Thoracoscopic biopsy in children with diffuse parenchymal lung disease

Lung biopsies in infants and children in critical care situation

INTRODUCTION

Lung biopsy is considered as the last step investigation for diagnosing lung diseases; however, its indication must be carefully balanced with its invasiveness. The present study aims to evaluate the diagnostic yield of lung biopsy in critically ill patients hospitalized in the pediatric intensive care unit (ICU).

MATERIAL AND METHODS

Children who underwent a lung biopsy in the ICU between 1995 and 2022 were included. Biopsies performed in the operating room and post-mortem biopsies were excluded.

RESULTS

Thirty-one patients were included, with a median age of 18 days (2 days to 10.8 years); 21 (67.7%) were newborns. All patients required invasive mechanical ventilation, 26 (89.7%) had a pulmonary hypertension, and 22 (70.9%) were placed under extracorporeal membrane oxygenation (ECMO). The lung biopsy led to a diagnosis in 81% of the patients. The diagnostic reliability seemed to decrease with age (95% in newborns, 71% in 1 month to 2 years and 0/3 patients aged over 2 years old). Diffuse developmental disorders of the lung accounted for 15 (49%) patients, primarily alveolar capillary dysplasia, followed by surfactant disorders in 5 (16%) patients. Complications occurred in 9/31 (29%) patients including eight under ECMO, with massive hemorrhages in seven cases.

DISCUSSION AND CONCLUSION

In critical situations, lung biopsy should be performed. Lung biopsy is a reliable diagnostic procedure for neonates in critical situation when a diffuse developmental disorder of the lung is suspected. The majority of lung biopsy complication was associated with the use of ECMO. The prospective evaluation of the complications of such procedure under ECMO, and particularly over 10 days of ECMO and in children over 2-year-old remains to be ascertained.

Diagnostic accuracy and therapeutic relevance of thoracoscopic lung biopsies in children

INTRODUCTION

Histopathological assessment of lung biopsies does play an important diagnostic role in children's interstitial lung disease (ChILD). Thoracoscopic lung biopsy has been shown to be safe and effective. The aim of this study was to evaluate the diagnostic accuracy of thoracoscopic lung biopsies in children with ChILD. Furthermore, therapeutic relevance of the procedure, operative details, and perioperative complications of our series were investigated.

METHODS

We retrospectively reviewed all consecutive thoracoscopic lung biopsies taken from children with suspected ChILD in our institution over an 11-year period. Feasibility and complications were evaluated as well as histopathological diagnoses according to the recent ChILD classification and relevance of the procedure for medical treatment.

RESULTS

Fifty-nine patients (54.2% male, median age 7 years [8 d-18 y]) underwent 112 thoracoscopic lung biopsies. An endostapler (27%), endoloop ligature (63%), or cut and suture technique (10%) were used. A chest tube was placed in 54% of the cases. Complications occurred in 15% of cases and mainly consisted of pneumothoraces or bleedings. Adequate tissue was obtained in all but one case and the biopsy led to a specific diagnosis according to the ChILD classification in 98%. Medical treatment of the underlying disease was changed due to the results of the biopsy in 86%.

CONCLUSIONS

The diagnostic accuracy of thoracoscopic lung biopsies in children with suspected ChILD is high. The histopathologic results lead to a disease-specific treatment in the majority of the cases. Thoracoscopic lung biopsy is a safe and effective procedure with a low complication rate.

Usefulness of Lung Biopsy in Pediatric Pulmonary Conditions

Lung biopsy, performed as a diagnostic procedure in children with pulmonary disease to guide treatment, may not provide a diagnosis or change therapy. We therefore reviewed our experience with the procedure to determine its use. We reviewed all children undergoing lung biopsy at two large children's hospitals, 2001 to 2010. Lesions were categorized as either diffuse or localized based on final radiological interpretations. Pathological interpretations and subsequent treatment regimens were reviewed for specificity of diagnoses and any changes in therapy. Of 99 patients, there were 14 diffuse and 85 localized pulmonary lesions. Biopsy confirmed the radiological diagnosis in 29 (29%), 71 per cent (70) receiving a new histopathological diagnosis, or a definitive one from a range or radiological possibilities, both diffuse (10 of 14) and diffuse lesions (60 of 85, both 71%). Forty-five per cent (44 of 99) had sufficient clinical data to ascertain treatment before and after biopsy. A significant change in treatment occurred in only 16 per cent (seven of 44) without a significant difference between diffuse (33% [three of nine]) and localized (11% [four of 35]) lesions ( P = 0.38). Twenty-five per cent (25 of 99) of patients undergoing lung biopsy died. Lung biopsy is performed for conditions with a high mortality rate. The procedure yields a definitive diagnosis in the majority of cases but infrequently changes therapy.

The utility of surgical lung biopsy in immunocompromised children

OBJECTIVE

To determine the utility of lung biopsy in immunocompromised pediatric patients with suspected infectious lung disease and to evaluate the risks and benefits of biopsy in the era of minimally invasive thoracic surgery.

STUDY DESIGN

We reviewed charts for 50 immunocompromised patients who underwent surgical lung biopsy between January 2000 and July 2011 at a free-standing, tertiary care, urban children's hospital. The primary outcome variable was "benefit from biopsy," defined as change in therapy based on biopsy results. The secondary outcome variable was survival to discharge. The χ(2) analysis was used for categorical variables and Student t test for continuous variables.

RESULTS

Biopsy provided a definitive histopathologic or microbiologic diagnosis in 25 patients (50%), the most common diagnosis being fungal infection (22%). Diagnostic and nondiagnostic biopsy results yielded benefit in 25 surviving patients (50%) for whom the biopsy results were used to tailor treatment. Taking more than one biopsy specimen did not improve diagnostic yield. Six patients (12%) had a major morbidity including reinsertion of chest tube after initial chest tube removal (3), prolonged air leak (1), and a new requirement for mechanical ventilation postoperatively (2). Two patients died postoperatively, but the mortalities were not clearly related to surgery. Underlying diagnoses included hematologic malignancy (64%), primary immunodeficiency (12%), organ transplant recipient (12%), and solid malignancy (10%). Twelve patients (24%) had undergone stem cell transplantation.

CONCLUSION

Lung biopsy in immunocompromised pediatric patients alters therapy in 50% of cases, but predictably carries identifiable morbidities. This study is limited by its retrospective nature.

Thoracoscopic resection of congenital pulmonary malformations in infants: is the feasibility related to the size of the lesion?

BACKGROUND

The size of congenital pulmonary malformation (CPM) in infants might interfere with the feasibility of thoracoscopic resection. This study was undertaken to evaluate the impact of the size of CPM on the applicability of video-assisted thoracic surgery (VATS) in infants.

METHODS

Twenty-two infants were operated on for CPM from November 2000 to June 2009. The intra- and postoperative course was analyzed retrospectively from patient charts. Preoperative scans were evaluated blindly by a radiologist to calculate the relation between the maximum size of the lesion and the thoracic diameter in VATS and open procedures.

RESULTS

VATS was performed in 14 (64%) of the 22 patients and thoracotomy in 8. VATS was successfully performed in 11 (79%) of the 14 patients, whereas VATS was converted to thoracotomy due to lack of overview in 3 (21%). The mean relative size of CPM at preoperative imaging was 0.34 ± 0.05 (range: 0.3-0.4) in patients who received successful VATS, 0.57 ± 0.06 (range: 0.5-0.6) in converted cases, and 0.68 ± 0.10 (range: 0.5-0.8) in infants who underwent thoracotomy. The relative CPM size was significantly lower in successful VATS than in cases of conversion (P<0.01) and thoracotomy (P<0.01).

CONCLUSIONS

The relative size of CPM at preoperative imaging might be useful information for a decision-making on the use of VATS in infants. A relative CPM size below 0.5, which is less than half of the thoracic diameter, indicates a good feasibility for thoracoscopic resection of CPM. A larger size may indicate that VATS might be technically difficult.