Biopsy Techniques

Bronchoscopy

Bronchoscopy allows your pulmonologist (lung specialist) to look into your airways and lungs. Bronchoscopy is used to evaluate and treat growths in the airway, diagnose and determine the extent of lung cancer, control bleeding, or remove objects blocking the airway. It can also be used to treat airway problems such as bleeding and obstruction.

There are two types of bronchoscopy: flexible or rigid. Flexible bronchoscopy is used whenever possible because it is more comfortable and does not require general anesthesia.

You may need to remove dentures, empty your bladder, and put on a hospital gown. Your heart rate, blood pressure, and oxygen level will be monitored during the procedure. You will have an IV line (intra-venous; into a vein) placed in your arm, and receive medication to sedate (relax) you.

Prior to placing the scope through your nose, an anesthetic ointment is given in the nose to numb your nasal passages to make you more comfortable. A local anesthetic in the form of a spray is given in your nose and mouth; this will numb your throat and reduce your gag reflex. More anesthetic is sprayed through the scope to numb your vocal cords. You may be asked to make a high-pitched sound while the scope is passed through the vocal cords.

You will not feel pain during the procedure, but you may feel pressure, or want to gag or cough. Therefore, most patients are given a mild sedative during the procedure; this will keep you comfortable even if you are not completely asleep. You may not eat or drink for about 2 hours, or until you can swallow without choking.

At 4–6 hours after the bronchoscopy, it is not uncommon to have shaking chills; this usually responds quickly to acetaminophen (Tylenol; 650 mg). A small amount of blood in your sputum is not uncommon after a biopsy. The following day you may feel tired and have a low-grade fever, general muscle aches or a sore throat. If you have any concerns about symptoms after a bronchoscopy, please call a physician at (631) 444-2981 during business hours or (631) 689-8333 on off-hours.

Results of a biopsy (tissue sample taken for analysis) may take 2–4 days to be available. As with most biopsies, a negative result does not prove that you don’t have cancer. There is always the chance of a “false-negative” result — a test result that is erroneously classified in a negative category because of imperfect testing methods or procedures.

Bronchoscopy Instructions

If you’re scheduled for a bronchoscopy, please read the following instructions carefully:

• You MUST arrange to have someone (not a taxi) drive you home after the bronchoscopy. This requirement is for your safety. Although you will be observed for several hours after the procedure, you will still be affected by medications you will receive. If you do not have a responsible driver, the procedure will be cancelled.
• DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT the night before the bronchoscopy. If you take over-the-counter medication or any blood thinners including aspirin, please alert the physician. You may be asked to refrain from taking these medications before the procedure.
• You should plan to arrive at University Medical Center 1 hour before the time of your procedure. Stop at Central Registration in the main lobby. Then report to the Endoscopy Suite on the 14th floor, north tower, of the hospital.
• The nurse in the holding area will start an IV line (intra-venous; into a vein), give you the necessary medication, and perform a brief medical evaluation.

You should plan to be in the recovery area for about 2 hours after the procedure is over. If you have any questions before the bronchoscopy, do not hesitate to call us at (631) 444-2981 during the day, or speak with the pulmonary physician on call at night or during the weekend at (631) 689-8333.

Mediastinoscopy

Sometimes a biopsy of the chest’s lymph nodes (pea-sized “glands” that filter impurities from the body) is needed to stage or diagnose lung cancer. This test is performed by a surgeon, who will make a small incision just above your breastbone, and slide a scope down next to your windpipe to remove some of these lymph nodes. The biopsy is performed under general anesthesia. It is done as an outpatient procedure. You will need to have pre-operative testing.

The results of the biopsy will be available in about 4–5 business days. Some people may complain of a sore throat. This will often resolve within a few weeks. If it does not, let your surgeon know. You will have a dressing over the incision, which can be removed after 24 hours, and then you may shower. There will also be small strips across the incision, which will fall off on their own within a few days or can be removed after a week.

Thoracoscopy

Thoracoscopy is a procedure that can be performed by a surgeon to look in your chest. This can be performed to take a biopsy of your lung, to look at the pleura (the lining of the outside of your lung), to remove fluid that can collect in the space between the lung and chest wall, to remove a nodule, or to remove part of the lung.

The surgeon will make a minimum of three small incisions on the side of your chest between the ribs. A scope is used to see the inside of your chest. The surgeon is able to insert the surgical tools through the other two incisions and perform the necessary procedure this way.

This operation is performed under general anesthesia and requires a stay in the hospital. You will need to have pre-operative testing.

After the surgery, you will have a drain, called a chest tube, placed in your chest. The tube helps to drain blood, fluid, and air from around the lung. It is put in the chest cavity through the skin and is attached to a collection system. This tube will usually remain in for about a day or two after surgery. Sometimes it will have to stay in longer as necessary. Once the tube is removed, most people are able to go home that day or the following day.

Thoracoscopy Instructions

Pre-Admission Testing

All patients who need surgery require routine blood tests, a urine test and an electrocardiogram (also known as ECG or EKG; a simple test that provides information about your heart health). This pre-admission testing will be done about 1–2 weeks ahead of your surgery day. Also at that visit you will meet with the nurse practitioner who will review your past medical history and complete a physical exam. It is very important that you tell us about all medications you take, and if you have any allergies.

Please make a list of all your medications including the dosages and how often you take them, and bring this list with you to that appointment. The nurse practitioner will discuss with you what medications you will continue and what should be stopped. In general, medications such as aspirin, clopidogrel (Plavix), and warfarin (Coumadin) will be stopped about a week before surgery to decrease the risk of bleeding at the time of surgery.

Other medications such as a multivitamin that contains vitamin E should also be stopped. If you are a diabetic, special instructions will be given to you about your oral medications and/or your insulin. The nurse practitioner will also ask you to sign a consent form giving your permission for surgery and anesthesia.

At this visit you will also meet with an anesthesiologist. This doctor will explain to you how you will be put to sleep for the procedure, and the different methods of controlling pain after surgery. Very often a catheter (thin tube), placed in your back prior to surgery, is used to help you manage pain after surgery. This special catheter is called an epidural catheter, and liquid pain medication is given to you through it.

An incentive spirometer will also be given to you. This is a device that helps you exercise your lungs after surgery by taking deep breaths. It is normal for you to want to take shallow breaths after the surgery because of the pain; this device encourages you to take deep breaths.

Using the Incentive Spirometer

To deep breathe with the incentive spirometer, do the following:

• Exhale (breathe out) slowly until you cannot push out any more air.
• Place the mouthpiece of the incentive spirometer between your lips, grasp it with your teeth, and close your lips over the mouthpiece.
• Take a slow deep breath through your mouth only.
• Hold your breath for 3 to 5 seconds.
• Remove the mouthpiece.
• Exhale.
• Repeat this exercise 5 to 10 times during every hour when you are awake.

After Surgery

When your surgery is completed, you will be taken to the recovery room, or post-anesthesia ICU (intensive care unit). The nurses there will monitor you until you are ready to be moved to the intermediate care unit of the hospital (16 South). Some patients, because of their other medical conditions, may require to be more closely monitored in an ICU overnight or a few days.

When you wake up you will notice that you are attached to a heart monitor, an IV line (intra-venous; into a vein), and a Foley catheter (thin tube in your bladder to drain urine). You will also notice that you have drainage tubes coming from the side of your chest where the surgery was performed; these tubes are called chest tubes and will drain fluid and air from around your lungs.

In general, patients have two chest tubes. These tubes will remain in for several days; usually, once they are all removed, you are ready to go home.

Exercises at Home

Some exercises increase the movement in your arm if they are done several times a day. These exercises help to prevent a condition called frozen shoulder (also known as adhesive capsulitis) that is characterized by stiffness, pain and limited motion in the shoulder joint:

• Raise your hand to touch your ear on the affected side. Try to walk your fingers over your head to reach your opposite ear.
• Stand 1–2 feet away from a wall. With your affected arm extended toward the wall, walk your fingers up the wall as high as you can. With each attempt, try to walk your fingers higher on the wall.

Follow-up Care

About 2–3 weeks after your discharge from the hospital, you will return to the clinic to see your surgeon. We will ask you to have a chest x-ray prior to that visit. At this visit, the surgeon will look at your incision, review the x-ray, and discuss further with you the results from your surgery.

Dos and Don’ts After Surgery

The following instructions consist of dos and don’ts to help you recover after your surgery. These guidelines are not meant as rigid rules, but as suggestions coming from our experience with patients who have been discharged from the hospital over the years. As a general rule, common sense is a good guideline. For example, there is no reason why you cannot walk up and down stairs, even if you have to take a rest in the middle.

The basic rule is: do what feels good and comfortable. This particularly holds true for the amount of daily walking, which is strongly suggested. Everybody is different and comes to surgery with a different set of lung functions. This will dictate how much a person can walk after surgery.

Dos

• Shower daily and wash incision and drain sites. Use Ivory soap. Let the water stream run over the incision and drain sites. Leave the incisions uncovered. Where the chest tubes used to be, the drain sites may drain for several days, and therefore may need a Band-Aid.
• Wear comfortable, clean clothing. Particularly suitable is cotton clothing, especially if drainage is still an issue.
• Walk as much as you feel able to. Stop when you are short of breath, rest, and then continue. You may not see a daily increase, but over a week’s time you should see an increase in the distance that you are able to walk. Fatigue and tiredness are expected. It is entirely normal that you may have to take a nap in the morning or in the afternoon. Avoid spending prolonged periods of time lying down during the daytime hours.
• Eat foods you find appealing. You may find that your appetite is not nearly as good as it was before you had your surgery. This is entirely normal. You may eat smaller portions and increase the frequency of your meals. We suggest that you weigh yourself twice a week and keep a record of your weight. If you notice that you gain 2–3 pounds over a 24–48 hour period, call us because you may be retaining water. It is normal to lose up to 10 percent of your weight after surgery. Patients often notice that their appetite and taste buds have changed — this is also normal.
• As long as you are taking pain medication, particularly narcotics, you should consider taking a stool softener or laxative. These medications can cause constipation, which may lead to nausea and increased pain.
• Take your pain medications as needed. In the beginning, you should take your medications on a regular basis as they were prescribed. Often, you receive two types of pain medication — one to maintain a steady level of pain relief, and another for “breakthrough” pain as needed.
• Remember, a good night’s sleep is worth a lot and makes the next day much easier. Therefore, taking pain medication at bedtime is a reasonable approach.

Don’ts

• If you were a smoker, do not restart. If your environment (apartment or house) still contains curtains, linens, and furniture full of smoke and tobacco odor that can give you the urge to smoke again, please have them cleaned. The majority of people who develop lung cancer in the U.S. do so because of smoking. If you need help quitting or if others in your household smoke, please call us — we can assist you with a smoking cessation program.
• Do not lift anything heavier than 10 pounds for about 4–6 weeks. Remember that your overall recovery takes about 10–12 weeks.
• Do not drive until your surgeon says that you can. Generally, at about 3 weeks you will be allowed to drive locally.

If you have any concerns or questions, call us at (631) 444-2981. If, by chance, none of the people that you met during your hospital stay answer, and you are connected with HealthConnect, they will be able to direct your call to one of the team members and they will get back to you shortly.

If further referrals to other specialists are needed, these referrals will be addressed at this appointment. The LCEC team will also discuss with you the long-term follow-up care you require.

Fine-Needle Aspiration

Fine-needle aspiration is the process of obtaining a sample of cells and tissue for examination by applying suction through a thin, hollow needle attached to a syringe. The sample of cells and bits of tissue is called a biopsy.

Needle biopsies can be obtained through the chest wall into the lung. Lesions (abnormalities) that can be evaluated in this way are those that are large enough and located near the outside of the lung. Not every lung lesion can be accessed with a needle.

The skin is cleaned and numbed with anesthesia (lidocaine) to prevent pain. The needle is guided into the lesion using imaging such as fluoroscopy or CT scanning. Pain is minimal because most of the pain fibers can be numbed with anesthesia. Some patients cough up a small amount of blood, but this is uncommon and typically mild.

Since the needle punctures the lung, it can sometimes collapse. The likelihood of this depends on the lesion size, depth, and lung condition. If mild, no treatment is needed; if significant, a small chest tube may be inserted to re-expand the lung. This may require a short hospital stay (1–2 days).

Results are typically available in 2–4 days. While accuracy is high, a negative result does not always rule out cancer due to the possibility of a “false-negative” result.

Fine-Needle Aspiration Instructions

• You MUST have a driver with you on the day of your biopsy or THE BIOPSY WILL NOT BE DONE. You cannot take a taxi or bus.
• Do not eat or drink anything after midnight the night before the biopsy.
• Do not take aspirin, ibuprofen (Advil, Genpril, Haltran, IBU, Menadol, Midol, Motrin), or vitamin E for 3–7 days prior to the biopsy. If you are taking any anti-coagulant (blood thinner) such as clopidogrel (Plavix), warfarin (Coumadin), or enoxaparin (Lovenox-heparin), please notify us immediately — these may need to be stopped with physician approval.
• If you see a hematologist for any blood-related condition, please let us know.
• If you are diabetic, please let us know so we can provide instructions on when to stop (temporarily) taking your diabetic medication.
• Take the main elevator to the 4th floor and report to CT Scan – Special Procedures to check in. Expect to be there for about 3–4 hours total.