A lung biopsy is a medical procedure that removes a small piece of lung tissue to check it under a microscope for infection, scarring (fibrosis), cancer, etc. Being told that you may need a lung biopsy can be frightening. It is natural to wonder whether the procedure is truly necessary, what doctors hope to learn from it, and whether the potential benefits are worth the risks. The most important thing to understand is that not everyone with interstitial lung disease (ILD) or pulmonary fibrosis needs a lung biopsy.
In many cases, doctors can reach a confident diagnosis using a medical history, bloodwork, pulmonary function testing and a high-resolution CT scan of the chest. A biopsy is generally considered when the diagnosis remains uncertain and examining lung tissue is reasonably likely to change the treatment plan.
Why might a doctor recommend a lung biopsy?
Interstitial lung disease is not a single disease. It is a broad category containing more than 200 conditions that can cause inflammation, scarring or both. Some of these conditions may look similar on a CT scan but require very different treatments. For example, one disease may be treated with an antifibrotic medication, while another may be treated by avoiding a particular exposure or using medication that suppresses inflammation.
A doctor may therefore recommend a biopsy when:
- The high-resolution CT scan does not show a clear or typical pattern.
- Several possible ILD diagnoses remain after other testing.
- The distinction between those diagnoses would change treatment.
- Hypersensitivity pneumonitis is suspected but cannot be confirmed through the exposure history, imaging, bloodwork or bronchoscopy.
- A less common condition, infection, malignancy or another lung process needs to be ruled out.
- The ILD remains “unclassifiable” after review by an experienced team.
The goal of a biopsy is not simply to give the disease another name. The result should provide information that could meaningfully influence care.
When might a biopsy not be necessary?
A biopsy may not be needed when the diagnosis is already sufficiently clear from less-invasive testing. For example, idiopathic pulmonary fibrosis, or IPF, is associated with a radiologic pattern called usual interstitial pneumonia, or UIP. When a high-resolution CT scan shows a definite UIP pattern and the patient’s history fits IPF, current guidelines generally recommend against surgical lung biopsy. A biopsy may also be unnecessary when:
- A connective tissue disease has already been diagnosed and the lung findings are consistent with that disease.
- Medication toxicity or radiation is the clear cause.
- The history and imaging strongly support an occupational or environmental lung disease.
- The biopsy result would not change the treatment recommendation.
- The risks of the procedure are greater than the expected benefit.
- The disease is advanced and the immediate priority is transplantation, symptom management or another urgent treatment decision.
Even a CT pattern described as “probable UIP” does not automatically mean that a biopsy is required. In some patients, an experienced multidisciplinary team can make a sufficiently confident diagnosis without obtaining lung tissue. The American Thoracic Society’s IPF diagnostic guidance emphasizes combining the clinical history, imaging and—when needed—pathology rather than relying on one test alone.
“Lung biopsy” can mean different procedures
Not every lung biopsy requires surgery. The type of procedure recommended depends on the suspected diagnosis, the location of the disease and the amount of tissue needed.
Transbronchial forceps biopsy: During this procedure, a doctor passes a bronchoscope through the mouth or nose and removes small tissue samples with forceps. These samples may help diagnose diseases that affect the airways or form granulomas, such as sarcoidosis. However, they are often too small to identify the patterns of fibrosis needed to distinguish certain ILDs.
Transbronchial lung cryobiopsy: Cryobiopsy is also performed through a bronchoscope, but a small probe freezes and removes a larger piece of lung tissue. It can provide more information than a standard forceps biopsy and may be an alternative to surgical biopsy for selected patients. However, it can cause bleeding or a collapsed lung and should generally be performed at a medical center with specific experience in the procedure. The European Respiratory Society guideline addresses the use of cryobiopsy as an alternative method of obtaining tissue in patients with undiagnosed ILD.
Surgical lung biopsy: A surgical lung biopsy usually involves video-assisted thoracoscopic surgery, often called VATS. A surgeon makes small incisions in the chest and removes tissue from more than one area of the lung.
Surgical biopsy generally provides the largest and most useful samples, but it is also the most invasive option and carries the greatest risk.
What are the possible benefits and risks?
The potential benefits and risks depend on the type of biopsy, the patient’s lung function, overall health, whether the procedure is elective and the experience of the medical center.
To learn more:
- View part 2 of this educational blog series: https://pulmonaryfibrosisnow.org/sign-up-form/
- Sign up for support group: https://pulmonaryfibrosisnow.org/sign-up-form/
- Join our community forum: https://www.facebook.com/groups/1198991686930106
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