CT-Guided Rather Than Thoracoscopic
The authors begin their article with the statement: “For patients with a solitary pulmonary nodule that is suspicious for malignancy (larger than 8–10 mm), surgery should generally be performed to evaluate for malignancy (1, 2). The procedure of choice is the minimally invasive video-assisted thoracoscopic surgery (VATS) for atypical lung parenchymal resection [...]” (1).
These statements must be contradicted. The 2018 German S3 Guideline “Prevention, Diagnosis, Treatment, and Follow-up of Lung Cancer” says on the topic of diagnosis: “For pleural-based tumors, ultrasound-guided techniques can be used for pleural puncture; for non–pleural-based tumors, CT-guided pleural puncture is strongly recommended”.
CT (computed tomography)–guided percutaneous biopsy of pulmonary nodules has shown high rates of success, of more than 90%, even for small nodules of less than 2 cm in diameter (2).
The limitations mentioned for thoracoscopic lung biopsy in the article by Lesser et al. (1), such as the depth of the pulmonary nodule (that is, the distance between nodule and pleura), or diffuse pleural adhesions and complications of postoperative pain due to these, are basically not present in CT-controlled lung biopsy.
The relatively common complication of pneumothorax after CT-guided lung biopsy can usually be treated by simple pleural puncture and aspiration, or by placing small-caliber catheters (6– to 9-French); larger catheters are hardly required (3).
Thus, the indication for thoracoscopic lung biopsy is essentially limited to cases of pulmonary nodules that remain diagnostically unclear even after repeated CT-guided biopsy, as well as to diagnosis of interstitial lung diseases—but even here, it is increasingly being replaced by the non-surgical method of transbronchial cryobiopsy (4).
To sum up, we would again like to cite the S3 Guideline: “In case of suspected lung cancer, a surgical biopsy is recommended only if less invasive methods of tissue sampling were non-diagnostic or could not be performed”.
Dr. med. Gernot Rott
Institut für diagnostische und interventionelle Radiologie
Bethesda-Krankenhaus, Duisburg, Germany
|1.||Lesser T, Doenst T, Lehmann T, Mukdessi J: Lung biopsy without pleural drainage—a randomized study of a commonly performed video-thoracoscopic procedure. Dtsch Arztebl Int 2019; 116: 329–34 VOLLTEXT|
|2.||Andrade JR, Rocha RD, Falsarella PM, et al.: CT-guided percutaneous core needle biopsy of pulmonary nodules smaller than 2 cm: technical aspects and factors influencing accuracy. J Bras Pneumol 2018; 44: 307–14 CrossRef MEDLINE PubMed Central|
|3.||Wu CC, Maher MM, Shepard JA: Complications of CT-guided percutaneous needle biopsy of the chest: prevention and management. Am J Roentgenol 2011; 196: W678–82 CrossRef MEDLINE|
|4.||Iftikhar IH, Alghothani L, Sardi A, Berkowitz D, Musani AI: Transbronchial lung cryobiopsy and video-assisted thoracoscopic lung biopsy in the diagnosis of diffuse parenchymal lung disease. A meta-analysis of diagnostic test accuracy. Ann Am Thorac Soc 2017;14: 1197–211 CrossRef MEDLINE|