Transbronchial Cryobiopsies for Diagnosing Interstitial Lung Disease: Real-Life Experience from a Tertiary Referral Center for Interstitial Lung Disease

The influence of the interventionalist's sex on the outcome and complications of transbronchial lung cryobiopsy

BACKGROUND

To date there are no data on sex aspects evaluating outcomes of interventional pneumology (IP). Our aim was to investigate sex differences in transbronchial lung cryobiopsy (TBLC) outcomes in the diagnosis of interstitial lung disease (ILD).

METHODS

All consecutive (TBLC)s performed for ILD evaluation between Nov 17 and Dec 21 at a tertiary referral center for ILDs and IP were analyzed. The indication for the procedure was determined by a multidisciplinary discussion (MDD). Final results including bronchoalveolar lavage (BAL) and histology were discussed in a 2nd MDD and outcomes and procedure related complications were assessed.

RESULTS

TBLC was performed in 406 patients (38.4 % female/67.8 years/FVC 76.8 %). Among 32 interventionalists, 16 females performed 53 % of interventions. Females had longer procedure times (29.9 vs. 26.6 min, p = 0.046), used fluoroscopy more often (76.7 vs. 50.3 %, p < 0.001) and obtained more samples (3.6 vs. 3.2, p = 0.021) than their male counterparts. No difference was found for major bleeding or pneumothorax. MDD was able to conclude on a diagnosis in 88.4 % of interventions performed by women and in 78.5 % performed by men (p = 0.010). In a multivariate analysis, female gender (OR 1.93) and lower FVC% values (OR 0.98) were significantly associated with diagnostic yield, whereas the number of biopsies, professional experience, use of fluoroscopy or antiplatelet drugs were not relevant.

CONCLUSION

The results of this study strengthen the role of women in endoscopy and may help to motivate women to pursue a career in IP.

Cryobiopsy for Secondary Pulmonary Alveolar Proteinosis

Secondary pulmonary alveolar proteinosis (SPAP) is one of the diffuse parenchymal lung diseases, and the utility and safety of transbronchial lung cryobiopsy (TBLC) for diagnosing SPAP are unknown. A case of SPAP diagnosed by TBLC is presented. Specimens that were useful for diagnosis were collected, and there was no adverse event following TBLC. The usefulness of TBLC for interstitial lung disease has been widely reported, but there are few reports of SPAP. We present the clinical course of TBLC in the diagnosis of SPAP.

Comparison of the diagnostic yield of transbronchial lung biopsies by forceps and cryoprobe in diffuse parenchymal lung disease

Background

Transbronchial lung cryobiopsy (TBLC) in the diagnosis of diffuse parenchymal lung disease (DPLD) has shown a promising yield in recent times, with low post-procedural mortality and morbidity.

Objectives

To compare the yield of TBLC and conventional transbronchial forceps lung biopsy (TBLB).

Methods

A prospective study was carried out in patients with DPLD over a period of 1 year in a tertiary respiratory care institute in New Delhi, India. All 87 patients enrolled underwent both TBLB and TBLC. The procedures were performed in the bronchoscopy suite under conscious sedation and local anaesthesia, with an attempt to take a minimum of three biopsy specimens by conventional TBLB followed by TBLC. A 1.9 mm cryoprobe with a freezing time of 4 - 5 seconds was used. An Arndt endobronchial blocker was used to control bleeding along with locally administered medications.

Results

TBLB and TBLC led to a definitive diagnosis in 27 (31.0%) and 69 (79.3%) cases, respectively. The commonest diagnoses were hypersensitivity pneumonitis, sarcoidosis and pulmonary tuberculosis. TBLC led to additional diagnoses in 42 cases (48.3%). Pneumothorax was observed in 12 cases (13.8%), and moderate bleeding occurred in 63 (72.4%). There were no procedure-related deaths.

Conclusion

TBLC had a better diagnostic yield than conventional TBLB in DPLD. It has the potential to become a safe day-care procedure in a resource-limited setting, if certain precautions are taken.

Study synopsis

What the study adds. Compared with transbronchial forceps lung biopsy, transbronchial lung cryobiopsy (TBLC) led to additional diagnoses in 42 (48.3%) of 87 patients with clinicoradiological features of diffuse parenchymal lung disease. Pneumothorax was observed in 12 cases (13.8%) and moderate bleeding in 63 (72.4%). TBLC without rigid bronchoscopy or advanced airway devices under conscious sedation had a good diagnostic yield with an acceptable adverse events profile.Implications of the findings. TBLC under conscious sedation is not resource intensive and can be carried out in settings with limited resources.

Role of Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Meta-analysis of 68 Studies and 6300 Patients

BACKGROUND

Diagnosis of interstitial lung disease (ILD) is based on multidisciplinary team discussion (MDD) with the incorporation of clinical, radiographical, and histopathologic information if available. We aim to evaluate the diagnostic yield and safety outcomes of transbronchial lung cryobiopsy (TBLC) in the diagnosis of ILD.

METHODS

We conducted a meta-analysis by comprehensive literature search to include all studies that evaluated the diagnostic yields and/or adverse events with TBLC in patients with ILD. We calculated the pooled event rates and their 95% confidence intervals (CIs) for the diagnostic yield by MDD, histopathologic diagnostic yield, and various clinical adverse events.

RESULTS

We included 68 articles (44 full texts and 24 abstracts) totaling 6386 patients with a mean age of 60.7±14.1 years and 56% men. The overall diagnostic yield of TBLC to achieve a definite or high-confidence diagnosis based on MDD was 82.3% (95% CI: 78.9%-85.2%) and histopathologic diagnosis of 72.5% (95% CI: 67.7%-76.9%). The overall rate of pneumothorax was 9.6% (95% CI: 7.9%-11%), while the rate of pneumothorax requiring drainage by a thoracostomy tube was 5.3% (95% CI: 4.1%-6.9%). The rate of moderate bleeding was 11.7% (95% CI: 9.1%-14.9%), while the rate of severe bleeding was 1.9% (95% CI: 1.4%-2.6%). The risk of mortality attributed to the procedure was 0.9% (95% CI: 0.7%-1.3%).

CONCLUSION

Among patients with undiagnosed or unclassified ILD requiring tissue biopsy for diagnosis, transbronchial cryobiopsy represents a reliable alternative to surgical lung biopsy with decreased incidence of various clinical adverse events.

Transbronchial cryobiopsy proven amyloid diffuse cystic lung disease complicating a transthyretin mutated (ATTRm) amyloidosis: a case report

We present a case report of transbronchial cryobiopsy proven diffuse amyloid cystic lung disease complicating a homozygous Val122Ile (V122I) transthyretin mutated amyloidosis (ATTRm). To the best of our knowledge, this is the first case in the literature reporting such pulmonary lesions in ATTRm amyloidosis, and notably diagnosed through cryobiopsy. A 51-year-old man from Mali with a past medical history of bilateral carpal tunnel syndrome presented erectile dysfunction, asthenia and worsening dyspnoea over the past year. He presented signs of cardiac failure; histological and radiological investigations diagnosed cardiac amyloidosis. He was found homozygote for the V122I mutation in transthyretin. A diffuse cystic lung disease (DCLD) was noted on computed tomography (CT) scan. We performed a transbronchial pulmonary cryobiopsy that revealed histological transthyretin amyloid deposits. This case report illustrates the safety and usefulness of cryobiopsy in the setting of DCLD and extends ATTRm amyloidosis as a possible cause of DCLD.

Transbronchial Lung Cryobiopsy in Patients with Interstitial Lung Disease: A Systematic Review

RATIONALE

In 2018, a systematic review evaluating transbronchial lung cryobiopsy (TBLC) in patients with interstitial lung disease (ILD) was performed to inform American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), and Asociación Latinoamericana del Tórax (ALAT) clinical practice guidelines on the diagnosis of idiopathic pulmonary fibrosis (IPF).

OBJECTIVE

To perform a new systematic review to inform updated guidelines.

METHODS

Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CCTR) were searched through June 2020. Studies that enrolled patients with ILD and reported the diagnostic yield or complication rates of TBLC were selected for inclusion. Data was extracted and then pooled across studies via meta-analysis. The quality of the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Histopathologic diagnostic yield (number of procedures that yielded a histopathologic diagnosis divided by the total number of procedures performed) of TBLC was 80% (95% CI 76-83%) in patients with ILD. TBLC was complicated by bleeding and pneumothorax in 30% (95% CI 20-41%) and 8% (95% CI 6-11%) of patients, respectively. Procedure-related mortality, severe bleeding, prolonged air leak, acute exacerbation, respiratory failure, and respiratory infection were rare. The quality of the evidence was very low due to the uncontrolled study designs, lack of consecutive enrollment, and inconsistent results.

CONCLUSION

Very low-quality evidence indicated that TBLC has a diagnostic yield of approximately 80% in patients with ILD, with manageable complications.

Idiopathic Pulmonary Fibrosis (an Update) and Progressive Pulmonary Fibrosis in Adults: An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline

Background: This American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Asociación Latinoamericana de Tórax guideline updates prior idiopathic pulmonary fibrosis (IPF) guidelines and addresses the progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than IPF. Methods: A committee was composed of multidisciplinary experts in ILD, methodologists, and patient representatives. 1) Update of IPF: Radiological and histopathological criteria for IPF were updated by consensus. Questions about transbronchial lung cryobiopsy, genomic classifier testing, antacid medication, and antireflux surgery were informed by systematic reviews and answered with evidence-based recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. 2) Progressive pulmonary fibrosis (PPF): PPF was defined, and then radiological and physiological criteria for PPF were determined by consensus. Questions about pirfenidone and nintedanib were informed by systematic reviews and answered with evidence-based recommendations using the GRADE approach. Results:1) Update of IPF: A conditional recommendation was made to regard transbronchial lung cryobiopsy as an acceptable alternative to surgical lung biopsy in centers with appropriate expertise. No recommendation was made for or against genomic classifier testing. Conditional recommendations were made against antacid medication and antireflux surgery for the treatment of IPF. 2) PPF: PPF was defined as at least two of three criteria (worsening symptoms, radiological progression, and physiological progression) occurring within the past year with no alternative explanation in a patient with an ILD other than IPF. A conditional recommendation was made for nintedanib, and additional research into pirfenidone was recommended. Conclusions: The conditional recommendations in this guideline are intended to provide the basis for rational, informed decisions by clinicians.

Efficacy and Safety of Pleural Cryobiopsy vs. Forceps Biopsy for Evaluation of Undiagnosed Pleural Effusion: A Systematic Review and Meta-Analysis

Background

Pleural cryobiopsy is a novel technique for the diagnosis of pleural pathologies. However, the safety and feasibility of this modality compared to standard forceps for pleural biopsy has not been fully elucidated. This systematic review and meta-analysis aims to establish the efficacy and safety of cryobiopsy for evaluation of undiagnosed pleural effusion.

Methods

For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and Web of science databases up to December 16, 2021 to identify relevant articles. We included randomized controlled trials, cohort studies, retrospectives studies and case series that compared pleural cryobiopsy and forceps biopsy. A qualitative assessment was performed using the QUADAS-2 tool.

Results

Of the 365 articles identified by our search, 15 studies were eligible for inclusion. The specimen sizes obtained with cryobiopsy were significantly larger compared with forceps biopsy (Standard mean difference 1.16; 95 % CI: 0.51–1.82; P < 0.01). Furthermore, the cryobiopsy tissue specimens were deeper (OR 2.68; 95 % CI: 1.39–5.16; P < 0.01) and qualitatively better with less crush artifacts (OR 0.06; 95 % CI: 0.01–0.26; P < 0.01). There was no significant difference in diagnostic yield (OR 1.32; 95 % CI: 0.79–2.21; P = 0.29) and mild to moderate bleeding events (OR 1.21; 95 % CI: 0.64–2.29; P = 0.57) between pleural cryobiopsy and forceps biopsy. No publication bias was observed among these studies.

Conclusions

Compared to flexible forceps biopsy pleural cryobiopsy obtained larger and deeper tissue specimens with less crush artifacts but does not show superiority for diagnostic yield. Further studies are still needed to verify these findings.

The diagnostic value of transbronchial lung cryobiopsy combined with rapid on-site evaluation in diffuse lung diseases: a prospective and self-controlled study

BACKGROUND

The etiology of interstitial lung diseases (ILDs) is varied. Early diagnosis and a specific pathological type could significantly improve the prognosis. Mostly, it is difficult to make the etiology diagnosis of ILD through traditional biopsy methods. It will be of great significance to explore an effective biopsy method.

METHODS

The prospective study was designed to evaluate the diagnostic value of transbronchial lung cryobiopsy (TBCB) combined with rapid on-site evaluation (ROSE), compared with conventional transbronchial lung biopsy (TBLB), in a large sample of ILD patients. All patients enrolled will undergo both TBLB and TBCB procedures. The study will observe the differences in the diagnostic efficiency of pathological typing and incidence of operation-related complications between TBCB and TBLB. Besides, it will analyze the relationship between the time of biopsy and the incidence of complications, the relationship between freezing time, size of specimen, and complications. And it will evaluate the consistency of pathological, clinical, and radiology.

DISCUSSION

It may be the first time that ROSE technique will be used in the diagnosis of ILD. The results of this study will clarify the value of TBCB in the diagnosis of ILD and confirm its safety and effectiveness, which is expected to significantly improve the efficiency of diagnosis in ILD patients.

TRAIL REGISTRATION

The trial was registered on the Chinese Clinical Trial Registry website ( http://www.chictr.org.cn/showproj.aspx?proj=57834 ) (Registration number: ChiCTR2000035492).

Transbronchial lung cryobiopsy for the diagnosis of interstitial lung diseases

PURPOSE OF REVIEW

Transbronchial lung cryobiopsy has shown promise in several studies in providing meaningful histological information in the multidisciplinary team diagnosis of fibrotic interstitial lung diseases. The purpose of this review is to describe recent literature providing support for the formal integration of cryobiopsy into the algorithm for interstitial lung disease diagnosis.

RECENT FINDINGS

Histopathological concordance between cryobiopsy and surgical biopsy and diagnostic agreement at multidisciplinary discussion have been reported good; furthermore, cryobiopsy may provide an increased diagnostic confidence to a level likely to influence management. Finally, although cryobiopsy is more likely to provide a probable usual interstitial pneumonia (UIP) pattern than a definite UIP pattern, given the limited sampling of sub-pleural lung parenchyma in most cases, finding of a probable UIP pattern at cryobiopsy samples is strongly predictive of a definite UIP pattern in the corresponding surgical biopsy and when a UIP pattern is found on cryobiopsy sample, this is associated with higher mortality compared with other histological patterns.

SUMMARY

Cryobiopsy is becoming a valid alternative to surgical lung biopsy for making histopathological diagnosis in patients with interstitial lung diseases of undetermined type in experienced centres, with standardized protocols, in order to have the best risks/diagnostic yields ratio.

Transbronchial lung cryobiopsy: prospective safety evaluation and 90-day mortality after a standardized examination protocol

BACKGROUND

Transbronchial lung cryobiopsy (TBLC) is a new method of bronchoscopic tissue sampling in patients with unclear diffuse parenchymal lung disease (DPLD). While not the gold standard, TBLC has a good diagnostic correlation with surgical lung biopsy, and retrospective analyses of peri-interventional complications and mortality are promising. However, prospective reports on 90-day mortality are lacking.

OBJECTIVES

This study addresses morbidity and 30- and 90-day mortality in TBLC after a standardized protocol.

METHODS

In this prospective study, 75 patients with DPLD requiring tissue sampling were included. A standardized protocol (including prophylactic use of an endobronchial balloon, postinterventional observation, and minimum sampling requirements) was used in all patients. Adverse events (pneumothorax, bronchial bleeding, premature discontinuation, prolonged monitoring at ICU, and fatal outcome) and 30- and 90-day mortality rates were recorded.

RESULTS

A total of 308 cryobiopsies were performed in 75 patients. Peri- and postinterventional pneumothorax were observed in 20% (9.3% mild and 10.7% moderate with the necessity of chest drainage), and bronchial bleeding was found in 29.3% (22.7% moderate and 6.7% severe). Total lung capacity below normal value was associated with the risk of pneumothorax (p = 0.009), and diffusion limitation for carbon monoxide below normal value was associated with the risk of bronchial bleeding (p = 0.044). No fatal events were observed within 30 days, and the 90-day mortality rate was 1.3%, but not related to the procedure itself.

CONCLUSION

As it gradually becomes the invasive procedure of choice in unclear DPLD, TBLC is a safe procedure with a low 30- and 90-day mortality.Trial registration ID: DRKS00026746 (German Clinical Trial Register).

Transbronchial Biopsy and Cryobiopsy in the Diagnosis of Hypersensitivity Pneumonitis among Patients with Interstitial Lung Disease

Rationale: Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) with a diagnosis based on clinical, radiological, and pathological findings. The evidence supporting transbronchial forceps lung biopsy (TBBx) and transbronchial lung cryobiopsy (TBLC) as sampling techniques to diagnose HP in patients with newly detected ILD has not been reviewed systematically.Objectives: A systematic review was performed to assess the diagnostic yield and complication rates of TBBx or TBLC in patients with newly detected ILD whose differential diagnosis includes HP and to inform the development of the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax clinical practice guidelines on the diagnosis of HP.Methods: Medline, Excerpta Medica Database, and the Cochrane Library were searched through October 2019. Studies that enrolled patients with ILD and reported the diagnostic yield of TBBx or TBLC were selected for inclusion. Data related to diagnostic yield and safety outcomes were extracted and then pooled across studies via meta-analysis. The quality of the evidence was appraised using the grading of recommendations, assessment, development, and evaluation (GRADE) approach.Results: The histopathologic diagnostic yields (number of procedures that yielded a histopathologic diagnosis divided by the total number of procedures performed) of TBBx and TBLC were 37% (95% confidence interval [CI], 32-42%) and 82% (95% CI, 78-86%), respectively, among patients with ILD. Among those diagnosed by TBBx, the proportion with HP could not be determined. However, among those diagnosed by TBLC, 13.4% had HP. TBBx was complicated by moderate to severe bleeding, severe bleeding, and pneumothorax in 4% (95% CI, 0-8%), 0% (95% CI, 0-1%), and 7% (95% CI, 2-13%) of patients, respectively. TBLC was complicated by any bleeding, severe bleeding, and pneumothorax in 11% (95% CI, 7-15%), 0% (95% CI, 0-1%), and 11% (95% CI, 9-14%) of patients, respectively. The quality of the evidence was very low because of the uncontrolled study designs, lack of consecutive enrollment, and inconsistent results.Conclusions: Very low-quality evidence indicated that TBLC had a higher diagnostic yield than TBBx among patients with ILD, although complications were similar.

Biopsy in interstitial lung disease: specific diagnosis and the identification of the progressive fibrotic phenotype

PURPOSE OF REVIEW

The evaluation of progression in fibrotic interstitial lung diseases (ILDs) may require a multidimensional approach. This review will cover the role and usefulness of lung biopsy in diagnosis and assessment of the progressive fibrotic phenotype.

RECENT FINDINGS

The identification of specific findings and the balance between inflammation and fibrosis on lung biopsy may help distinguishing different disease entities and may likely determine the effect of treatment and possibly prognosis. The fibrotic morphological patterns potentially associated with a progressive phenotype include usual interstitial pneumonia (UIP), fibrotic nonspecific interstitial pneumonia, pleuroparenchymal fibroelastosis, desquamative interstitial pneumonia, fibrotic hypersensitivity pneumonitis and other less common fibrotic variants, with histopathological findings of UIP at the time of diagnosis being predictive of worse outcome compared with other patterns. The prognostic significance of lung biopsy findings has been assessed after both surgical lung biopsy (SLB) and transbronchial lung cryobiopsy (TBLC), the latter becoming a valid alternative to SLB, if performed in experienced centres, due to significantly lower morbidity and mortality.

SUMMARY

Lung biopsy plays an important role in diagnosis and identification of the progressive fibrotic phenotype. The introduction of less invasive procedures could potentially expand the role of lung sampling, including for example patients with a known diagnosis of ILD or at an earlier stage of the disease.

Acute Pulmonary Graft-Versus-Host Disease in a Patient with Adult T-cell Leukemia-Lymphoma Diagnosed by a Cryobiopsy

A 51-year-old woman with adult T-cell leukemia-lymphoma was hospitalized in order to undergo allogeneic hematopoietic stem-cell transplantation. On day 29 after transplantation, she began to experience hypoxia upon exertion. Chest computed tomography revealed centrilobular granular shadows, and pulmonary function tests revealed a remarkable obstructive ventilatory impairment compared to before transplantation. A histopathological analysis following a transbronchial lung cryobiopsy revealed acute graft-versus-host disease (GVHD). We herein report a rare case of histopathologically diagnosed acute pulmonary GVHD with spontaneous remission.

Transbronchial cryobiopsy for diagnosing parenchymal lung diseases: real-life experience from a tertiary referral center

Background and Objectives:

Transbronchial cryobiopsy (cryo-TBB) is increasingly being used in the diagnosis of diffuse parenchymal lung diseases (DPLD). Varying diagnostic success and complication rates have been reported. Herein we report our experience with cryo-TBB, focusing on diagnostic yield, factors affecting diagnosis, and safety.

Methods:

This retrospective study was conducted in a tertiary referral chest diseases hospital. Data regarding the patients, procedures, complication rates, diagnostic yield, and the final diagnosis made by a multidisciplinary committee at all diagnosis stages were evaluated.

Results:

We recruited 147 patients with suspected DPLD. The definitive diagnosis was made pathologically in 98 of 147 patients (66.6%) and using a multidisciplinary approach in 109 of 147 (74.1%) cases. The number of samples had a significant effect on diagnostic success. Histopathologic diagnostic yield and diagnostic yield with a multidisciplinary committee after a single biopsy were 50%, and histopathological diagnostic yield and diagnostic yield with multidisciplinary committee increased to 71.4% and 85.7%, respectively, with a second biopsy (p = 0.034). The incidence of mild-to-moderate hemorrhage was 31.9%; no severe hemorrhage occurred. Pneumothorax rate was 15.6%, and the mortality rate was 0.68%.

Conclusions:

Cryo-TBB has sufficient diagnostic yield in the context of a multidisciplinary diagnosis with acceptable complication rates. Performing at least 2 biopsies and from at least 2 segments increases diagnostic success.

Transbronchial lung cryobiopsy for connective tissue disease-related interstitial lung disease and interstitial pneumonia with autoimmune features: a single center retrospective case series

OBJECTIVE

Transbronchial lung cryobiopsy (TBLC) has been recently introduced for diagnosing interstitial lung diseases. We aimed to assess the effectiveness and safety of TBLC by identifying the specific patterns of histology in the diagnosis of connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial pneumonia with autoimmune features (IPAF).

METHODS

The clinical-radiological-pathological data from the Affiliated Hospital of Guilin Medical University between July 1, 2017, and October 31, 2020, of patients whose clinical-radiological or clinical-radiological-pathological diagnosis was CTD-ILD or IPAF and who underwent TBLC, transbronchial lung biopsy (TBLB), or surgical lung biopsy were retrospectively analyzed and summarized with review. The size of biopsy samples, complications, and diagnostic yield were compared.

RESULTS

Fourteen patients met the inclusion criteria, of whom 12 underwent TBLC, 1 underwent TBLB, and 1 underwent each procedure at different times. Compared to the size of TBLB specimens (5.625 ± 0.479 mm²), the size of TBLC specimens (12.00 (12.00, 15.00) mm²) was much larger (Z = - 3.262, P = 0.001). The diagnostic yields of TBLC and TBLB were 100.00% (13/13) and 0.00% (2/2), respectively (P = 0.0095). The most frequent complication was mild bleeding. The risk of bleeding between TBLB (1/2, 50.00%) and TBLC (10/13, 76.92%) did not differ significantly (P = 0.469).

CONCLUSION

TBLC can add extra diagnostic value by effectively identifying specific types of histology for patients with suspected CTD-ILD or IPAF, with a procedure that is safe from adverse events. Key Points • Transbronchial lung cryobiopsy has been introduced recently for diagnosing interstitial lung disease. • Transbronchial lung cryobiopsy was found to be effective and safe in the diagnosis for patients with suspected interstitial lung disease. It can be used as a preferred method for biopsy when the clinical-radiological diagnosis is uncertain.

Implementation of transbronchial lung cryobiopsy in a tertiary referral center for interstitial lung diseases: a cohort study on diagnostic yield, complications, and learning curves

Background

Transbronchial lung cryobiopsy (TBLC) has been introduced as an alternative to surgical lung biopsy (SLB) in the diagnostics of interstitial lung diseases (ILD). Despite controversy on safety, TBLC is increasingly implemented in ILD centers with an apparent diagnostic yield comparable to SLB. The aim of this study was to assess TBLC implementation experiences from a tertiary Danish ILD center regarding diagnosis, complications, and learning curves for TBLC performance.

Methods

TBLC was prospectively performed in a cohort of patients with unclassifiable ILD based on a preceding multidisciplinary clinical and radiological revision. TBLC was performed as an outpatient procedure with the patients in general anesthesia using a flexible bronchoscope with 1.9 or 2.4 mm cryoprobes. Learning curves for TBLC performance were calculated using cumulated sum (CUSUM) scores for diagnostic yield, pneumothorax, and bleeding.

Results

From February 2017 to March 2020 141 patients (86 (61%) men, median age 69 years [IQR, 60–74 years]) had TBLC performed. A histological and confirmative diagnosis was made in 101 patients (75.2%) and 124 patients (87.9%, i.e. clinical diagnostic yield), respectively, in whom idiopathic interstitial pneumonias constituted the majority (67.3%) of the clinical diagnoses. We observed 2 deaths (1.4%) within 30 days of TBLC, but no procedure-related mortality or severe bleeding. Moderate bleeding occurred in 23 patients (16.3%), pneumothorax in 21 patients (14.9%) with only 14 patients (9.9%) requiring a pleural drain. Based on the CUSUM score analysis, the diagnostic yield obtained was satisfactory throughout the period.

Conclusion

This study reports experiences of outpatient TBLC implementation in a tertiary referral ILD center from the largest investigated TBLC cohort in Scandinavia The diagnostic yield and prevalence of complications obtained by TBLC from this single center study on unclassifiable ILD support outpatient TBLC as a valuable and safe alternative to SLB to diagnose ILD in well-selected patients. The learning curves for TBLC were acceptable in the hands of experienced bronchoscopists.

Transbronchial lung cryobiopsy (TBLC) in the diagnosis of interstitial lung disease: experience of first 100 cases performed under conscious sedation with flexible bronchoscope

BACKGROUND

Diagnosing the aetiology of interstitial lung disease (ILD) may require histology via a surgical lung biopsy (SLB). SLB is associated with significant complications. Transbronchial lung cryobiopsy (TBLC) can provide large, adequate biopsies with fewer complications offering a potential alternative to SLB.

AIMS

This study evaluated the safety, diagnostic yield and impact of TBLC on diagnostic certainty in the multidisciplinary diagnosis (MDD) of ILD within routine clinical practice.

METHODS

A retrospective study of all TBLC performed in a tertiary institute from March 2014 to December 2016 was performed. Procedures were performed using a flexible bronchoscope and cryoprobe without fluoroscopic guidance.

RESULTS

One hundred procedures were performed on 85 patients. A total of 272 cryobiopsies were obtained with a mean biopsy diameter of 5.9 ± 3.2 mm. Ninety-seven percent contained alveolated lung tissue. Diagnosis based against MDD gold standard was confirmed using TBLC in 67.1% of patients and in 72/100 procedures. Three patients proceeded to SLB. The addition of histological information changed the clinic-radiological diagnosis in twelve patients. The most common diagnosis based on clinical-radiologic-pathologic correlation at MDD was idiopathic pulmonary fibrosis (IPF) (51.2%) and hypersensitivity pneumonitis (15.9%). Moderate bleeding occurred in 18% of cases and five patients (5%) developed pneumothorax requiring intervention. Eleven patients required admission, with a mean length of stay of 1.3 ± 0.9 days.

CONCLUSION

TBLC aids the diagnosis of ILD in the appropriate patient and may be an acceptable alternative to SLB with fewer complications. Further work on standardizing the procedure is required.

Acute onset systemic lupus erythematosus interstitial lung disease: A case report

A 40-year-old Japanese man was diagnosed with systemic lupus erythematosus. Chest computed tomography showed patchy consolidation in both lungs. A cryobiopsy and bronchoalveolar lavage showed organizing pneumonia, not acute lupus pneumonia or diffuse alveolar hemorrhage. This case demonstrates the usefulness of cryobiopsy for the management of systemic lupus erythematosus interstitial lung disease.

Transbronchial Cryobiopsy in the Diagnosis of Fibrotic Interstitial Lung Disease

CONTEXT.—

Transbronchial cryobiopsy is an emerging procedure to obtain lung tissue for diagnosis of interstitial lung disease and has gained popularity because it is less invasive and has a lower rate of complications compared with nonselective surgical lung biopsy.

OBJECTIVE.—

To provide an overview of the status of the medical literature regarding transbronchial cryobiopsy.

DATA SOURCES.—

A literature search was performed using PubMed search engine. The terms "cryobiopsy" or "cryoprobe" and "interstitial lung disease" or "diffuse parenchymal lung disease" or "pulmonary fibrosis" were used, with the search concluding at the end of November 2019.

CONCLUSIONS.—

While the diagnostic yield of transbronchial cryobiopsy is slightly lower than surgical lung biopsy, a growing amount of literature suggests that with a multidisciplinary approach cryobiopsy provides diagnostic and prognostic information approaching that of surgical lung biopsy with lower morbidity and mortality.

[The updated S2k guideline for the diagnosis of idiopathic pulmonary fibrosis : Essential aspects for pathology]

Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic progressive fibrosing nonreversible interstitial lung disease of largely unknown origin. In high-resolution computer tomography (HRCT) and histopathology it presents with a UIP pattern. To diagnose IPF, (i) an ILD of known origin must be excluded (e.g., hypersensitivity pneumonitis, lung involvement in autoimmune or other systemic disease, and drug-induced ILD) and either (ii) the presence of a UIP pattern in HRCT or (iii) specific combinations of HRCT and histopathology is necessary. The diagnosis of IPF requires interdisciplinary collaboration and a structured procedure. The updated S2k guideline focuses on the IPF diagnostic process and describes the criteria of a UIP pattern in HRCT and histopathology that are differentiated into the categories "UIP pattern," "probable UIP pattern," "indetermined for UIP," and "alternative pattern." Depending on the anamnestic, clinical and serologic findings, HRCT, and - if acquired - histomorphology features, an algorithm to diagnose the IPF is recommended. If a UIP pattern in HRCT is present, IPF can still be diagnosed without further bioptic examination. Additionally, recommendations for the use of surgical lung biopsy (SLB), transbronchial lung biopsy, and the relatively new transbronchial lung cryobiopsy (TBLC) procedure are provided. In contrast to the international guideline, the S2k guideline group evaluated TBLC based on recent studies to be advantageous compared to the SLB, as the diagnostic value and the side-effect rate was assessed to be acceptable and more patients with progressed ILD can be biopsied by TBLC. It is therefore expected that by using TBLC the rate of unclassifiable ILDs can be reduced.

Transbronchial cryobiopsy increases diagnostic confidence in interstitial lung disease: a prospective multicentre trial

INTRODUCTION

The accurate diagnosis of individual interstitial lung diseases (ILD) is often challenging, but is a critical determinant of appropriate management. If a diagnosis cannot be made after multidisciplinary team discussion (MDTD), surgical lung biopsy is the current recommended tissue sampling technique according to the most recent guidelines. Transbronchial lung cryobiopsy (TBLC) has been proposed as an alternative to surgical lung biopsy.

METHODS

This prospective, multicentre, international study analysed the impact of TBLC on the diagnostic assessment of 128 patients with suspected idiopathic interstitial pneumonia by a central MDTD board (two clinicians, two radiologists, two pathologists). The level of confidence for the first-choice diagnoses were evaluated in four steps, as follows: 1) clinicoradiological data alone; 2) addition of bronchoalveolar lavage (BAL) findings; 3) addition of TBLC interpretation; and 4) surgical lung biopsy findings (if available). We evaluated the contribution of TBLC to the formulation of a confident first-choice MDTD diagnosis.

RESULTS

TBLC led to a significant increase in the percentage of cases with confident diagnoses or provisional diagnoses with high confidence (likelihood ≥70%) from 60.2% to 81.2%. In 32 out of 52 patients nondiagnostic after BAL, TBLC provided a diagnosis with a likelihood ≥70%. The percentage of confident diagnoses (likelihood ≥90%) increased from 22.7% after BAL to 53.9% after TBLC. Pneumothoraces occurred in 16.4% of patients, and moderate or severe bleeding in 15.7% of patients. No deaths were observed within 30 days.

INTERPRETATION

TBLC increases diagnostic confidence in the majority of ILD patients with an uncertain noninvasive diagnosis, with manageable side-effects. These data support the integration of TBLC into the diagnostic algorithm for ILD.

Transbronchial Cryobiopsy in the Diagnosis of Diffuse Lung Disease

Transbronchial cryobiopsy, a new diagnostic procedure in patients with diffuse lung disease, provides larger and better-preserved lung specimens compared to forceps biopsy. The diagnostic yield of cryobiopsy is much better than that of forceps biopsy and slightly lower than that of surgical lung biopsy, but with a lower complication rate compared to the latter. Literature suggests that in the multidisciplinary approach to patients with diffuse lung disease cryobiopsy provides diagnostic and prognostic information similar to surgical lung biopsy. Cryobiopsy can also be performed in some patients unsuitable for surgical biopsy, yet in whom histologic input is needed.

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.

[The multidisciplinary discussion-the gold standard in diagnosing interstitial lung diseases]

Interstitial lung diseases present clinically with unspecific respiratory symptoms and occur idiopathically or etiologically linked to various causes. The morphology of interstitial lung diseases (radiology or histopathology) may also be unspecific in the individual case, due to the limited arsenal of reaction patterns of the lungs. Only the combination of all findings assembled during multidisciplinary discussion (MDD) between pulmonologist, radiologist and pathologist, and if required other specialties, enables a highly reliable final diagnosis, permitting improved, personalized patient treatment. The necessity for histological evaluation and the means of tissue acquisition should also be decided on during MDD, considering clinical and radiological differential diagnoses, the risks involved in the procedures and patient-specific characteristics. In the current review, we discuss MDD as the diagnostic gold standard and exemplify its merit presenting a case of interstitial lung disease.

Ongoing challenges in pulmonary fibrosis and insights from the nintedanib clinical programme

The approvals of nintedanib and pirfenidone changed the treatment paradigm in idiopathic pulmonary fibrosis (IPF), and increased our understanding of the underlying disease mechanisms. Nonetheless, many challenges and unmet needs remain in the management of patients with IPF and other progressive fibrosing interstitial lung diseases.This review describes how the nintedanib clinical programme has helped to address some of these challenges. Data from this programme have informed changes to the IPF diagnostic guidelines, the timing of treatment initiation, and the assessment of disease progression. The use of nintedanib to treat patients with advanced lung function impairment, concomitant emphysema, patients awaiting lung transplantation and patients with IPF and lung cancer is discussed. The long-term use of nintedanib and an up-to-date summary of nintedanib in clinical practice are discussed. Directions for future research, namely emerging therapeutic options, precision medicine and other progressive fibrosing interstitial lung diseases, are described.Further developments in these areas should continue to improve patient outcomes.

High Diagnostic Accuracy of Transbronchial Cryobiopsy in Fibrotic Interstitial Lung Diseases Compared to Final Explant Diagnosis

BACKGROUND

A diagnostic lung biopsy may be required in some cases of fibrotic interstitial lung diseases (ILD). Transbronchial cryobiopsy has been suggested as a possible alternative to surgical lung biopsy. However, previous estimates of its diagnostic yield were not validated compared to the definitive diagnosis in explanted lungs.

OBJECTIVES

We aimed to assess the diagnostic accuracy of cryobiopsy in fibrotic ILD patients who subsequently had lung transplantation.

METHODS

All 197 patients who underwent lung transplantation at our Center due to fibrotic ILD from January 2010 to May 2018, were screened for the presence of a pre-transplant cryobiopsy. Fourteen patients who underwent cryobiopsy before transplantation were identified. Two expert lung pathologists blindedto the explant diagnoses, independently examined these cryobiopsy specimens to decide if they match guideline criteria for usual interstitial pneumonia (UIP) pattern or an alternative diagnosis. The primary measure was the diagnostic accuracy of cryobiopsy to detect or refute a UIP pattern, as compared to the final explant diagnosis.

RESULTS

Median time between cryobiopsy and transplantation was 1.4 years. All 14 cryobiopsy samples contained adequate alveolar tissue. The explant diagnosis of 13/14 patients was UIP. The two pathologists correctly diagnosed or refuted UIP in the cryobiopsy specimen in 12/14 cases (85.7%) and 11/14 cases (78.6%), respectively. The level of diagnostic agreement between pathologists was good (kappa 0.59, p = 0.016).

CONCLUSIONS

Compared to the final explant diagnosis, transbronchial cryobiopsy had high diagnostic accuracy and good inter-observer agreement for UIP pattern. These findings support a potential diagnostic role for cryobiopsy in experienced centers.

Lung Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: A Series Contribution to a Debated Procedure

Introduction: Transbronchial cryobiopsy is an alternative to surgical biopsy for the diagnosis of fibrosing interstitial lung diseases, although the role of this relatively new method is rather controversial. Aim of this study is to evaluate the diagnostic performance and the safety of transbronchial cryobiopsy in patients with fibrosing interstitial lung disease. Materials and methods: The population in this study included patients with interstitial lung diseases who underwent cryobiopsy from May 2015 to May 2018 at the Division of Pneumology of San Giuseppe Hospital in Milan and who were retrospectively studied. All cryobiopsy procedures were performed under fluoroscopic guidance using a flexible video bronchoscope and an endobronchial blocking system in the operating room with patients under general anaesthesia. The diagnostic performance and safety of the procedure were assessed. The main complications evaluated were endobronchial bleeding and pneumothorax. All cases were studied with a multidisciplinary approach, before and after cryobiopsy. Results: Seventy-three patients were admitted to this study. A specific diagnosis was reached in 64 cases, with a diagnostic sensitivity of 88%; 5 cases (7%) were considered inadequate, 4 cases (5%) were found to be non-diagnostic. Only one major bleeding event occurred (1.4%), while 14 patients (19%) experienced mild/moderate bleeding events while undergoing bronchoscopy; 8 cases of pneumothorax (10.9%) were reported, of which 2 (2.7%) required surgical drainage. Conclusions: When performed under safe conditions and in an experienced center, cryobiopsy is a procedure with limited complications having a high diagnostic yield in fibrotic interstitial lung disease.