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Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Fluoroscopically Invisible Solitary Pulmonary Nodules^*

A Prospective Trial

^* From the Department of Pulmonology and Critical Care Medicine (Drs. Herth, Eberhardt, and Becker), Thoraxklinik Heidelberg, Heidelberg, Germany; and Interventional Pulmonology (Dr. Ernst), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Correspondence to: Armin Ernst, MD, FCCP, Director, Interventional Pulmonology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; e-mail: aernst{at}bidmc.harvard.edu

Abstract

Study objectives: Transbronchial biopsy (TBBX) for solitary pulmonary nodules (SPNs) is usually performed under fluoroscopic guidance, but the diagnostic yield depends on lesion size and varies widely. Nodules < 3 cm frequently cannot be visualized fluoroscopically. An alternative guidance technique, endobronchial ultrasound (EBUS), also allows visualization of pulmonary nodules. This study assessed the diagnostic yield of EBUS-guided TBBX in fluoroscopically invisible SPNs.

Design: The study was a prospective trial using a crossover design.

Patients and methods: All patients with SPNs and indications for bronchoscopy were included in the study. An EBUS-guided examination was performed in patients with fluoroscopically invisible nodules. The EBUS probe was introduced through a guide catheter into the presumed segment. If a typical ultrasonic picture of solid tissue could be seen, the probe was removed and the catheter left in place. The biopsy forceps were introduced and specimens taken.

Results: One hundred thirty-eight consecutive patients with SPNs were examined. Of those, 54 patients presented with SPNs that could not be visualized with fluoroscopy. The mean diameter of the nodules was 2.2 cm. In 48 patients (89%), the lesion was localized with EBUS, and in 38 patients (70%) the biopsy established the diagnosis. The 16 patients with undiagnosed SPNs were referred for surgical biopsy; 10 of those lesions were malignant and 6 were benign. The diagnosis in nine patients (17%) saved the patients from having to undergo a surgical procedure. The only complication was a pneumothorax in one patient.

Conclusions: EBUS-guided TBBX is a safe and very effective method for SPNs that cannot be visualized by fluoroscopy. The procedure may increase the yield of endoscopic biopsy in patients with these nodules and avert the need for surgical procedures.

Key Words: bronchoscopy • endobronchial ultrasound • lung cancer • solitary pulmonary nodules • transbronchial lung biopsy

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