Lung biopsy

A lung biopsy removes a few tiny pieces of a spot in the lung so a pathologist can look at them under a microscope. The spot may be called a nodule (small, under 3 cm) or a mass (larger). CT scans find many of these, often by chance.

A scan can show the size and shape of a nodule, but it cannot say for sure what it is made of. A biopsy can. The common causes are:

If it is cancer, the sample tells your doctors the exact type and allows genetic (molecular) testing of the tumor. Those results guide the choice of surgery, radiation, targeted drugs or immunotherapy.

On the planning CT, the lung looks almost black because it is full of air, and the nodule is a small white or gray spot. We measure the shortest safe path from the skin to the spot, between the ribs and away from blood vessels.

Not every nodule needs a biopsy. Many small ones are simply watched with follow-up CT scans, because most are not cancer. A biopsy makes sense when a nodule is large enough, is growing or looks suspicious, and when the answer will change your treatment.

Your lung doctor, surgeon and our team often decide together which approach fits your nodule best. Sometimes a PET scan is done first to help decide.

A little preparation makes the biopsy safer and smoother. These are the five things we ask every patient to do. See also before your procedure.

1. 1
   Getting ready

   At El Camino Hospital, a nurse starts an IV and gives you moderate (twilight) sedation. You lie on the CT table on your back, front or side, depending on where the nodule is.

2. 2
   Planning scan

   A low-dose CT scan shows the nodule. We mark the skin, clean it and numb it with local anesthetic, which stings briefly.

3. 3
   Taking the samples

   Guided by quick CT scans, we move a thin needle to the edge of the nodule and take several small samples through it. You feel pressure, and you may hear a click. Sometimes we leave a tiny marker (fiducial) to help with later treatment.

4. 4
   Check scan

   We remove the needle, apply skin glue and do a final CT to look for any air leak or bleeding.

5. 5
   Recovery and X-ray

   You rest for about 2 hours, then have a chest X-ray. If your lung looks good, you go home.

On the planning scan I look for the shortest path that crosses the fewest lung surfaces, because every surface crossed raises the chance of an air leak. I ask patients to breathe the same easy way each time, and I explain what I am doing as I go. Most people tell me it was easier than they feared.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

1. First 2–3 hours
   Rest in recovery, lying on the biopsy side if we ask you to. A chest X-ray checks for an air leak before you leave.
2. Rest of the day
   Take it easy at home. No driving, alcohol or important decisions after sedation. You can eat normally, starting light.
3. Day 1
   Shower as usual. Most people go back to desk work and driving. Mild soreness is normal.
4. Up to 1 week
   Some cough and blood-streaked spit are normal. No heavy lifting, hard exercise, baths or swimming. Avoid flying.
5. 1–2 weeks
   Skin glue falls off on its own. Back to all activities.

For pain, acetaminophen (Tylenol) is usually enough. Ibuprofen is fine for most people unless we have told you to avoid it. Pain that keeps getting worse is not normal and should be checked.

Results are usually ready in about 2 business days and go to the doctor who referred you. Genetic testing of a cancer, or a second opinion from another pathology lab, can add several days. Tests for slow-growing infections like TB or fungus can take up to 4 weeks.

A needle biopsy gives a clear answer in about 9 out of 10 cases. If the result is unclear or does not match the scan, your doctors may repeat the biopsy, try bronchoscopy, recommend surgery or keep watching the nodule.

Air leak (pneumothorax). This is the most common problem. Air escapes from the lung through the needle hole and collects between the lung and the chest wall, letting part of the lung fall in (collapse). Some air leak shows up in about 1 in 5 people. Most leaks are small, cause no symptoms and go away on their own. You may just need a second X-ray a few hours later or the next day. Read more about pneumothorax.

About 1 in 15 to 1 in 20 people need a small chest tube to remove the air. It is placed through the same area with numbing medicine, and it usually stays 1 to 2 days while the hole seals, so you stay in the hospital overnight. The risk is higher with emphysema, deeper nodules and smaller nodules.

Bleeding. Coughing up a little blood or blood-streaked spit is common and usually stops within minutes to days. Heavy bleeding into the lung is rare. Rare risks include infection and air bubbles entering the bloodstream (air embolism), which occurs in far fewer than 1 in 1,000 biopsies.