Biopsy - Diagnostic Evaluation

BIOPSY

Biopsy, the excision of a small amount of tissue, may be per-formed to permit examination of cells from the pharynx, larynx, and nasal passages. Local, topical, or general anesthesia may be administered, depending on the site and the procedure (see also “Lung Biopsy Procedures” below).

Pleural Biopsy

Pleural biopsy is accomplished by needle biopsy of the pleura or by pleuroscopy, a visual exploration through a fiberoptic bron-choscope inserted into the pleural space. Pleural biopsy is per-formed when there is pleural exudate of undetermined origin and when there is a need to culture or stain the tissue to identify tu-berculosis or fungi.

Lung Biopsy Procedures

When the chest x-ray findings are inconclusive or show pul-monary density (indicating an infiltrate or lesion), biopsy may be performed to obtain lung tissue for examination to identify the nature of the lesion. There are several nonsurgical lung biopsy techniques that are used because they yield accurate information with low morbidity: (1) transcatheter bronchial brushing, (2) trans-bronchial lung biopsy, or (3) percutaneous (through-the-skin) needle biopsy.

In transcatheter bronchial brushing, a fiberoptic broncho-scope is introduced into the bronchus under fluoroscopy. A small brush attached to the end of a flexible wire is inserted through the bronchoscope. Under direct visualization, the area under suspi-cion is brushed back and forth, causing cells to slough off and ad-here to the brush. The catheter port of the bronchoscope may be used to irrigate the lung tissue with saline solution to secure ma-terial for additional studies. The brush is removed from the bron-choscope and a microscopic slide is made. The brush may be cut off and sent to the pathology laboratory for analysis.

This procedure is useful for cytologic evaluations of lung le-sions and for the identification of pathogenic organisms (Nocar-dia, Aspergillus, Pneumocystis carinii, and other pathogens). It isespecially useful in the immunologically compromised patient.

A transbronchial lung biopsy uses biting or cutting forceps in-troduced by a fiberoptic bronchoscope. A biopsy is indicated when a lung lesion is suspected and the results of routine sputum samples and bronchoscopic washings are negative.

Another method of bronchial brushing involves the introduc-tion of the catheter through the transcricothyroid membrane by needle puncture. After this procedure, the patient is instructed to hold a finger or thumb over the puncture site while coughing to prevent air from leaking into the surrounding tissues.

Percutaneous needle biopsy may be accomplished with a cut-ting needle or by aspiration with a spinal-type needle that pro-vides a tissue specimen for histologic study. Analgesia may be administered before the procedure. The skin over the biopsy site is cleansed and anesthetized and a small incision is made. The biopsy needle is inserted through the incision into the pleura with the patient holding the breath in mid-expiration. Using fluoro-scopic monitoring, the surgeon guides the needle into the pe-riphery of the lesion and obtains a tissue sample from the mass. Possible complications include pneumothorax, pulmonary hem-orrhage, and empyema.

NURSING INTERVENTIONS

After the procedure, recovery and home care are similar to those for bronchoscopy and thoracoscopy. Nursing care involves mon-itoring the patient for shortness of breath, bleeding, and infec-tion. In preparation for discharge, the patient and/or family is instructed to report pain, shortness of breath, visible bleeding, or redness of the biopsy site or pus to the health care provider immediately. Patients who have undergone biopsy are often anx-ious because of the need for the biopsy and the potential find-ings; the nurse must consider this in providing postbiopsy care and teaching.

Lymph Node Biopsy

The scalene lymph nodes are enmeshed in the deep cervical pad of fat overlying the scalenus anterior muscle. They drain the lungs and mediastinum and may show histologic changes from in-trathoracic disease. When these nodes are palpable on physical examination, a scalene node biopsy may be performed. A biopsy of these nodes may be performed to detect lymph node spread of pulmonary disease and to establish a diagnosis or prognosis in such diseases as Hodgkin’s disease, sarcoidosis, fungal disease, tuberculosis, and carcinoma.

Mediastinoscopy is the endoscopic examination of the medi-astinum for exploration and biopsy of mediastinal lymph nodes that drain the lungs; this examination does not require a thora-cotomy. Biopsy is usually performed through a suprasternal inci-sion. Mediastinoscopy is carried out to detect mediastinal involvement of pulmonary malignancy and to obtain tissue for diagnostic studies of other conditions (eg, sarcoidosis).

An anterior mediastinotomy is thought to provide better ex-posure and diagnostic possibilities than a mediastinoscopy. An incision is made in the area of the second or third costal cartilage. The mediastinum is explored and biopsies are performed on any lymph nodes found. Chest tube drainage is required after the procedure. Mediastinotomy is particularly valuable to determine whether a pulmonary lesion is resectable.

NURSING INTERVENTIONS

Postprocedure care focuses on providing adequate oxygenation, monitoring for bleeding, and providing pain relief. The patient may be discharged a few hours after the chest drainage system is removed. The nurse should instruct the patient and family about monitoring for changes in respiratory status, taking into consid-eration the impact of anxiety about the potential findings of the biopsy on their ability to remember those instructions.