta
Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Background: Image-guided tru-cut lung biopsy is a surgical procedure done to obtain a sample of lung tissue for histological analysis or for other analyses. However, when image-guided facilities are not readily available, a nonimage-guided lung biopsy may be desirable. Methods: This was a prospective case series of all patients seen in the cardiothoracic surgery unit of a teaching hospital for a 2-year period with clinical and radiologic features suspicious of a malignancy or other lung pathologies, and with evidence of advanced disease. The biodata, clinical features, volume of the specimen, the presence or absence of contaminants or complications, and the histological diagnosis were also collected and descriptively studied. Results: Baseline characteristics – Sixteen patients were seen with a mean age of 49.4 ± 13.7 years (28–67 years). There were 11 (68.8%) females in the sample. With regards to presenting symptoms: 14 patients had predominantly cough, 8 had predominantly dyspnea, and 5 had a combination of various other symptoms. Seven patients (43.8%) had pleural effusion which was drained before the biopsy. Biopsy results – The mean volume of the samples obtained was 1.72 ± 3.8 cm3 (0.02–15.00 cm3). The biopsy sample was contaminated by skeletal muscles in two patients (12.5%). Eleven (68.8%) samples were malignant whereas five (31.2%) were nonmalignant pathologies. There were no major complications such as subcutaneous emphysema or pneumothorax or hemothorax recorded after the procedure in any of the patients. Conclusion: It is possible to do a nonimage-guided tru-cut lung biopsy and yet achieved some level of safety, minimal or no complication, and less cost, even in advanced disease with pleural effusion.
Keywords: Lung biopsy, nonimage guided, tru-cut
|How to cite this article:|
Okonta KE, Ofori SN, Agugua CC, Osademe P. Nonimage-guided tru-cut biopsy of lung masses in adult Nigerians in a limited-resource setting. Niger J Cardiovasc Thorac Surg 2020;5:34-7
|How to cite this URL:|
Okonta KE, Ofori SN, Agugua CC, Osademe P. Nonimage-guided tru-cut biopsy of lung masses in adult Nigerians in a limited-resource setting. Niger J Cardiovasc Thorac Surg [serial online] 2020 [cited 2022 Jul 2];5:34-7. Available from: http://www.nigjourcvtsurg.org/text.asp?2020/5/2/34/336859
| Introduction|| |
The prevalence of lung cancer, pulmonary granulomatous lesions, and other lung pathologies is quite common in our environment.,,, Proper management of a patient requires accurate histologic diagnosis. However, getting a sample of the tumour or lesion for histological diagnosis can be challenging, especially in resource-limited settings. These challenges range from the lack of resources for image-guided biopsies to the limited availability of the expertise needed to carry out these procedures., And even when the facility for imaging is available, many patients cannot afford to pay for the services as payment is mainly out-of-pocket payment for which many of the patients do not have the means to sustain it. Needle biopsy, open biopsy, transbronchial biopsy, thoracoscopic biopsy, and mediastinoscopy biopsy are some of the methods that could be used to obtain tissue for histologic examination. The method to be used depends on the safety, invasiveness, cost of the staging, and the probability of obtaining a representative tissue sample.,, Image-guided (ultrasound or computed tomography scan) lung biopsy with the tru-cut needle is considered the gold standard method. However, where there are no facilities for image-guided biopsies or where accessibility is a challenge, lung biopsy can be done with image guidance. This will entail that the expert will have a sound knowledge of the anatomy of the lungs and the position of vital structures within the chest.
In this paper, we present a case series of nonimage-guided tru-cut biopsies.
| Methods|| |
This was a prospective case series of consecutive patients seen in the cardiothoracic unit of a teaching hospital in Nigeria over a 2-year period (August 2018–July 2020) who presented with symptoms and radiologic findings suspicious of a malignancy or granulomatous lesion in the lungs. All patients gave informed consent and had tru-cut needle biopsy to obtain tissue for histology. Data on age, sex, presenting symptoms, and the presence of pleural effusion were collected as baseline. Following the lung biopsy, data on the volume of the specimen, the presence or absence of contaminants, complications, and the histological diagnoses were also collected [Table 1]. Plain chest radiographs were done for all the patients after the biopsy to rule out some common complications with this procedure such as subcutaneous emphysema or pneumothorax or hemothorax. None of the patients developed any of these complications.
Details of the procedure
- Syringes (2 ml and 10 ml sizes)
- 2% xylocaine10 ml
- Size 11 blade
- Mosquito artery forceps
- Size 18 FG tru-cut needle (®Medplus Inc.).
Description of a typical procedure undertaken on patients in this series
Where patients had a lung tumor with pleural effusion, the effusion was first drained through closed tube thoracostomy. And thereafter, pleurodesis was done for malignant effusion only. We could not perform the tru-cut biopsies in real-time as there was no dedicated fluoroscopy unit in our hospital. Therefore, the films of the chest radiograph or chest computerized tomography scans were carefully studied, and the area, size, and position of the lesion or tumor were marked before the procedure. The area of the lung habouring the tumour as noted by the chest radiology will be delineated with respect to the intercostal space or spaces,the zone of the affected lung with regard to upper, middle, or lower lung zone; the side of the chest with regards to anterior, lateral or posterior, the possible vital structures around it. The biopsies were performed in the theatre, with the film mounted on a viewing board in direct vision of the Surgeon to enable Surgeon to make repeated assessments of the lesion in other to facilitate getting a representative tissue sample. During the procedure, the patient was comfortably positioned in a sitting position or slightly inclined angle of 30°–45°. The area of interest was cleaned in succession with Savlon and povidone-iodine. A weal was raised over the desirable intercostal space with a size 2-ml syringe and subsequently replaced with a 10-ml syringe, deepened to the intercostal muscle, periosteum, and the parietal pleura. With the size 11 blade mounted on Bard-Parker handle, a stab incision was made over the intercostal space [Figure 1]. The incision was subsequently deepened into the pleural space using mosquito forceps to carefully tease off tissues so as to avoid intervening tissue like muscle on the way when applying the tru-cut needle [Figure 2]. The biopsy gun was charged and advanced in depth according to the estimation from the chest radiology and/or the chest computerized tomography [Figure 3]. Multiple biopsies of 5 or 6 bits are then taken and immediately put in a formalin. Thereafter, firm dressing was applied over the incision [Figure 4].
| Results|| |
Sixteen patients were seen with a mean age of 49.4 ± 13.7 years (28–67 years). There were 11 (68.8%) females in the sample. With regard to presenting symptoms, 14 patients had predominantly cough, 8 had predominantly dyspnea, and 5 had a combination of weight loss, chest pain, and hemoptysis. Seven patients (43.8%) had pleural effusion which was drained before biopsy.
| Biopsy results|| |
The mean volume of the samples obtained was 1.72 ± 3.8 cm3 (0.02–15.00 cm3). The lung biopsy sample was contaminated with skeletal muscles in two patients (12.5%). Eleven (68.8%) samples were malignant whereas five (31.2%) were nonmalignant pathologies. The histologic diagnoses were adenocarcinoma with different variants in 9 patients, metastatic carcinoma in 1 patient, non-Hodgkin's lymphoma in 1 patient, chronic granulomatous disease in 2 patients (which were confirmed cases of pulmonary tuberculosis), chronic interstitial lung disease in 2 patients, and chronic bronchitis in 1 patient. There was no complication following the lung biopsies.
| Discussion|| |
In lung lesions, it is important to establish a histological diagnosis, as this may guide subsequent treatment strategies. Percutaneous biopsy is one method used to obtain tissue for histological diagnosis. Image-guided percutaneous biopsy is recommended in other to increase the chances of obtaining a representative tissue sample and reduce the chances of obtaining an insufficient sample and severe complications such as pneumothorax, hemothorax, and hemoptysis.,
In resource-limited settings, image-guided procedures may not be feasible. Thorough knowledge of chest anatomy and surgical expertise are needed to perform blind biopsy procedures. This is made all the more challenging because, in settings like ours, patients tend to present with advanced stages of the disease with complications like pleural effusion. The need to find centres, where image-guided biopsies are available, can delay diagnosis. By the time, this is eventually done, the tumor is staged as unresectable as noted in previous study. Whereas, with skilled operators, nonimage tru-cut biopsies can help to establish the histology earlier and mitigate this issue. The mortality of lung cancer is higher among patients with more advanced diseases, and the best outcomes are seen in early-stage cancers. The aim, therefore, in resource-limited centers should be to make histological diagnosis available as early as possible in the disease process to enhance the patients' chances of survival.
Image-guided bronchoscopy is recommended for pulmonary lesions around 1 cm or less in diameter. However, in our patients, we were able to perform the tru-cut biopsies even for lesions that were about 1 cm in diameter. Although the volume of the tissues obtained ranged between 0.02 and 15.00 cm3, the amount was sufficient for histological analyses.
The nonimage-guided percutaneous tru-cut biopsy is not without limitations. These is the possibility of missing the tumor, a high chance of injury to some vital structures, and air embolism when the lung tissue surrounding the tumour is inadvertently injured. There is also the risk of subcutaneous emphysema or hemothorax or pneumothorax and, if large enough, can result in hemodynamic instability. However, the 16 patients in this series did not have any of the complications listed above and representative samples were biopsied in all the patients. This result may have been achieved because of the experience of the Surgeon who performed all the biopsies and with quality time spent studying the radiological films prior to the biopsies.
| Conclusion|| |
The absence of image guidance should not delay or stop the diagnosis of possible lung malignancy. This is because, with careful evaluation of the patients and the plain chest radiological films, nonimage-guided tru-cut biopsies were done to achieve histological diagnosis in a convenience sample of 16 patients without complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]