1
|
Kalverda KA, Ninaber MK, Wijmans L, von der Thüsen J, Jonkers RE, Daniels JM, Miedema JR, Dickhoff C, Hölters J, Heineman D, Kant M, Radonic T, Shahin G, Cohen D, Boerrigter B, Nijman S, Nossent E, Braun J, Mathot B, Poletti V, Hetzel J, Dijkgraaf M, Korevaar DA, Bonta PI, Annema JT. Transbronchial cryobiopsy followed by as-needed surgical lung biopsy versus immediate surgical lung biopsy for diagnosing interstitial lung disease (the COLD study): a randomised controlled trial. Lancet Respir Med 2024:S2213-2600(24)00074-2. [PMID: 38640934 DOI: 10.1016/s2213-2600(24)00074-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND An adequate diagnosis for interstitial lung disease (ILD) is important for clinical decision making and prognosis. In most patients with ILD, an accurate diagnosis can be made by clinical and radiological data assessment, but in a considerable proportion of patients, a lung biopsy is required. Surgical lung biopsy (SLB) is the most common method to obtain tissue, but it is associated with high morbidity and even mortality. More recently, transbronchial cryobiopsy has been introduced, with fewer adverse events but a lower diagnostic yield than SLB. The aim of this study is to compare two diagnostic strategies: a step-up strategy (transbronchial cryobiopsy, followed by SLB if the cryobiopsy is insufficiently informative) versus immediate SLB. METHODS The COLD study was a multicentre, randomised controlled trial in six hospitals across the Netherlands. We included patients with ILD with an indication for lung biopsy as assessed by a multidisciplinary team discussion. Patients were randomly assigned in a 1:1 ratio to the step-up or immediate SLB strategy, with follow-up for 12 weeks from the initial procedure. Patients, clinicians, and pathologists were not masked to the study treatment. The primary endpoint was unexpected chest tube drainage, defined as requiring any chest tube after transbronchial cryobiopsy, or prolonged (>24 h) chest tube drainage after SLB. Secondary endpoints were diagnostic yield, in-hospital stay, pain, and serious adverse events. A modified intention-to-treat analysis was performed. This trial is registered with the Dutch Trial Register, NL7634, and is now closed. FINDINGS Between April 8, 2019, and Oct 24, 2021, 122 patients with ILD were assessed for study participation; and 55 patients were randomly assigned to the step-up strategy (n=28) or immediate SLB (n=27); three patients from the immediate SLB group were excluded. Unexpected chest tube drainage occurred in three of 28 patients (11%; 95% CI 4-27%) in the step-up group, and the number of patients for whom the chest tube could not be removed within 24 h was 11 of 24 patients (46%; 95% CI 2-65%) in the SLB group, with an absolute risk reduction of 35% (11-56%; p=0·0058). In the step-up strategy, the multidisciplinary team diagnostic yield after transbronchial cryobiopsy alone was 82% (64-92%), which increased to 89% (73-96%) when subsequent SLB was performed after inconclusive transbronchial cryobiopsy. In the immediate surgery strategy, the multidisciplinary team diagnostic yield was 88% (69-97%). Total in-hospital stay was 1 day (IQR 1-1) in the step-up group versus 5 days (IQR 4-6) in the SLB group. One (4%) serious adverse event occurred in step-up strategy versus 12 (50%) in the immediate SLB strategy. INTERPRETATION In ILD diagnosis, if lung tissue assessment is required, a diagnostic strategy starting with transbronchial cryobiopsy, followed by SLB when transbronchial cryobiopsy is inconclusive, appears to result in a significant reduction of patient burden and in-hospital stay with a similar diagnostic yield versus immediate SLB. FUNDING Netherlands Organisation for Health Research and Development (ZonMW) and Amsterdam University Medical Centers.
Collapse
Affiliation(s)
- Kirsten A Kalverda
- Department of Respiratory Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.
| | - Maarten K Ninaber
- Department of Respiratory Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Lizzy Wijmans
- Department of Respiratory Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jan von der Thüsen
- Department of Pathology and Clinical Bioinformatics, Erasmus Medical Center, Rotterdam, Netherlands
| | - René E Jonkers
- Department of Respiratory Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Johannes M Daniels
- Department of Respiratory Diseases, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jelle R Miedema
- Department of Respiratory Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Chris Dickhoff
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jürgen Hölters
- Department of Respiratory Diseases, Canisius Wilhelmina Ziekenhuis, Nijmegen, Netherlands
| | - David Heineman
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Merijn Kant
- Department of Respiratory Diseases, Amphia Hospital, Breda, Netherlands
| | - Teodora Radonic
- Department of Pathology, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ghada Shahin
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Danielle Cohen
- Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
| | - Bart Boerrigter
- Department of Respiratory Diseases, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Suzan Nijman
- Department of Respiratory Diseases, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Esther Nossent
- Department of Respiratory Diseases, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jerry Braun
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bas Mathot
- Department of Respiratory Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Venerino Poletti
- Department of Medical Specialties, Giovan Battista Morgagni Hospital, University of Forlì, Forlì, Italy; Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Jürgen Hetzel
- Department of Medical Oncology and Pneumology, Eberhard Karls University, Tübingen, Germany; Department of Pneumology, Cantonal Hospital of Winterthur, Winterthur, Switzerland
| | - Marcel Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel A Korevaar
- Department of Respiratory Diseases, Amsterdam University Medical Centers, Vrij Universiteit Amsterdam, Amsterdam, Netherlands
| | - Peter I Bonta
- Department of Respiratory Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Jouke T Annema
- Department of Respiratory Diseases, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
2
|
Visser MPJ, van Grimbergen I, Hölters J, Barendregt WB, Vermeer LC, Vreuls W, Janssen J. Performance insights of endobronchial ultrasonography (EBUS) and mediastinoscopy for mediastinal lymph node staging in lung cancer. Lung Cancer 2021; 156:122-128. [PMID: 33931293 DOI: 10.1016/j.lungcan.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/28/2021] [Accepted: 04/02/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Endobronchial Ultrasonography (EBUS) and mediastinoscopy are used for mediastinal lymph node staging in patients with suspected non-small cell lung carcinoma (NSCLC). In our hospital, confirmatory mediastinoscopy has been largely abandoned, which may reduce the number of surgical interventions and health care costs. This study provides insight into EBUS and mediastinoscopy performance in patients with proven NSCLC from January 2007 until January 2019. METHODS This is a single-centre, retrospective study, evaluating unforeseen N2 rates, negative predictive value and survival, providing insight into the diagnostic yield of EBUS and mediastinoscopy. Surgical lung resection with lymph node dissection was used as reference. RESULTS A total of 418 patients with proven NSCLC after lung resection (mean age: 66 years; 61 % male) and 118 patients who underwent mediastinoscopy, have been included in the study. The overall prevalence of N2 metastases after lung resection was 10.5 %. The percentage of unforeseen N2 cases after negative EBUS was 14.5 %, and 14.3 % after negative mediastinoscopy. Over the past nine years, none of the confirmatory mediastinoscopies were tumor positive after negative EBUS results. The median survival in patients with surgically confirmed N2 metastases was 33 months, compared to 23 months in patients with EBUS/mediastinoscopy-proven N2 metastases. CONCLUSION Despite optimisation of mediastinal staging procedures, it remains difficult to identify all patients with N2 metastases in the workup of NSCLC. In our institute, confirmatory mediastinoscopy has no added value after tumor-negative EBUS procedures, and has been abandoned as standard procedure.
Collapse
Affiliation(s)
- M P J Visser
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands.
| | - I van Grimbergen
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| | - J Hölters
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| | - W B Barendregt
- Department of Surgery, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| | - L C Vermeer
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| | - W Vreuls
- Department of Pathology, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| | - J Janssen
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532SZ, Nijmegen, the Netherlands
| |
Collapse
|