Fig. 14.1
A representative case to show the importance of scope rotation. (a) A patient with a lung mass on the right S6 on chest CT. (b) During bronchoscopy, initial X-ray fluoroscopy shows that the radial EBUS probe seems to have reached the lesion; however, there was no EBUS signal detected. Aggressive scope rotation to 180° while changing the operating hand from left to right succeeded in detecting a tumor signal on EBUS and subsequent diagnosis
14.3 Role of the Assistant
Fluoroscopy-guided biopsy requires an assistant who will use the devices; proper coordination with the operator becomes a key to success. With improper operation of the assistant, diagnostic accuracy may be affected, and unexpected complications may occur.
14.4 Transbronchial Biopsy (TBB)
Prior assessment of the probability to reach a peripheral pulmonary lesion by fluoroscopic biopsy is important. Biopsy devices, such as brush, forceps, etc., are observed as two-dimensional on X-ray fluoroscopy; the choice of biopsy technique should be based on the probability to reach a peripheral pulmonary lesion, such as “reachable,” “difficult to reach,” and “unreachable” (Fig. 14.2). As described above, the tip of the flexible bronchoscope should be rotated toward the area of the target lesion; otherwise, potentially “reachable” lesions would be determined as “unreachable” (Fig. 14.3). In general, each pulmonary segment may be reached by the same manner of bronchoscope manipulation. According to the chest computed tomography (CT) scan, the direction and degree of the bronchoscope rotation may be simulated (Fig. 14.4).
Fig. 14.2
Assessment of the probability to reach a peripheral pulmonary lesion under X-ray fluoroscopy
Fig. 14.3
Inappropriate scope operation. Since bronchoscope rotation is not enough, lateral view shows that the tip of the scope is not directed toward the lesion
Fig. 14.4
Simulation before examination. Simulate the direction and degree of bronchoscope rotation according to the chest CT scan. For example, for a lesion in the right S3b, rotate the scope to the left
14.4.1 Reachable Lesions
These lesions may be easily reached under fluoroscopy guidance; in addition, check for movement of the X-ray shadow of the tumor while performing biopsy. For tumors in apical segments or those with surrounding inflammation and fibrosis, biopsy may sometimes be difficult. In such cases, it would be better to add transbronchial needle aspiration (TBNA) (Fig. 14.5).
Fig. 14.5
TBNA for an apical tumor with fibrosis. The forceps biopsy (TBB) specimen reveals inflammatory changes with fibrosis only. Additional TBNA specimen shows adenocarcinoma. TBB transbronchial biopsy TBNA transbronchial needle aspiration
14.4.2 Difficult to Reach Lesions
For these lesions, the affected bronchus may be accessed using the curette, which is used to scrape gently the side of the target lesion under X-ray fluoroscopy. The Sasada transbronchial angled forceps (STAF®, Machida, Tokyo, Japan) is also useful (Fig. 14.6) [1]. As with the other methods, it is better to carry out TBNA in order to make a route for sampling from the bronchi to the lesion.
Fig. 14.6
Transbronchial biopsy using the STAF® for tuberculoma. First TBB specimen reveals normal bronchial mucosa, but the fourth specimen reveals epithelioid granuloma with Langerhans giant cells. TBB transbronchial biopsy,STAF Sasada transbronchial angled forceps
14.4.3 Unreachable Lesions
Try considering the curette and TBNA, as described above. However, if adequate samples or an accurate diagnosis is not obtained, try guided bronchoscopy (e.g., VBN, EBUS, etc.) or consider other approaches, such as transthoracic or surgical.
14.4.4 For Reliable Tissue Collection
- 1.
Simulate the direction and degree of bronchoscope rotation according to the chest CT scan.
- 2.
While rotating the bronchoscope and doing up-down movements of the tip, check for tumor movement under X-ray fluoroscopy while palpating the tumor with the use of biopsy devices (closed biopsy forceps or brush) to determine the biopsy site.
- 3.
Open and jab the forceps against the biopsy site, and then close it slowly while feeling the resistance of the lesion.
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