Video-assisted thoracoscopic lung biopsy in the diagnosis of interstitial lung disease: a prospective, multi-center study in 224 patients

Local Anesthetic Thoracoscopy: A Focus on Indications, Techniques and Complications

The main purpose of this narrative review is to educate general practitioners about a crucial pleural procedure, namely local anesthetic thoracoscopy (LAT), and to provide established respiratory physicians with an expert opinion-based summary of the literature. This narrative review focuses on the indications, technical aspects and complications of LAT, highlighting its safety and high degree of diagnostic sensitivity for patients who present with an unexplained pleural effusion and have a high pre-test probability of cancer.

[Management of ANCA-associated vasculitides]

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune-mediated inflammation of small and medium-sized vessels that can affect virtually any organ system and bears the risk of irreversible organ damage. Without treatment the mortality rates are high, which necessitates rapid diagnosis and initiation of treatment. Histological confirmation, which is not feasible in all cases, should be strived for, especially to delineate differential diagnoses and vasculitis mimics. The new American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) classification criteria are primarily designed for study purposes and show limitations in the routine application. Globally, the recently updated EULAR recommendations represent the most up to date management guidelines. Therapeutically, rituximab and cyclophosphamide in combination with glucocorticoids remain the pillars of treatment in remission induction for severe organ-threatening and life-threatening diseases. For the first time, mepolizumab and avacopan represent approved treatment options for specific entities that make a significant contribution to steroid reduction. New attention has been paid to patient-reported outcomes, for which a disease-specific outcome questionnaire is now available.

Diagnostic yield and safety of transbronchial lung cryobiopsy and surgical lung biopsy in interstitial lung diseases: a systematic review and meta-analysis

INTRODUCTION

Transbronchial lung cryobiopsy (TBLC) is increasingly being used as an alternative to video-assisted thoracoscopic surgery (VATS) biopsy to establish the histopathologic pattern in interstitial lung disease (ILD).

METHODS

A systematic literature search of the PubMed and Embase databases, from October 2010 to October 2020, was conducted to identify studies that reported on diagnostic yield or safety of VATS or TBLC in the diagnosis of ILD.

RESULTS

43 studies were included. 23 evaluated the diagnostic yield of TBLC after multidisciplinary discussion, with a pooled diagnostic yield of 76.8% (95% confidence interval (CI) 70.6-82.1), rising to 80.7% in centres that performed ≥70 TBLC. 10 studies assessed the use of VATS and the pooled diagnostic yield was 93.5% (95% CI 88.3-96.5). In TBLC, pooled incidences of complications were 9.9% (95% CI 6.8-14.3) for significant bleeding (6.9% for centres with ≥70 TBLC), 5.6% (95% CI 3.8-8.2) for pneumothorax treated with a chest tube and 1.4% (95% CI 0.9-2.2) for acute exacerbation of ILD after TBLC. The mortality rates were 0.6% and 1.7% for TBLC and VATS, respectively.

CONCLUSIONS

TBLC has a fairly good diagnostic yield, an acceptable safety profile and a lower mortality rate than VATS. The best results are obtained from more experienced centres.

Single versus multiple video-assisted thoracocopic lung biopsy for suspected interstitial lung disease: a perspective on diagnostic efficacy and length of hospital stay

Background

Nearly one-third of the patients with interstitial lung disease (ILD) require surgical biopsy for a definite diagnosis. Video-assisted thoracoscopic surgical (VATS) biopsy has replaced open lung biopsy, but the number of biopsy required to achieve an accurate diagnose is controversial.

Objectives

Our study aims to show that a well-planned single VATS biopsy is as effective as multiple biopsies for the accurate diagnosis of ILD by reduced days of hospital stay.

Methods

We included 111 patients with suspected ILD who underwent VATS biopsy in our study. Patients were separated into three groups according to the number of biopsies obtained. The differences between groups for diagnostic yield, mean time for chest tube removal, perioperative complications, and approximate volume per biopsy were analyzed statistically.

Results

Eighteen single, 74 double, and 19 triple biopsies were made. Mean times of chest tube removal and hospital stay for single, double, and triple biopsy were 3.5, 4.8, and 6.1 days respectively. The number of biopsy and length of hospital stay was strongly related (p = 0.02), but there was no difference for diagnostic yield between single and multiple biopsy groups (p > 0.05). There was no intraoperative complication or perioperative mortality. In postoperative period, eight patients with multiple biopsies had prolonged air leak.

Conclusion

Although classical knowledge suggests multiple biopsies from different locations of the lung are essential, recent reports have shown that the site and the number of biopsy are not as effective as previously thought in achieving the diagnosis for ILD. Our results show that a "single" biopsy, decided with multidisciplinary evaluation, is an effective and safe diagnostic tool, with lesser days of hospital stay.

Main novel aspects

1. The classical knowledge that multiple biopsies should be taken from different regions of the lung in the diagnosis of interstitial lung diseases has changed over time.2. Diagnostic concordance between multiple biopsy specimens is above 85%.3. A "single" biopsy, decided with multidisciplinary evaluation, is an effective and safe diagnostic tool with lower days of hospital stay.

Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review

The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.

The safety profile of a protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe for interstitial lung disease

INTRODUCTION

Transbronchial lung cryobiopsy (TBLC) has emerged as a promising alternative to surgical lung biopsy for the diagnosis of interstitial lung disease. However, uncertainty remains regarding its overall complications due to a lack of procedural standardization including the size of cryoprobe utilized.

METHODS

This is a prospective cohort study of a protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe. 201 consecutive subjects were enrolled at a single academic center.

RESULTS

The average biopsy size was 106.2 ± 39.3 mm². Complications included a total pneumothorax rate of 4.9% with 3.5% undergoing chest tube placement. Severe bleeding defined by the Nashville Working Group occurred in 0.5% of cases. There were no deaths at 30-days.

DISCUSSION

A protocolized transbronchial cryobiopsy program utilizing a 2.4 mm cryoprobe in can achieve a high diagnostic yield with a favorable safety profile.

Surgical Lung Biopsy for Interstitial Lung Disease. Safety and Feasibility at a Tertiary Referral Center

Rationale: Video-assisted thoracoscopic surgery (VATS) remains the gold standard for interstitial lung disease (ILD) characterization when histology is deemed necessary. There is diminishing use of VATS owing to increased reliance on high-resolution computed tomographic patterns, as well as concerns regarding the potential morbidity and mortality of the procedure.Objectives: The goal of this study was to evaluate the safety and tolerability of VATS among a broad group of patients with ILD referred to a tertiary care center.Methods: Data for all patients with ILD who underwent VATS lung biopsies at Inova Fairfax hospital for the period from December 2012 to September 2019 were collected. Clinical, physiologic, and functional parameters as well as postoperative outcomes including any complications, hospital length of stay, and mortality were collated.Results: There were 268 diagnostic VATS biopsies performed during the period. The mean age of the cohort was 63 ± 13 years, 54% were male, and 25% were ultimately diagnosed with idiopathic pulmonary fibrosis. Two hundred twenty-nine patients were scheduled (85%, Elective VATS group) whereas 39 were inpatients (15%). In the elective group, the 1-month complication rate was 8%, whereas 4% had a severe complication, and there were no deaths. The only mortalities were in the group who were hospitalized before the VATS (4/39 = 10%). Complications were less frequent when VATS was requested by the tertiary referral ILD team. Of the elective group, 87% patients were discharged the same day.Conclusions: This report demonstrates the safety, tolerability, and feasibility of VATS lung biopsy as a same-day procedure in the modern era, especially if patients are first vetted by a team with expertise in the field of ILD. These results support a lower threshold to pursue a VATS biopsy when histology is required for an ILD diagnosis.

The Application of Transbronchial Lung Cryobiopsy and Uniportal and Tubeless Video-Assisted Thoracic Surgery in the Multidisciplinary Diagnosis of Interstitial Lung disease-A Real-World Prospective Study

The application of transbronchial lung cryobiopsy (TBLC) and uniportal and tubeless video-assisted thoracic surgery (UT-VATS) in the multidisciplinary diagnosis of interstitial lung disease (ILD) has not been demonstrated in real-world clinical practice. This prospective study included 137 patients with no definitive diagnosis who were the subject of two multidisciplinary discussion (MDD) sessions. As indicated in the first MDD, 67 patients underwent UT-VATS and 70 underwent TBLC. The specificity of biopsy information and its contribution to final MDD diagnosis were evaluated in the second MDD. The post-operative complications and hospitalization costs associated with the two biopsy methods were compared. UT-VATS was favored for patients initially diagnosed with idiopathic pulmonary fibrosis (IPF), bronchiolitis-associated interstitial lung disease (RB-ILD)/desquamative interstitial pneumonia (DIP) and undefined idiopathic interstitial pneumonia (UIIP), while TBLC was preferred for pulmonary lymphangioleiomyomatosis (PLAM) and pulmonary alveolar proteinosis (PAP). The spirometry parameters were better in patients who underwent UT-VATS than those who underwent TBLC. UT-VATS provided more specific pathological results than TBLC (85.7 vs 73.7%, p = 0.06). In patients initially diagnosed with UIIP, pathological information from UT-VATS was more clinically useful than that obtained from TBLC, although both tests contributed similarly to cases initially diagnosed as interstitial pneumonia with auto-immune features (IPAF)/connective tissue disease-related ILD (CTD-ILD). The safety of UT-VATS was comparable with TBLC although TBLC was cheaper during hospitalization (US$4,855.7 vs US$3,590.9, p < 0.001). multidisciplinary discussion decisions about biopsies were driven by current knowledge of sampling and diagnosis capacity as well as potential risks of different biopsy methods. The current MDD considered UT-VATS more informative than TBLC in cases initially diagnosed as UIIP although they were equally valuable in patients initially diagnosed with IPAF/CTD-ILD.

Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline

Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.

Complications and hospital admission in the following 90 days after lung cryobiopsy performed in interstitial lung disease

Transbronchial lung cryobiopsy (TBLC) is an emerging technique for the diagnosis of interstitial lung disease (ILD), but its risk benefit ratio has been questioned. The objectives of this research were to describe any adverse events that occur within 90 days following TBLC and to identify clinical predictors that could help to detect the population at risk.

METHODS

We conducted an ambispective study including all patients with suspected ILD who underwent TBLC. Data were collected concerning the safety profile of this procedure and compared to various clinical variables.

RESULTS

Overall, 257 TBLCs were analysed. Complications were observed in 15.2% of patients; nonetheless, only 5.4% of all patients required hospital admission on the day of the procedure. In the 30 and 90 days following the TBLC, rates of readmission were 1.3% and 3.5% and of mortality were 0.38%, and 0.78% respectively. Two models were built to predict early admission (AUC 0.72; 95% CI 0.59-0.84) and overall admission (AUC 0.76; 95% CI 0.67-0.85).

CONCLUSIONS

Within 90 days after TBLC, 8.9% of patients suffered a complication serious enough to warrant hospital admission. Modified MRC dyspnoea score ≥2, FVC<50%, and a Charlson Comorbidity Index score ≥2 were factors that predicted early and overall admission.

Nonintubated Video-Assisted Thoracoscopic Surgery Lung Biopsy for Interstitial Lung Disease

Interstitial lung diseases are a heterogeneous group with diffuse parenchymal lung disease. Because most patients with interstitial lung diseases have impaired pulmonary function, the risks of thoracic surgery are an important issue when considering surgical lung biopsy. The nonintubated video-assisted thoracoscopic surgery lung biopsy for interstitial lung disease is a safe and feasible option in carefully selected patients with interstitial lung disease.

Tissue Continues to Be the Issue: Role of Histopathology in the Context of Recent Updates in the Radiologic Classification of Interstitial Lung Diseases

CONTEXT.—

High-resolution computed tomography (HRCT) imaging has an increasingly important role in clinical decision-making in patients with interstitial lung diseases. The recent Fleischner Society white paper on the diagnostic criteria for idiopathic pulmonary fibrosis highlights the advances in our understanding of HRCT imaging in interstitial lung diseases.

OBJECTIVE.—

To discuss the evidence and recommendations outlined in the white paper as it pertains to the radiologic diagnosis of interstitial lung disease, specifically highlighting the current limitations of HRCT in confidently predicting histopathologic findings.

DATA SOURCES.—

The recent Fleischner Society white paper and other studies pertaining to the role of HRCT in predicting histopathology in interstitial lung diseases are reviewed.

CONCLUSIONS.—

High-resolution computed tomography is highly predictive of a usual interstitial pneumonia (UIP) pattern on histopathology when the HRCT shows a typical UIP pattern on a "confident" read by the radiologist. A probable UIP pattern is also very predictive of a UIP pattern on histopathology, and histopathologic confirmation is not needed for most patients demonstrating this pattern in the appropriate clinical setting. A UIP pattern may be seen in a substantial proportion of patients with an "indeterminate UIP" pattern on HRCT and in many patients for whom the HRCT suggests an alternative diagnosis; histopathologic confirmation should be considered in patients demonstrating these patterns whenever feasible.

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.

A single-institution study of concordance of pathological diagnoses for interstitial lung diseases between pre-transplantation surgical lung biopsies and lung explants

BACKGROUND

By comparing diagnoses made by pre-transplant surgical lung biopsy (SLB) and the final pathologic diagnosis of the explanted pathology (EP), we aimed to study the factors that could impact pathologic diagnoses in patients with interstitial lung disease (ILD).

METHODS

We retrospectively reviewed the lung transplant database at Cleveland Clinic [01/01/2006-12/31/2013] to include all lung transplant recipients with a prior diagnosis of ILD. Two pulmonary pathologists independently reviewed each SLB and lung explant. The diagnoses were labeled as concordant (same diagnosis on SLB and explant) or discordant (diagnosis on SLB and explant were different) by consensus.

RESULTS

Of 389 patients transplanted for ILD, 217 had an SLB before transplant. Pathological diagnoses were concordant in 190 patients (87.6%) [165 UIP (86.8%), 13 NSIP (6.8%), 8 CHP (4.2%) and 4 other diagnoses (2.1%). In 27 cases (12.4%), the diagnosis on SLB differed from EP. 8/27 were diagnosed with UIP on SLB and of these, 5 were re-classified as NSIP. 14/19 (73.7%) patients with a SLB diagnosis "other than UIP" were re-categorized as UIP based on explant. Discordant cases had a greater time between SLB and EP than concordant cases (1553 days vs 1248 days).

CONCLUSIONS

The pathologic diagnosis of ILD by SLB prior to lung transplant is accurate in most patients, but may be misleading in a small subset of patients. The majority of discordant cases that were reclassified as UIP could be due to a sampling error, or perhaps, an increased time from the date of the SLB to transplant. Future studies examining how multidisciplinary consensus diagnosis affects this discordance are necessary.

Interstitial Pneumonia With Autoimmune Features: An Emerging Challenge at the Intersection of Rheumatology and Pulmonology

Interstitial lung disease (ILD) remains a cause of significant morbidity and mortality in patients with connective tissue disease (CTD)-associated ILD. While some patients meet clear classification criteria for a systemic rheumatic disease, a subset of patients do not meet classification criteria but still benefit from immunosuppressive therapy. In 2015, the American Thoracic Society and European Respiratory Society described classification criteria for interstitial pneumonia with autoimmune features (IPAF) to identify patients with lung-predominant CTD who lack sufficient features of a systemic rheumatic disease to meet classification criteria. Although these criteria are imperfect, they are an important attempt to classify the patient with undifferentiated disease for future study. Rheumatologists play a key role in the evaluation of potential IPAF in patients, especially as many patients with a myositis-spectrum disease (e.g., non-Jo-1 antisynthetase syndrome, anti-melanoma differentiation-associated protein 5 antibody inflammatory myositis, or anti-PM/Scl antibody-associated inflammatory myositis) would be classified under IPAF using the currently available criteria for inflammatory myositis, and would therefore benefit from rheumatologic comanagement. The aim of this review was to describe the historical context that led to the development of these criteria and to discuss the limitations of the current criteria, diagnostic challenges, treatment options, and strategies for disease monitoring.

Spontaneous ventilation anesthesia combined with uniportal and tubeless thoracoscopic lung biopsy in selected patients with interstitial lung diseases

Background

The current guidelines emphasize the significant role of video-assisted thoracic surgical lung biopsy (VATS-LB) for a definite diagnosis of interstitial lung diseases (ILD), but they also encourage physicians to maintain the balance between the surgical benefits as well as risks. Both spontaneous ventilation video-assisted thoracic surgery (VATS) and uniportal VATS have emerged as remarkable progresses in VATS. We combined these two types of VATS and refined them to uniportal spontaneous ventilation VATS without urinary catheterization and chest tube drainage [uniportal and tubeless VATS (UT-VATS)] to perform LB in selected patients with ILD.

Methods

From January 2014 to May 2015, 43 patients were included in the study. The surgical data was retrospectively analyzed.

Results

The mean diffusion capacity for carbon monoxide (DLCO) of patients was 57.6%±13.0%, forced vital capacity (FVC) was 73.1%±17.0%. There was no 30-day mortality. No patient required a switch to intubated anesthesia. The mean age was 49.6±10.7 years. The general median operative duration was 22±5 minutes, with 25±3 minutes for multiple specimens and 15±2 minutes for single specimen, respectively. Intra-operative conversion to 2-portal VATS followed by chest tube drainage and urinary catheterization occurred in 3 (7.0%) patients due to extensive pleural adhesion, and postoperative chest tube insertion was documented in 1 (2.3%) patient due to subcutaneous emphysema. No postoperative mechanical ventilation was noted. Precise histopathological diagnosis was achieved in 38 (88.4%) patients.

Conclusions

Uniportal and tubeless thoracoscopic LB using spontaneous ventilation anesthesia can be considered a feasible and safe operation method for selected patients with ILD.

Use of transbronchial cryobiopsy in the diagnosis of interstitial lung disease-a systematic review and cost analysis

BACKGROUND

Histological diagnosis by surgical lung biopsy for interstitial lung disease (ILD) is currently limited. Transbronchial cryobiopsy via flexible bronchoscope may this for more patients. The relative costs, diagnostic yields and safety of this approach and more traditional approaches have not been determined.

OBJECTIVES

To perform a systematic review and meta-analysis of transbronchial cryobiopsy, forceps transbronchial biopsy and video assisted (VATS) surgical lung biopsy assessing their relative diagnostic yields and safety. To perform a cost analysis to demonstrate any savings through change to the newer technique.

METHODS

We performed a systematic review of the literature using MEDLINE and EMBASE for all original articles on the diagnostic yield and safety of transbronchial cryobiopsy, forceps transbronchial biopsy and VATS-biopsy in ILD up to February 2016. Data were extracted on yield and complication rates, in addition to study characteristics. Theoretical cost analysis was performed from local institution financial data, 2015-16 reimbursement tariffs and results of the systematic review.

RESULTS

A meta-analysis of 11 investigations for transbronchial cryobiopsy, 11 for forceps transbronchial biopsy and 24 for VATS-biopsy revealed diagnostic yields of 84.4% (75.9-91.4%), 64.3% (52.6-75.1%) and 91.1% (84.9-95.7%), respectively. Pneumothorax occurred in 10% (5.4-16.1%) of transbronchial cryobiopsy procedures, moderate bleeding in 20.99% (5.6-42.8%), with three deaths reported. Surgical mortality was 2.3% (1.3-3.6%). Cost analysis demonstrated potential savings of £210 per patient in the first year and £647 in subsequent years.

CONCLUSIONS

Transbronchial cryobiopsy represents a potentially cost-saving approach to improve histological diagnosis in ILD, however is accompanied by a significant risk of moderate bleeding.

Single versus multiple lung biopsies for suspected interstitial lung disease

BACKGROUND

There is a belief that in patients with suspected interstitial lung disease, multiple biopsies from different lobes are more likely to result in a diagnosis. We compared the results of single biopsies with those of multiple biopsies in terms of positive yield of histological diagnoses and the patients' postoperative outcomes.

METHODS

Data of 115 patients who underwent video-assisted thoracoscopic lung biopsy, between 2009 and 2015, for suspected interstitial lung disease were analyzed retrospectively and grouped according to single or multiple lung biopsies. High-resolution computed tomography of the chest was reviewed prior to the procedure, and the most appropriate areas for sampling were chosen. Data analysis was carried out with the Mann-Whitney U test, using MedCalc version 16.1 statistical software.

RESULTS

Of the 115 patients, 67 had a single biopsy and 48 had more than one biopsy. A histological diagnosis was arrived at in all cases. The duration of chest drainage (p = 0.033) and postoperative hospital stay (p = 0.012) were longer in the multiple-biopsies group.

CONCLUSION

A single lung biopsy is sufficient to arrive at a diagnosis of interstitial lung disease when the sampling site is guided by high-resolution computed tomography and a multidisciplinary approach. Multiple biopsies are less cost-effective, offer no added advantage in terms of diagnostic yield, and are associated with more morbidities and a longer hospital stay.

Surgical Lung Biopsy for Interstitial Lung Diseases

This review addresses common questions regarding the role of surgical lung biopsy (SLB) in the diagnosis and treatment of interstitial lung disease (ILD). We specifically address when a SLB can be diagnostic as well as when it may be avoided; for example, when the combination of the clinical context and the imaging pattern seen on high-resolution CT (HRCT) chest scans can provide a confident diagnosis. Existing studies on the diagnostic utility as well as the complications associated with SLB are reviewed; also reviewed are the performance characteristics and reliability of HRCT scans of the chest in predicting the underlying histopathologic findings of the lung. The review is formatted in the form of answers to questions that clinicians regularly ask when considering an SLB in a patient with ILD.

Efficacy of minimally invasive surgery in diagnosis of interstitial lung disease

OBJECTIVE

This study aimed to evaluate the efficacy and safety of video-assisted thoracic surgery in reaching a specific diagnosis in patients with interstitial lung disease.

METHODS

Thirty-eight patients with interstitial lung disease (19 males, 19 females; mean age 47.73 years) who had undergone video-assisted thoracic surgery at Ghaem Hospital, Mashhad, Iran, between 2010 and 2013 were evaluated retrospectively in this study. Preoperative evaluations including cardiac and pulmonary assessments were performed. Data were recorded in forms prepared for this study and included age, sex, symptoms, imaging findings, operation duration, chest drain withdrawal time, postoperative hospital stay, hospital mortality, and specific diagnosis of the disease.

RESULTS

The most common symptom was dyspnea (38 patients, 100%). The most common computed tomography finding was a reticular pattern (30 patients, 78.94%). Surgery complications included persistent air leak in 3 (7.9%) cases and wound infection in 2 (5.26%). There was no hospital death and no need for reoperation. The average of operative time was 50 min. The mean time for chest drain withdrawal and postoperative hospitalization was 4 and 5 days, respectively. The most common diagnoses were usual interstitial pneumonia in 9 (23.68%) patients and sarcoidosis in 6 (15.78%). A specific diagnosis was not reached in 2/38 (5.26%) patients after video-assisted thoracic surgery.

CONCLUSION

Video-assisted thoracic surgery is a highly effective and safe method for establishing a specific diagnosis in patients with interstitial lung disease.

Diagnostic yield and postoperative mortality associated with surgical lung biopsy for evaluation of interstitial lung diseases: A systematic review and meta-analysis

OBJECTIVES

Surgical lung biopsy plays an important role in providing pathologic results, thus complementing the diagnostic rationale for suspected interstitial lung diseases. We performed a systematic review and meta-analysis regarding the diagnostic yield and postoperative mortality rate of surgical lung biopsy in patients with suspected interstitial lung diseases because of the wide variation in previously reported effectiveness and safety concerns.

METHODS

We systematically searched for published studies between 2000 and 2014 evaluating surgical lung biopsy in the diagnosis of interstitial lung diseases. Subgroup analysis was performed to identify the possible source of study heterogeneity.

RESULTS

Twenty-three studies contributed 2148 patients for the analysis. The median diagnostic yield was 95% (range, 42%-100%), with idiopathic pulmonary fibrosis as the most frequent diagnosis (618, 33.5%). Surgical lung biopsy was mainly guided by high-resolution computed tomography manifestations. Biopsy site, biopsy number, and the surgical lung biopsy method may not be associated with the diagnostic accuracy. The pooled postoperative mortality rate for included studies was 3.6% (95% confidence interval, 2.1-5.5), with significant heterogeneity observed. Subgroup analysis revealed that exclusion criteria based on immunocompromised status, mechanical ventilation, and severe respiratory dysfunction (diffusing capacity of lung for carbon monoxide <35% or forced vital capacity <55% predicted), but not surgical lung biopsy technique or underlying interstitial lung disease subtype, may be possible sources of heterogeneity.

CONCLUSIONS

We demonstrated a satisfactory diagnostic performance with a favorable safety profile of surgical lung biopsy in the diagnosis of suspected interstitial lung diseases. Surgical lung biopsy is especially recommended in patients with clinical information indicative but atypical of idiopathic pulmonary fibrosis, whereas the benefit of surgical lung biopsy should be carefully balanced against the risk for patients with immunocompromised status, mechanical ventilation dependence, or severe respiratory dysfunction.

Familial and sporadic idiopathic pulmonary fibrosis: making the diagnosis from peripheral blood

Background

Peripheral blood biomarkers might improve diagnostic accuracy for idiopathic pulmonary fibrosis (IPF).

Results

Gene expression profiles were obtained from 89 patients with IPF and 26 normal controls. Samples were stratified according to severity of disease based on pulmonary function. The stratified dataset was split into subsets; two-thirds of the samples were selected to comprise the training set, while one-third was reserved for the validation set. Bayesian probit regression was used on the training set to develop a gene expression model for IPF versus normal. The gene expression model was tested by using it on the validation set to perform class prediction. Unsupervised clustering failed to discriminate between samples of different severity. Therefore, samples of all severities were included in the training and validation sets, in equal proportions. A gene signature model was developed from the training set. The model was built in an iterative fashion with the number of gene features selected to minimize the misclassification error in cross validation. The final model was based on the top 108 discriminating genes in the training set. The signature was successfully applied to the validation set, ROC area under the curve = 0.893, p < 0.0001. Using the optimal threshold (0.74) accurate class predictions were made for 77% of the test cases with sensitivity = 0.70, specificity = 1.00.

Conclusions

By using Bayesian probit regression to develop a model, we show that it is entirely possible to make a diagnosis of IPF from the peripheral blood with gene signatures.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2164-15-902) contains supplementary material, which is available to authorized users.

The diagnosis efficacy and safety of video-assisted thoracoscopy surgery (VATS) in undefined interstitial lung diseases: a retrospective study

OBJECTIVES

To evaluate the efficacy and safety of lung biopsies by video-assisted thoracoscopy surgery (VATS) in the diagnosis of undefined interstitial lung disease (ILD).

PATIENTS AND METHODS

The retrospective analysis was performed in 32 who patients underwent VATS for the diagnosed with ILD from Jan 2007 to Dec 2011. The main reason for VATS for all the patients was due to no specific diagnosis could be obtained after non-invasive methods, transbronchial lung biopsy (TBLB) examination and the consultation with pulmonologist, radiologist and pathologist. The clinical profiles, chest high resolution computerized tomography (HRCT), laboratory profile, TBLB as well as the diagnosis of before and after the VATS were analyzed. The surgery site, biopsy number, duration of the thoracic drain, post-operative complications were also recorded. The 30- and 90-day post-operative mortality rates were calculated. The risk factors associated with the incidence of post-operative complications were assessed.

RESULTS

The specific diagnosis could be established in all patients after VATS lung biopsies, with change from previous ones in 27 (84.4%). Among 20 cases (62.5%) diagnosed as unclassified ILD before the surgery, 14 (70.0%) were diagnosed as nonspecific interstitial pneumonia (NSIP), 3 (15.0%) as idiopathic pulmonary fibrosis (IPF) and 3 (15.0%) as connective tissue disease-related ILD (CTD-ILD). Among the 7 cases with complete change of diagnosis after VATS, 4 (57.1%) were cryptogenic organizing pneumonia (COP). The number of site of biopsy had no significant impact on the diagnostic efficacy. There were no significant change of vital sign and lung function after the VATS. 21 (65.6%) patients had post-operative complications, including pulmonary infection (56.3%), pulmonary atelectasis (28.1%) and pneumothorax (25.0%). The 30- and 90-day mortality rates were 0 and 5.2% respectively. Patients were divided into 2 groups based on the incidence of post-operative complications, and no significant difference was found in regards to the age, body mass index (BMI), smoking index, lung function, anesthesia method, duration of remaining the thoracic drain and the use of immunosuppressive drugs or steroids.

CONCLUSIONS

VATS is a safe and effective procedure for the diagnosis of ILD which were unclassified after routine evaluation, transbronchial lung biopsy and consultation with pulmonologist, radiologist and pathologist.

Surgical biopsy of suspected interstitial lung disease is superior to radiographic diagnosis

BACKGROUND

Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure.

METHODS

We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes.

RESULTS

Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time.

CONCLUSIONS

Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high.