Thoracoscopic Lung Biopsy Is a Safe Procedure in Diagnosing Usual Interstitial Pneumonia

Digital quantification of p16-positive foci in fibrotic interstitial lung disease is associated with a phenotype of idiopathic pulmonary fibrosis with reduced survival

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is associated with increased expression of cyclin-dependent kinase inhibitors such as p16 and p21, and subsequent induction of cell cycle arrest, cellular senescence, and pro-fibrotic gene expression. We sought to link p16-expression with a diagnosis of IPF or other fibrotic interstitial lung diseases (ILDs), radiographic pattern, senescent foci-specific gene expression, antifibrotic therapy response, and lung transplant (LTx)-free survival.

METHODS

Eighty-six cases of fibrosing ILD were identified with surgical lung biopsy. Immunohistochemistry for p16 was performed on sections with the most active fibrosis. p16-positive foci (loose collection of p16-positive fibroblasts with overlying p16-positive epithelium) were identified on digital slides and quantified. Cases were scored as p16-low (≤ 2.1 foci per 100 mm²) or p16-high (> 2.1 foci per 100 mm²). Twenty-four areas including senescent foci, fibrotic and normal areas were characterized using in situ RNA expression analysis with digital spatial profiling (DSP) in selected cases.

RESULTS

The presence of p16-positive foci was specific for the diagnosis of IPF, where 50% of cases expressed any level of p16 and 26% were p16-high. There was no relationship between radiographic pattern and p16 expression. However, there was increased expression of cyclin-dependent kinase inhibitors, collagens and matrix remodeling genes within p16-positive foci, and cases with high p16 expression had shorter LTx-free survival. On the other hand, antifibrotic therapy was significantly protective. DSP demonstrated that fibroblastic foci exhibit transcriptional features clearly distinct from that of normal-looking and even fibrotic areas.

CONCLUSIONS

We demonstrated the potential clinical applicability of a standardized quantification of p16-positive fibroblastic foci. This method identifies an IPF phenotype associated with foci-specific upregulation of senescence-associated and matrix remodeling gene expression. While these patients have reduced LTx-free survival, good response to antifibrotic therapies was observed in those who were treated.

Outcomes of Video-Assisted Thoracic Surgical Lung Biopsy for Interstitial Lung Diseases

Purpose: Surgical lung biopsy (SLB) is an important diagnostic tool for interstitial lung disease (ILD), yet the risk factors for SLB are still debatable and long-term outcomes remain unknown.

Methods: We retrospectively reviewed the records of 85 consecutive patients with ILD who underwent SLB by video-assisted thoracic surgery (VATS) from 2008 to 2019. Risk factors for complications and differences of outcomes between idiopathic pulmonary fibrosis (IPF) and other ILDs were examined.

Results: All patients who underwent VATS had no mortality or acute exacerbation of ILD within 90 days of SLB. The rate of complication was 9.4%, and there were no statistically significant risk factors for complications. While the IPF group was not significantly different from the non-IPF group with regard to surgical parameters or complications, patients with IPF had significantly higher rates of mortality (50% vs. 9% in 5 years; p <0.001) and readmission due to acute exacerbation (75% vs. 8% in 5 years; p <0.001).

Conclusion: VATS lung biopsy for ILD can be a safe approach regardless of underlying phenotypes. An accurate diagnosis of IPF via SLB may be beneficial for correct patient management.

Perioperative risk factors in surgical lung biopsy for the diagnosis of interstitial lung disease: a single-centre experience

BACKGROUND

The aim of this study was to evaluate mortality and morbidity after surgical lung biopsy in patients with interstitial lung diseases and to investigate perioperative risk factors for complications.

METHODS

A total of 132 enrolled patients were divided into three groups: group 1 (70), patients with operation scheduled before admission; group 2 (48), patients with operation determined after medical therapy; and group 3 (14), patients with emergent operation followed by steroid therapy. Complications were classified according to the Clavien-Dindo system. The 30- and 90-day mortality and complication rates were evaluated, and perioperative risk factors were investigated.

RESULTS

Overall complication rate was 19.7%. The 30- and 90-day in-hospital mortality rates were 1.5% and 3.0%, respectively. Complication rates more than grade II were significantly different between the three groups (P = 0.045). Patients in group 1 revealed only class I or II complications and no mortalities. Elevated oxygen demand after operation was an independent risk factor for any complications, complications more than class II and any events (P < 0.001, P = 0.042 and P < 0.001, respectively). The New York Heart Association Functional Classification (NYHA) class IV was a statistically significant risk factor for any complications (P = 0.036, odds ratio 7.93). Higher NYHA class (III and IV) showed significantly higher risk in occurrence of any events after lung biopsy.

CONCLUSION

Prepared surgical lung biopsy for interstitial lung disease is feasible with reasonable morbidity. Higher NYHA class and elevated oxygen demand after the surgery could imply post-operative outcomes. Alternative diagnostic methods such as transbronchial biopsy or bronchoalveolar lavage should be considered prior to surgical lung biopsy especially in high-risk patients.

A Safe and Minimally Invasive Method for Thoracoscopic Lung Biopsy in Interstitial Lung Disease

Background: Interstitial lung disease (ILD) represents a spectrum of lung diseases that may contain different levels of fibrosis and inflammation. Sometimes, the clinical picture and imaging studies are insufficient to determine the diagnosis and lung biopsy becomes crucial, which may be performed in a thoracoscopic or open manner. The aim of this study was to present a new minimally invasive biopsy method that seems to be technically easy, safe, and inexpensive. Herein, we present a minimally invasive method for thoracoscopic lung biopsy using a Vicryl loop. Methods: The charts of patients with suspected ILD who underwent thoracoscopic lung biopsy using a Vicryl loop between 2007 and 2017 were analyzed retrospectively. Results: Nine patients were identified, four were boys and five were girls. The median age was 76 months. The mean weight of the patients was 10.9 kg. The mean chest tube removal time was 3.8 days. The mean surgical time was 37 minutes. There was an air leakage for 13 days in one child postoperatively. Conclusions: Thoracoscopic lung biopsy with a knot and scissors is an easily applicable and minimally invasive method that may be performed in children with suspected ILD.

The complimentary role of transbronchial lung cryobiopsy and endobronchial ultrasound fine needle aspiration in the diagnosis of sarcoidosis

PURPOSE

Transbronchial lung cryobiopsy (TBLC) is a novel technique that has proved to be useful in diagnosing various interstitial lung diseases (ILD). The use of TBLC to diagnose sarcoidosis in an unselected patient population is unknown, and could be complimentary to endobronchial ultrasound fine needle aspiration (EBUS-FNA).

METHODS

A retrospective analysis of 36 patients in a single, tertiary-care, academic medical center was conducted to describe the yield of both EBUS-FNA and TBLC in the diagnosis of suspected sarcoidosis over a three year period. A grading system to evaluate the presence and extent of specific radiographic features on computed tomography chest imaging studies was compared to the results of EBUS-FNA and TBLC. Complications associated with the procedures were also noted.

RESULTS

The overall diagnostic yield in our cohort (all pathologic diagnosis considered) was 80.6% (29 out of 36 patients had a definite pathologic diagnosis). Eighteen patients referred for possible sarcoidosis had a positive bronchoscopic specimen confirming the diagnosis of sarcoidosis. For those patients with a pathologic diagnosis of sarcoidosis, the diagnostic yield for EBUS-FNA and TBLC was 66.7% each (12 out of 18 patients), while the combined diagnostic yield for EBUS-FNA and TBLC increased to 100%. For all cases, the pneumothorax rate was 11.1%.

CONCLUSIONS

TBLC appears to be a safe and complimentary technique to diagnose sarcoidosis and could be considered part of the diagnostic armamentarium in bronchoscopic centers.

Classification of idiopathic interstitial pneumonias using anti-myxovirus resistance-protein 1 autoantibody

Chronic fibrosing idiopathic interstitial pneumonia (IIP) can be divided into two main types: idiopathic pulmonary fibrosis (IPF), a steroid-resistant and progressive disease with a median survival of 2-3 years, and idiopathic non-specific interstitial pneumonia (INSIP), a steroid-sensitive and non-progressive autoimmune disease. Although the clinical courses of these two diseases differ, they may be difficult to distinguish at diagnosis. We performed a comprehensive analysis of serum autoantibodies from patients definitively diagnosed with IPF, INSIP, autoimmune pulmonary alveolar proteinosis, and sarcoidosis. We identified disease-specific autoantibodies and enriched KEGG pathways unique to each disease, and demonstrated that IPF and INSIP are serologically distinct. Furthermore, we discovered a new INSIP-specific autoantibody, anti-myxovirus resistance-1 (MX1) autoantibody. Patients positive for anti-MX1 autoantibody constituted 17.5% of all cases of chronic fibrosing IIPs. Notably, patients rarely simultaneously carried the anti-MX1 autoantibody and the anti-aminoacyl-transfer RNA synthetase autoantibody, which is common in chronic fibrosing IIPs. Because MX1 is one of the most important interferon-inducible anti-viral genes, we have not only identified a new diagnostic autoantibody of INSIP but also obtained new insight into the pathology of INSIP, which may be associated with viral infection and autoimmunity.

Recent advances in diagnostic bronchoscopy

The field of diagnostic bronchoscopy has been revolutionized in the last decade primarily with the advent of endobronchial ultrasound (EBUS) but also with the addition of multiple different techniques for "guided-bronchoscopy". These advances have had a substantial impact in the management of lung cancer with bronchoscopy now providing both diagnosis and mediastinal staging in a single procedure. EBUS has, in fact, become the first choice for staging of the mediastinum over cervical mediastinoscopy (CM). Although EBUS is now a well-established technique, there are continuous efforts from the scientific community to improve its diagnostic performance, and these will be reviewed in this manuscript. The term "guided-bronchoscopy" was recently coined to describe a myriad of techniques that guide our bronchoscopes or bronchoscopic tools into the periphery of the lungs in addition to our conventional fluoroscopy. Electromagnetic and non-electromagnetic navigation, thin and ultrathin scopes, as well as radial-probe EBUS have collectively increased our yield for smaller peripheral lung lesions and continue to evolve. Despite this improved diagnostic yield, there is still ample room for improvement and newer techniques are under way. With new therapies available for patients with interstitial lung disease, achieving a specific histologic diagnosis is now of paramount importance. Given the high morbidity and mortality of surgical biopsies, bronchoscopic cryobiopsy is being rapidly adopted as a safer and effective alternative, and it is likely going to play a major role in the management of these diseases in the near future. This manuscript we will focus on recent advances in EBUS, guided-bronchoscopy, and the use of cryobiopsy.

Utility of Transbronchial vs Surgical Lung Biopsy in the Diagnosis of Suspected Fibrotic Interstitial Lung Disease

BACKGROUND

Surgical lung biopsy (SLB) is invasive and not possible in all patients with undiagnosed interstitial lung disease (ILD). We hypothesized that transbronchial biopsy (TBB) findings combined with clinical and high-resolution CT (HRCT) data leads to a confident diagnosis congruent to SLB and therefore avoids the need for SLB in some patients.

METHODS

We evaluated 33 patients being investigated for suspected ILD who underwent HRCT, TBB, and SLB. First, clinicians, radiologists, and a pathologist reviewed the clinical information and HRCT and TBB findings. Clinicians were asked to provide a diagnosis and were also asked if SLB was needed for a more confident diagnosis. Subsequently, the clinical, HRCT, and SLB data were reviewed, and the same participants were asked to provide a final diagnosis. Clinician consensus and overall agreement between TBB- and SLB-based diagnoses were calculated.

RESULTS

Four patients had definite usual interstitial pneumonia (UIP) on HRCT and would not be considered for biopsy using current guidelines. Of the 29 patients without a definitive HRCT diagnosis, the clinicians felt confident of the diagnosis (ie, would not recommend SLB) in six cases. In these cases, there was 100% agreement between TBB and SLB diagnoses. UIP was the most common diagnosis (n = 3) and was associated with an HRCT diagnosis of possible UIP/nonspecific interstitial pneumonia-like. Agreement was poor (33%) between TBB and SLB diagnoses when confidence in the TBB diagnosis was low.

CONCLUSIONS

Information from TBB, when combined with clinical and HRCT data, may provide enough information to make a confident and accurate diagnosis in approximately 20% to 30% of patients with ILD.

Interstitial lung diseases in the hospitalized patient

BACKGROUND

Interstitial lung diseases (ILDs) are disorders of the lung parenchyma. The pathogenesis, clinical manifestations, and prognosis of ILDs vary depending on the underlying disease. The onset of most ILDs is insidious, but they may also present subacutely or require hospitalization for management. ILDs that may present subacutely include acute interstitial pneumonia, connective tissue disease-associated ILDs, cryptogenic organizing pneumonia, acute eosinophilic pneumonia, drug-induced ILDs, and acute exacerbation of idiopathic pulmonary fibrosis. Prognosis and response to therapy depend on the type of underlying ILD being managed.

DISCUSSION

This opinion piece discusses approaches to differentiating ILDs in the hospitalized patient, emphasizing the role of bronchoscopy and surgical lung biopsy. We then consider pharmacologic treatments and the use of mechanical ventilation in hospitalized patients with ILD. Finally, lung transplantation and palliative care as treatment modalities are considered. The diagnosis of ILD in hospitalized patients requires input from multiple disciplines. The prognosis of ILDs presenting acutely vary depending on the underlying ILD. Patients with advanced ILD or acute exacerbation of idiopathic pulmonary fibrosis have poor outcomes. The mainstay treatment in these patients is supportive care, and mechanical ventilation should only be used in these patients as a bridge to lung transplantation.

Critically Ill Patients with Interstitial Lung Disease

Interstitial lung disease (ILD) is a clinical syndrome of various etiologies and histopathologic categorization that, when clinically significant, impair respiratory function. Patients with ILD may develop critical illness from respiratory failure, nonpulmonary organ failure, or after surgical procedures. Additionally, the intensivist must be adept at recognizing exacerbation syndromes, which can complicate the disease course of some forms of ILD. This article discusses mechanical ventilation, noninvasive mechanical ventilation, exacerbation syndromes, and surgical concerns for patients with ILD who are critically ill.

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.

Thoracoscopic lung biopsy in 285 patients with diffuse pulmonary disease

Background

Surgical lung biopsy is generally considered the most appropriate method for diagnosing diffuse lung disease. However, there are few reports focusing on only one thoracoscopic technique. This study was designed to determine the morbidity and mortality related to video-assisted thoracoscopic lung biopsy in a single center, thereby providing data on the severity of morbidity and clarifying the risk factors.

Methods

We analyzed 285 patients with undiagnosed diffuse lung disease who underwent video-assisted thoracoscopic lung biopsy at Kanagawa Cardiovascular and Respiratory Center from February 2007 to April 2012. We recorded the severity of postoperative complications using the Clavien-Dindo classification.

Results

The surgical morbidity was 7.0% (20/285), including delayed pulmonary fistulas in 11 patients, acute exacerbation in 3, prolonged air leakage (>7 days) in 2, hypoxemia in 2, atrial fibrillation in 1, and premature ventricular contraction in 1. Based on the Clavien-Dindo classification, grade I, II, IIIa, IIIb, and IVa complications accounted for 20%, 10%, 50%, 5%, and 15%, respectively. The 30-day mortality was 0%. The diagnostic yield was 100%. Although acute exacerbation occurred in 2 patients with idiopathic pulmonary fibrosis and 1 with fibrotic nonspecific interstitial pneumonia, there were no distinctive features that allowed preoperative prediction of acute exacerbation.

Conclusions

Our findings indicate that video-assisted thoracoscopic lung biopsy is a feasible procedure. We hope to clarify risk factors in future research.

[Idiopathic pulmonary fibrosis: diagnosis and treatment in 2013]

Idiopathic pulmonary fibrosis (IPF), the etiopathogeny of which is still unknown, is the most frequent and severe of idiopathic interstitial pneumonias. It progressively leads, sometimes more acutely when exacerbations occur, to a restrictive respiratory insufficiency. Its prognosis is very dark with a median survival of 3-5 years. No treatment so far has been curative. Its diagnostic and therapeutic management has been greatly improved due to the technical progress in terms of high-resolution tomodensitometry, to the availability of new drugs with a real antifibrotic potential and to the production of international recommendations. The diagnosis is reached in 2/3 of IPF patients presenting with a typical usual interstitial pneumonitis (UIP) CT-scan pattern. It requires a videothoracoscopic biopsy in the remaining patients. Multidisciplinary discussions are key to a proper diagnosis of IPF. Pirfenidone is presently the only drug with a real antifibrotic potential in mild to moderate forms of the disease (FVC>50% and DLCO>35% predicted). The other ones have proved either inefficient or toxic. It is highly recommended to include patients in innovative targeted protocols. Non-pharmacological management of these patients comprises long-term oxygen therapy, pulmonary rehabilitation and overall lung transplantation. Pulmonary hypertension, to be detected regularly during the follow-up, is associated to a dark prognosis. No specific treatment is efficient in this context. Several comorbidities, particularly frequent in IPF, should be treated when present: gastro-oesophageal reflux, obstructive sleep apnea, emphysema. The particular high frequency of bronchopulmonary cancer should be highlighted.

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.

The current position of surgical lung biopsy in the diagnosis of idiopathic pulmonary fibrosis

A new international statement defines usual interstitial pneumonia (UIP) which is a histological and radiological form of idiopathic pulmonary fibrosis (IPF) more precisely than previously. In the diagnosis of IPF, either in high resolution computed tomography (HRCT) a UIP pattern must be present or alternatively specific combinations of HRCT and surgical lung biopsy findings can be accepted. In about two third of the cases IPF can be diagnosed by clinical and radiological criteria. Thus surgical lung biopsy is needed in about one third of cases to achieve the ultimate diagnosis, which requires multidisciplinary cooperation. In large clinical trials conducted during the last decade, lung biopsy was performed in about 30-60% of the cases. The most serious complication of lung biopsy is mortality within 30 days after the procedure, with a frequency of about 3-4% reported in most studies. Because of the histological variability, surgical lung biopsy should be taken from a minimum of two lobes. The number of fibroblast foci in surgical lung biopsy has been shown to correlate with survival in several studies.

The role of lung biopsy in the diagnosis and management of idiopathic interstitial pneumonia

Idiopathic interstitial pneumonias (IIP) are a relatively common cause of diffuse lung disease marked by varying degrees of inflammation and fibrosis within the lung, leading to substantial morbidity and mortality. Knowledge and progress in therapeutics have been hindered by inconsistent definitions and challenges in diagnosis. Present classification schemes are based on morphologic definitions that frequently require synthesis of clinical, radiologic and histopathologic information. This review focuses on the present state of diagnosis, and the role that history, radiographic imaging and surgical lung biopsy have on the diagnosis of IIPs. Surgical lung biopsy plays a key role in distinguishing specific IIPs in patients whose imaging studies lack features diagnostic of usual interstitial pneumonia. The final diagnosis is based on the combined clinical, radiographic and histologic findings, and is best accomplished using a dynamic, multidisciplinary approach. More accurate diagnoses should increase the ability to study and understand the biology, natural history and potential therapies for this group of devastating diseases.

Morbidity and mortality in patients with usual interstitial pneumonia (UIP) pattern undergoing surgery for lung biopsy

BACKGROUND

Previous studies revealed that surgical lung biopsy in usual interstitial pneumonia (UIP) patients is accompanied with higher morbidity and mortality. The aim of this retrospective analysis was to assess morbidity and mortality of patients with suspected UIP undergoing surgical lung biopsy.

METHODS

We conducted a retrospective study of 45 patients with suspected UIP pattern undergoing surgical biopsy for diffuse pulmonary infiltrates in our department. Data concerning medical history, histology, and survival status were extracted from the medical database of the University Medical Center Freiburg.

RESULTS

UIP was diagnosed by experienced pneumo-pathologists according to the criteria of American Thoracic Society/European Respiratory Society (ATS/ERS) consensus classification. Due to adhesions the surgeon decided in two patients to perform wedge resection via open surgery. In 43 patients lung biopsy was performed via Video-assisted thoracoscopy (VATS). No intraoperative complications were observed. Postoperative complications consisted of bradyarrhythmia (n = 1), gastrointestinal bleeding (n = 1), bacterial pneumonia (n = 1), candida pneumonia (n = 1) and acute exacerbation (n = 1). There was no 30-day mortality, but one patient was lost in follow-up and therefore censored. The intraoperative placed thoracic drain was removed at the first postoperative day in most cases (mean day of removal 1.9, ±2.6). The mean length of hospital stay was 8.1 days (±6.8).

CONCLUSIONS

We conclude that surgical biopsy can be safely performed in patients with suspected UIP.

Risk of Acute Exacerbation After Video-assisted Thoracoscopic Lung Biopsy for Interstitial Lung Disease

Biopsy by video-assisted thoracoscopic surgery (VATS) for interstitial pneumonia allows collection of samples sufficient for accurate histologic diagnosis. Although VATS is relatively safe, several reports have suggested that surgical lung biopsy may be a risk factor for acute exacerbation of idiopathic pulmonary fibrosis (IPF). We retrospectively reviewed data on the 113 cases that underwent biopsy by VATS to diagnose diffuse parenchymal lung disease in our department between 1994 and 2006, and analyzed its complications, in particular, risk of acute exacerbation of IPF. As the final diagnosis, idiopathic interstitial pneumonia was most frequent, involving 52 cases, of which IPF was most frequently found followed by nonspecific interstitial pneumonia and cryptogenic organizing pneumonia, in that order. Among our cases, there were 2 deaths after VATS (mortality rate, 1.8%), and both were IPF cases with acute exacerbation. When examining clinical markers in the 2 fatal IPF cases with acute exacerbation, we found that the percentage of predicted forced vital capacity was 55 or lower, percentage of predicted carbon monoxide diffusing capacity was 40 or lower, serum interstitial pneumonia markers KL-6 and SP-D were elevated, intraoperative inhalation of 100% O2 was 80 minutes or longer, and postoperative thoracic drainage was required for 10 days or longer. Although acute exacerbations of IPF seem to occur at any time during the course of disease, it is important to be aware of the possibility of acute exacerbation of IPF after VATS.

Aggregate risk score for predicting mortality after surgical biopsy for interstitial lung disease

In order to develop a practical risk score for 90-day mortality following surgical lung biopsy (SLB) for interstitial lung disease (ILD) we reviewed 311 consecutive patients undergoing SLB for ILD between 2002 and 2009. Postoperative complication, 30-day and 90-day mortality rates were 11.5%, 9% and 10.6% respectively. Univariable and multivariable analyses, validated by bootstrap statistics, were used to identify factors associated with 90-day mortality. A scoring system was developed by proportionally weighting the regression coefficients of the significant predictors of 90-day mortality: age >67 (P < 0.0001, weighted score 1.5), preoperative intensive care unit (ICU) admission (P = 0.006, weighted score 2), immunosuppressive treatment (P = 0.004, weighted score 1.5) and open surgery (P = 0.03, weighted score 1). Patients were grouped in four classes showing incremental risk of death at 90 days: class A, score 0 (2%); class B, score 1-2 (12%); class C, score 2.5-3 (40%); class D, score >3 (86%); P <0.0001). SLB entails a considerable surgical risk with an overall 90-day mortality around 10%. We were able to develop a practical risk score which, if validated by other independent studies, can be easily used to stratify the risk of SLB candidates and assess the cost-effectiveness of this procedure.

Twist expression associated with the epithelial-mesenchymal transition in gastric cancer

This study aimed to investigate the expression of Twist in gastric cancer tissues and its correlation between Twist and the epithelial-mesenchymal transition (EMT). By means of RT-PCR and Western blot, the mRNA and protein expressions of Twist, E-cadherin, and Vimentin in 61 gastric cancer tissues and adjacent normal tissues were detected. The positive rates of Twist, E-cadherin, and Vimentin mRNA expression in gastric cancer tissues were 73.9. 40.6, and 60.9 %, respectively; compared to the expression of these genes in adjacent normal tissues (2.9, 75.4, and 27.5 %), the differences were significant (p < 0.05). The E-cadherin protein expression level in gastric cancer tissues was significantly lower than that in the adjacent normal tissues (p < 0.05). After the transfection of Twist siRNA into the MKN45 cells, the protein expression of Twist was significantly reduced (p < 0.05), the protein expression of E-cadherin was significantly increased, and the number of cells that passed through the Transwell chamber was significantly lower than that in the non-transfected control group as well as the transfected control group (p < 0.05). Twist may be associated with the epithelial-mesenchymal transition in gastric cancer and the tumorigenesis, invasion, and metastasis of gastric cancer.

[Surgical lung biopsy: Indications and therapeutic implications]

Surgical biopsy of lung parenchyma can be used to establish a diagnosis in interstitial lung disease both of acute and chronic presentation. The present article summarizes the current indications, the therapeutic implications, the different surgical techniques and postoperative complications of the procedure. Common controversies and problems related to surgical lung biopsy are also presented.

Interstitial lung disease: the initial approach

In the last decade, significant progress has been made toward a better understanding of interstitial lung disease (ILD). A valuable tool for the clinician is high-resolution computed tomography, which aids in narrowing the differential diagnosis in patients with ILD and obviates the need for surgical lung biopsy when a usual interstitial pneumonia pattern is present. Clinicians evaluating and caring for patients with ILD need to recognize associated comorbidities. Substantial evidence shows that implementation of a multidisciplinary approach provides a high standard of care for patients, leading to improvements in the accuracy of clinical diagnosis that can significantly affect patient outcome.

Diffuse alveolar damage: a common phenomenon in progressive interstitial lung disorders

It has become obvious that several interstitial lung diseases, and even viral lung infections, can progress rapidly, and exhibit similar features in their lung morphology. The final histopathological feature, common in these lung disorders, is diffuse alveolar damage (DAD). The histopathology of DAD is considered to represent end stage phenomenon in acutely behaving interstitial pneumonias, such as acute interstitial pneumonia (AIP) and acute exacerbations of idiopathic pulmonary fibrosis (IPF). Acute worsening and DAD may occur also in patients with nonspecific interstitial pneumonias (NSIPs), and even in severe viral lung infections where there is DAD histopathology in the lung. A better understanding of the mechanisms underlying the DAD reaction is needed to clarify the treatment for these serious lung diseases. There is an urgent need for international efforts for studying DAD-associated lung diseases, since the prognosis of these patients has been and is still dismal.

Video-assisted thoracoscopy for the diagnosis of diffuse parenchymal lung disease

OBJECTIVE

To evaluate the role of video-assisted thoracoscopy in the diagnosis of diffuse parenchymal lung diseases.

METHODS

The medical charts of patients suspected of having diffuse parenchymal lung disease were retrospectively reviewed, as were the results of the anatomopathological examination of lung biopsy specimens collected through video-assisted thoracoscopy.

RESULTS

Of the 48 patients included in the study, 25 (52.08%) were female and 23 (47.92%) were male. The mean age was 58.77 years (range, 20-76 years). A total of 54 biopsy fragments were submitted to anatomopathological examination: 24 (44.44%) from the lingula; 10 (18.52%) from the left lower lobe; 7 (12.96%) from the right middle lobe; 6 (11.11%) from the right lower lobe; 5 (9.26%) from the left upper lobe; and 2 (3.71%) from the right upper lobe. The mean duration of thoracic drainage was 2.2 days. Adverse events included conversion to thoracotomy, in 2 patients (4.17%), and residual pneumothorax, in 1 (2.08%). The definitive diagnosis was made in 46 patients (95.83%), and idiopathic interstitial pneumonia was the predominant diagnosis (in 54.18%). The most common diagnoses were usual interstitial pneumonia (in 29.27%), nonspecific interstitial pneumonia (in 16.67%) and hypersensitivity pneumonia (in 12.50%).

CONCLUSIONS

Lung biopsy through video-assisted thoracoscopy is a safe, effective and viable procedure for the diagnosis of diffuse parenchymal lung diseases.

Diagnostic surgical lung biopsies for suspected interstitial lung diseases: a retrospective study

BACKGROUND

Current guidelines for interstitial lung disease support a surgical biopsy for optimal diagnosis and treatment, yet only a minority of patients undergo such biopsy. Our objectives were to address the properties of a surgical lung biopsy for suspected interstitial lung disease, the diagnostic yield of the procedure, and whether it resulted in changes in diagnosis and treatment.

METHODS

A retrospective nationwide study including 73 patients (mean age, 57.3 years; 58% males) who underwent a surgical lung biopsy for suspected interstitial disease in Iceland between 1986 and 2007 was conducted. Patient records and histologic specimens were reviewed. Before the surgical biopsy a transbronchial or computed tomography-guided biopsy had been performed in two thirds of the patients.

RESULTS

The complication rate for surgical lung biopsy was 16%, and 30-day operative mortality was 2.7%, both significantly higher in patients with preoperative respiratory failure. After the procedure, a definite histopathologic diagnosis was obtained in 81% of the patients. Usual interstitial pneumonia was the most common diagnosis (31%). The clinical diagnosis was changed for 73% of the patients, and in 53% of the patients the biopsy resulted in changes in treatment.

CONCLUSIONS

Surgical lung biopsy is a powerful tool for diagnosis of suspected interstitial lung disease. It results in a specific diagnosis for the majority of patients and changes in treatment for more than half. Operative morbidity and mortality are low but still significant, so patients should be carefully selected for the procedure, especially those with respiratory failure.

Significance of bronchoscopic lung biopsy in clinical practice

PURPOSE

At present bronchoscopic lung biopsy (BLB) is widely used to diagnose various lung diseases. However placing of BLB in the diagnostic sequence of various clinical situations is not so clear. The purpose of the study was to evaluate the diagnostic value of BLB in a daily clinical practice.

MATERIAL AND METHODS

The data obtained from the case records of all 304 patients who had undergone BLB since January 1996 to December 2007 at the Centre of Pulmonology and Allergology of Vilnius University Hospital Santariskiu klinikos (Vilnius, Lithuania) were examined.

RESULTS

Most of indications for BLB were a peripheral lung nodule (40% of all the cases), dissemination in the lung (24% of all BLBs) and non-resolving pulmonary infiltrates (16.3% of all biopsies). Adequate lung tissue for histological examination was obtained in 85% of the cases. Based on the pathological diagnosis and findings of other diagnostic methods the final clinical diagnosis was verified for most of the patients. However, at least in 8% of the cases, the final clinical diagnosis was yet syndromic. Of all the BLBs, serious complications occurred in 8 (2.6%) patients. Clinically significant pneumothorax requiring chest tube treatment occurred in 5 (1.6%) of 304 patients. Severe bleeding occurred in 3 (1%) out of all BLBs.

CONCLUSION

BLB is a relatively effective and safe method for diagnosing lung diseases. In most cases of the lung infiltrate, nodule, dissemination and diffuse changes, BLB is suitable to choose method for lung biopsy.

Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care unit

Idiopathic pulmonary fibrosis (IPF) is the commonest cause of interstitial lung disease. Till date there is no proven successful treatment. The prognosis is poor with a median survival of 3 years. Patients with IPF presented with acute respiratory failure are often referred to the intensive care unit for ventilatory support. Available data showed that outcome of these patients is very poor and mechanical ventilation is mostly futile. Patients and their families should be informed about the prognosis, outcome and overall outlook before making decision about ventilation and organ support. Available outcome data should be used to develop institutional and professional guidelines to help in making these difficult decisions.

Recent advances in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) remains the most common of the idiopathic interstitial pneumonias and portends a poor prognosis. Significant strides have been made in the approach to diagnosis and in the ability to predict outcome in the last few years. Advances in high-resolution CT (HRCT) scanning have allowed an accurate diagnosis obviating the need for surgical biopsy in many patients. Furthermore, HRCT scanning may aid in determining prognosis and identifying disease progression. The appropriate use of the HRCT scan requires a multidisciplinary iterative approach incorporating all available data to reach a final diagnosis. However, there remains great heterogeneity in disease progression. Pulmonary hypertension and acute exacerbations of IPF negatively influence prognosis and are increasingly a target of therapy. There has been an increase in the number of well-designed clinical trials of IPF that have focused on more specific targets. While no cure has yet been found, each trial expands our understanding regarding the natural course of the disease and the impact of targeted therapy. In the interim, lung transplantation, which appears to improve survival in a subset of IPF patients, remains the only intervention. The objective of this article is to review advances in the understanding of IPF and the evidence for the findings outlined above.

Complications of Video-Assisted Thoracoscopic Lung Biopsy in Patients with Interstitial Lung Disease

BACKGROUND

Current guidelines recommend surgical lung biopsy for diagnosis of interstitial lung diseases (ILDs) in selected patients. To shed light on the risk-benefit ratio for this recommendation, we examined the morbidity and mortality associated with video-assisted thoracoscopic surgical (VATS) lung biopsy in a group of outpatients.

METHODS

A retrospective cohort study was conducted of 68 consecutive ambulatory patients with radiographically apparent interstitial lung disease (ILD) referred for VATS biopsy during a 6-year period. Incidence of postoperative mortality, prolonged air leaks, pneumonias, and re-admissions were calculated. Risk factors for complications of surgery were examined.

RESULTS

Three deaths occurred within 60 days after biopsy for a mortality rate of 4.4% (95% confidence interval [CI], 1% to 12%), and 19.1% (95% CI, 11% to 31%) experienced one or more complications of surgery. Risk factors for morbidity included preoperative dependence on oxygen therapy and pulmonary hypertension. The three patients who died had usual interstitial pneumonia on their biopsy specimen and were reintubated postoperatively for acute lung injury. Aggregation of articles published over the past 10 years reporting on surgical lung biopsy for the diagnosis of ILD yielded a postoperative mortality rate of 2% to 4.5%.

CONCLUSIONS

VATS lung biopsy for diagnosis of ILD, even in ambulatory patients, is not an entirely benign procedure. Biopsy rarely may trigger an acute exacerbation of usual interstitial pneumonitis. The risk of postoperative complications appears to be greatest in those dependent on oxygen and those who have pulmonary hypertension. This information may be used in weighing the risk-benefit ratio of biopsy in individual patients.

Relationship between histopathological features and the course of idiopathic pulmonary fibrosis/usual interstitial pneumonia

BACKGROUND

Fibroblastic focus (FF) is the typical histopathological feature of idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP). A study was undertaken to analyse FF at diagnosis, to analyse the histopathological findings at necropsy, and to examine their association with the course of the disease.

METHODS

A retrospective study was made of 76 UIP cases collected over a period of 30 years from one university hospital; 64 had idiopathic IPF. The surface area of one slide of each lung biopsy specimen was defined by image analysis and the total number of FF was quantified. The histological features of necroscopic lung samples were re-analysed in 11 cases. Clinical follow up information was obtained from the registers.

RESULTS

Patients with < or =50 FF/cm(2) (n = 34) in the lung biopsy specimen had a median survival of 89 months (95% CI 38 to 140) compared with 49 months (95% CI 36 to 62) in those with >50 FF/cm(2) (n = 42, p = 0.0358). Diffuse alveolar damage (DAD) was detected in 10 necropsy samples and almost prevented the histopathological confirmation of UIP in six cases. Accumulation of neutrophils occurred in nine cases. There was no association between FF at diagnosis and DAD at necropsy, or between FF and exacerbation of the disease before death.

CONCLUSIONS

The number of FF in lung samples before death is associated with poor survival but not with DAD, which is a common feature in necropsy specimens of patients with UIP. FF cannot predict an acute exacerbation of IPF.

Transbronchial biopsy in usual interstitial pneumonia

BACKGROUND

Usual interstitial pneumonia (UIP) is a slowly progressive, usually fatal form of idiopathic interstitial pneumonia for which there is no effective treatment. Transbronchial biopsy (TBB) has been utilized only to exclude other diseases such as sarcoidosis, lymphangitic carcinoma, and infection, for example, but TBB is generally considered to have little role in confirming UIP.

OBJECTIVE

To determine whether diagnostic changes of UIP can be appreciated on TBB specimens.

DESIGN

Retrospective analysis of TBB specimens from patients with proven UIP.

SETTING

Two study sites in the United States.

PARTICIPANTS

Twenty-one patients with UIP confirmed by surgical lung biopsy and/or lung explant, and 1 patient with UIP confirmed by clinical and radiographic findings along with follow-up information.

MEASUREMENTS AND RESULTS

Adequate tissue for diagnosis was available in 18 cases; in 7 cases (32% overall), there were varying combinations of interstitial fibrosis in a patchwork pattern along with fibroblast foci and/or honeycomb change. These features were considered diagnostic of UIP. Interstitial fibrosis along with fibroblast foci or honeycomb change were seen in two other cases, but the fibrosis lacked a patchwork pattern, and these features were considered consistent with UIP. Nonspecific interstitial fibrosis alone was found in nine cases.

CONCLUSIONS

In summary, characteristic histologic features of UIP can be identified on TBB specimens more often than previously appreciated. TBB may be more useful in confirming UIP than previously recognized.