CT Guided Lung Biopsy

What is a CT scan?

A CT scan is an X-ray test that takes detailed images of the inside of your body. It is performed while you lie on a table. The table passes through the CT scanner, which is a large doughnut shaped machine, you will pass through this hole while you lay on the table.

What is a biopsy?

A biopsy is a procedure where a sample of tissue is taken from an organ or area of your body to help diagnose an illness.

When you have a CT guided lung biopsy, a sample of lung tissue is taken with the help of a CT scan to guide where the sample should be taken from.

Why do I need a CT guided lung biopsy?

You will have had a CT scan, which has shown an abnormality in your chest. This may have been referred to as a “shadow”. In order to work out what the abnormality is, a sample of it is taken and is looked at under a microscope.

What has caused this abnormality on my scan?

There are many possible causes of these abnormalities. These can include growths or cancers, infections, inflammation and scarring. The decision to offer you a biopsy usually means that your team are concerned that the abnormal area is potentially a cancer or other serious illnesses.

What tests will I have before this biospy?

You will normally have had other tests before you have been offered a CT guided lung biopsy. These would usually include chest X-rays, breathing tests, blood tests CT scans. You may also have had a different type of CT scan called a PET (Positron emission tomography) scan.

The team may also have tried other types of biopsies, such as an examination of the airways of your lungs using a special camera (this is known as a Bronchoscopy).

In preparation for a CT guided lung biopsy you will have:

• Blood tests: you will have your blood clotting and blood count checked. This is to make sure there is nothing which will make you more likely to bleed during the biopsy

• MRSA swabs: these are taken from your nose and groin.

Where is this test done?

The test is done on Tuesday mornings in the CT department (part of X-ray department) of the University Hospital of North Tees.

How do I get ready for this test?

Before the test:

It is important that you let us know about all of your current medication. Some medications may have to be stopped before the biopsy. These include:

• Blood thinners (anti-coagulants): these medicines include Apixaban, Rivaroxaban, Edoxaban, Dabigatran, Warfarin and low molecular weight heparin.

These need to be stopped in advance of the biopsy. The team will tell you how long they should be stopped for and whether you need to take any alternatives.

• Anti-platelet medicines: these include Clopidogrel, Ticagrelor, Prasugrel. They are usually given after heart or stroke problems. They can cause bleeding and need to be stopped before the test.

The team will tell you how long you should stop taking them. If you have recently had a heart or a stroke problem, the team will talk to you about the risk of stopping these medicines for a period of time against the benefit of having the biopsy.

You will usually not have to stop or change your dose of Aspirin if you are taking this.

• Diabetes medicines: we may need to change or adjust your diabetes medicine if you are taking this.

• Other medicines: there is usually no need to stop or change any of your other medicines.

What else will I need to consider before my biopsy?

Smoking

If you can, you should stop or cut down how much you smoke. This potentially helps your lung to heal faster after the biopsy.

Cutting down smoking may make feelings of worry or nervousness worse due to nicotine withdrawal. It is a good idea to use nicotine replacement therapy (patches, gum, inhalators) to help with this. If you want help to stop smoking, please tell us and we will get you the right information.

Transport

You should not drive yourself home from the test. You should plan who will bring you to and take you home from the test. If you cannot arrange this, you will need hospital transport. If you need this, we will explain how to arrange this.

On the day of the test

• Clothing: wear loose and comfortable clothes. You will change into a gown for the actual test.

• Eating: you DO NOT need to fast. You should eat a light breakfast before coming to hospital.

• Medication: you should take all of your medicines as normal unless you have been told to change or stop any.

Can I bring a relative or friend with me?

You can bring a relative or friend with you to the X-ray department. However, they will not be able to come into the CT scan room when the test is being done or to the recovery room after the test is finished.

Will I need general anaesthetic?

No, this test is done with a local anaesthetic. You will be awake during the procedure.

Can I have sedation for this test?

Yes, if you are extremely nervous or worried about having the test. Your team can arrange for you to have a tablet sedative 1 to 2 hours before the test. Please let the team know so that this can be prescribed.

How long will the test take?

The biopsy usually takes about 30 minutes from starting the test to leaving the CT scanning room. It can take longer if it is a more complicated biopsy.

You will stay after the test for 4 to 6 hours to make sure you are recovering and have not developed any complications or problems.

Can I still have the test if I am pregnant?

The biopsy usually takes about 30 minutes from starting the test to leaving the CT scanning room. It can take longer if it is a more complicated biopsy.

You will stay after the test for 4 to 6 hours to make sure you are recovering and have not developed any complications or problems.

Can I arrange to have an interpreter?

If you need an interpreter, then this will be arranged. It is our policy that your family or friends cannot act as interpreter for you.

How is the test done?

On the day of your test, please attend the Day Case Unit.

Please bring a bag with nightclothes, toiletries and your normal medication in case you have to stay overnight.

You will be shown to the changing area to change into the gown for the procedure and the biopsy proceeds as follows:

1. Consent: the Doctor performing the test will talk you through it and once you are happy that you understand it, you will be asked to sign the consent form. The procedure cannot proceed without you signing this.
2. CT scanning room: you will then be taken through to the CT scan and asked to get up on to the CT scan bed. If you need help to do this, please let us know.
3. Positioning: you will be asked to lie on your front, back or side, depending on what is thought to be the best position to take the biopsy.
4. Deciding where to biopsy: You will usually have a brief CT scan to find the best area to have the biopsy. A small mark will then be made in the skin.
5. Getting ready to biopsy: the Doctor will clean their hands and put on sterile gowns and gloves. They will then clean the skin on your chest with sterilising solution. They will then apply sterile drapes to keep the area clean.

Local anaesthetic will then be injected under your skin and into the muscles between your ribs where the biopsy needle will be inserted

6. Biopsy: once the skin is numb, the Doctor will insert the biopsy needle through your skin and muscles, between the ribs and into the abnormal area in your lung. They may pause and leave the room to take more brief CT scans to make sure the needle is where it needs to be.

When the Doctor is satisfied, they will then take the biopsy. You may hear a click when this happens, but should not feel anything else.

7. After the biopsy: once the Doctor is happy that they have the biopsy, you will then be transferred on to a different bed and taken to the recovery area

8. Getting ready to go home: you will go to the Medical Day Case Unit. The Nursing staff will monitor you regularly including checking your “vital signs” (pulse, blood pressure, temperature, breathing rate and oxygen levels).

3 to 4 hours after the biopsy, you will have a chest X-ray to make sure your lung has not been damaged.

9. Going home: if you are well and your chest X-ray is satisfactory, you will then go home. You will be told when you can restart any medications that you were told to stop before the test. If you have not been told this, then please ask the staff so that they can make sure this is clear.

You will be contacted by the lung team when they have your results to talk through the next step.

Will the test hurt?

There is usually a small scratch-like sensation as the local anaesthetic is injected. After this, you should not feel any significant pain or discomfort.

After the local anaesthetic wears off, you may have some pain or aching in the area of the chest where the biopsy was taken from. This is usually mild and can be managed with simple painkillers such as paracetamol.

Are there any side effects or risks?

A CT guided lung biopsy is a safe procedure. The majority of patients have no serious side effects. You should be aware of the following:

Common or minor side effects

Pain after the biopsy

This is usually mild and can be treated with simple painkillers such as paracetamol or ibuprofen. The pain usually settles over 24-48 hours.

Bruising and bleeding from the biopsy

This is usually very minor and it settles quickly.

Coughing up blood

A small amount of bleeding occurs within the lung after the biopsy in 1 in 5 patients. You may cough up a small amount of blood. This normally settles quickly and doesn’t cause any harm. Up to 1 in 20 patients may cough up more blood and may need to stay in hospital for observation.

Less common or more serious risks or side effects

Failure to biopsy

In a small number of patients, it is not technically possible to reach the abnormal area in the lung with the CT biopsy.

Pneumothorax

Air may leak out of the lung into the chest cavity. This causes the surface of the lung to peel away from the inside lining of the chest. The term for this is pneumothorax. This happens in up to 1 in 4 patients. It can make it painful to breathe.

If it is a small amount of air and you are well, then nothing needs to be done and the lung will heal itself and absorb the air that has escaped.

Much less commonly, in approximately 1 in 20 patients, a larger amount of air leaks out and causes the lung to collapse and make you breathless. If this happens then you will usually have to stay in hospital overnight.

You may also need to have a procedure called a chest drain. This procedure involves inserting a plastic tube between your ribs into your chest cavity to let the air out and the lung re-expand. If you have a chest drain, you will normally need to stay in hospital for at least 24 hours.

Infection

All equipment used during the procedure is sterile and the Doctor doing the test will use the same techniques that a surgeon would use when doing an operation.

Rarely, an infection may develop in the skin, known as cellulitis. If you notice reddening, pain or pus at the biopsy site, you must tell your Doctor, the lung team or attend accident and emergency for assessment.

Very rarely, an infection can develop which causes pus inside your chest cavity. This is known as empyema. This is a serious infection and you would need to be admitted to hospital for antibiotics and other possible procedures.

Radiation exposure

The CT scanner uses X-rays that are a form of radiation. The amount of radiation used varies from patient to patient. This radiation can increase the risk of future cancers. This risk is small and you would only have been recommended for a biopsy if the risk is outweighed by the potential benefit from the biopsy.

Severe Bleeding

Extremely rarely, a patient may have severe bleeding and will need a procedure to stop the bleeding or a blood transfusion.

Air embolus

During the biopsy, air can get into the blood vessels in your lung. It can then travel to the heart where it can cause a heart attack or travel to the brain where it can cause a stroke. This is extremely rare and happens in less than 1 in 1000 patients.

Death

The risk of death from a CT guided lung biopsy is very small. It is less than 1 in 1000 patients. The risk is mainly associated with either severe bleeding or an air embolus.

The list of possible risk or side effects from a CT guided lung biopsy can appear frightening. It is important to remember that the majority of patients have no serious side effects and they are discharged the same day as their biopsy.

Do I have to have this test?

You have been offered this test because the team are concerned that the abnormality in your chest is potentially serious. They feel that this test offers the best chance of getting a diagnosis with the least risk to your health.

The final decision about having the test is yours, and no one can force you to have it against your will.

What happens if I choose not to have the test?

If you choose not to have the test, then the team who organised it will talk to you to find out why. If they can answer any concerns you may have, you might then decide to have the test.

If you have definitely decided not to have the test, your team would try to find an alternative test or a plan that does not involve a biopsy.

Will this test definitely give me an answer?

The Doctor doing the test will do their best to make sure a sample is taken from the abnormality. Sometimes, as mentioned previously it may not be possible to get a sample.

When a sample is taken, it is not guaranteed that it will explain what caused the abnormality. In this situation, you may be asked to have another CT guided biopsy or a different procedure to get a sample.

Is there an alternative to this test?

There may be alternative tests to a CT guided lung biopsy. This will depend on what abnormalities are on your scan.

It may be possible to have a camera test of lungs (known as a bronchoscopy) to take a sample from the abnormality or from the lymph glands underneath your breastbone (if they are also abnormal).

If there are abnormalities or shadows in other organs, it could be possible to do biopsies of these.

Will I go home the same day as my test?

Yes, as long as the test goes well and you feel well after it without any complications.

When will I get the results?

The biopsy results will normally be available to your team within 5 to 7 working days. This can take longer if it is complicated to study the biopsy, or if it needs to be sent out to another hospital for further tests.

When the team have your result, they will normally review this with your other tests in a weekly Lung Multi-Disciplinary Team meeting. This meeting will then come up with recommendations as to what the next best step is for you.

Can I drink alcohol after this test?

We would ask you to refrain from alcohol the evening after the test but after this, it should be fine.

Can I travel after this test?

As long as you are well car, train and bus journeys are fine.

Air travel: you should not fly for 6 weeks after the test.

When can I go back to work?

As long as you are well, you can go back to work the next day. If your job involves heavy lifting, we would ask you to avoid this for 1 to 2 weeks.

References

1. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Heerink WJ et al. Eur Radiol (2017) 27:138–148.

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