Thoracoscopic Lung Biopsy Research Articles

Surgical biopsy: its appropriateness in diagnosing interstitial lung disease

Our goal is to update advances in the use of surgical lung biopsy in the idiopathic interstitial pneumonias. We discuss an approach for identifying patients with idiopathic interstitial pneumonias who may benefit from surgical lung biopsy, newer surgical approaches and complications and risks of surgery. A consensus statement on idiopathic interstitial pneumonias has described the natural history and response to therapy of idiopathic interstitial pneumonias. The statement discussed selection of patients with idiopathic interstitial pneumonias for surgical lung biopsy and avoidance of unneeded biopsy, particularly for patients with 'classical' radiographic findings of idiopathic pulmonary fibrosis. Video-assisted thoracoscopic lung biopsy continues to be the standard procedure for surgical lung biopsy. Newer approaches have used outpatient surgery for selected patients, earlier removal of chest tubes and modifications of surgical technique. At-risk patients include those with respiratory failure, rapid progression of disease, pulmonary hypertension and advanced disease. Standard video-assisted thoracoscopic lung biopsy should be considered in patients with interstitial lung diseases of unknown cause who have a subacute course, ground-glass opacities on high-resolution computed tomography or features atypical for idiopathic pulmonary fibrosis, as these patients may respond to therapy. A step-wise process for selection of patients for surgical lung biopsy is recommended.

Clinicopathologic study of cryptogenic organizing pneumonia

To study the clinicopathologic features and differential diagnosis of cryptogenic organizing pneumonia (COP). The clinical, radiologic and pathologic features of 11 patients with COP confirmed by open or video-assisted thoracoscopic (VATS) lung biopsy were analyzed. Treatment information and follow-up data were also obtained. COP usually affected female patients over 40 years of age. Clinical presentations included cough, sputum and exertional dyspnea. High-resolution computerized tomography showed scattered speckled, patchy and trabecular shadows over both lung fields. Honeycomb changes were not found. Histologically, polypoid growths of granulation tissue were noted within respiratory bronchioles, small airways and alveolar spaces. These lesions had a patchy and peribronchiolar distribution and were uniform in appearance. The overall response rate to glucocorticoid was 81.8% (P < 0.01). The duration of follow up ranged from 6 to 134 months. Apart from one patient who developed aggravation of symptoms, the disease pursued a relatively stable clinical course. In general, COP responds well to glucocorticoid therapy. Open or VATS lung biopsy is important for arriving at a definitive diagnosis, especially for those cases presenting with atypical clinical and radiographic manifestations. Multiple biopsies with larger samples are preferred in order to avoid misdiagnosis.

Wegener’s granulomatosis presenting as a thyroid mass

A 71-year-old patient was referred for suspected hyperthyroidism because of a 15-kg weight loss, suppressed thyroid stimulating hormone (TSH), and a 4-cm nodule in the left thyroid lobe. Both free T4 and T3 were normal. Antithyroglobulin, anti-TSH receptor and antimicrosomal antibodies were absent. Thyroid scintigraphy showed a cold nodule in the left thyroid lobe. CAT scan of the neck revealed a 4-cm inhomogeneous nodule at the left side. An elevated sedimentation rate suggested bacterial thyroiditis, localized Quervain thyroiditis, malignancy, and the fibrosing variant of Hashimoto's thyroiditis or Riedel's thyroiditis. A fine needle biopsy of the thyroid nodule showed no malignant cells but was inconclusive. A true cut biopsy demonstrated atypical inflammation and also failed to reveal the diagnosis. Therefore, the patient was admitted to the hospital for further work-up and was unexpectedly found to have nodular lesions in the lung on a chest X-ray. Additional blood analysis revealed a positive cytoplasmic ANCA-titer. After inconclusive peripheral lung biopsies, a left hemithyroidectomy and a very large video-assisted thoracoscopic lung biopsy were performed, both revealing extensive zones of necrosis surrounded by granulomatous foci pointing to the diagnosis of Wegener's granulomatosis (WG) disease. To our knowledge, this is the first report of a well-documented WG of the thyroid gland. Although extremely rare, WG should be included in differential diagnosis of inflammatory lesions of the thyroid gland.

Iatrogenic Kaposi's sarcoma following steroid therapy for nonspecific interstitial pneumonia with HHV-8 genotyping

We present a case of iatrogenic Kaposi's sarcoma (KS) in a 64-year-old, human immunodeficiency virus (HIV)-negative woman with nonspecific interstitial pneumonia (NSIP) following steroid therapy. She suffered from longstanding exertional dyspnea, and was diagnosed to have NSIP by a thoracoscopic lung biopsy. After 4 months of steroid therapy, multiple purplish nodular or patchy skin lesions developed throughout the entire body. Microscopically, the skin lesions, consisting of closely packed spindle cells forming slit-like vascular structures, were diagnosed as typical KSs. The tumor cells were positive for CD34, factor VIII-related antigen, and human herpesvirus 8 (HHV-8) immunostainings. Using fresh tumor tissue and peripheral blood, polymerase chain reactions revealed the presence of HHV-8. Phylogenetic analysis of HHV-8 ORF K1 genes disclosed that the strain belonged to the subtype II/C and had the M allele at the right-hand side of the genome. To the best of our knowledge, this case report is the first documentation of iatrogenic KS associated with NSIP. A brief review focusing on the HHV-8 genotypes of iatrogenic KS is also presented.

Diffuse Nodular Interstitial Infiltrations with Bilateral Hilar Lymphadenopathy

□ 이달의 X선 □Lymphocytic interstitial pneumonia(LIP) is an uncommon conditio n in which the alveolar septa and extra-alveolar interstitial space are markedly expanded by small lymphocytes, plasma cells and histiocytes. Chest radiographs generally show nonspecific patterns with the most common patter n showing bibasilar reticular or reticulonodular infiltrates. Hilar or mediastinal lymphadenopathy and pleural e ffusions are usually absent. We encountered a 42-year-old female patient who was admitted to hospital because of exertional dyspnea and palpitation. The chest X-ray showed an enlarged bilateral hilar shadow and diffusely increas ed bronchovascular markings in both lung fields. The chest CT showed diffuse nodular infiltrations with mild septal thickening and combined patchy ground glass opacity in both lungs, and conglomerated mediastinal and bilateral hila r lymphadenopathy. A diagnosis of LIP was made from the tissue pathology taken by a thoracoscopic lung biopsy. The patient showed clinical and radiographic improvement after 3 months of treatment with prednisolone. We report a case of LIP presenting as diffuse nodular interstitial infiltrations with multiple mediastinal and bilateral hilar lym phadenopathy. (Tuberc Respir Dis 2006; 61: 294-298)Key words: Lymphocytic interstitial pneumonia, Diffuse nodular infiltrations, Bilateral hilar lymphadenopathy.Address for correspondence : Chi Hong Kim, M.D. Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6 Ji-dong, Paldal-gu, Suwon 442-723, Korea Phone: 031-249-7361, Fax : 031-253-8898 E-mail : chihongk@yahoo.co.krReceived : May. 25. 2006 Accepted : Jul. 4. 2006

Video-assisted thoracoscopic lung biopsy in children

Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. Video-assisted thoracoscopy (VATS) is less invasive than open thoracotomy and its development is associated with expansion of indication for lung biopsies. Lung biopsy remains an important investigation in the diagnosis of few of the lung disorders despite improved diagnostic yield of high resolution computed tomography scanning. Thoracoscopic lung biopsy is becoming the procedure of first choice for the diagnosis of many localized and diffuse lung diseases. We report a small series of eight patients who underwent VATS lung biopsy to demonstrate the safety and efficacy of this procedure.

Langerhans Cell Sarcoma Arising from Langerhans Cell Histiocytosis: A Case Report

Langerhans cell sarcoma (LCS) is a neoplastic proliferation of Langerhans cells that have overtly malignant cytologic features. It is a very rare disease and theoretically, it can present de novo or progress from an antecedent Langerhans cell histiocytosis (LCH). However, to our knowledge, LCS arising from an antecedent LCH has not been reported on. We present here a case of LCS arising from a pulmonary LCH. A 34 yr-old man who was a smoker, had a fever and a chronic cough. Computed tomographic (CT) scan revealed multiple tiny nodules in both lungs. The thoracoscopic lung biopsy revealed LCH. The patient quit smoking, but he received no other specific treatment. One year later, the follow up chest CT scan showed a 4 cm-sized mass in the left lower lobe of the lung. A lobectomy was then performed. Microscopic examination of the mass revealed an infiltrative proliferation of large cells that had malignant cytologic features. Immunohistochemical stains showed a strong reactivity for S-100 and CD68, and a focal reactivity for CD1a. We think this is the first case of LCS arising from LCH.

Corticosteroid for plasma cell granuloma of the lung?

Summary A 69-year-old man presented pleural-based masses and a marked hypergammaglobulinemia. Thoracoscopic lung biopsy revealed the lung pathology as prominent lymphoplasmacytic infiltrates admixed with fibrosis, consistent with plasma cell granuloma (PG). Treatment with corticosteroid (CS) induced complete remission of the lung lesions and normalization of hypergammaglobulinemia. Discontinuation of CS resulted in a resurgence of the lung lesion, which again was remitted on resumption of CS, stressing an efficacy of CS in the condition. This and other published cases affirm the value of treatment with corticosteroids as an acceptable choice for primary and recurrent pulmonary PG.

Tuberous Sclerosis Complex Complicated by Pulmonary Multinodular Shadows

A 41-year-old woman with a history of epilepsy was referred for multiple nodular ground-glass opacities on a chest computed tomography (CT) scan. They were initially suspected of representing atypical adenomatous hyperplasia or well-differentiated adenocarcinoma. However, the subsequent brain CT and magnetic resonance imaging (MRI) scans revealed a coarse nodular calcification and cortical tubers. A subungual fibroma was also noted. Histological examination of a video-assisted thoracoscopic lung biopsy specimen disclosed multiple nodules of type II pneumocyte hyperplasia with septal thickening. Based on all of these findings taken together, a diagnosis of tuberous sclerosis complex with multifocal micronodular pneumocyte hyperplasia (MMPH) was made.

COMPLICATIONS OF VIDEO ASSISTED THORACOSCOPIC LUNG BIOPSY IN PATIENTS WITH INTERSTITIAL LUNG DISEASE

PURPOSE: Current practice guidelines recommend video assisted thoracoscopic lung biopsy (VATSLB) for patients with interstitial lung diseases (ILDs) who do not have diagnostic CT scans. However, VATSLB in this population carries risk. The reported incidence of death after biopsy in patients with idiopathic pulmonary fibrosis (IPF) is up to 17%. We examined the morbidity and mortality associated with VATSLB in a group of outpatients with undefined ILD.

Pulmonary involvement in Erdheim‐Chester disease

Erdheim-Chester disease is a disseminated non-Langerhans' cell histiocytosis involving multiple organs with characteristic sclerotic musculoskeletal lesions. This is the report of the case of a 53-year-old woman with extensive and progressive pulmonary disease. Computed tomography scans revealed diffuse infiltrative lung disease. Thoracoscopic lung biopsy and a biopsy of the right femur lesion were performed. The histopathology revealed that she had non-Langerhans' cell histiocytosis; Erdheim-Chester disease. The characteristic lesions of Erdheim-Chester disease, including involvement of the orbit, pericardium, periaorta, and bone were detected. This helped to further confirm that the patient had Erdheim-Chester disease with associated pulmonary involvement. As Erdheim-Chester disease is a rare non-Langerhans' cell histiocytosis that may be misdiagnosed as interstitial lung disease or other pulmonary disorders, this diagnosis should be considered in the differential diagnosis of such lung lesions.

Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases

Methods Between January 2000 and April 2004, a total of 20 patients underwent wedge pulmonary resection by uniportal VATS for diagnosis of suspected interstitial lung diseases according to a standardized technique described elsewhere. In brief, only one incision (2-2.5 cm long) is placed in the chest opposite to the target area to be sampled for biopsy. As a rule, the fourth or fifth intercostal space in the midposterior axillary line is selected for wedge biopsy of the apical and basal segments of the lower lobe, and the sixth intercostal space in the scapular line is selected for the middle lobe and the lingula. A 5-mm thoracoscope is routinely used, along with roticulating grasping and stapling instruments, while the target areas are approached along a sagittal plane, developing the entire procedure according to a craniocaudal perspective (Figure 1). The specimen is removed from the chest with an endobag and injected with formalin to avoid collapse of the diseased alveoli and histologic artifacts. We used this technique in 11 male and 9 female patients with a median age of 56 years (range 32-80 years). Preoperative median forced expiratory volume in 1 second was 2.14 L (range 1.17-3.21 L).The median forced expiratory volume in 1 second and diffusing capacity of lung for carbon monoxide percentage values were 74% (range 54%-101%) and 58% (range 39%-79%), respectively.

A Case of Pulmonary Cryptococcosis in an Immunocompetent Patient

We experienced a case of pulmonary cryptococcosis in an immunocompetent patient who presented with uncommon radiological findings. He complained of a dry cough for 3 weeks. The chest X-ray and CT showed multiple, variable sized, and irregular patch consolidations with cavities combined with some ground glass opacities in both lower lung fields. The diagnosis was made histologically via a thoracoscopic lung biopsy. The patient was administered oral fluconazole has since been well. (Tuberc Respir Dis 2005; 59: 700-704)

Efficacy and Safety of Medical Thoracoscopic Lung Biopsy Obtained by Stapler Device

PURPOSE: To evaluate the diagnostic yield and the quality of biopsy in patients who underwent medical thoracoscopic lung biopsy (MTLB) using stapler device under regional anaesthesia, and neuroleptic analgesia for the evaluation of peripheral mass or diffuse interstitial lung disease.

Invited commentary

Invited commentary

P0674 GRANULOMATOUS PNEUMONITIS AND SCLEROSING CHOLANGITIS (PSC)IN A CHILD WITH CROHN???S DISEASE (CD): RESPONSE TO INFLIXIMAB (IFX)

Introduction: Pulmonary CD is rare, and commonly attributed to aminosalicylate (5ASA) medications. We report a case of granulomatous pneumonitis in a child with CD not on 5ASA who responsed to IFX therapy. Methods: Restrospective case report Results: A 13-yr-old was diagnosed with gastroduodenal and colonic CD and PSC 4 yrs prior to developing lung disease. She was taking 6MP, prednisone and ursodeoxycholic acid when she developed fever with epigastric and back pain. Labs included WBC=8.2, ESR>120, alk phos=1037, AST=48, ALT=63, T. Bili= 3.6, D. Bili=1.1, amylase=152, and lipase=149. ERCP demonstrated sludge and purulent material. The child improved on antibiotics (abx). Several days later she presented with a cough and increasing back pain. Chest x-ray (CXR) and chest CT revealed a right lower lung field infiltrate. She again improved on abx. A few wks later, fever, chills and back pain recurred. CXR and chest CT revealed right middle lobe and left lower lobe pneumonia. The child was discharged after improvement on abx, only to be rehospitalized several days later with back pain and cough. Right middle and lingular densities on CXR were found that were noted on CT to be 2 rounded densities in the right middle lobe and 1 in the lingula. There was no mediastinal adenopathy. Despite ongoing therapy, CT 2 wks later showed multiple pleural and intraparenchymal pulmonary lesions of varying sizes, most of which were nodular in configuration. Pulmonary embolism was ruled out and an immunologic evaluation was negative. Thoracoscopic lung biopsy showed multiple epithileal cell noncaseating granulomas without interstitial fibrosis. Tissue cultures for bacteria, fungus and tuberculosis were negative. It was felt that the child had CD with multiorgan involvement. She was treated with 5 mg/kg IFX and had a rapid clinical improvement with rapid clearing of the CXR. A 2nd dose of IFX 2 wks later was followed by marked decrease in ESR, amylase, lipase and alk phos. However, 2 wks later the patient again developed abdominal and back pain with an increased ESR and mild elevations of AST, ALT, amylase and lipase. CXR showed no recurrent or new infiltrates. A 3rd dose of IFX resulted in rapid improvement. Pulmonary function studies showed normal lung function at the 1st episode, a restrictive process at the nodular stage and reversal after IFX. Conclusion: Granulomatous pneumonitis can be due to CD itself, rather than a complication of 5ASA therapy. In this child, infliximab resulted in dramatic clinical and radiologic improvement. Coincidentally, IFX also caused biochemical improvement of both the patient’s PSC and pancreatitis.

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD)

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) designates interstitial lung changes in smokers, characterized histologically by bronchiolocentric accumulation of pigmented alveolar macrophages and fibrotic or cellular inflammatory changes of pulmonary interstitium. The definition is nearly identical to that of condensate pneumopathy, smoker's pneumopathy or smoker's lung, defined by accumulation of pigmented alveolar macrophages with bland alveoloseptal or peribronchial fibrosis and cellular inflammation of the bronchial wall. In addition to respiratory bronchiolitis, which is found in nearly all smokers, RB-ILD comprises a broad spectrum of varying degrees of the interstitial reaction to the exogenous injury of inhalation smoking with gradual transition to desquamative interstitial pneumonia (DIP). In most cases RB-ILD manifestations are subclinical and detected coincidentally. Radiographic features are reticulonodular and ground glass opacities of the lung. The high resolution computed tomography reveals centrilobular nodules, ground glass opacities, thickening of bronchial walls, and in some cases a reticular pattern. Mild emphysema is frequent. Lung function analysis reveals only minor restrictive or obstructive defects in most cases, often combined with hyperinflation. CO diffusing capacity is slightly to moderately impaired. Pronounced interstitial lung diseases with serious restrictive defects and arterial hypoxemia have been reported infrequently. In differential diagnosis smoking related interstitial lung diseases (DIP, Langerhans cell histiocytosis, idiopathic pulmonary fibrosis) and other interstitial lung diseases have to be excluded. In most cases diagnosis can be achieved by bronchoalveolar lavage and transbronchial lung biopsy. In cases of pronounced interstitial lung disease or assumption of an additional interstitial lung disease besides RB-ILD a thoracoscopic or open lung biopsy can be necessary. RB-ILD has a favourable prognosis. After smoking cessation lung changes are reversible. Corticosteroid therapy is not necessary. A fatal outcome of RB-ILD has not been reported. Follow-up examinations are advisable in order to preclude other interstitial lung diseases. RB-ILD seems to be more frequent than it is assumed at present. The clinical picture is masked in most cases by the concomitant smoking induced chronic bronchitis. Thus only pronounced cases with structural changes and resulting differential diagnostic problems are diagnosed.

Clinicopathologic features of usual interstitial pneumonia and its differential diagnosis from idiopathic nonspecific interstitial pneumonia

To investigate the clinicopathologic features of usual interstitial pneumonia (UIP) and its differential diagnosis from idiopathic nonspecific interstitial pneumonia (INSIP). The clinical and pathological features of 15 UIP and 11 cases of INSIP, having received open or video-assisted thoracoscopic lung biopsies and having follow-up information were reviewed. UIP occurred more often in males over 50 years of age. Clinical findings included progressive shortness of breath, cough, sputum and crackles over both lung fields. High resolution computerized tomography (HRCT) showed patchy attenuation, especially over both lower lobes. Honeycombing was found in 8 cases. Histologically, UIP was characterized by scattered fibrotic foci, fibrosis (often associated with honeycombing) and pulmonary architectural destruction. It had a heterogeneous appearance, with alternating areas of normal lung, interstitial inflammation, fibrosis and honeycomb changes. The frequencies of fibroblastic foci, muscle sclerosis, honeycomb changes, diffuse fibrosis and pulmonary architectural destruction in UIP and INSIP were 100% and 27.3% (P<0.001), 80.0% and 36.4% (P<0.05), 86.7% and 27.3% (P<0.001), 100% and 54.5% (P<0.01) and 100% and 45.5% (P<0.05), respectively. The response rate to glucocorticoid was 26.7% and 72.7% (P<0.05) in UIP and INSIP respectively. The distinction between UIP and INSIP is difficult if based on clinical examination alone. HRCT is helpful for differential diagnosis in some difficult cases. Definite diagnosis depends mainly on open lung biopsies. Key histologic features of UIP include heterogeneous appearance with interstitial inflammation, fibroblastic foci, scar formation and honeycomb changes.

Bronchiolitis Obliterans Organizing Pneumonia and Bronchogenic Carcinoma Coexisting in Different Parts of the Lungs

Bronchiolitis obliterans organizing pneumonia (BOOP) coexisting with nonsmall cell lung cancer in a separate part of the lungs is rare. We report the case of a man diagnosed with BOOP by video-assisted thoracoscopic lung biopsy; the patient also had adenocarcinoma in a different part of the lungs. The BOOP was treated with corticosteroids and the carcinoma was surgically resected. Outcome and clinical course were good after both procedures. The possibility of BOOP associated with bronchogenic carcinoma at a distant part of the lungs, although rare, must be taken into account in the differential diagnosis of radiographic alterations that may present in either of the 2 diseases.

Pulmonary Epithelioid Hemangioendothelioma: An Unusual Case and a Review of the Literature

We describe a case of pulmonary epithelioid hemangioendothelioma, previously known as intravascular bronchoalveolar tumor, in a 35-year-old woman with an initial diagnosis made by transbronchial biopsy. This is a rare disease, with approximately 50 cases described in the literature. All previous cases have been diagnosed by surgical lung biopsy. Although our patient underwent thoracoscopic lung biopsy, the diagnosis was initially made on transbronchial biopsy; to our knowledge, this has not been previously described in the English-language literature. We also described findings on high-resolution CT, both typical and atypical relative to previously published reports. This tumor can affect multiple organs. The prognosis is very unpredictable, with life expectancy ranging from 1 to 15 years. There is no single effective treatment, though spontaneous regression and response to chemotherapy and interferon are reported.