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      Transbronchial Lung Cryobiopsy in the Diagnosis of Fibrotic Interstitial Lung Diseases

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          Abstract

          Background

          Histology is a key element for the multidisciplinary diagnosis of fibrotic diffuse parenchymal lung diseases (f-DPLD) when the clinical-radiological picture is nondiagnostic. Transbronchial lung cryobiopsy (TBLC) have been shown to be useful for obtaining large and well-preserved biopsies of lung parenchyma, but experience with TBLC in f-DPLD is limited.

          Objectives

          To evaluate safety, feasibility and diagnostic yield of TBLC in f-DPLD.

          Method

          Prospective study of 69 cases of TBLC using flexible cryoprobe in the clinical-radiological setting of f-DPLD with nondiagnostic high resolution computed tomography (HRCT) features.

          Results

          Safety: pneumothorax occurred in 19 patients (28%). One patient (1.4%) died of acute exacerbation. Feasibility: adequate cryobiopsies were obtained in 68 cases (99%). The median size of cryobiopsies was 43.11 mm 2 (range, 11.94–76.25). Diagnostic yield: among adequate TBLC the pathologists were confident (“high confidence”) that histopathologic criteria sufficient to define a specific pattern in 52 patients (76%), including 36 of 47 with UIP (77%) and 9 nonspecific interstitial pneumonia (6 fibrosing and 3 cellular), 2 desquamative interstitial pneumonia/respiratory bronchiolitis–interstitial lung disease, 1 organizing pneumonia, 1 eosinophilic pneumonia, 1 diffuse alveolar damage, 1 hypersensitivity pneumonitis and 1 follicular bronchiolitis. In 11 diagnoses of UIP the pathologists were less confident (“low confidence”). Agreement between pathologists in the detection of UIP was very good with a Kappa coefficient of 0.83 (95% CI, 0.69–0.97). Using the current consensus guidelines for clinical-radiologic-pathologic correlation 32% (20/63) of cases were classified as Idiopathic Pulmonary Fibrosis (IPF), 30% (19/63) as possible IPF, 25% (16/63) as other f-DPLDs and 13% (8/63) were unclassifiable.

          Conclusions

          TBLC in the diagnosis of f-DPLD appears safe and feasible. TBLC has a good diagnostic yield in the clinical-radiological setting of f-DPLD without diagnostic HRCT features of usual interstitial pneumonia. Future studies should consider TBLC as a potential alternative to SLBx in f-DPLD.

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          Most cited references19

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          Complications of video-assisted thoracoscopic lung biopsy in patients with interstitial lung disease.

          L Kaiser, Joseph Shrager, D J Rossman … (2007)
          Current guidelines recommend surgical lung biopsy for diagnosis of interstitial lung diseases (ILDs) in selected patients. To shed light on the risk-benefit ratio for this recommendation, we examined the morbidity and mortality associated with video-assisted thoracoscopic surgical (VATS) lung biopsy in a group of outpatients. A retrospective cohort study was conducted of 68 consecutive ambulatory patients with radiographically apparent interstitial lung disease (ILD) referred for VATS biopsy during a 6-year period. Incidence of postoperative mortality, prolonged air leaks, pneumonias, and re-admissions were calculated. Risk factors for complications of surgery were examined. Three deaths occurred within 60 days after biopsy for a mortality rate of 4.4% (95% confidence interval [CI], 1% to 12%), and 19.1% (95% CI, 11% to 31%) experienced one or more complications of surgery. Risk factors for morbidity included preoperative dependence on oxygen therapy and pulmonary hypertension. The three patients who died had usual interstitial pneumonia on their biopsy specimen and were reintubated postoperatively for acute lung injury. Aggregation of articles published over the past 10 years reporting on surgical lung biopsy for the diagnosis of ILD yielded a postoperative mortality rate of 2% to 4.5%. VATS lung biopsy for diagnosis of ILD, even in ambulatory patients, is not an entirely benign procedure. Biopsy rarely may trigger an acute exacerbation of usual interstitial pneumonitis. The risk of postoperative complications appears to be greatest in those dependent on oxygen and those who have pulmonary hypertension. This information may be used in weighing the risk-benefit ratio of biopsy in individual patients.
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            Acute exacerbation of interstitial pneumonia following surgical lung biopsy.

            Masanori Kitaichi, Takeshi Johkoh, Toyoharu Yokoi … (2006)
            Surgical lung biopsy (SLB) plays an important role in the diagnosis of interstitial pneumonia, however, the occurrence of acute respiratory failure following SLB remains largely unreported. We evaluated the incidence, clinical features, therapy and prognosis of acute exacerbation of interstitial pneumonia following SLB. Retrospective study of consecutive patients who underwent SLB to establish a diagnosis of diffuse lung disease between May 1989 and April 2000. Patients with an acute exacerbation following lung biopsy were studied, and the HRCT images of the chest before and after surgery were reviewed. Among the 236 consecutive patients with interstitial pneumonia who underwent a surgical lung biopsy, five (2.1%) (IPF, 3; NSIP, 1; COP, 1) developed acute exacerbation of the diffuse lung disease in the course of 1-18 days after SLB. The extent of parenchymal involvement on HRCT before surgery was not significantly different between operated and contralateral nonoperated lung. Significantly increased regions of parenchymal involvement on HRCT were seen postoperatively compared with the preoperative CT in both the operated (20.7+/-12.5% versus 38.2+/-10.8%, P = 0.0431) and nonoperated lung (22.7+/-13.8% versus 70.5+/-24.4%, P = 0.0431), but the extent of the parenchymal involvement was significantly greater on the nonoperated side (P = 0.0251). Two of the 3 IPF patients died from the acute exacerbation. It is important to be aware of the possibility of acute exacerbation of interstitial pneumonia following SLB even after an apparently uneventful immediate postoperative course. The asymmetric image findings suggest that intraoperative respiratory management is a possible etiologic factor.
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              High short-term mortality following lung biopsy for usual interstitial pneumonia.

              Julie M Allen, H D Tazelaar, Evan Myers … (2001)
              Usual interstitial pneumonia (UIP) is a specific histological pattern of interstitial pneumonia most often associated with the clinical syndrome of idiopathic pulmonary fibrosis (IPF). There is controversy regarding the use of surgical lung biopsy in the diagnosis of UIP, and the risk of lung biopsy in these patients is largely unknown. This study investigated the 30 day surgical mortality rate in patients undergoing surgical lung biopsy for UIP. Patients undergoing surgical lung biopsy over a 10-yr period from 1986-1995 with the ultimate diagnosis of UIP (with or without underlying connective tissue disease) were identified. Pathology, computed tomography, medical records, and survival were assessed. Ten of sixty patients with usual interstitial pneumonia were found to be dead within 30 days of surgical biopsy. All of these were patients with idiopathic UIP, unassociated with connective tissue disease (clinical condition of IPF). In conclusion, patients with usual interstitial pneumonia of the idiopathic type, who present with atypical features, may be at higher risk for death following surgical biopsy than patients presenting with more typical features or patients with other interstitial illnesses.
              Article 0 comments Cited 46 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Martin R. J. Kolb: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2014
                Publication date (Electronic): 28 February 2014
                Volume: 9
                Issue: 2
                Electronic Location Identifier: e86716
                Affiliations
                [1 ]Department of Diseases of the Thorax, G.B Morgagni Hospital, Forlì, Italy
                [2 ]Department of Pathology, S. Maria Nuova Hospital-I.R.C.C.S, Reggio Emilia, Italy
                [3 ]Department of Pathology, Mayo Clinic, Scottsdale, Arizona, United States of America
                [4 ]Department of Pathology, G.B Morgagni Hospital, Forlì, Italy
                [5 ]Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
                [6 ]Biostatistics and Clinical Trials Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola Forlì-Cesena, Italy
                [7 ]Department of Radiology, G.B Morgagni Hospital, Forlì, Italy
                [8 ]Department of Pathology, Verona University, Verona, Italy
                McMaster University, Canada
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: GLC ST AC TVC JHR Carlo Gurioli VP MC. Performed the experiments: GLC Carlo Gurioli VP. Analyzed the data: GLC ST AD EC PT SP CR Christian Gurioli MR. Contributed reagents/materials/analysis tools: EC PT. Wrote the paper: GLC ST AC TVC JHR VP MC.

                Article
                Publisher ID: PONE-D-13-42052
                DOI: 10.1371/journal.pone.0086716
                PMC ID: 3938401
                PubMed ID: 24586252
                SO-VID: 3577e938-98d8-4e6f-a0c7-f9f8458ed53d
                Copyright statement: Copyright @ 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 15 October 2013
                Date accepted : 11 December 2013
                Page count
                Pages: 7
                Funding
                This study is supported by Associazione Morgagni Malattie Polmonari. The sponsor covers only the publication's costs. The entire study was realized without any financial support. In particular the funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Clinical research design
                Subject: Prospective studies
                Subject: Diagnostic medicine
                Subject: Pathology
                Subject: Anatomical pathology
                Subject: Histopathology
                Subject: Clinical pathology
                Subject: General pathology
                Subject: Drugs and devices
                Subject: Medical devices
                Subject: Pulmonology
                Subject: Interstitial lung diseases

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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