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Ann Thorac Surg 2000;69:1016-1018
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: GENERAL THORACIC

The lingula is an appropriate site for lung biopsy

^a Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
^b Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
^c Department of Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA

Address reprint requests to Dr Temes, Department of Surgery, The Cleveland Clinic, 2500 Metro Health Dr, Cleveland, OH 44109-1998

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Lung biopsy is commonly performed for diagnosis of diffuse pulmonary disease. The lingula offers technical advantages for biopsy, however the quality of tissue obtained by lingula biopsy has been questioned. We sought to determine whether lingula biopsy was a satisfactory site for biopsy in terms of diagnostic yield, therapeutic interventions, and survival results.

Methods. All diagnostic lung biopsies performed for diffuse lung disease at 3 university affiliated hospitals between July 1, 1992 and December 31, 1998 were retrospectively reviewed. Patients were divided into 2 groups, depending upon site of biopsy: patients with lingula biopsy only and those with biopsies from other sites.

Results. There were 75 patients; 20 underwent biopsy of the lingula alone, 48 had biopsy of other sites with or without biopsy of the lingula, and location of biopsy was unknown in 7 patients. Histologic diagnosis was achieved in all patients. Significant beneficial therapeutic changes were made in 14 lingula patients, and consisted of immunosuppression in 12 cases. Three patients died in the hospital or within 30 days. Fourteen patients survived 1 year. There was no significant difference between patients that had biopsy of the lingula alone and those that had biopsies from other sites in urgency, technique, histologic diagnosis, rate of therapeutic interventions, hospital mortality, or 1 year survival.

Conclusions. Lung biopsy of the lingula compared to other anatomic sites has equivalent diagnostic yield, therapeutic significance, and survival. Given the technical ease of biopsy, when disease is present radiographically it is the preferred site for lung biopsy.

	Introduction

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Lung biopsy is eventually performed in one-third of patients with interstitial lung disease of unknown etiology. The lingula is technically very easy to biopsy since a large portion of lung is suspended upon a narrow pedicle, which is easily transected using staplers. However, the quality of tissue obtained has been questioned. We sought to determine whether the lingula was a suitable site for biopsy in terms of diagnostic yield, therapeutic interventions, and survival results.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
All diagnostic surgical lung biopsies performed for multi lobar involvement with nodular or interstitial pulmonary disease (diffuse lung disease) on preoperative radiographs at 3 university affiliated hospitals between July 1, 1992 and December 31, 1998 were retrospectively reviewed. Patients with solitary nodules or other focal processes were excluded.

Our approach had been to biopsy the lingula preferentially whenever disease was present radiographically in this area. When patient stability and technical considerations permitted, additional biopsies were also obtained from the left lower lobe. In cases in where disease was predominantly right sided, biopsies were taken from the right. If patient condition and technical factors permitted, more than 1 lobe was biopsied.

Patients were separated into 2 groups: those with lingula biopsy alone and those whose procedure included specimens obtained from other sites (with or without biopsies from the lingula). Results were compared by urgency, technique, diagnostic yield, pathologic results, culture results, whether a therapeutic change was made, type of therapy change, hospital mortality, and 1 year survival. Comparisons between groups were performed using Fisher’s exact test.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There were 75 patients identified. Twenty-six were women and 49 were men. Mean age was 56 years (range 7 to 85). There were 20 patients in the lingula only group, and 48 patients with biopsies from other sites. Seven patients had biopsies from unknown locations or left upper lobe otherwise not specified: these patients were excluded from analysis.

Urgency by group is shown in Table 1. Elective biopsies were defined as scheduled admissions to the hospital solely for the operative procedures. Urgent procedures were defined as biopsies performed during hospitalization for respiratory failure in patients not requiring 100% nonrebreather face mask oxygen supplementation or mechanical ventilation. Emergent biopsies were defined as biopsies performed during hospitalization for respiratory failure in patients receiving 100% nonrebreather face mask oxygen supplementation or mechanical ventilation. There were no significant differences in urgency between the groups (p > 0.5). The urgency of the procedure was unknown in 1 patient.

Histologic diagnosis were achieved in 100% of patients and are shown in Table 2. There were no significant differences in histologic diagnosis between groups (p = 0.20 to 1.0).

Significant beneficial therapeutic changes were defined as new treatments initiated as a result of lung biopsy. Withdrawal of medications, withdrawal of other therapies, or withdrawal of life support were not classified as significant beneficial therapeutic changes. Therapy change data was available in 67 patients. The frequency of therapeutic changes are shown in Table 1. Types of therapeutic changes are also shown in Table 1. There were no significant differences in frequency and type of therapeutic changes between groups (p = 0.28 to 0.58).

Hospital mortality was defined as death during the same hospitalization or within 30 days of operation. Data was available for 67 patients. No patient died of surgical complications, however many of the deaths occurred when life support was withdrawn after a diagnosis of irreversible pulmonary failure was made. Data are shown in Table 1. There was no significant difference in hospital mortality between the groups (p > 0.5).

One year survival data was available in 53 patients, and in 15 patients data was not available, or less than 1 year had passed from the time of biopsy. One year survival is shown in Table 1. There were no significant differences in 1 year survival between groups (p = 0.23).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Lung biopsy is commonly performed for diagnosis of diffuse pulmonary disease. The lingula is an appealing site for biopsy since the lung is suspended by a narrow pedicle, which is easily transected using staplers. Unfortunately, the quality of tissue obtained has been questioned.

Wetstein reported 20 immunocompromised patients, each receiving biopsies of the lingula and other sites during the same operation. He found lingula biopsies to be identical to those obtained from other locations in 100% of the patients [1]. Miller and associates reviewed 73 patients, 47 of whom were immunocompetent, and found that lingula biopsies were representative and diagnostic [2]. They also reported the lingula was a preferred target in terms of surgical accessibility and size of specimens obtained [2].

In contrast, Newman and colleagues performed histology on biopsies of the lingula, left lower lobe, and right upper lobe in 50 consecutive autopsies (cause of death and presence of lung disease not reported) [3]. They found fibrosis and vascular disease to be significantly more common in the lingula than in the other 2 locations. The clinical relevance of these findings in patients with diffuse pulmonary disease undergoing lung biopsy is unknown. They concluded that the lingula may not be an appropriate site for lung biopsy.

We reviewed our results in a large group of primarily immunocompetent patients with diffuse pulmonary processes, in order to determine whether biopsy of the lingula compared to other locations resulted in diagnostic, therapeutic, or survival differences.

Our histologic diagnostic yield was 100%. This compares favorably to reported rates in immunocompetent patients of 71–100% [4–6]. Usual interstitial pneumonia, bronchiolitis, diffuse alveolar damage, honeycomb lung, and pneumonia were our most common diagnosis. Others have reported usual interstitial pneumonia in 27%, bronchiolitis in 18% to 26%, malignancy in 5% to 13%, and infection in 0% to 4% of immunocompetent patients [4–6]. There were no significant differences in histologies between the 2 groups.

Other series report 0% to 10% yields for bacterial, fungal, and viral cultures in the elective setting [4, 5]. In immunocompetent patients infection has been found in only 4% of patients receiving open lung biopsies [6]. Although we routinely obtained cultures, we found no clinically significant positive cultures for aerobic bacteria, anaerobic bacteria, or mycobacteria. The single fungal infection was diagnosed on histology before culture results were available. The few viral, protozoal, and fungal infections in our series were generally diagnosed pathologically. Thus, routine cultures had minimal clinical impact in our series of predominantly immunocompetent patients.

Significant beneficial therapeutic changes were made in 61% of our patients as a result of lung biopsy. Previous authors have reported changes in therapy in 46% to 54% of all patients receiving lung biopsy and in 18% to 41% of immunocompetent patients [5, 6]. These data are difficult to interpret since definitions vary between authors. Therapy changes were more common in patients with lingula biopsies than in patients with biopsies from other sites, although the difference was not statistically significant. When significant beneficial therapeutic changes were made, they consisted of immunosuppression in 74% of cases overall. There was no significant difference in the frequency with which immunosuppression was instituted between biopsy groups.

Previous reports have documented overall hospital mortality rates of 0% to 60% [5–7]. Our overall hospital mortality was 27%. Operative mortality is an indirect measure of diagnostic accuracy since those in whom an incorrect diagnosis was made would be expected to fare poorly. Patients with lingula biopsies had lower operative mortality, although this difference was not statistically significant.

The overall 1 year survival in our patients was 59%. Like operative mortality, 1 year survival is also an indirect measure of diagnostic accuracy. Survival was slightly better in lingula biopsy patients, although the difference was not statistically significant.

There were no significant differences between patients receiving biopsies of the lingula and those obtaining biopsies from other sites in alpha error calculations. Power analysis (PASS 6.0, NCSS Software, Kaysville, UT) demonstrated 720 patients would be necessary to detect 10% difference in therapy change, hospital mortality, or 1-year survival with Beta of 20% (80% power) and Alpha of 0.05. These sample sizes are not achievable using only recent data. Although power of 80% was not achieved, lingula biopsy yielded a 100% diagnostic rate and similar diagnosis and culture results to biopsies from other sites. Hospital mortality and 1-year survival in lingula biopsy patients were better than those with biopsies from other sites.

Is the lingula an appropriate site for lung biopsy? Previous reports are inconclusive. Our comparable diagnostic, therapeutic, and survival results imply the lingula is equivalent to other anatomic sites. In addition, the lingula is technically easier to biopsy and yields greater amounts of tissue for analysis. Consequently, we believe the lingula is an appropriate site for lung biopsy. In addition, the surgical ease of biopsy and consequently shorter procedure in these patients imply that the lingula should be biopsied preferentially in patients with diffuse disease and radiographic involvement of this area of the lung.

	Acknowledgments

 
We are indebted to statistician Clifford R. Qualls, PhD, Professor Emeritus, Mathematics and Statistics, University of New Mexico for his invaluable assistance in analysis of this data.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Wetstein L. Sensitivity and specificity of lingula segmental biopsies of the lung. Chest 1986;90:383-386.[Abstract/Free Full Text]
2. Miller R.R., Nelems B., Muller N.L., Evans K.G., Ostrow D.N. Lingula and right middle lobe biopsy in the assessment of diffuse lung disease. Ann Thorac Surg 1987;44:269-273.[Abstract]
3. Newman S.L., Michel R.P., Wang N.S. Lingular biopsy. Am Rev Respir Dis 1985;132:1084-1086.[Medline]
4. Bensard D.D., McIntyre R.C., Jr, Waring B.J., Simon J.S. Comparison of video thoracoscopic lung biopsy to open lung biopsy in the diagnosis of interstitial lung disease. Chest 1993;103:765-770.[Abstract/Free Full Text]
5. Walker W.A., Cole F.H., Jr, Khandekar A., Mahfood S.S., Watson D.C. Does open lung biopsy affect treatment in patients with diffuse pulmonary infiltrates?. J Thorac Cardiovasc Surg 1989;97:534-540.[Abstract]
6. Kramer M.R., Berkman N., Mintz B., Godfrey S., Saute M., Amir G. The role of open lung biopsy in the management and outcome of patients with diffuse lung disease. Ann Thorac Surg 1998;65:198-202.[Abstract/Free Full Text]
7. LoCicero J., III Does every patient with enigmatic lung disease deserve a lung biopsy?. Chest 1994;106:706-708.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hector A. Dox Jorge A. Wernly Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Temes, R. T. Articles by Wernly, J. A. Search for Related Content PubMed PubMed Citation Articles by Temes, R. T. Articles by Wernly, J. A. Related Collections Related Article