Surgical Lung Biopsy,
London

For most of the modern era of interstitial lung disease, the diagnostic ladder ran in one direction. Clinical history. High-resolution CT. Bronchoalveolar lavage and transbronchial forceps biopsy. And, when those were insufficient, surgical lung biopsy — a defined operation, typically VATS, designed to obtain tissue of a size and architecture that histopathology could meaningfully report on. The operation was unambiguous, the indication was clear, and the diagnostic gain was real.

That pathway has changed substantially. Transbronchial lung cryobiopsy — the cryoprobe passed through a flexible bronchoscope to freeze and harvest a tissue fragment from peripheral lung — emerged in the early 2010s and matured rapidly. The COLDICE study in 2020 (Troy et al., Lancet Respiratory Medicine) established its diagnostic concordance with surgical biopsy. The 2024 COLD randomised trial showed that a step-up strategy — cryobiopsy first, surgical biopsy only when cryobiopsy is inconclusive — delivers a multidisciplinary diagnostic yield of 89%, against 88% with immediate surgical biopsy, and at one day in hospital rather than five. Cryobiopsy is now the routine first-line histological step in ILD.

The question this page exists to answer is therefore not what surgical lung biopsy is, but what it is now. The answer is narrower and sharper than it used to be: surgical biopsy is reserved for the indications cryobiopsy cannot meet — peripheral disease the cryoprobe cannot reach, multiple anatomic regions that need to be sampled in a single sitting, a cryobiopsy that has been done and not produced a diagnosis, a patient in whom cryobiopsy is contraindicated, and the specific scenario of pulmonary sequestration in which the biopsy is also the treatment.

A residual indication is not a lesser indication. It is the indication where the procedure still earns its place — and where doing it well, with the multidisciplinary structure that turns tissue into diagnosis, still matters.

Key takeaways

1. Surgical lung biopsy is no longer the first diagnostic step in ILD. After EBUS-guided transbronchial cryobiopsy, what remains for surgery is a sharper indication: cryobiopsy non-diagnostic or contraindicated, peripheral or subpleural disease the cryoprobe cannot reach, multiple discordant patterns, or pulmonary sequestration.
2. The MDT, not the biopsy, makes the diagnosis. Burge, Okiror et al. (Thorax 2015) showed ILD MDT re-presentation of 71 consecutive VATS lung biopsies changed the original histology diagnosis in 30% of cases, with further confidence adjustments in another 21%.
3. The COLDICE study (Troy et al., Lancet Respir Med 2020) established cryobiopsy with diagnostic concordance of 70.8% vs SLB and 76.9% for high-confidence MDD. The 2024 COLD trial showed a step-up strategy gives 89% MDD yield vs 88% with immediate SLB — at 1 day in hospital vs 5.
4. Pulmonary sequestration is the other classical surgical indication, where the biopsy is also the treatment. CT angiography preoperatively is essential to define the aberrant systemic arterial supply, which must be identified and controlled before division.
5. Diffuse small nodules where pattern recognition is the question — sarcoidosis, hypersensitivity pneumonitis, organising pneumonia — remain a legitimate surgical biopsy indication where less invasive sampling has been non-diagnostic. Multiple nodules suspicious for metastatic disease belong on the pulmonary metastasectomy pathway, not here.

Pulmonary sequestration is a rare congenital anomaly in which a segment of lung tissue has no normal connection to the bronchial tree and receives its blood supply from an aberrant systemic artery — usually arising from the descending thoracic aorta, occasionally from the abdominal aorta or, rarely, from a coeliac or splenic artery. Two anatomical subtypes are recognised: intralobar sequestration sits within normal lung parenchyma and shares the same visceral pleura; extralobar sequestration has its own pleural covering and lies separately within the chest, occasionally below the diaphragm.

Presentation in adulthood is most commonly with recurrent lower-zone pulmonary infection, haemoptysis, or as an incidental finding on cross-sectional imaging performed for another reason. In a young or middle-aged adult presenting with recurrent same-zone pneumonia or with a persistent posteromedial basal opacity on CT, sequestration sits high on the differential and warrants positive exclusion or confirmation.

Surgical resection is the definitive treatment, and the operation is both diagnostic and curative. The critical preoperative investigation is CT angiography, which defines the aberrant arterial supply, identifies the venous drainage pattern, and allows operative planning. The aberrant systemic artery must be identified and controlled before division of the sequestered segment — uncontrolled bleeding from a divided systemic artery, in a vessel that has not been ligated proximally, is a recognised intraoperative complication and historically a cause of significant morbidity.

The contemporary surgical approach is VATS or robotic in the majority of cases, with thoracotomy reserved for cases of inflammatory adhesion, extensive prior infection, or when the systemic supply is unusually large or anatomically unfavourable. Hospital stay is comparable to other thoracic resections of similar extent; symptomatic resolution after resection is the expected outcome.

Multiple bilateral pulmonary nodules raise a different diagnostic question from a single suspicious nodule. The clinical task is not to determine whether a particular nodule is malignant but to recognise the pattern of disease they collectively represent — and the differential is wide. Sarcoidosis. Hypersensitivity pneumonitis. Organising pneumonia. Granulomatosis with polyangiitis. Miliary tuberculosis. Pulmonary metastatic disease of various primary origins. Each carries a different management implication; getting the pattern right matters.

The diagnostic ladder for diffuse nodules begins with the same modalities as ILD — HRCT, MDT pattern interpretation, bronchoalveolar lavage, transbronchial biopsy, and where appropriate EBUS-TBNA of mediastinal or hilar nodes if pathological lymphadenopathy is present. Where less invasive sampling has been non-diagnostic and the clinical question persists, surgical biopsy of a wedge taken from a region of dominant disease — combined where appropriate with sampling of a less-affected zone — can provide the architectural framework the histopathologist needs to make the call.

This is a distinct indication from biopsy for suspected metastatic disease, where multiple nodules are themselves the cancer rather than the imaging signature of a non-neoplastic process. That pathway runs through the pulmonary metastasectomy framework. It is also distinct from biopsy of a single suspicious sub-centimetre nodule, which is typically approached either by ION robotic navigational bronchoscopy with on-table tissue diagnosis or by combined biopsy-resection in a single sitting — see the ION robotic bronchoscopy and combined biopsy-robotic pages.

The unifying principle across these adjacent pathways is that biopsy is decided by clinical question, not by the existence of nodules in the imaging. The work at consultation is to match the question to the right diagnostic step.

More than any other procedure in thoracic surgery, surgical lung biopsy depends on the multidisciplinary team to convert the procedure into clinical value. A wedge of lung in a pot is not a diagnosis. The diagnosis is produced when the tissue is read in light of the clinical history, the exposure record, the immunology, the lung physiology, and the high-resolution CT — in the same room, by the same group, at the same time.

The pathway routinely engages: respiratory medicine with ILD subspecialty expertise as the clinical anchor and longitudinal manager of the patient; thoracic radiology for HRCT pattern interpretation; pulmonary pathology with specific ILD experience, because non-specialist histopathology reporting demonstrably miscalls a meaningful proportion of cases as the 2015 work above demonstrates; specialist nursing for continuity through the diagnostic and treatment pathway; rheumatology where connective-tissue disease is in the differential; and interventional pulmonology for transbronchial cryobiopsy and where EBUS sampling of associated lymphadenopathy is required.

All surgical biopsy cases are presented at the ILD MDT both before the operation (to confirm the indication and the targeted regions) and after (to integrate the histology with the rest of the picture). Where the diagnosis is uncertain or where the surgical role is exclusively diagnostic, that uncertainty is named at the consultation rather than resolved by assumption.

Surgical lung biopsy is performed at London Bridge Hospital and The Lister Hospital Chelsea. Both hold the da Vinci Xi robotic platform alongside a full VATS service, and both have access to the perioperative infrastructure required for thoracic surgery in patients with significant underlying lung disease — including high-dependency care for the small proportion of patients in whom postoperative respiratory support is required.

For patients with significant fibrotic lung disease, advanced ILD, or co-existing pulmonary hypertension, the perioperative pathway is typically co-ordinated at London Bridge Hospital because of its on-site medical infrastructure and the integrated respiratory and intensive care services.

Outpatient consultations are also available at HCA clinics in Canary Wharf and the City of London. All imaging, MDT correspondence, and prior pathology are reviewed before the consultation; the consultation focuses on whether surgical biopsy adds enough to the diagnostic certainty in the specific case to justify the operation.

Insurance and self-pay: Mr Okiror is recognised by all major UK private medical insurers including AXA, BUPA, WPA, Vitality, Cigna, and Aviva. Self-pay and international patients are equally welcome. Transparent estimates covering surgical, hospital, and anaesthetic costs are provided by Jo Mitchelson before any commitment is made — 020 7952 2882 or pa@lungsurgeon.co.uk.

1. Burge GA, Okiror L, Trotter S, Langman G, Payyappilly S, Naidoo P, Reynolds J, Djearman M, Hussain S, Hoey E, Steyn R, Rajesh P, Bishay E, Naidu B, Kalkat M, Petkova D, Ghani S, Burge PS. Interstitial lung disease MDT presentations post VATS lung biopsy changes the original histological diagnosis in 30%. Thorax 2015;70(Suppl 3):A27 (S41). doi:10.1136/thoraxjnl-2015-207770.47.
2. Troy LK, Grainge C, Corte TJ, Williamson JP, Vallely MP, Cooper WA, et al; COLDICE Investigators. Diagnostic accuracy of transbronchial lung cryobiopsy for interstitial lung disease diagnosis (COLDICE): a prospective, comparative study. Lancet Respir Med 2020;8(2):171–181. PMID 31578168.
3. COLD Study Investigators. Transbronchial cryobiopsy followed by as-needed surgical lung biopsy versus immediate surgical lung biopsy for diagnosing interstitial lung disease: a randomised controlled trial. Lancet Respir Med 2024. (Step-up strategy: 89% MDD yield, 1-day stay vs immediate SLB 88% yield, 5-day stay.)
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6. Hetzel J, Wells AU, Costabel U, Colby TV, Walsh SLF, Verschakelen J, et al. Transbronchial cryobiopsy increases diagnostic confidence in interstitial lung disease: a prospective multicenter trial. Eur Respir J 2020;56(6):1901520. PMID 32675208.
7. Mikolasch TA, Borg E, Thakrar R, Holmes V, Booth HL, Porter JC, Navani N. Transbronchial cryobiopsies in the diagnosis of interstitial lung diseases — first UK experience. Thorax 2015;70(Suppl 3):A27 (S42). doi:10.1136/thoraxjnl-2015-207770.48.