Lung biopsies: what they reveal and how they are done

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

If a doctor suspects that you may have lung cancer, you will probably undergo a lung biopsy. So today I'm talking about how that procedure is done and what results may mean with Dr. Ronaldo Ortiz-Pacheco. He's an assistant professor of medicine at Upstate.

Welcome to "The Informed Patient," Dr. Ortiz-Pacheco.

Ronaldo Ortiz-Pacheco, MD: Thanks for having me.

Host Amber Smith: Let's talk first about how lung cancer biopsies are done. This would be scheduled after a medical scan shows something unusual in the lung. Is that right?

Ronaldo Ortiz-Pacheco, MD: Yes, that's correct. Right now, the United States Preventive Services Task Force recommends lung cancer screening for all patients 55 to 80 years old who have smoked 20 pack-years, or who have quit within the last 15 years.

Pack-year means the amount a person smokes per day multiplied by the amount of years that they've been smoking. So a person who smokes one pack per day for 10 years has a 10 pack-year history. So the more pack-years, the higher the riskof lung cancer.

And those patients are the ones who are encompassed in the lung cancer screening. There's different ways to categorize spots on the lungs; lung nodules is the medical term, and depending on the size, depending on the location, depending on how that nodule looks determines if a nodule will be a candidate for biopsy.

Host Amber Smith: And are the biopsies done in the hospital?

Ronaldo Ortiz-Pacheco, MD: Yes. Right now, currently, at Upstate, we do our biopsies in the hospital via either interventional radiology, thoracic surgery or pulmonology.

Host Amber Smith: And when the biopsy's actually done, is the person sedated, or can they feel the biopsy happening?

Ronaldo Ortiz-Pacheco, MD: So it depends on what type of biopsy is being done. Usually, if an interventional radiologist is doing a biopsy, it usually involves a needle going through the skin, into the lung, into the lesion. Those patients are usually sedated. They'll have some sort of local anesthetic to the area where the needle is going to be introduced.

For patients undergoing surgery or bronchoscopy, we usually have them under general anesthesia, with an anesthesiologist present during the case.

Host Amber Smith: And when you find a node or a nodule, are those cells that make up that node or nodule, are they inside the lung, or could they be on the exterior surface of the lung?

Ronaldo Ortiz-Pacheco, MD: So it depends on the type of cancer. It depends on what we're suspecting of what's going on. A lot of the cancers can have their origin in the actual meat of the lung, as I call it. The medical term, scientific term, is the parenchyma. But you can definitely have lung cancer arise within the airways, within the tubing inside the lung.

The way I like to describe the lungs to patients is think of a tree, and your main windpipe, your trachea, is the trunk of the tree, and it's hollow on the inside, and that divides into two big branches, your left and your right side, and then they start dividing into basically little microscopic berries, if you will. And cancer can arise from any portion of the tracheal-bronchial tree, as they call it, or the actual meat, parenchyma, of the lung.

Host Amber Smith: And we should be clear, I mean, we talked about lung cancer screening for people that have been smokers, but you can get lung cancer even if you're not a smoker. Is that right?

Ronaldo Ortiz-Pacheco, MD: That's correct. The biggest risk factor for any cancer is age. Unfortunately, we have a lot of patients who don't meet the screening criteria. And they get a CT scan, either a trauma workup, or they're having some sort of symptoms, and those patients are found to have either a large mass or an incidental pulmonary nodule, which needs to be followed, depending on its characteristics, size, for an extended period of time, whether it be three months, six months or a year, depending on patient risk factors.

Host Amber Smith: Now, what can you tell us about the endoluminal system that Upstate has?

Ronaldo Ortiz-Pacheco, MD: So the endoluminal system: We have currently the Ion by Intuitive. It is the same company that makes the da Vinci surgical robot. The Ion endoluminal system is basically a robotic bronchoscopy.

It's kind of like an endoscopy, if you would go for a gastroenterologist to check your esophagus or going for a colonoscopy, checking the colon; we check the airways. It basically takes out the human element of having to navigate ourselves and replaces that with a robot. So we actually drive the robot with a control panel up into a suspected nodule.

We make a virtual map of the lungs using a preexisting CT scan. We're able to segment the target that we want, meaning we get to make a virtual image of that nodule. And the bronchoscope itself, the machine itself, kind of makes a path which we follow, based on the imaging that we have. It's a 3D image. superimposed onto a live view, and we can drive up to the area in question and then biopsy the nodule, with needles, forceps, cytology brushing (brushing to collect sample cells), just to maximize the amount of cells that we can get to identify what exactly is going on with that nodule.

Host Amber Smith: So what you're able to obtain through this newer system, that's still considered a biopsy?

Ronaldo Ortiz-Pacheco, MD: Yes, it's considered a biopsy. Depending on the location, depending on some of the imaging technologies that are available to us. Sometimes it is preferable to undergo a bronchoscopic biopsy, rather than one by interventional radiology or surgery.

Doing a bronchoscopic biopsy allows us to also take a look at the lymph nodes within the chest and allows us to do a procedure called staging, which is basically looking at the lymph nodes and making sure that those lymph nodes are not involved with any cancer cells. That's not to say that this is the end-all, be-all way to biopsy lung cancer.

Everything has its trade-offs, right? With bronchoscopic biopsy, not using a robotic bronchoscope, historically, the yields have been anywhere between 30% to 70%, depending on the size and location of the nodule. With the robotic platform, particularly the ones that we have here at Upstate, we're able to bring up that yield to high 70s, maybe even low 90s, depending on, again, size, location and other imaging that we use intraoperatively to identify where the nodule is.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Ronaldo Ortiz-Pacheco. He's an assistant professor of medicine at Upstate, where he specializes in lung cancer biopsy.

Now, this seems like a very precise procedure. How can it be done accurately if the patient is breathing? Because wouldn't that cause the lungs to move?

Ronaldo Ortiz-Pacheco, MD: So that's always a limitation. We try to minimize the amount of movement that the patient has during the procedure, particularly the robotic bronchoscopy.

We use full anesthesia. We use a paralytic. That happens mostly during general anesthesia as well. So the only movement that we're seeing is the breathing that the breathing machine is doing for the patient. We try to be as accurate as possible by getting a CT scan the day of the procedure to allow for any small variations that might have been present during any prior CT scans, which can affect the accuracy of which we can go and get the nodule at.

And we have different maneuvers that we can do during the operation to ensure that we don't have focal areas of lung collapse, the nodule doesn't move just by different anatomic processes that happen during surgery, and basically try to be as accurate as possible.

Host Amber Smith: Does a biopsy run the risk of disturbing the cancer cells so that they spread?

Ronaldo Ortiz-Pacheco, MD: There's only, I would probably say only case reports, of supposed cancer being spread by biopsies. It's not something that's very common, particularly with lung cancers. That's not to say that there aren't some cancers that run the risk of, quote unquote, "seeding the tract," meaning seeding the area where you stick a needle into and actually causing the cancer to kind of spread within that tract, but in terms of lung cancer, that's very rare that it happens. I haven't heard of any cases, at least in my career, of that happening.

Host Amber Smith: When you're doing the biopsy, and you're visualizing the cells, can you tell whether it looks cancerous? Can you tell just by looking?

Ronaldo Ortiz-Pacheco, MD: So when we do the biopsies, we usually have cytology, a cytology tech, who has an on-call pathologist to discuss the case.

We basically give them a sample, where they put it on a slide, and they take a look at the cells under the slide, and they can identify if cells are abnormal. If they're normal, if it's an adequate specimen, meaning there's cells and not just blood, they can also tell, if it's very obvious, if there's evidence of cancer on the actual slides. But the actual results take about maybe three to five business days, usually, to get all of the special stains done, all of the special surface markers on the tumor cells. So it's definitely a process that takes about three to five days. But usually we can have a pretty good idea of where we're at during the biopsy.

And that kind of dictates where we will take a biopsy from, or if we keep going in the same direction, or if we need to move a little bit and see if we can get a different area, which will yield a different result.

Host Amber Smith: How do you instruct your patients to prepare for a lung biopsy?

Ronaldo Ortiz-Pacheco, MD: So I think the most important rule is don't eat anything after midnight or at least eight hours before a procedure. It's standard with any procedure that goes under any anesthesia.

If they're on blood thinners, usually we like to tell them to hold them for about two to three days before doing that. If they're on a medication called Plavix, which a cardiologist or a general practitioner might have placed them on for heart disease, we usually tell them to hold that for five days. Aspirin is usually safe for these procedures. A low-dose, baby aspirin is usually OK for them.

Host Amber Smith: What is recovery like?

Ronaldo Ortiz-Pacheco, MD: For robotic bronchoscopy, barring any complications, which are pretty low, the patient usually goes home the same day. Recovery is usually about one to two hours in the recovery area, in the procedural suite, and usually an X-ray afterwards. And then we just instruct them that if they have any chest pain, difficulty breathing, within the next eight to 12 hours to come back to the hospital.

Usually patients complain of a scratchy throat or maybe a little bit of a sore throat from where the breathing tube is inserted by the anesthesiologist. And some patients can have maybe a little bit of blood come up when they cough, but it's usually just a few specks of blood, and it's usually self-limited, anywhere between a couple of hours to maybe a day and a half after the procedure itself. But usually, patient recovery time is same day.

Host Amber Smith: Now, you said it may take three to five days to get the results. Will the results be clear enough that it is either cancer or it's not?

Ronaldo Ortiz-Pacheco, MD: Our pathologists are very well-trained, and they can usually be very spot-on with what type of cancer cells are present on the samples that we give them.

And that's all based on special dyes that they put on the cells. It's special markers that identify what type of cancer cells are available on that sample.

We always run the risk of not getting a diagnosis, which is actually one of the risks that I always tell my patients, right? We always talk about complications during the procedure, and I always say that one of the risks is, "Hey, we might not get a diagnosis, and we might have to do another procedure," whether it be a repeat bronchoscopy or ask a radiologist to see if they can biopsy from the outside or talk to a surgeon and see if the patient is a candidate for a more invasive biopsy.

Surgery is probably the most accurate way of getting any diagnosis for cancer. The problem is that involves a bigger surgery. It involves general anesthesia, usually involves the recovery period about one to two days, again, barring any complications. And also, it involves patient being healthy enough to have a portion of their lung taken out, right? That's what usually these surgeries entail.

Host Amber Smith: If it is cancer, how quickly do lung cancers grow and how urgently do you need treatment to begin?

Ronaldo Ortiz-Pacheco, MD: I think the person who answers that will win a Nobel Prize. If we kind of step back and explain a little bit about lung cancer, there's two big types of lung cancer that we worry about, which is the non-small cell and the small cell.

Usually, small cells can be pretty aggressive. Within a couple of weeks they can progress to pretty big sizes that do compromise the airway, unless there's some sort of intervention, which is usually chemotherapy.

And then the non-small cell is divided into two types, which is the adenocarcinoma and the squamous cell carcinoma, "adeno" meaning that the cells look more like glandular tissue, and "squamous cell" is more of cells arising from the surface of tissues.

In terms of how fast they grow, there are some adenocarcinomas that grow over a period of 10 years. Patients can live with them, and they'll usually pass away from something else. And there are other adenocarcinomas that are pretty aggressive. Within three months' time, they can double in size.

So in terms of how fast cancers can grow, I usually tell my patients it's not an emergency for me to go and get a biopsy or set up a biopsy when I'm thinking somebody has lung cancer. But it is an urgency, right? I really wouldn't want to wait maybe more than a month before identifying a nodule and going after the biopsy.

Three months' time? It's kind of stretching it because usually, on average, there is an increase in the size of nodules, it's called a doubling time, and we use that three-month mark as kind of like the average. So I usually don't like to wait more than three months.

Host Amber Smith: What other information can you get from the biopsy?

Ronaldo Ortiz-Pacheco, MD: Not all nodules are cancer. Not all masses are cancer. We can figure out that hey, you know, this is an infection, right? Is it related to a bacteria that's similar to tuberculosis? Is it fungus? Is it a benign nodule due to inflammation, right?

So, not all nodules, not all masses, are cancer, but cancer is a life-changing diagnosis. It can be a potentially devastating diagnosis, right? And that's usually what we think about, when we go after these nodules.

Host Amber Smith: Does the biopsy give you any ability to do a genetic analysis on the sample?

Ronaldo Ortiz-Pacheco, MD: Yes. If we get enough tissue on it, whether it be with enough needle passes or with forceps, right, to get a good hunk of tissue, we can run that genetic analysis, which usually the pathologists do.

Host Amber Smith: If there is a mass, and it's noncancerous, does it need to come out?

Ronaldo Ortiz-Pacheco, MD: I always like to engage the thoracic surgeons in that case.

It depends on how fast it's growing, if it's compromising any organs within the chest. Usually, if there's a mass, and it's growing, I would rather a surgeon take a look at it and possibly consider removing the mass and then having a final pathologic analysis of what that mass really is. But it all depends on symptoms that the mass is causing, if it's compromising any other structures within the chest. The one we worry about is the heart and the vessels that run inside the chest. We don't want that to get compressed.

Host Amber Smith: So after you have the biopsy, then does that help inform what next steps may happen, what the treatment might be?

Ronaldo Ortiz-Pacheco, MD: Yes. So it all depends on how the patient is, how healthy they are, if they're strong enough for surgery. Usually, if we identify Stage 1 lung cancer, meaning it's a cancer that's localized to one portion of the lung, usually the best way to treat it is with surgery, but not all patients can tolerate surgery, so there's other ways of treating it.

We can talk to a radiation oncologist and have that area irradiated again, depending on the size of the tumor involvement. For patients with more advanced diseases, there are different strategies to help treat the cancer. It will usually involve some sort of chemotherapy or chemotherapy with some combination of surgery or radiation. For patients with Stage 4 cancer, which means cancer that's spread outside of the chest or outside of the localized region, usually the treatment for that is chemotherapy, and as you mentioned before, with the ability to get genetic testing, having special targeted therapies for that type of specific cancer.

Host Amber Smith: Well, Dr. Ortiz-Pacheco, I want to thank you for making time for what's been a really good overview of lung cancer biopsy. Thank you so much.

Ronaldo Ortiz-Pacheco, MD: Of course. This is what we're here for, and we're a busy service, and anything for the people of Syracuse and the surrounding area.

Host Amber Smith: My guest has been assistant professor of medicine Dr. Ronaldo Ortiz-Pacheco.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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