The authors begin their article with the statement: “For patients with a solitary pulmonary nodule that is suspicious for malignancy (larger than 8–10 mm), surgery should generally be performed to evaluate for malignancy (1, 2). The procedure of choice is the minimally invasive video-assisted thoracoscopic surgery (VATS) for atypical lung parenchymal resection […]” (1).
These statements must be contradicted. The 2018 German S3 Guideline “Prevention, Diagnosis, Treatment, and Follow-up of Lung Cancer” says on the topic of diagnosis: “For pleural-based tumors, ultrasound-guided techniques can be used for pleural puncture; for non–pleural-based tumors, CT-guided pleural puncture is strongly recommended”.
CT (computed tomography)–guided percutaneous biopsy of pulmonary nodules has shown high rates of success, of more than 90%, even for small nodules of less than 2 cm in diameter (2).
The limitations mentioned for thoracoscopic lung biopsy in the article by Lesser et al. (1), such as the depth of the pulmonary nodule (that is, the distance between nodule and pleura), or diffuse pleural adhesions and complications of postoperative pain due to these, are basically not present in CT-controlled lung biopsy.
The relatively common complication of pneumothorax after CT-guided lung biopsy can usually be treated by simple pleural puncture and aspiration, or by placing small-caliber catheters (6– to 9-French); larger catheters are hardly required (3).
Thus, the indication for thoracoscopic lung biopsy is essentially limited to cases of pulmonary nodules that remain diagnostically unclear even after repeated CT-guided biopsy, as well as to diagnosis of interstitial lung diseases—but even here, it is increasingly being replaced by the non-surgical method of transbronchial cryobiopsy (4).
To sum up, we would again like to cite the S3 Guideline: “In case of suspected lung cancer, a surgical biopsy is recommended only if less invasive methods of tissue sampling were non-diagnostic or could not be performed”.
References
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