RespiratoryTier 2Topic

Tissue biopsy, including biopsies of pleura, lung parenchyma, and lymph nodes

Overview

Tissue sampling of respiratory structures - encompasses pleural biopsy, lymph node biopsy (peripheral or via EBUS/mediastinoscopy), and lung parenchymal biopsy (transbronchial, CT-guided percutaneous, or surgical/VATS) - the approach chosen depends on the target and required diagnostic yield
The least invasive technique capable of achieving the diagnosis is generally preferred, escalating to surgical biopsy only when needed

Approach by target

Target	Typical approach
Pleura	Closed pleural (Abrams) biopsy or, increasingly, image-guided percutaneous biopsy - better yield for malignancy than closed biopsy
Mediastinal/hilar lymph node	EBUS-TBNA first-line; mediastinoscopy if EBUS non-diagnostic and suspicion remains high
Peripheral lung nodule	CT-guided percutaneous biopsy - higher pneumothorax risk with deeper/smaller lesions
Diffuse parenchymal disease (ILD)	Transbronchial biopsy (cryobiopsy increasingly preferred over forceps for larger, better samples) or surgical (VATS) biopsy if bronchoscopic sampling is non-diagnostic

Cytology vs biopsy

Pleural fluid cytology alone (no biopsy) has a lower sensitivity for malignancy than image-guided pleural biopsy - repeat sampling with biopsy is warranted if cytology is negative but suspicion remains high

Risks

Pneumothorax is the principal shared risk across percutaneous/transbronchial approaches; risk scales with needle/probe depth and pre-existing emphysema
Bleeding risk requires standard peri-procedural anticoagulation management

Indications

Malignant pleural effusion, mediastinal lymphadenopathy, interstitial lung disease, solitary pulmonary nodule

A non-diagnostic biopsy

A non-diagnostic biopsy does not exclude disease - persistent clinical suspicion warrants escalation to a more invasive (higher-yield) technique rather than reassurance

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