Parenchymal cryobiopsies for interstitial lung diseases: a step forward in disease management

Cryobiopsy versus open lung biopsy in the diagnosis of interstitial lung disease (COLDICE): protocol of a multicentre study

Introduction

Transbronchial lung cryobiopsy (TBLC) is a novel, minimally invasive technique for obtaining lung tissue for histopathological assessment in interstitial lung disease (ILD). Despite its increasing popularity, the diagnostic accuracy of TBLC is not yet known. The COLDICE Study (Cryobiopsy versus Open Lung biopsy in the Diagnosis of Interstitial lung disease allianCE) aims to evaluate the agreement between TBLC and surgical lung biopsy sampled concurrently from the same patients, for both histopathological and multidisciplinary discussion (MDD) diagnoses.

Methods and analysis

This comparative, multicentre, prospective trial is enrolling patients with ILD requiring surgical lung biopsy to aid with their diagnosis. Participants are consented for both video-assisted thoracoscopic surgical (VATS) biopsy and TBLC within the same anaesthetic episode. Specimens will be blindly assessed by three expert pathologists both individually and by consensus. Each tissue sample will then be considered in conjunction with clinical and radiological data, within a centralised MDD. Each patient will be presented twice in random order, once with TBLC data and once with VATS data. Meeting participants will be blinded to the method of tissue sampling. The accuracy of TBLC will be assessed by agreement with VATS at (1) histopathological analysis and (2) MDD diagnosis. Data will be collected on interobserver agreement between pathologists, interobserver agreement between MDD participants, and detailed clinical and procedural characteristics.

Ethics and dissemination

The study is being conducted in accordance with the International Conference on Harmonisation Guideline for Good Clinical Practice and Australian legislation for the ethical conduct of research.

Trial registration number

ACTRN12615000718549.

Diffuse parenchymal lung disease

Between September 2015 and August 2016 there were >1500 publications in the field of diffuse parenchymal lung diseases (DPLDs). For the Clinical Year in Review session at the European Respiratory Society Congress that was held in London, UK, in September 2016, we selected only five articles. This selection, made from the enormous number of published papers, does not include all the relevant studies that will significantly impact our knowledge in the field of DPLDs in the near future. This review article provides our personal view on the following topics: early diagnosis of idiopathic pulmonary fibrosis, current knowledge on the multidisciplinary team diagnosis of DPLDs and the diagnostic role of transbronchial cryobiopsy in this diagnostic setting, insights on the new entity of interstitial pneumonia with autoimmune features, and new therapeutic approaches for scleroderma-related interstitial lung disease.

Pulmonary Abscess as a Complication of Transbronchial Lung Cryobiopsy

We present the case of a 49-year-old man who developed pulmonary abscess as a complication of transbronchial lung cryobiopsy. He had been receiving prednisone therapy, but otherwise had no specific risk factors for lung abscess. Cryobiopsy is a novel technique for obtaining peripheral lung parenchymal tissue for the evaluation of diffuse parenchymal lung diseases. Cryobiopsy is being increasingly proposed as an alternative to surgical lung biopsy or conventional bronchoscopic transbronchial forceps biopsy, but the safety profile of the procedure has not been fully appreciated. Pulmonary abscess has been rarely reported as a complication of other bronchoscopic procedures such as endobronchial ultrasound-guided needle biopsy, however, to our knowledge this is the first reported case of pulmonary abscess complicating peripheral lung cryobiopsy.

Transbronchial Cryobiopsy in Diffuse Lung Disease: Update for the Pathologist

CONTEXT

- Transbronchial cryobiopsy has recently been proposed as an alternative to surgical biopsy in the diagnosis of diffuse lung disease.

OBJECTIVE

- To familiarize pathologists with transbronchial cryobiopsy, including what it is, how it is performed, how it compares to other techniques of lung biopsy in diffuse lung disease, what are the technical issues relating to it, what the complications are, how cryobiopsies should be interpreted, and the clinical usefulness of cryobiopsy.

DATA SOURCES

- All the available literature on cryobiopsy in diffuse lung disease through May 2016, primarily in the last 5 years, was reviewed, and some unpublished data known to the authors were included.

CONCLUSIONS

- Cryobiopsies are considerably larger than forceps biopsies and allow pattern recognition approaching that of a surgical lung biopsy in many cases. Artifacts associated with cryobiopsy are minimal. In comparison with surgical lung biopsies, the diagnosis rate with cryobiopsies is lower, in the neighborhood of 80%, versus higher than 90% for surgical lung biopsies. Cryobiopsy is proposed as an alternative to surgical lung biopsy and a technique that may appreciably decrease the number of patients who require surgical lung biopsy for diagnosis. This is important because the mortality from cryobiopsy is very small (0.1% to date) compared with surgical lung biopsy (1.7% for elective procedures and considerably higher for nonelective procedures).