[Transbronchial lung biopsy using cryoprobes]

The efficacy and safety of modified transbronchial cryobiopsy in the diagnosis of interstitial lung disease

The objective of this study is to investigate the efficacy and safety of flexible transbronchial cryobiopsy (TBCB) in the diagnosis of diffuse parenchymal lung disease (DPLD) in a routine bronchoscopy examination room under analgesia and sedation, using neither endotracheal intubation or rigid bronchoscope nor fluoroscopy or general anesthesia. The data from 50 DPLD patients with unknown etiology who were treated in the Affiliated Hospital of Guilin Medical College from May 2018 to September 2020 were collected, and 43 were eventually included. The specimens obtained from these 43 patients were subjected to pathological examination, pathogenic microorganism culture, etc, and were analyzed in the clinical-radiological-pathological diagnosis mode to confirm the efficacy of TBCB in diagnosing the cause of DPLD. Subsequently, the intraoperative and postoperative complications of TBCB and their severity were closely observed and recorded to comprehensively evaluate the safety of TBCB. For the 43 patients included, a total of 85 TBCB biopsies were performed (1.98 [1, 4] times/case), and 82 valid tissue specimens were obtained (1.91 [1, 4] pieces/case), accounting for 96.5% (82/85) of the total sample. The average specimen size was 12.41 (1, 30) mm2. Eventually, 38 cases were diagnosed, including 11 cases of idiopathic pulmonary fibrosis, 5 cases of connective tissue-related interstitial lung disease, 5 cases of nonspecific interstitial pneumonia, 4 cases of tuberculosis, 4 cases of occupational lung injury, 3 cases of interstitial pneumonia with autoimmune characteristics, 1 case of lung cancer, 2 cases of interstitial lung disease (unclassified interstitial lung disease), 1 case of hypersensitivity pneumonitis, 1 case of pulmonary alveolar proteinosis, and 1 case of fungal infection. The remaining 5 cases were unclarified. For infectious diseases, the overall etiological diagnosis rate was 88.4% (38/43). With respect to complications, pneumothorax occurred in 4 cases (9.3%, 4/43, including 1 mild case and 3 moderate cases), of which 3 cases (75%) were closed by thoracic drainage and 1 case (25%) was absorbed without treatment. In addition, 22 cases experienced no bleeding (51.2%) and 21 cases suffered bleeding to varying degrees based on different severity assessment methods. TBCB is a minimally invasive, rapid, economical, effective, and safe diagnostic technique.

Bronchoalveolar Lavage Complements Transbronchial Cryobiopsy Diagnosis in Diffuse Interstitial Lung Diseases

BACKGROUND

Bronchoalveolar lavage (BAL) is a technique classically used for the study of diffuse interstitial lung diseases (DILDs). Given the recent advances in the diagnosis of DILD by transbronchial cryobiopsy (TBCB), it is relevant to assess what BAL can contribute to TBCB.

PATIENTS AND METHODS

This is a retrospective descriptive study that included patients with DILD who, between 2013 and 2017, underwent BAL and TBCB in the same bronchoscopy intervention. We evaluated the complementary information provided by BAL to TBCB that facilitated the diagnosis by a multidisciplinary committee. Epidemiological, clinical, and functional variables and high-resolution chest tomography findings were recorded, along with complications associated with the procedures.

RESULTS

A total of 60 patients were included. TBCB, conditioned by the underlying radiologic pattern, provided diagnostic information in 75% of cases. BAL provided complementary information that supported the diagnosis and treatment in 22% of cases. Differential BAL findings were related to microbiology, cell count, and immunology. Regarding the safety of the procedure, 47% of the patients experienced complications, although none were serious.

CONCLUSION

BAL findings contribute to TBCB findings in the diagnosis of DILDs, with no serious complications associated with their combined use.

The Role of Ultrasonography in the Diagnosis and Decision Algorithm for the Management of Pneumothorax after Transbronchial Lung Cryobiopsy

BACKGROUND

Pneumothorax is one of the main complications of transbronchial lung cryobiopsy (TBLC). Chest ultrasound (CUS) is a radiation-free alternative method for pneumothorax detection.

OBJECTIVE

We tested CUS diagnostic accuracy for pneumothorax and assessed its role in the decision algorithm for pneumothorax management. Secondary objectives were to evaluate the post-procedure pneumothorax occurrence and risk factors.

METHODS

Eligible patients underwent TBLC, followed by chest X-ray (CXR) evaluation 2 h after the procedure, as our standard protocol. Bedside CUS was performed within 30 min and 2 h after TBLC. Pneumothorax by CUS was defined by the absence of lung sliding and comet-tail artefacts and confirmed with the stratosphere sign on M-mode. Pneumothorax size was determined through lung point projection on CUS and interpleural distance on CXR and properly managed according to clinical status.

RESULTS

Sixty-seven patients were included. Nineteen pneumothoraces were detected at 2 h after the procedure, of which 8 (42.1%) were already present at the first CUS evaluation. All CXR-detected pneumothoraces had a positive CUS detection. There were 3 discordant cases (κ = 0.88, 95% CI: 0.76-1.00, p < 0.001), which were detected by CUS but not by inspiration CXR. We calculated a specificity of 97.5% (95% CI: 86.8-99.9) and a sensitivity of 100% (95% CI: 87.2-100) for CUS. Pneumothorax rate was higher when biopsies were taken in 2 lobes and if histology had pleural representation. Final diagnosis was achieved in 79.1% of patients, with the most frequent diagnosis being hypersensitivity pneumonitis. Regarding patients with large-volume pneumothorax needing drainage, the rate of detection was similar between CUS and CRX.

CONCLUSION

CUS can replace CXR in detecting the presence of pneumothorax after TBLC, and the lung point site can reliably indicate its size. This useful method optimizes time spent at the bronchology unit and allows immediate response in symptomatic patients, helping to choose optimal treatment strategies, while preventing ionizing radiation exposure.

Safety and diagnostic yield of transbronchial lung cryobiopsy by flexible bronchoscopy using laryngeal mask airway in diffuse and localized peripheral lung diseases: A single-center retrospective analysis of 326 cases

Background

Intubation with either an endotracheal tube or a rigid bronchoscope is generally preferred to provide airway protection as well as to manage unpredictable complications during transbronchial lung cryobiopsy (TBLC). The laryngeal mask airway has been described as a safe and convenient tool for airway control during bronchoscopy.

Aims and Objectives

In this study, we evaluated the safety and outcome of using a laryngeal mask airway (LMA) as a conduit for performing TBLC by flexible video bronchoscopy (FB).

Methods

We retrospectively analyzed the database of the patients who underwent TBLC between November 2015 and September 2019. The procedure was performed using FB through LMA under general anesthesia. Prophylactic occlusion balloon was routinely used starting January 2017 onwards. Radial endobronchial ultrasound (R-EBUS) guidance was used for TBLC in the localized lung lesions when deemed necessary. Multidisciplinary consensus diagnostic yield was determined and periprocedural complications were recorded.

Results

A total of 326 patients were analysed. The overall diagnostic yield was 81.60% (266/326) which included a positive yield of 82.98% (161/194) in patients with diffuse lung disease and 79.54% (105/132) in patients with localized disease. Serious bleeding complication occurred in 3 (0.92%) cases. Pneumothorax was encountered in 8 (2.45%) cases. A total of 9 (2.76%) cases had at least 1 major complication.

Conclusion

This study demonstrates that the use of LMA during TBLC by flexible bronchoscopy allows for a convenient port of entry, adequate airway support and effective endoscopic management of intrabronchial haemorrhage especially with the use of occlusion balloon.

Transbronchial Cryobiopsy in Interstitial Lung Diseases: State-of-the-Art Review for the Interventional Pulmonologist

Interstitial lung diseases are a heterogenous group of disorders that are often difficult to diagnose precisely. Clinical, laboratory, radiographic, and histologic information may be needed to arrive at the correct diagnosis. The multidisciplinary discussion has been proven to be useful in this patient group. Transbronchial cryobiopsy has become a popular method for obtaining tissue samples. Over the course of the last decade, there has been a significant amount of research assessing the feasibility, safety, and diagnostic endpoints of transbronchial cryobiopsy in patients with interstitial lung disease. Data continues to mount to support its use, which has been reflected in guidelines and expert panel reports. Patient selection, procedural performance, and appropriate specimen handling are critical factors for success. A coordinated approach by pulmonologists with expertise in interstitial lung diseases, interventional pulmonologists, and thoracic pathologists is essential. In this evidence-based narrative review, we address transbronchial cryobiopsies from these three distinct perspectives. In addition, the current literature was used to address nine common procedural questions.

Diagnostic approach in parenchymal lung diseases: transbronchial lung biopsy or cryobiopsy?

Background/aim

Diagnosis of interstitial lung diseases requires a multidisciplinary approach, and a gold standard for histological diagnosis is open lung biopsy. Transbronchial lung biopsy (TBLB) and in recent years an alternative method, cryobiopsy (TBLC), are used for the diagnosis of parenchymal lung lesions. The aim of this study is to compare the efficacy of concomitant conventional TBLB and TBLC.

Materials and methods

A total of 82 patients who underwent TBLC for diagnosis of diffuse parenchymal lung diseases at Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital between 2015 and 2018 were screened retrospectively and included in the study. Of the patients, 53.7% (n: 44) were male, and 46.4% (n:38) of them were female. The mean age was 58.37 (±9.33) years. First TBLB and then TBLC were performed to all patients in the same session and their diagnostic performances were compared.

Results

Although both procedures were done in the same session, 45 patients (54.9%) were diagnosed with TBLB and 75 patients (91.5%) were diagnosed with TBLC (P ˂ 0.001). Hemorrhage was observed in 39 patients (47.6%), but only one had a massive hemorrhage. Pneumothorax was observed in 6 patients (7.3%) and none of them required tube drainage.

Conclusion

Transbronchial lung cryobiopsy is a promising technique for the diagnosis of parenchymal lung diseases compared to transbronchial lung biopsy. 

Transbronchial biopsy results according to diffuse interstitial lung disease classification. Cryobiopsy versus forceps: MULTICRIO study

BACKGROUND

In recent years, transbronchial cryobiopsy (TBCB) has come to be increasingly used in interventional pulmonology units as it obtains larger and better-quality samples than conventional transbronchial lung biopsy (TBLB) with forceps. No multicenter studies have been performed, however, that analyse and compare TBCB and TBLB safety and yield according to the interstitial lung disease (ILD) classification.

OBJECTIVES

We compared the diagnostic yield and safety of TBCB with cryoprobe sampling versus conventional TBLB forceps sampling in the same patient.

METHOD

Prospective multicenter clinical study of patients with ILD indicated for lung biopsy. Airway management with orotracheal tube, laryngeal mask and rigid bronchoscope was according to the protocol of each centre. All procedures were performed using fluoroscopy and an occlusion balloon. TBLB was followed by TBCB. Complications were recorded after both TBLB and TBCB.

RESULTS

Included were 124 patients from 10 hospitals. Airway management was orotracheal intubation in 74% of cases. Diagnostic yield according to multidisciplinary committee results for TBCB was 47.6% and for TBLB was 19.4% (p<0.0001). Diagnostic yield was higher for TBCB compared to TBLB for two groups: idiopathic interstitial pneumonias (IIPs) and ILD of known cause or association (OR 2.5; 95% CI: 1.4-4.2 and OR 5.8; 95% CI: 2.3-14.3, respectively). Grade 3 (moderate) bleeding after TBCB occurred in 6.5% of patients compared to 0.8% after conventional TBLB.

CONCLUSIONS

Diagnostic yield for TBCB was higher than for TBLB, especially for two disease groups: IIPs and ILD of known cause or association. The increased risk of bleeding associated with TBCB confirms the need for safe airway management and prophylactic occlusion-balloon use.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT02464592.

Transbronchial cryobiopsy validity in diagnosing diffuse parenchymal lung diseases in Egyptian population

Objectives

We aimed to evaluate the efficacy, safety, and diagnostic utility of transbronchial cryobiopsy (TBCB) in diagnosing diffuse parenchymal lung diseases (DPLDs) in an Egyptian population and to identify common DPLD pathologies among them.

Methods

This prospective interventional study enrolled 25 Egyptian patients presenting to the Main Alexandria University Hospital who had clinical and radiological features of DPLD, but insufficient elements to achieve definite features of usual interstitial pneumonia on chest high-resolution computed tomography. Twelve patients were subjected to TBCB and 13 to forceps transbronchial lung biopsy (TBLB).

Results

The diagnostic yield was significantly higher among the TBCB group (83.3%), and increased to 100% with clinicopathological correlation vs the TBLB group (38.5%, P=0.041). Granulomatous diseases (24%, either sarcoidosis or hypersensitivity pneumonitis) were the commonest pathology, followed by malignancy (12%) in both groups. TBCB sizes were 2.5–5 mm vs 1-3 mm in TBLB (P<0.001), with preserved tissue architecture (91.7% vs 38.5%, respectively; P=0.011). Only 8.3% were complicated by insignificant bleeding grade 2 after TBCB, but no pneumothorax was detected.

Conclusion

TBCB is a safe, tolerable procedure with high diagnostic yield for evaluating DPLD with indefinite usual interstitial pneumonia pattern on high-resolution computed tomography.

A Multidisciplinary Proposal for a Diagnostic Algorithm in Idiopathic Pulmonary Fibrosis: The Role of Transbronchial Cryobiopsy

The diagnosis of idiopathic pulmonary fibrosis (IPF) is a complex process that requires the multidisciplinary integration of clinical, radiological, and histological variables. Due to its diagnostic yield, surgical lung biopsy has been the recommended procedure for obtaining samples of lung parenchyma, when required. However, given the morbidity and mortality of this technique, alternative techniques which carry a lower risk have been explored. The most important of these is transbronchial cryobiopsy -transbronchial biopsy with a cryoprobe- which is useful for obtaining lung tissue with less comorbidity. Yield may be lower than surgical biopsy, but it is higher than with transbronchial biopsy with standard forceps. This option has been discussed in the recent clinical guidelines for the diagnosis of IPF, but the authors do not go so far as recommend it. The aim of this article, the result of a multidisciplinary discussion forum, is to review current evidence and make proposals for the use of transbronchial cryobiopsy in the diagnosis of IPF.

Bleeding risk of transbronchial cryobiopsy compared to transbronchial forceps biopsy in interstitial lung disease - a prospective, randomized, multicentre cross-over trial

Background

Bronchoscopic cryobiopsy is a new method of bronchoscopic tissue sampling in interstitial lung disease. In case of transbronchial biopsies, the resultant tissue samples are of high quality, and the lung parenchyma seen in the samples is adequate for a histological diagnosis in most cases. Bleeding after transbronchial biopsy is the most important procedure- associated complication and may be life threatening. This study addresses the risk of bleeding of transbronchial cryobiopsy.

Methods

In this prospective, randomized, controlled multicentre study 359 patients with interstitial lung disease requiring diagnostic bronchoscopic tissue sampling were included. Both conventional transbronchial forceps biopsy and transbronchial cryobiopsy were undertaken in each patient. The sequence of the procedures was randomized. Bleeding severity was evaluated semi-quantitatively as “no bleeding”, “mild” (suction alone), “moderate” (additional intervention) or “severe” (prolonged monitoring necessary or fatal outcome), for each intervention.

Results

In 359 patients atotal of 1160 cryobiopsies and 1302 forceps biopsies were performed. Bleeding was observed after forceps biopsy in 173 patients (48.2%) and after cryobiopsy in 261 patients (72.7%).

Bleeding was significantly greater in the cryobiopsy group (cryobiopsy/forceps biopsy: no bleeding 27.3%/51.8%; mild 56.5%/44.0%; moderate 15.0%/4.2%; severe 1.2%/0%; p < 0.001). The rate of clinically relevant bleeding (moderate or severe) was higher after the cryobiopsy procedures compared to the forceps biopsies (16.2% vs. 4.2%, p < 0.05). No fatal bleeding complications occurred.

Conclusions

Compared to transbronchial forceps biopsy, transbronchial cryobiopsy was associated with an increased risk of bleeding which is of clinical relevance. Therefore training and additional precautions for bleeding control should be considered.

Trial registration

The study was registered with clinicaltrials.gov (NCT01894113).

Idiopathic pulmonary fibrosis: prognostic impact of histologic honeycombing in transbronchial lung cryobiopsy

Background

Prognostic evaluation in idiopathic pulmonary fibrosis (IPF) may be important as it can guide management decisions, but the potential role of honeycomb changes in providing information about outcome and survival of patients with IPF, particularly if diagnosed using cryobiopsy, has not been evaluated. Aim of this study was to determinate whether a relationship exists between honeycombing on cryobiopsy and clinical/radiological picture and outcome in patients with IPF and to assess whether the same pathologic criteria that have been used to define the UIP pattern (usual interstitial pneumonia) for surgical biopsy can also be applied to cryobiopsy.

Methods

Sixty-three subjects with a multidisciplinary diagnosis of IPF and a UIP pattern on cryobiopsy were evaluated. Patients were classified into two sub-groups depending on the presence of honeycombing on histology.

Results

The presence of honeycombing on cryobiopsy did not identify a specific phenotype of patients as it did not correlate with radiological and clinical picture and it was not associated neither with the risk of death (p = 0.1192) or with the event-free survival (p = 0.827); a higher number of samples and the presence of pleura on biopsy were instead associated with an increase in the finding of honeycombing.

Conclusions

The same pathologic criteria that have been used to define the UIP pattern in surgical biopsies (with honeycombing changes considered as non-mandatory for the definition of the pattern itself) can be applied to cryobiopsy samples, as the presence of these changes do not define different clinical or radiological phenotypes of patients with IPF.

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement

BACKGROUND

Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC.

METHODOLOGY

This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus.

RESULTS

The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC.

CONCLUSION

This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.

Efficacy and safety of trans-bronchial cryo in comparison with forceps biopsy in lung allograft recipients: Analysis of 402 procedures

BACKGROUND

Trans-bronchial forceps biopsy (TBFB) is the gold standard to establish the presence of allograft rejection or infection after lung transplantation. We aimed to analyze the diagnostic yield and safety of trans-bronchial cryobiopsy (TBCB) in lung allografts.

METHODS

Retrospective analysis of 402 TBB procedures in 362 lung recipients was performed between 2011 and 2016. Half of the cases (201) were performed by TBCB and the other half by TBFB. One hundred random slides of TBB specimens from lung allografts were reviewed for artifacts, bleeding, and histological evidence.

RESULTS

Both TBB groups were comparable in age, gender distribution, and time following transplantation. Acute rejection was diagnosed in 21.9% of the TBCB group vs 14.9% in the TBFB group (P = .09) and only 2 cases (1%) of nondiagnostic tissue in TBCB group and 4 cases (2%) in TBFB group (P = .685). Complications of pneumothorax and bleeding occurred in 9 (4.5%) vs 8 (4%) and 5 (2.5%) vs 4 (2%) in TBCB vs TBFB groups, respectively. The TBCB specimens were larger than TBFB (average 16.6 vs 6.6 mm² ; P < .001). Crush and bleeding artifacts were seen in 11 (22%) and 23 (46%) of TBFB, respectively, yet none in TBCB group (P < .001).

CONCLUSION

Trans-bronchial cryobiopsy is safe and effective for diagnosis of lung allograft rejection.

The safety and efficacy of different methods for obtaining transbronchial lung cryobiopsy in diffuse lung diseases

INTRODUCTION

Most data on transbronchial lung cryobiopsy (TBLC) are from single centers, with little evidence on the outcome of different methods for performing TBLC.

OBJECTIVE

To report the diagnostic yield and safety of TBLC with different procedural techniques.

MATERIALS AND METHODS

Retrospective multicenter study of subjects who underwent TBLC for the diagnosis of diffuse parenchymal lung diseases (DPLDs). The procedure was performed using various methods: flexible or rigid bronchoscopy, with or without the use of fluoroscopy or occlusion balloon.

RESULTS

In total, 128 subjects (59% women) with a mean age of 48.9 years were included. The overall diagnostic yield of TBLC was 78.1%, with a definite diagnosis on multidisciplinary discussion made in 57 (44.5%) subjects. On a multivariate analysis, the diagnostic yield was associated with the number of biopsies taken {ajdusted odds ratio [AOR] [95% confidence interval (CI)], 2.17 [1.29-3.67]}. The incidence of pneumothorax was lower in subjects who underwent TBLC with fluoroscopic guidance (5.9% vs 20.9%), [AOR (95% CI), 0.26 (0.07-0.94)]. Moderate-to-severe bleeding occurred less frequently when an occlusion balloon was used [1.8% vs 35.7%; AOR (95% CI), 0.02 (0.001-0.18)], after adjusting for age, use of fluoroscopy, number of biopsies obtained and number of lobes sampled. Four deaths occurred; 2 because of acute exacerbation of idiopathic pulmonary fibrosis.

CONCLUSIONS

Transbronchial lung cryobiopsy was found to offer a reasonable yield in the diagnosis of DPLDs. The incidence of pneumothorax and moderate-to-severe bleeding was lower with the use of fluoroscopy and an occlusion balloon, respectively.

Learning curve for transbronchial lung cryobiopsy in diffuse lung disease

INTRODUCTION

Transbronchial lung cryobiopsy (TBLC) is increasingly used in the diagnosis of diffuse lung disease (DLD), but no data have yet been published on the learning curve associated with this technique.

AIM

To evaluate diagnostic yield, lung tissue sample length and area, and procedure-related complications in a cohort of TBLC procedures to define the learning curve and threshold for proficiency.

METHODS

Retrospective analysis of the first 100 TBLCs performed in different segments of the same lobe in patients with suspected DLD. We compared diagnostic yield, sample length and area, and complications between consecutive groups of patients.

RESULTS

The overall diagnostic yield for TBLC was 82%. Median sample length was 5.4mm (IQR, 5-6) and median area was 19.5mm2 (IQR, 13.3-25). Pneumothorax was the most common complication (18%). On comparing the two groups of 50 consecutive patients, a significant difference was found for diagnostic yield (74% vs 90%; p=0.04), sample length (5.0mm [2.5-16] vs 6.0mm [4-12;] p<0.01) and area (17.5mm2 [6-42] vs 21.5mm2 [10-49]; p<0.01). Logarithm regression was applied to median diagnostic yield and sample length and area for groups of 10 consecutive patients to define the learning curve, which plateaued after approximately 70 procedures.

CONCLUSIONS

Our findings suggest that proficiency in TBLC is achieved at approximately the 70th procedure; however they need to be validated in more series and cohorts.

Feasibility of Radial Endobronchial Ultrasound-Guided Bronchoscopic Cryobiopsy without Fluoroscopy for Lung Parenchymal Lesions

Background

Cryobiopsy is used to biopsy peripheral lung lesions through flexible bronchoscopy with fluoroscopic guidance. However, fluoroscopy is not available at some institutions. This study evaluated the feasibility of radial endobronchial ultrasound-guided bronchoscopic cryobiopsy without fluoroscopy.

Methods

This retrospective study was conducted at Chang Gung Memorial Hospital, Linkou branch, in Taiwan. This study enrolled patients who received bronchoscopy examinations with cryotechnology between July 2014 and June 2016. The data were collected through medical chart review.

Results

During the study period, 101 patients underwent bronchoscopy examinations with cryotechnology. Ninety patients with endobronchial tumors were excluded from this study. Eleven patients who underwent radial endobronchial ultrasound-guided bronchoscopic cryobiopsy for lung parenchymal lesions were enrolled into this study. The mean age was 61.1 ± 13.8 years. Five patients were men, and the other six were women. The number of cryobiopsies ranged from 1 to 3. In the histological biopsies, the mean specimen diameter was 0.53 ± 0.23 cm, and the mean biopsy area was 0.20 ± 0.19 cm². Nine of 11 patients had pathological diagnoses. No complications, including pneumothorax, respiratory failure, or major bleeding, were recorded after the procedure.

Conclusions

Endobronchial ultrasound is used to ensure biopsy location, and endobronchial ultrasound-guided cryobiopsy is a feasible technique to biopsy peripheral lung lesions in selected cases at institutions without fluoroscopy equipment. This study provided some rationale for further studies examining the impact of fluoroscopy.

Transbronchial lung cryobiopsy: Associated complications

INTRODUCTION

Transbronchial lung cryobiopsy (TBC) has emerged as a diagnostic alternative to surgical lung biopsy in interstitial lung disease (ILD). Despite its less invasive nature, some associated complications have been described.

OBJECTIVE

To evaluate complications of TBC and associated factors.

METHODS

Prospective evaluation of all patients with ILD submitted to TBC in our centre. Clinicodemographic variables and factors associated to TBC complications were analyzed. The effect of the variables on the complication risk was evaluated by a logistic regression model.

RESULTS

Ninety patients were included (mean age 60±13 years; 58.9% male). Twenty-two patients presented pneumothorax, 18 (81.8%) of which were treated with chest tube drainage [median air leak time: 1 day (IQR=2)]. Grade 2 and 3 bleeding was observed in 13 (14.4%) cases. Presence of visceral pleura in the sample accounted for almost more than 10 times the odds of pneumothorax (OR=9.59, 95% CI 2.95-31.17, p<0.001). Increased body mass index (BMI) was associated with bleeding (16% additional odds for each BMI unit increase (OR=1.16, 95% CI 1.01-1.34, p=0.049).

CONCLUSION

The most frequent complication of TBC was pneumothorax, although rapidly reversible. There was a positive association between pneumothorax and the presence of pleura in the biopsy samples as well as between bleeding and increased BMI. More studies about TBC complications are needed to improve the selection of the candidates for this procedure.

Update in diagnosis and management of interstitial lung disease

The field of interstitial lung disease (ILD) has undergone significant evolution in recent years, with an increasing incidence and more complex, ever expanding disease classification. In their most severe forms, these diseases lead to progressive loss of lung function, respiratory failure and eventually death. Despite notable advances, progress has been challenged by a poor understanding of pathological mechanisms and patient heterogeneity, including variable progression. The diagnostic pathway is thus being continually refined, with the introduction of tools such as transbronchial cryo lung biopsy and a move towards genetically aided, precision medicine. In this review, we focus on how to approach a patient with ILD and the diagnostic process.

Transbronchial Cryobiopsy in Interstitial Lung Disease: Are We on the Right Path?

BACKGROUND

A definitive and specific diagnosis of interstitial lung disease (ILD) often requires a histologic analysis of the lung parenchyma. A transbronchial biopsy with forceps has a limited diagnostic yield for idiopathic interstitial pneumonias. The incorporation of a transbronchial lung cryobiopsy for diagnosing ILD appears to be very promising, although there are only a few published studies in this regard. Our paper shows the results of using this technique in our center.

METHODS

This was a prospective study including 55 patients with ILD diagnosed from January 2012 to January 2015. The methodology used, the overall diagnostic yield, and the number and the location of samples, in addition to complications, have been reported.

RESULTS

In 38 (69%), 10 (20.8%), and 7 (12.7%) cases, we obtained a certain, highly likely, and unclassifiable diagnosis of interstitial pneumonia, respectively. With 18 cases, usual interstitial pneumonia was the most common diagnosis. The most common complication was a pneumothorax in 8 patients (14.5%).

CONCLUSIONS

A transbronchial lung cryobiopsy using a flexible cryoprobe has a good diagnostic yield and might be an alternative to consider in cases of diffuse ILD in which a histologic sample is required for diagnosis. This technique could avoid a large number of surgical biopsies.

Transbronchial cryobiopsy in interstitial lung disease: experience in 106 cases - how to do it

Transbronchial biopsy using forceps (TBB) is the first diagnostic technique performed on patients with interstitial lung disease (ILD). However, the small size of the samples and the presence of artefacts in the tissue obtained make the yield variable. Our objectives were 1) to attempt to reproduce transbronchial cryobiopsy under the same conditions with which we performed conventional TBB, that is, in the bronchoscopy unit without intubating the patient and without fluoroscopy or general anaesthesia; 2) to describe the method used for its execution; and 3) to analyse the diagnostic yield and its complications. We carried out a prospective study that included 106 patients with clinical and radiological features suggestive of ILD who underwent cryo-transbronchial lung biopsy (cryo-TBB) under moderate sedation without endotracheal intubation, general anaesthesia or use of fluoroscopy. We performed the procedure using two flexible bronchoscopes connected to two video processors, which we alternated until obtaining the number of desired samples. A definitive diagnosis was obtained in 91 patients (86%). As for complications, there were five pneumothoraces (4.7%) and in no case was there severe haemorrhage or exacerbation of the underlying interstitial disease. Cryo-TBB following our method is a minimally invasive, rapid, safe and economic technique that can be performed in a bronchoscopy suite under moderate sedation without the need for intubating the patient or using fluoroscopy and without requiring general anaesthesia.

Pulmonary Parenchymal Lymphoma Diagnosed by Bronchoscopic Cryoprobe Lung Biopsy

A 51-year-old man presented with progressively worsening lung infiltrates and respiratory failure. Extensive investigations including bronchoscopy with bronchoalveolar lavage and conventional transbronchial forceps biopsies failed to establish the diagnosis. After transfer to our institution, he underwent repeat bronchoscopy with transbronchial cryobiopsy, which provided large, high-quality biopsy specimens establishing the diagnosis of parenchymal diffuse large B-cell lymphoma.

Update in diagnosis and management of interstitial lung disease

The field of interstitial lung disease (ILD) has undergone significant evolution in recent years, with an increasing incidence and more complex, ever expanding disease classification. In their most severe forms, these diseases lead to progressive loss of lung function, respiratory failure and eventually death. Despite notable advances, progress has been challenged by a poor understanding of pathological mechanisms and patient heterogeneity, including variable progression. The diagnostic pathway is thus being continually refined, with the introduction of tools such as transbronchial cryo lung biopsy and a move towards genetically aided, precision medicine. In this review, we focus on how to approach a patient with ILD and the diagnostic process.

Diffuse Parenchymal Lung Diseases with Clinicoradiological Discordance: Role of Transbronchial Lung Biopsy as a Diagnostic Tool - An Observational Study

INTRODUCTION

The diagnosis of Diffuse Parenchymal Lung Disease (DPLD) requires a multidisciplinary approach with reconciliation of clinicoradiological and histopathological data. But when the preliminary clinicoradiological profile fails to suggest a diagnosis, an adequate lung biopsy specimen with meticulous histological examination and a multidisciplinary approach usually yields results. There is also a high chance of sampling error due to patchy and heterogeneous involvement of the disease process and due to the small volume of tissue taken. As seen in our study, Trans-Bronchial Lung Biopsy (TBLB) if performed by an experienced bronchoscopist can be done as an outpatient procedure yielding adequate specimens for diagnosis and guide effective treatment in these patients.

AIM

To study the utility and diagnostic yield of TBLB in DPLD patients when there is clinicoradiological discordance.

MATERIALS AND METHODS

The current retrospective observational study was undertaken in the Institute of Chest Diseases, Government Medical College, Kozhikode, Kerala, India, from January 2012 to December 2014. Out of 169 DPLD patients who attended the tertiary care centre, 66 patients without a definite diagnosis by clinicoradiological assessment were included in the study. They underwent TBLB using a fibre-optic video bronchoscope. An open lung biopsy was advised if the TBLB did not yield a definite diagnosis.

RESULTS

Among the 66 patients, histopathological confirmation was obtained in 51 patients, 39 of which were by TBLB (59%). Few diagnoses like invasive adenocarcinoma, Pneumocystis jirovecii pneumonia and Aspergillus infection were least expected.

CONCLUSION

TBLB if performed correctly can be an effective intervening modality in establishing the diagnosis of DPLD before going for an invasive surgical biopsy.

Transbronchial cryobiopsy in diffuse parenchymal lung diseases

PURPOSE OF REVIEW

The diagnostic yield of conventional transbronchial lung biopsy varies among various parenchymal lung diseases: in pulmonary sarcoidosis and lymphangitis carcinomatosa, a diagnosis can be obtained in up to 80% of patients; this method is considered inadequate, however, in identifying more complex histological patterns such as usual interstitial pneumonitis or nonspecific interstitial pneumonitis, mainly because the specimens are tiny and the interpretation is confounded by crush artifacts. Recently, the use of cryoprobes has achieved a significant impact on this issue. This review is about this promising application of cryobiopsy in the diagnostic process of diffuse parenchymal lung diseases.

RECENT FINDINGS

Recent studies document that with transbronchial cryobiopsies, the diagnosis of usual interstitial pneumonitis can be made confidently by pathologists with a good interobserver agreement. Pneumothorax is the main complication (reported in up to one-quarter of cases in some series); bronchial bleeding is usually controlled using Fogarty balloon.

SUMMARY

Transbronchial cryobiopsy is a promising new technique that may become a valid alternative to surgical lung biopsy in the near feature.

Usefulness of an angioplasty balloon as selective bronchial blockade device after transbronchial cryobiopsy

BACKGROUND AND OBJECTIVE

Transbronchial cryobiopsy (TBCB) is a technique in which frozen samples of lung are obtained using a probe inserted through a bronchoscope. We performed a retrospective study to assess the performance of the TBCB procedure complemented by segmental bronchial blockade using an angioplasty balloon, in terms of diagnostic yield and safety in diffuse parenchymal lung disease (DPLD).

METHODS

Data from 100 patients with suspected DPLD (clinical and radiological findings), who underwent TBCB in our institution to establish a definitive diagnosis, were reviewed. In our institution, TBCB is monitored with fluoroscopy and performed under general anaesthesia by a multidisciplinary team (an anaesthesiologist, a pulmonologist and an interventional radiologist). In each patient, four samples were collected using a 2.4-mm distal diameter cryoprobe. To control bleeding, the biopsied segmental bronchus was blocked with a 6-mm diameter angioplasty balloon, inserted over a 0.035-inch angled hydrophilic guidewire. After the cryoextraction, the balloon was inflated for 3 min intervals until bleeding stopped.

RESULTS

Overall, 98% of samples had diagnostic value. In 85% of cases, DPLD was confirmed, while in 7%, cancer was diagnosed. Complications were observed in 16% of the patients: 13 patients developed moderate haemorrhage, and 3 developed pneumothorax.

CONCLUSION

Transbronchial cryobiopsy had a high diagnostic yield for DPLD. Performing the procedure under fluoroscopy guidance and using angioplasty balloon for selective bronchial blockade achieved a low rate of iatrogenic complications directly associated with the technique.

Efficacy and safety of cryobiopsy versus forceps biopsy for interstitial lung diseases and lung tumours: A systematic review and meta-analysis

Forceps biopsy (FB) is the most commonly used diagnostic tool for lung pathologies. FB is associated with a high diagnostic failure rate. Cryobiopsy (CB) is a novel technique providing a larger specimen size, few artefacts, more alveolar parts and superior diagnostic yield. CB, however, has drawbacks such as higher bleeding and pneumothorax rate. We conducted a meta-analysis to investigate the specimen area, diagnostic rate and bleeding severity in CB versus FB in interstitial lung diseases (ILDs) and lung tumours. A systematic literature search of PUBMED, BIOSIS PREVIEW and OVID databases was conducted using specific search terms. Eligible studies including RCTs and non-RCTs comparing cryobiopsy/cryotransbronchial biopsy (CB/CTBB) and forceps biopsy/forceps transbronchial biopsy (FB/FTBB) for specimen area, diagnostic rate and bleeding rate in ILDs and lung tumours were analysed. Two reviewers independently extracted data and evaluated the quality of the studies. Eight studies involving 916 patients were analysed. Specimen area (mm(2) ) was significantly larger in CB/CTBB than FB/FTBB (standard mean difference = 1.21, 95% confidence interval (0.94, 1.48), P < 0.00001). The diagnostic rate was significantly higher in CB/CTBB than FB/FTBB (Risk ratio 1.36, 95% confidence interval (1.16, 1.59), P = 0.0002). Three studies compared the bleeding severity with only one showing significantly more bleeding in CB. Cryobiopsy/cryotransbronchial shows superiority to FB/FTBB for specimen area and diagnostic rate. CB/CTBB has better efficacy over FB/FTBB.

Transbronchial lung biopsy with a flexible cryoprobe: First case report from India

Sarcoidosis and tuberculosis are granulomatous disorders that mimic each other both clinically and radiologically. Both can present with fever and pulmonary nodules and often require the performance of transbronchial lung biopsy (TBLB) for diagnosis. In recent studies, the flexible cryoprobe for carrying out TBLB has been found to be useful in the diagnosis of disorders diffusely involving the lung parenchyma. Here, we present the case of a 29-year-old man who presented with fever and cough and was found to have multiple small nodules in both lungs. TBLB with a flexible cryoprobe helped in differentiating between sarcoidosis and tuberculosis.

Safety and Diagnostic Yield of Transbronchial Lung Cryobiopsy in Diffuse Parenchymal Lung Diseases: A Comparative Study versus Video-Assisted Thoracoscopic Lung Biopsy and a Systematic Review of the Literature

BACKGROUND

A diagnosis of interstitial lung diseases (ILDs) may include surgical lung biopsy (SLB), which is associated with significant morbidity and mortality and also appreciable costs. Transbronchial lung cryobiopsy (TBLC) is adopting an important role.

OBJECTIVES

The aim of this study was to compare the diagnostic yield (DY) and safety of TBLC and SLB in a large cohort of patients and to perform a systematic review of the literature as well as a meta-analysis.

METHODS

We performed a retrospective analysis of 447 cases with ILD undergoing TBLC and/or SLB and a systematic review of the literature (MEDLINE and Embase for all original articles on the DY and safety of TBLC in ILDs up to July 2015).

RESULTS

A total of 150 patients underwent SLB and 297 underwent TBLC. The median time of hospitalization was 6.1 days (SLB) and 2.6 days (TBLC; p < 0.0001). Mortality due to adverse events was observed for 2.7% (SLB) and 0.3% (TBLC) of the patients. Pneumothorax was the most common complication after TBLC (20.2%). No severe bleeding was observed. TBLC was diagnostic for 246 patients (82.8%), SLB for 148 patients (98.7%, p = 0.013). A meta-analysis of 15 investigations including 781 patients revealed an overall DY of 0.81 (0.75-0.87); the overall pooled probability of developing a pneumothorax, as retrieved from 15 studies including 994 patients, was 0.06 (95% CI 0.02-0.11).

CONCLUSION

Cryobiopsy is safe and has lower complication and mortality rates compared to SLB. TBLC might, therefore, be considered the first diagnostic approach for obtaining tissue in ILDs, reserving the surgical approach for cases in which TBLC is not diagnostic.

A New Tool for Transbronchial Cryobiopsies in the Lung: An Experimental Feasibility ex vivo Study

BACKGROUND

Transbronchial cryobiopsy (TBCB) is a minimally invasive procedure to establish a diagnosis of interstitial lung disease though with the disadvantage that samples have to be extracted together with the bronchoscope.

OBJECTIVES

The aim of the present study was to evaluate the feasibility of a new cryoprobe with which biopsy samples can be obtained through the working channel of the flexible bronchoscope.

METHODS

The feasibility of obtaining transbronchial specimens with TBCB was tested and the technique was compared to transbronchial forceps biopsy (TBFB) in a prospectively randomized ex vivo animal study using a standard flexible bronchoscopy technique. The rate of successful biopsies and the duration of the sampling procedure were recorded for both methods. Size and quality of the biopsies were histologically evaluated and measured.

RESULTS

Biopsy samples could be obtained in 93.3% of TBCB and in 79.0% of TBFB procedures (p = 0.182). Sampling procedure time did not differ in any clinically relevant manner between the two methods. The mean specimen area of TBCB samples was significantly higher compared to that of TBFB samples (8.08 ± 5.80 vs. 2.61 ± 2.14 mm2; p < 0.0001). TBCB specimens showed less artifacts and a significantly higher percentage of alveolar tissue (53.57 vs. 25.42%; p = 0.0285) than TBFB specimens.

CONCLUSIONS

It is feasible to retrieve TBCB samples of good quality and size with the new mini cryoprobe through the working channel of the bronchoscope, while the bronchoscope remains within the central airways throughout the whole procedure. Further studies are necessary to evaluate the safety and efficacy in an in vivo setting.

Radiology-guided forceps biopsy and airway stenting in severe airway stenosis

PURPOSE

We aimed to determine the feasibility, safety, and effectiveness of radiology-guided forceps biopsy and airway stenting in patients with severe airway stenosis.

MATERIALS AND METHODS

This study involved 28 patients with severe airway stenosis who underwent forceps biopsy between October 2006 and September 2011. Chest multislice computed tomography was used to determine the location and extent of stenosis. Sixteen patients had tracheal stenosis, two patients had stenosis of the tracheal carina, six patients had stenosis of the left main bronchus, and four patients had stenosis of the right main bronchus. Forceps biopsy and stenting of the stenosed area were performed under fluoroscopic guidance in digital subtraction angiography and the biopsy specimens were analyzed histopathologically. We contacted the patients via phone call and utilized a standardized questionnaire to determine their medical condition during a postoperative three-month follow-up.

RESULTS

The technical success rate of radiology-guided forceps biopsy was 100%. Biopsy specimens were obtained in all patients. Dyspnea was relieved immediately after stent placement. No serious complications, such as tracheal hemorrhage or perforation, mediastinal emphysema, or asphyxia, occurred.

CONCLUSION

Radiology-guided forceps biopsy and airway stenting can be used for the emergency treatment of severe airway stenosis. This method appears to be safe and effective, and it may be an alternative therapeutic option in patients who cannot tolerate fiberoptic bronchoscopy.

Transbronchial lung biopsy: the pathologist's point of view

BACKGROUND AND AIMS

The efficacy of flexible cryoprobe in providing high-quality tissue specimens through bronchoscopy for making a diagnosis remains debatable. In this study, we have compared the diagnostic yield of cryoprobe with conventional sampling by forceps.

METHODS

Forty-one patients scheduled to undergo transbronchial lung biopsy (TBLB) in a pulmonary hospital in Tehran, Iran. Each patient underwent conventional TBLB and flexible cryoprobe TBLB (FCLB) sequentially. Specimen adequacy was defined by the presence of at least 50 alveolar spaces or a positive diagnostic yield. Adequacy of specimens, number and percentage of alveolar spaces without artifact, type of artifact, presence of bronchiolar structures and the diagnosis made based on the results of the two methods separately were compared.

RESULTS

The mean values of tissue section area obtained by forceps and cryoprobe were 6 mm(2) [standard deviation (SD) ± 6.7] and 22 mm(2) (SD ± 19.1), respectively (P < 0.001). Specimens were adequate in 26 cases of conventional TBLB and 40 cases of FCLB (P < 0.001). Of adequate specimens, 14 samples obtained by TBLB and 28 samples obtained via FCLB were diagnostic. A significant difference was also detected between diagnostic and non-diagnostic specimens (P = 0.04). Frequency of specimens with >75% artifact-free lung parenchyma was significantly higher in FCLB method.

CONCLUSION

FCLB method provides larger tissue samples with better quality compared with TBLB. Higher-quality specimens are associated with less artifact and higher diagnostic yield. Multisite randomized trials are required to improve our knowledge about the benefits and indications of TBLB with cryoprobe.

Cryobiopsy in the diagnosis of diffuse interstitial lung disease: yield and cost-effectiveness analysis

BACKGROUND

Assessment of patients with suspected interstitial lung disease (ILD) includes surgical lung biopsy (SLB) when clinical and radiological data are inconclusive. However, cryobiopsy is acquiring an important role in the ILD diagnostic process. The objective of this study was to evaluate the diagnostic yield, safety and economic costs of the systematic use of cryobiopsy in the assessment of patients with suspected ILD.

METHODS

This was a retrospective observational study of patients who had undergone transbronchial cryobiopsy for evaluation of ILD from January 2011 to January 2014. The procedures were performed with a video bronchoscope using a cryoprobe for the collection of lung parenchyma specimens, which were analyzed by pathologists. Diagnostic yield, complications and economic costs of this technique were analyzed.

RESULTS

Criobiopsy specimens from a total of 33 patients were included. A specific diagnosis was obtained in 26, producing a diagnostic yield of 79%. In 5 patients, SLB was required for a histopathological confirmation of disease, but the procedure could not be performed in 4, due to severe comorbidities. The most frequent complications were pneumothorax (12%) and gradei (9%) or gradeii (21%) bleeding. There were no life-threatening complications. The systematic use of cryobiopsy saved up to €59,846.

CONCLUSION

Cryobiopsy is a safe and potentially useful technique in the diagnostic assessment of patients with ILD. Furthermore, the systematic use of cryobiopsy has an important economic impact.

[Advances in respiratory health 2010: Techniques and Transplantation Section]

Five articles and an editorial on interventional pneumology were published in Archivos de Bronconeumología. Two of these articles deal with bronchoscopy, one with lung biopsy with cryoprobes, one with thermoplasty in asthma and the last with tracheobronchomalacia. We also review several publications in international journals, with special emphasis on endobronchial ultrasound. Four original articles on idiopathic pulmonary fibrosis were published in Archivos de Bronconeumología: one special article comparing two treatments and a Cochrane systematic review on the efficacy of non-steroidal drugs in this disease. Finally, we highlight studies in lung transplantation, consisting of 14 publications from different continents and with highly diverse contents: one editorial, one letter to the editor, one procedures manual and nine international publications on donor characteristics, various types of complications, experimental results in the field of preservation, and the casuistics obtained in distinct diseases in which transplantation is an option.

Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial

BACKGROUND AND OBJECTIVE

Transbronchial lung biopsy (TBLB) is required for evaluation in selected patients with interstitial lung disease (ILD). The diagnostic yield of histopathologic assessment is variable and is influenced by factors such as the size of samples and the presence of crush artefacts left by conventional biopsy forceps. We compared the diagnostic yield and safety of TBLB with cryoprobe sampling versus conventional forceps sampling.

METHODS

This randomized clinical trial analysed data for 77 patients undergoing TBLB for evaluation of ILD; patients were assigned to either a conventional-forceps group or a cryoprobe group. Two pathologists assessed the tissue samples and agreed on histopathologic diagnoses. We also compared the duration of procedures, complications and sample-quality variables.

RESULTS

The most frequent diagnosis observed in the cryoprobe group was non-specific interstitial pneumonia. Histopathologic diagnoses were identified in more cases in the cryoprobe group (74.4%) than in the conventional-forceps group (34.1%) (P < 0.001), and the diagnostic yield was higher in the cryoprobe group (51.3% vs 29.1% in the conventional forceps group; P = 0.038). A larger mean area of tissue was harvested by cryoprobe (14.7 ± 11 mm(2) ) than by conventional forceps (3.3 ± 4.1 mm(2)) (P < 0.001). More grade 2 bleeding (not statistically significant) occurred in the cryoprobe group (56.4%) than in the conventional-forceps group (34.2%). No differences in other complications were observed.

CONCLUSIONS

TBLB by cryoprobe is safe and potentially useful in the diagnosis of ILD. Larger multisite randomized trials are required to confirm the potential benefits of this procedure. Clinical trial registration at ClinicalTrials.gov: NCT01064609.

Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy

BACKGROUND AND OBJECTIVE

The gold standard for the histological diagnosis of interstitial lung diseases (ILD) is an open lung biopsy (OLB). Tissue samples obtained by forceps transbronchial lung biopsies (TBB) are usually too small. We aim to evaluate the efficacy and safety of cryo-TBB for the diagnosis of ILD and to explore its role as substitute for OLB.

METHODS

Seventy-five patients (mean age 56.2 years) with clinical and radiological features suggestive of ILD underwent cryo-TBB under moderate sedation. The diagnostic contribution on the work-up of suspected ILD was assessed.

RESULTS

No major complications occurred during cryo-TBB procedures. The mean cross-sectional area of the biopsy specimen obtained was 9 mm2 with an average of 70% alveolated tissue. The most common pathological diagnoses were idiopathic nonspecific interstitial pneumonitis (n = 22), cryptogenic organizing pneumonia (n = 11) and usual interstitial pneumonitis (n = 7). There were three patients of pulmonary Langerhans cell histiocytosis and one patient of pulmonary lymphangioleiomyomatosis. A definite and probable clinicopathological consensus diagnosis was possible in 70% and 28% of patients, respectively. In only 2% of patients' diagnosis could not be established.

CONCLUSIONS

Cryo-TBB is a safe and effective minimally invasive modality for the diagnosis of ILD. No OLB is needed in the majority of patients.

[Adult pulmonary Langerhans' cell histiocytosis: approach to the reality of the Spanish population]

BACKGROUND AND OBJECTIVE

Pulmonary Langerhans cell histiocytosis (PLCH) is a rare respiratory disease closely associated with smoking. The aim of the study is to know the reality of PLCH in the Catalonian population.

MATERIAL AND METHODS

We included all patients diagnosed of PLCH in 8 different Catalonian hospitals from April 2011 to December 2012. Epidemiologic, clinical, radiological, functional, diagnostic and therapeutic variables were collected, both at the beginning and at the last visit of the process.

RESULTS

Thirty two patients were included. Overall, patients were middle-aged (38 years), with no gender predominance. Most of them were smokers (71.9%). The main pulmonary function values (forced vital capacity 75.9%, forced expiratory volume in one second 68.9%, diffusing capacity of the lung for carbon monoxide 59.6%) and radiological findings (cysts 89.7%, nodules 60.3%) showed no significant changes during evolution. However, the disease progressed with a worsening lung function in 34.4% of cases. The analysis of the functional outcome (forced vital capacity, forced expiratory volume in one second, and diffusing capacity of the lung for carbon monoxide) did not reveal significant differences according to the persistence or not of smoking (P<0.05).

CONCLUSION

Our patients with PLCH had similar clinical and radiological characteristics to those described in other populations. The results observed regarding the relationship with smoking suggest that there may be other factors beyond smoking, which influence on the evolution of the disease. It therefore seems advisable to design prospective studies to investigate this aspect.

Transbronchial lung cryobiopsy in the diagnosis of fibrotic interstitial lung diseases

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.