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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 3
| Issue : 1 | Page : 13-16 |
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Transbronchial lung biopsy in interstitial lung diseases at a tertiary care center in Western India
Ketaki Utpat, Rakesh Rajpurohit, M Dharani, Unnati Desai, Aravind Raj, Saby Kunjumon, S Sharad, Sucheta Bhalerao
Department of Pulmonary Medicine, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India
| Date of Submission | 11-Apr-2022 |
| Date of Acceptance | 12-Jun-2022 |
| Date of Web Publication | 27-Dec-2022 |
Correspondence Address:
Dr. Unnati Desai
Department of Pulmonary Medicine, TNMC and BYL Nair Hospital, Mumbai - 400 008, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jalh.jalh_14_22
Background: Interstitial lung diseases (ILDs) are a heterogeneous group of disorders with a wide spectrum. Diagnosis of ILD is by a multidisciplinary approach with clinical, radiological, and histopathological correlation. With the increasing knowledge on the clinical and radiological spectrum, there is a renewed interest to clarify and research the pathological aspect too. Materials and Methods: A retrospective study was conducted at a tertiary care hospital based on the available medical records of 65 patients with IEC permission. The role of transbronchial lung biopsy (TBLB) in diagnosing ILD was studied by comparing with high-resolution computed tomography findings. Data were analyzed in percentages. Results and Interpretation: Out of 65 cases, there were 30 cases (46%) of chronic hypersensitivity pneumonitis (HP), 12 cases (18%) of sarcoidosis, 12 cases (18%) of usual interstitial pneumonia (UIP), 9 cases (14%) of nonspecific interstitial pneumonia (NSIP), 1 case (2%) of lymphocytic interstitial pneumonia (LIP), and 1 (2%) case of cryptogenic organizing pneumonia (COP). TBLB yielded pathological diagnosis suggesting ILDs in 65% of patients. In addition, ill-formed granulomas were observed in 14 of 30 (47%) of chronic HP, noncaseating granulomas in 7 of 12 (58%) of sarcoidosis, and diffuse lymphocytic infiltrates and organizing pneumonia pattern in 100% of LIP and COP patients, respectively, whereas yield in cases of UIP and NSIP is 17% and 33%, respectively. Conclusion: Thus, TBLB is a promising minimally invasive technique for diagnosing ILD with a total yield of 65%. More specifically, the yield is more in cases of sarcoidosis, chronic HP, and rare ILDs such as LIP and COP, as compared to UIP and NSIP.
Keywords: Bronchoscopy, interstitial lung diseases, transbronchial lung biopsy
How to cite this article:
Utpat K, Rajpurohit R, Dharani M, Desai U, Raj A, Kunjumon S, Sharad S, Bhalerao S. Transbronchial lung biopsy in interstitial lung diseases at a tertiary care center in Western India. J Adv Lung Health 2023;3:13-6 |
How to cite this URL:
Utpat K, Rajpurohit R, Dharani M, Desai U, Raj A, Kunjumon S, Sharad S, Bhalerao S. Transbronchial lung biopsy in interstitial lung diseases at a tertiary care center in Western India. J Adv Lung Health [serial online] 2023 [cited 2023 Jun 11];3:13-6. Available from: https://www.jalh.org//text.asp?2023/3/1/13/365488 |
| Introduction | |  |
Interstitial lung diseases (ILDs) are a wide spectrum of disorders sharing similar clinical, radiological, physiological, and pathological manifestations. Hence, clinical evaluation alone is not sufficient in making an etiological diagnosis of many ILDs. High-resolution computed tomography (HRCT) thorax is helpful in making a diagnosis in certain diseases such as sarcoidosis, usual interstitial pneumonia (UIP), and cryptogenic organizing pneumonia (COP) because of their specific pattern.[1] However, in routine practice, the patient usually presents at a later stage or when already on steroid therapy, making it difficult to arrive at proper diagnosis. In such a situation, it is mandatory to do histopathological examination of lung tissue for arriving at proper diagnosis and to decide regarding further treatment. Furthermore, doing an open lung biopsy in a patient with compromised pulmonary function is associated with higher morbidity and mortality.
Objectives
The objective of the study was to study the diagnostic yield of transbronchial lung biopsy (TBLB) in ILD patients.
| Materials and Methods | | |
This was a retrospective, observational study. It was an independent subanalysis of data collected for an IEC-approved study. The medical records of patients with radiological evidence of interstitial lung disease (diagnosed with clinic-radiological correlation) who underwent TBLB at our tertiary care center over a period of 2 years were analyzed. The detailed history including their occupation, smoking, and any other drug intake was also noted. They underwent a TBLB using a fiber-optic bronchoscope under topical anesthesia. All prerequisites for bronchoscopy were followed. Four to six TBLB samples were taken from lung segments that had ground-glass opacities, nodules avoiding areas of fibrosis and samples were directly transferred into formalin fixative. Biopsy from upper lobes was avoided due to the increased risk of pneumothorax. Disposable 1.8 mm Boston Scientific flexible bronchoscopy forceps with spike were used for biopsy. The specimens along with clinical summary and probable diagnosis after clinicoradiological correlation were submitted for further histopathological examination. Statistical analysis was calculated with percentages and mean.
| Results | | |
A total of 65 cases who underwent TBLB were included in this study. Of these, 20 (31%) were men and 45 (69%) were women. The mean age of the study group was 49.8 years with a standard deviation of 14.85. Out of 65 patients, 17 (26%) cases were in the age group of 21–40 years, 30 (46%) patients were in the age group of 41–60 years, and 18 (28%) patients were between 61 and 80 years. Based on the pattern in HRCT thorax, 30 (46%) cases were diagnosed as chronic hypersensitivity pneumonitis (HP), 12 (18%) as cases of sarcoidosis and usual interstitial pattern (probable) each, 9 (14%) as nonspecific interstitial pneumonia (NSIP), and 1 (2%) as lymphocytic interstitial pneumonia (LIP) and COP each.
Based on the histopathological findings on the TBLB sample, pathological diagnosis suggesting ILDs was noted in 42 (65%) patients, whereas normal bronchial mucosa in 23 (35%) patients. In addition, findings suggesting the specific diagnosis in the form of ill-formed granuloma were observed in 14 of 30 (47%) of chronic HP, noncaseating granuloma in 7 of 12 (58%) of sarcoidosis, and diffuse lymphocytic infiltrates and organizing pneumonia pattern in 100% of LIP and COP patients, respectively, whereas specific pathological finding consistent with UIP and NSIP was seen in only 2 of 12 (17%) and 3 of 9 (33%) cases, respectively [Table 1]. | Table 1: Yield of transbronchial lung biopsy with the clinic-radiological diagnosis of interstitial lung disease
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Most patients tolerated the procedure well. Singular cases of transient desaturation needing supplemental oxygen for 24 h postprocedure, streaky hemoptysis, and small pneumothorax were noted.
| Discussion | | |
The first TBLB by Dr. Anderson was reported in 1965.[2] It was performed using rigid biopsy forceps through a Negus bronchoscope. Then, in 1974, David et al. presented the TBLB procedure using flexible bronchoscope, leading to its widespread use in replacing rigid bronchoscope.[3] The main diagnostic utility of TBLB lies in arriving at specific diagnosis in patients with ILDs by avoiding open lung biopsy. The main limiting factor for performing TBLB is the small size of the specimen and associated crush artifacts.[4] However, TBLB is still considered the procedure of choice in the diseases which predominantly involve terminal and respiratory bronchioles or lymphatics.[5] TBLB is a relatively safe procedure, used in the diagnosis of various conditions such as ILDs, infectious and malignant diseases involving interstitium including miliary TB and lymphangitis carcinomatosis, respectively.[6] Various ILDs where TBLB was performed in our study include sarcoidosis, chronic HP, and idiopathic interstitial pneumonias such as UIP, NSIP, LIP, and COP.
Out of 65 cases included in our study, 20 (31%) were men and 45 (69%) were women. The predominant (46%) age group was of 41–60 years with a mean age of 49.8 years. Based on the imaging pattern seen in HRCT thorax, chronic HP was the most common ILD included in this study accounting for 46%, followed by sarcoidosis and UIP in 12 (18%) cases, 9 (14%) cases of NSIP, and 1 (2%) case of LIP and COP each. On histopathological evaluation of TBLB sample, pathological diagnosis was possible in 42 patients with a diagnostic yield of 65%, whereas, in the remaining 23 (35%) patients, it was not diagnostic as it had only bronchial tissue without any lung parenchyma. This was consistent with results from various studies where the overall diagnostic yield of TBLB was highly variable ranging from 25% to 75%.[4],[6],[7],[8] The reason being the yield of TBLB varied depending on the underlying ILD.
The yield of TBLB in the case of sarcoidosis in our study was 58%. However, yield depended on the stage of the disease. The yield was higher in Stage 2 and Stage 3 disease when compared to Stage 1.[4] Leonard et al. compared the diagnostic yield from TBLB, transbronchial needle aspiration, and Bronchoalveolar lavage (BAL) in sarcoidosis, where the yield from TBLB alone was around 54%.[9] Furthermore, Sehgal et al. compared the efficacy and safety of cup versus alligator forceps for TBLB in sarcoidosis patients where the yield is around 60% with both forceps (64.3% vs. 60.6%).[10]
TBLB had a yield of 47% in cases of chronic HP in our study which is also consistent with various studies. Wang et al. showed a diagnostic yield of 30%.[11] Kumar et al. studied the profile of HP and showed the diagnostic yield of TBLB of 50%.[12]
The yield of TBLB was 17% in UIP cases in our study. Tomassetti et al. and Berbescu et al. both showed a TBLB yield of 30% and 32% in UIP cases, respectively.[13],[14] However, as per recent ATS/ERS/JRS/ALAT guidelines on Idiopathic pulmonary fibrosis (IPF), for patients with typical UIP on HRCT thorax, strong recommendations were made against performing any form of lung biopsy.[15]
NSIP is one of the idiopathic interstitial pneumonias. Most NSIP is associated with secondary causes such as connective tissue diseases and drug induced. However, idiopathic cases are also common. Lung biopsy in NSIP is not indicated in all cases. It is indicated when the underlying etiology is not identified.[16] TBLB is the most commonly used technique in cases of COP, as it has the highest diagnostic value among various noninvasive and semi-invasive procedures. In the study involving a case report with a literature review of COP, TBLB was diagnostic in 13 out of 15 patients with a diagnostic yield of 87%.[17] Furthermore, in another prospective study on COP, TBLB was diagnostic in 16 patients out of 32 patients with a total yield of 50%.[18] In our study, the yield of TBLB in COP and LIP was 100%, although they contributed to only 2% of the total study population. This small sample size was a limitation of our study.
LIP is a type of ILDs, usually associated with other systemic conditions such as connective tissue disorders like Sjogren syndrome and infectious causes such as human immunodeficiency virus and Epstein–Barr virus.[19] However, idiopathic cases have also been reported.[20],[21] LIP involves inflammatory reaction causing cellular expansion and infiltration of interstitium by reactive T- and B-lymphocytes and plasma cells.[22] Even though there were no studies elaborating about TBLB yield in LIP, there are various case reports where TBLB has been performed.[23] These suggest that TBLB can be diagnostic with proper clinical and radiological correlation.
| Conclusion | | |
Thus, TBLB is a potentially useful procedure for the diagnosis of ILDs as a part of multidisciplinary approach. This is more significant in developing countries where funds and facilities for other semi-invasive procedures such as video assisted thoracoscopic surgery (VATS) are not ubiquitously available. The diagnosis of ILD is with multi-disciplinary discussion (MDD); however, of these, the pathological part is often not done as VATS is difficult and often unavailable. Transbronchial lung cryobiopsy has been initiated in many centers but requires a special setup and involves risks. The lung biopsy is the most underutilized part of the ILD investigation bucket highlighted in the ILD India registry papers too. With our study, we aim to utilize a commoner and easily available TBLB in ILD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Wells AU. High-resolution computed tomography in the diagnosis of diffuse lung disease: A clinical perspective. Semin Respir Crit Care Med 2003;24:347-56.  |
| 2. | Andersen HA, Fontana RS, Harrison EG Jr. Transbronchoscopic lung biopsy in diffuse pulmonary disease. Dis Chest 1965;48:187-92. |
| 3. | Levin DC, Wicks AB, Ellis JH. Transbronchial lung biopsy via the fibreoptic bronchoscope. Am Rev Respir Dis 1974;110:4-12. |
| 4. | Kebbe J, Abdo T. Interstitial lung disease: The diagnostic role of bronchoscopy. J Thorac Dis 2017;9:S996-1010. |
| 5. | Casoni GL, Cordeiro CR Jr., Tomassetti S, Romagnoli M, Chilosi M, Cancellieri A, et al. The role of transbronchial biopsy in the diagnosis of diffuse parenchymal lung diseases: Pro. Rev Port Pneumol 2012;18:57-60. |
| 6. | Suraj KP, Narayan KV, Edakalavan J, Kumar NK. Diffuse parenchymal lung diseases with clinicoradiological discordance: Role of transbronchial lung biopsy as a diagnostic tool – An observational study. J Clin Diagn Res 2016;10:OC01-4. |
| 7. | Ensminger SA, Prakash UB. Is bronchoscopic lung biopsy helpful in the management of patients with diffuse lung disease? Eur Respir J 2006;28:1081-4. |
| 8. | Ghiani A, Neurohr C. Diagnostic yield, safety, and impact of transbronchial lung biopsy in mechanically ventilated, critically ill patients: A retrospective study. BMC Pulm Med 2021;21:15. |
| 9. | Leonard C, Tormey VJ, O'Keane C, Burke CM. Bronchoscopic diagnosis of sarcoidosis. Eur Respir J 1997;10:2722-4. |
| 10. | Sehgal IS, Bal A, Dhooria S, Agrawal P, Gupta N, Ram B, et al. A prospective randomized controlled trial comparing the efficacy and safety of cup vs. alligator forceps for performing transbronchial lung biopsy in patients with sarcoidosis. Chest 2016;149:1584-6. |
| 11. | Wang LJ, Cai HR, Xiao YL, Wang Y, Cao MS. Clinical characteristics and outcomes of hypersensitivity pneumonitis: A population-based study in China. Chin Med J (Engl) 2019;132:1283-92. |
| 12. | |
| 13. | Tomassetti S, Cavazza A, Colby TV, Ryu JH, Nanni O, Scarpi E, et al. Transbronchial biopsy is useful in predicting UIP pattern. Respir Res 2012;13:96. |
| 14. | Berbescu EA, Katzenstein AL, Snow JL, Zisman DA. Transbronchial biopsy in usual interstitial pneumonia. Chest 2006;129:1126-31. |
| 15. | Raghu G, Remy-Jardin M, Myers JL, Richeldi L, Ryerson CJ, Lederer DJ, et al. Diagnosis of idiopathic pulmonary fibrosis. An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med 2018;198:e44-68. |
| 16. | Kligerman SJ, Groshong S, Brown KK, Lynch DA. Nonspecific interstitial pneumonia: Radiologic, clinical, and pathologic considerations. Radiographics 2009;29:73-87. |
| 17. | Ding QL, Lv D, Wang BJ, Zhang QL, Yu YM, Sun SF, et al. Macrolide therapy in cryptogenic organizing pneumonia: A case report and literature review. Exp Ther Med 2015;9:829-34. |
| 18. | Poletti V, Cazzato S, Minicuci N, Zompatori M, Burzi M, Schiattone ML. The diagnostic value of bronchoalveolar lavage and transbronchial lung biopsy in cryptogenic organizing pneumonia. Eur Respir J 1996;9:2513-6. |
| 19. | Chitnis A, Vyas PK, Chaudhary P, Ghatavat G. Case-based discussion: Lymphocytic interstitial pneumonia a rare presentation in an immunocompetent adult male. Lung India 2015;32:500-4. [ PUBMED] [Full text] |
| 20. | İlhan S, Özkan S. Idiopathic lymphocytic interstitial pneumonia. Istanbul Med J 2016;17:35-8. |
| 21. | Sasikumar C, Utpat K, Joshi JM. Idiopathic lymphocytic interstitial pneumonia. Med J Dr DY Patil Vidyapeeth 2018;11:363. |
| 22. | Panchabhai TS, Farver C, Highland KB. Lymphocytic interstitial pneumonia. Clin Chest Med 2016;37:463-74. |
| 23. | Terada T. Follicular bronchiolitis and lymphocytic interstitial pneumonia in a Japanese man. Diagn Pathol 2011;6:85. |
[Table 1]
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