how to do a lung biopsy JF

Make sure patient consented not just for biopsy but for possible chest tube insertion

review prior imaging, think about supine vs. prone, vs. lateral decubitis etc

when the patient on the table, CALL CYTO** 

loc the nodule on CT

place straws on patient

scan again, decide which straw to mark and what cross section

start the approach the usu fashion

prep, drape, numb superficial and deep

make sure you think about R and L and how the CT image may be flipped relative to your angle of view of the patient (R of image of may not be your right side)

make skin nick

advance starting with a coaxial 18 gauge biopsy needle (francine tip i beleive)

this part may be difficult, working through ribs and through the window, decide where to access the lesion (periphery, the meat of it, etc)

once you have accessed the lesion, use the 21 gauge 15 cm needle (percucut) through the 18 gauge

use the depth marker- JF likes to put around 12.5 cm, so needle is just past 18 gauge access needle

insert needle, attach syringe, use the suction lock or apply continuous suction yourself.  if your aspirating air, you are not within the lesion

when have bloody aspirate, take the entire system (needle and syringe) hand to cytotech

if aspirates are not fruitful, look at imaging again, consider mild angulation of access needle cranial, caudal, medial, lateral to obtain more sample

usually 3-4 FNA are desired

obtain final 18 gauge FNA on way out

scan full lungs to exclude PTX

apply sterile dressing

dc patient to OPHA.  

If no PTX- dc in 1.5 hours

if decent size PTX to follow:  start with CXR either stat and T+2hrs or just T+2hrs

 

AM Technique:

use Temno Evolution 18 gauge sidecut needle

document tissue within sidenotch of device prior to obtaining core biopsy

produces a robust 18 gauge by 10 cm core in a safe (relative to biopince) system

 

Special Considerations:

Lower lobe biopsies:  lung will move a lot with breathing.  Want to develop consistent system for biopsy.  

Have patient take small breath in and out and then hold it.  Have patient repeat this during instrumentation and prior to intraprocedural CT imaging

Addt'l tip  have to ensure patient does not move from time marking patient to performing biopsy

be cognizant of artifcats obscuring view of needle tip during needle placement scans

 

Good paper:

needles we use

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Bone Marrow Biopsy

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Guthrie style

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use 11G green needle- coaxial system

the path of entry is the long axis of the iliac bones at level of SI joint, on CT

do prelim scan

mark spot

prep, drape

numb to bone- periosteum

advance needle to bone

then dig into bone, 1-2 cm 

check on CT
remove stylet

aspirate blood and marrow

then take 2 cm core by spinning

spin on the way out

hold pressure and done

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US Guided Targeted Liver Bx:
can be very challenging

good spots are L lobe subxiphoid

or under R ribcage

be very careful to sample appropriately- have had negative biopsies even though imaging appears that needle skewered the lesion

think about getting a safe biopsy from a small lesion vs. getting a slightly less safe biopsy from an area of definitive tumoral involvement- dont want to repeat biopsy because did not sample the lesion accurately

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FOR ADRENAL BIOPSY:
Need to rule out pheochromocytoma first

if biopsy Pheo can result in hypertensive crisis

exclude pheo clinically first

make sure adequate workup prior to performing adrenal biopsy

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