Pleural Biopsy

(Biopsy-Pleural, Percutaneous Pleural Biopsy)

Procedure overview

What is a pleural biopsy?

A biopsy is a procedure performed to remove tissue or cells from the body for examination under a microscope. A pleural biopsy is a procedure in which a sample of the pleura (the membrane that surrounds the lungs) is removed with a special biopsy needle or during surgery to determine if infection, cancer, or another condition is present.

There are three types of pleural biopsies:

• Needle biopsy. After a local anesthetic is given, the doctor inserts the special biopsy needle into the pleural space (the space between the pleura and the chest wall) to obtain a sample. Ultrasound (high-frequency sound waves) or computed tomography (CT scan, a combination of X-rays and computer technology) may be used to guide the biopsy needle insertion. Most pleural biopsies are performed using this technique. This procedure may also be referred to as a thoracentesis.
• Thoracoscopic biopsy. A special type of endoscope (thin, flexible, lighted tube) is inserted into the pleural space under either local or general anesthesia. Through the endoscope, the doctor is able to visualize the pleural tissue and take a biopsy of any suspicious tissue.
• Open biopsy. After a general anesthetic is given, the doctor makes an incision in the skin and surgically removes a piece of the pleura. Depending on the lab findings, further surgery may be performed.

Other related procedures that may be used to help diagnose lung problems include chest X-ray, chest fluoroscopy, CT scan of the chest, bronchoscopy, bronchography, chest ultrasound, lung biopsy, lung scan, mediastinoscopy, positron emission tomography (PET scan), pulmonary angiogram, pulmonary function tests, and thoracentesis. Please see these procedures for additional information.

Anatomy of the respiratory system

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The respiratory system is made up of the organs involved in the exchange of gases, and consists of the:

• Nose
• Pharynx
• Larynx
• Trachea
• Bronchi
• Lungs

The upper respiratory tract includes the:

• Nose
• Nasal cavity
• Ethmoidal air cells
• Frontal sinuses
• Maxillary sinus
• Larynx
• Trachea

The lower respiratory tract includes the lungs, bronchi, and alveoli.

What are the functions of the lungs?

The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells.

The lungs are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax (the part of the body between the base of the neck and diaphragm).

The lungs are enveloped in a membrane called the pleura.

The lungs are separated from each other by the mediastinum, an area that contains the following:

• The heart and its large vessels
• Trachea (windpipe)
• Esophagus
• Thymus
• Lymph nodes

The right lung has three sections called lobes. The left lung has two lobes. When you breathe, the air enters the body through the nose or the mouth. It then travels down the throat through the larynx (voice box) and trachea (windpipe) and goes into the lungs through tubes called mainstem bronchi.

One mainstem bronchus leads to the right lung and one to the left lung. In the lungs, the mainstem bronchi divide into smaller bronchi and then into even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli.

Reasons for the procedure

Reasons for which a pleural biopsy may be performed include, but are not limited to, the following:

• To evaluate an abnormality of the pleura seen on chest X-ray
• To diagnose the cause of a pleural infection (caused by bacteria, virus, or fungus) or other condition
• To investigate pleural effusion (fluid collection in the pleural space)
• To determine if a pleural mass is malignant (cancerous) or benign
• To obtain further information after pleural fluid analysis suggests the presence of cancer, tuberculosis, or other infection

There may be other reasons for your doctor to recommend a pleural biopsy.

Risks of the procedure

As with any surgical procedure, complications may occur. Possible complications of a pleural biopsy may include, but are not limited to, the following:

• Pneumothorax. Collapse of the lung, causing air to become trapped in the pleural space. 
• Bleeding in the lung
• Infection

Pleural biopsy is contraindicated in certain bleeding conditions.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

• The doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have.
• You will be asked to sign a consent form that gives your permission to do the biopsy. Read the form carefully and ask questions if something is not clear.
• Generally, fasting is not required before the procedure.
• Notify your doctor if you are sensitive to or are allergic to any medication, latex, tape, or anesthetic agents (local and general).
• Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• If you are pregnant or suspect that you may be pregnant, you should notify your doctor.
• You may have a diagnostic procedure, such as a chest X-ray, chest fluoroscopy, ultrasound, or CT scan, performed prior to the procedure to assist the doctor in identifying the specific location on the chest to perform the procedure.
• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A pleural biopsy may be performed on an outpatient basis or a part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, a pleural biopsy follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
2. You will be asked to remove clothing, and will be given a gown to wear.
3. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) may be monitored before and during the procedure.
4. You may receive supplemental oxygen as needed, through a face mask or nasal cannula (tube).
5. You will be placed in a sitting position with your arms raised and resting on an overbed table. This position aids in spreading out the spaces between the ribs for needle insertion. If you are unable to sit, you may be placed in a side-lying position on the edge of the bed on your unaffected side.
6. You will be asked to hold still, exhale deeply, and hold your breath when told to during the procedure.
7. The skin at the puncture site will be cleansed with an antiseptic solution.
8. You will receive a local anesthetic at the site where the biopsy is to be performed. You may experience a brief stinging sensation at the site of the anesthetic injection.
9. When the area is numb, the doctor will insert a needle between the ribs in your back. You may experience some pressure at the site where the needle is inserted.
10. Once the doctor has entered the pleural space with the needle, fluid may be withdrawn slowly.
11. The doctor will insert the biopsy needle into the site. One or more samples of pleural tissue will be obtained.
12. The biopsy needle will be withdrawn and firm pressure will be applied to the biopsy site for a few minutes until any bleeding has stopped.
13. A sterile adhesive bandage or dressing will be applied.
14. The tissue sample will be sent to the lab for examination.
15. You may have a chest X-ray taken immediately after the biopsy.

After the procedure

After the procedure, you will be monitored until your blood pressure, pulse, and breathing are stable. If the procedure was done at the bedside, you will remain in your hospital room. If the procedure was performed on an outpatient basis, you will be discharged to your home, unless your doctor decides otherwise. If the procedure was performed on an outpatient basis, you should plan to have another person drive you home.

The dressing over the puncture site will be monitored for bleeding or other drainage.

You may have an additional chest X-ray performed a few hours after the procedure.

When the recovery period is over, you may resume your usual diet and activities unless your doctor advises you differently. Your doctor may ask you to avoid strenuous physical activity for a few days.

The biopsy site may be tender or sore for several days after a needle biopsy. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Notify your doctor to report any of the following:

• Fever and/or chills
• Redness, swelling, or bleeding or other drainage from the puncture site
• Shortness of breath or difficulty breathing
• Coughing up blood

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.