الفهرس 
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Abstract
The identification of the peripherally settled pulmonic nodules has remained a diagnostic quandary. Within the setting of recent guidelines for carcinoma screening
Term solitary pulmonary nodule refers to a rounded lesion thirty millimetre or smaller in diameter with a minimum of two thirds of its margins enclosed by pulmonary parenchyma.
Specific clinical options have an effect on the probability of benignity or malignancy, and in conjunction with the imaging characteristics of the lesion will impact each the diagnostic approach and selection of therapeutic choices.
Diffuse pattern of pulmonary nodules, ranging from a few millimeters to 1 cm in diameter, may indicate interstitial or airspace disease . The main distribution of the nodules may indicate the underlying disease.
Surgical resection is favored for lesions at high risk of malignancy, whereas radiological follow-up is preferred for low risk lesions. For patients with intermediate risk lesions, additional tests are recommended, which should be selected based on nodule size, location, relation to a patent airway, risk of complications in the individual patient, and available expertise. CT scan-guided transthoracic needle aspiration (TTNA) is generally preferred for nodules located in proximity of the chest wall or for deeper lesions, provided that fissures do not need to be traversed and there is no surrounding emphysema.
For peripheral nodules, radial endobronchial ultrasound (EBUS) guided biopsy and electromagnetic navigation guidance are recommended if available. unavailability of advanced diagnostic techniques in most centers makes conventional bronchoscopy is still performed for many patients with peripheral pulmonary lesions.
The bronchoscope usually becomes wedged at a segment of the tree, and the endoscopic tools, such as diagnostic brushes or forceps, are pushed out toward the targeted lung area, guided by fluoroscopy.
Video assisted thoracic surgery (VATS) can perform those previously mentioned indications; however it is an invasive procedure requiring general anaesthesia, two surgical openings or thoracotomy and selective double lumen intubation. It entails a long duration of hospitalization and is contraindicated in very ill patients
Forceps lung biopsy during thoracoscopy under local anaesthesia has been used for many years by pulmonologists and has been frequently described as an integral technique of medical thoracoscopy
Thoracoscopic lung biopsy can be done using endoscopic stapler or using coagulating forceps. Coagulating forceps set at 60 to 100 watt can coagulate and seal the cut surface.
Ultrasound (US) is most often used for imaging guidance for procedures of the pleura or pleural space.US is commonly used to access pleural fluid collections or for biopsy of peripheral lung and pleural lesions.
Transthoracic needle biopsy (TTNB) is a commonly performed procedure in thoracic interventional radiology. TTNB can safely and efficiently provide an accurate cytologic or histologic diagnosis.
In the present study forty five patients with peripheral parenchymal lung lesions with chest wall contact which are undiagnosed by noninvasive testing were recruited from the Alexandria main university hospital, chest diseases department. They were randomly allocated into three equal groups:-
- group A: fifteen patients underwent transbronchial lung biopsy under fluoroscopic guidance.
- group B: fifteen patients underwent medical thoracoscopy and thoracoscopic lung biopsies using coagulating forceps .
- group C: fifteen patients underwent US-guided transthoracic core needle biopsies
Patients with any of the following findings were excluded:
1-Coagulation deficit (prothrombin level <50% or platelet count <70,000 cells.mm), 2-severe respiratory insufficiency (arterial carbon dioxide tension (Pa,CO2) >60 mmHg) 3-inability to oxygenate the patient during the procedure 4-mechanical ventilation 5- radiological signs suggesting significant pleural adhesions or major bullous degeneration of the lung.
As regard the histopathological diagnosis of lung biopsies in our study, two cases (13.3%) in bronchoscopy group, six cases (40%) in thoracoscopy group and four cases (40%) in US group were diagnosed as malignant deposits. two (13.3%) patients in bronchoscopy group a single case (6.7%) of each group of thoracoscopy and US had bronchioloalveolar carcinoma .two (13.3%) patients of bronchoscopy cases, three (20%) of thoracoscopy cases and four (26.7%) patients of US cases had invasive adenocarcinoma. One case in each of bronchoscopy and thoracoscopy groups had small cell lung cancer. A single case in bronchoscopy group had cryptogenic organizing pneumonia while two (13.3%) cases in each group showed other forms of interstitial lung disease. We met inconclusive results in five cases (33.3%),two cases (13.3%) and four cases (26.7%) in bronchoscopy, thoracoscopy and US guided groups respectively. Thus, diagnostic accuracy in our study was 67.7%, 87.7% and 73.3% in bronchoscopy, thoracoscopy and US guided groups respectively.
Only minor complications were encountered in the studied group of patients. Local wound infection was observed in three patients (20%) in thoracoscopy group only and it was managed by frequent sterile dressings ,local antiseptic solution and local antibiotics. Subcutaneous emphysema was encountered in 4 patients (26.7%) only in thoracoscopy group. Pneumothorax was encountered only in one patient (6.7%) of each of bronchoscopy and US groups. persistent air leak was not encountered in any of the three groups . chest pain was reported in only one patient (6.7%) in bronchoscopy group, 8 patients (53.3%) in thoracoscopy group and in 5patients (33.3%)of cases in US group. Haemoptysis was not reported in thoracoscopy group while it was reported in eight (53.3%) cases of bronchoscopy group and two (13.3%) cases of US group. Haemoptysis was mild and self-limited in 1-2 days in all cases and in addition we did not encounter significant bleeding in any of the three groups.