Video-assisted Thoracic Surgery Lung Biopsy Research Articles

Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Diseases and Peripheral Pulmonary Lesions - A Stepwise Approach.

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted thoracic surgery lung biopsy (SLB) for diagnosing interstitial lung diseases (ILDs). The indication for TBLC has primarily been to sub-classify a specific ILD subtype when this cannot be achieved on the basis of a preceding multidisciplinary team discussion. Although SLB is considered the gold standard for establishing a histological diagnosis, TBLC has been gradually suggested as the first-choice histological diagnostic modality in patients with unclassified ILDs due to a comparable diagnostic yield with SLB, but superior to SLB in terms of complications, including mortality. During recent years, radial endobronchial ultrasound (R-EBUS) and electromagnetic navigation bronchoscopy (ENB)-guided TBLC for peripheral pulmonary lesions have also been described as safe procedures, which may improve the diagnostic yield compared to forceps biopsies. Still, the diagnostic properties of TBLC rely on the quality of the procedure's performance. This article aims to describe the stepwise approach to conducting TBLC with a flexible bronchoscope for the different indications mentioned, which might be helpful for novice bronchoscopists performing TBLC.

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.

The clinical characteristics of pulmonary benign metastasizing leiomyoma

Objective: Pulmonary benign metastasizing leiomyoma (PBML) is a rare entity that leiomyoma of uterus metastasized to the lung. The clinical characteristics of this rare disease were analyzed in this article. Methods: The detailed clinical records of 7 patients diagnosed as PBML at Peking Union Medical College Hospital between January 2001 and June 2015 were reviewed. Results: All patients were women with median age of 44 years (range 28-62). Symptoms included dyspnea (2/7), chest pain (1/7), cyanosis (1/7), cough (1/7) and bloody sputum (1/7), while 4/7 cases were asymptomatic. Six patients had the past-history of leiomyoma of uterus 20 months to 14 years ago among whom 5 patients received hysterectomy. Chest CT showed bilateral, random-distributed multiple round solid nodules, or diffuse-distributed miliary nodules, or single solid nodule, even some small cavities. Extra-pulmonary metastasis was found in left superclavicular lymph node (1 case) and right heart (1 case). Histological tissues were obtained by video-assisted thoracic surgery lung biopsy (4/7), mass resection on tricuspid valve (1/7), transbronchil lung biopsy (1/7), and CT-guided percutaneous lung biopsy (1/7). Pathology showed an interlacing pattern by spindle cells having elongated nuclei without cellular atypia. Ki-67 index was less than 1%. Molecules such as smooth muscle antibody, estrogen receptor (ER) and progestrone receptor (PR) were positive in immunohistochemistry staining. Neither letrozole nor zoladex was effective. Two patients responded to bilateral adnexectomy, presenting as shrunk nodules. No relapsed disease was seen in one patient with single nodule after resection. There was only one patient with disease-related mortality, whose chest CT showed milliary nodules. Conclusion: Although CT findings of PBML are similar to malignancies, the clinical outcome is good. Despite the positive expression of ER and PR, the effectiveness of hormone related treatment is limited. And periodical follow up is suggested even to those uneventful patients.

Awake Thoracoscopic Biopsy of Interstitial Lung Disease

Surgical biopsy of interstitial lung disease (ILD) performed through general anesthesia and video-assisted thoracic surgery (VATS) is still associated with not negligible mortality and morbidity rates. We hypothesized feasibility and minimized side-effects of VATS lung biopsy performed by regional anesthesia methods in awake patients. Thirty patients with clinical and radiologic diagnosis of undetermined ILD underwent awake VATS lung biopsy under thoracic epidural anesthesia (20 patients) or intercostal blocks (10 patients). Primary outcome was technical feasibility scored from 0 (not performed) to 4 (excellent). Cardiorespiratory variables, including the ratio of arterial oxygen to fraction of inspired oxygen (PaO(2)/FiO(2)) and arterial carbon dioxide (PaCO(2)) were also assessed at fixed time points. Mean age was 62 ± 10 years. No patient needed conversion to general anesthesia. The feasibility score was 3.4 ± 0.7. Feasibility score correlated with percent predicted diffusing capacity of lung for carbon monoxide (R = 0.67, p = 0.0001). Operative time and global in-operating room time (anesthesia time + operative time) was 22 ± 5 minutes and 47 ± 11 minutes, respectively. The average number of biopsies was 1.8 ± 0.4 per patient. There was no operative mortality and 1 minor complication (3.3%). Mean hospital stay was 1.4 ± 0.7 days and procedure-related cost was 2700 ± 472 euros. Both anesthesia methods resulted in optimal feasibility although by intercostal blocks procedure-related cost was lower (2,410 ± 337 vs 2,800 ± 486 euros, p < 0.002) than by epidural anesthesia. Precise histopathologic diagnosis was achieved in 29 (97%) patients. Our study has shown that in patients with ILD, awake VATS lung biopsy was easily feasible by regional anesthesia and resulted in low morbidity, excellent diagnostic yield, short hospital stay, and low cost.

Fluorodeoxyglucose (FDG) uptake in pulmonary rheumatoid nodules diagnosed by video-assisted thoracic surgery lung biopsy: two case reports and a review of the literature

Two cases of rheumatoid nodules evaluated by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and video-assisted thoracic surgery (VATS) biopsy are reported. The first case was that of a 44-year-old woman who presented with a cavitated nodule with intense standardized uptake values (SUVs) both in the early (max 3.4) and delayed (max 4.4) phases, suggesting malignancy. However, after VATS biopsy, she was diagnosed as having a rheumatoid nodule with vasculitis. The second case was that of a 74-year-old woman admitted with bilateral lung nodules, two of which showed intense early (max 2.2) and delayed (max 6.0) phase SUVs, and mild early (max 0.6) and delayed (max 0.9) phase SUVs. These two nodules were finally proven to be a lung cancer and rheumatoid nodule without vasculitis, respectively. These cases show that rheumatoid nodules with an enhanced inflammatory process, such as vasculitis, can appear false-positive for malignancy on FDG-PET/CT scan images.

TGF-β1 in bronchoalveolar lavage fluid in diffuse parenchymal lung diseases and high-resolution computed tomography score

In the pathogenesis of diffuse parenchymal lung diseases (DPLDs), growth factors, including transforming growth factor beta1 (TGF-beta1), are responsible for cell proliferation, apoptosis, chemotaxis, and angiogenesis, and also for the production and secretion of some components of the extracellular matrix. The aim of the study was to evaluate correlations in DPLDs between TGF-beta1 levels in bronchoalveolar lavage (BAL) fluid and high-resolution computed tomography (HRCT) score. The study was performed in 31 DPLD patients in whom a selection of lung segments with high and low intensity of abnormalities was estimated by HRCT score. All patients underwent BAL with TGF-beta1 measured by an enzyme immunoassay in BAL fluid and video-assisted thoracic surgery lung biopsy from both selected segments. All 31 patients were diagnosed, and based on histopathology, they were classified into 2 groups: idiopathic interstitial pneumonia (usual interstitial pneumonia - 12, nonspecific inter stitial pneumonia - 2, cryptogenic organizing pneumonia - 2, and desquamative interstitial pneumonia - 1) and granulomatous disease (sarcoidosis - 7, extrinsic allergic alveolitis - 5, and histiocytosis X - 2). The final analysis was performed in 28 patients who showed nonhomogenous distribution on HRCT. TGF-beta1 levels in BAL fluid were significantly higher in the areas with high intensity of abnormalities assessed by HRCT score (P = 0.018, analysis of variance). These levels were not different between the groups, but a trend towards higher levels in idiopathic inter stitial pneumonia was observed. The results confirm that TGF-beta1 may be a good but not specific marker of fibrosis in DPLDs. A significant positive correlation between TGF-beta1 levels in BAL fluid and the HRCT score was observed.

Complications after ultrasonic lung parenchyma biopsy: a strong note for caution

This study aimed to determine the possible cause for an unacceptable frequency of postresectional pneumothorax in cases of ultrasonic scalpel use without a further reinforcing maneuver in lung biopsy during video-assisted thoracic surgery (VATS). Data for a series of 16 consecutive VATS lung biopsy patients (group A) in which a disturbingly high number of minor and medium complications occurred were compared with data for a group of 20 patients previously subject to the same ultrasonic lung biopsy method (group B) without complication. The two groups were identical in terms of all significant factors considered in relation to ultrasonic scalpel biopsy. Six notable air leakage complications occurred among the 16 patients of group A. One patient needed redrainage while still in the hospital. Two other patients required readmission and redrainage. In 4 of the 16 cases, late pneumothorax was detected after a "silent" 48-h postoperative period prolonging their hospital stay. Altogether, three medium complications occurred in group A, as compared with none in group B. The drainage duration in group B was not significantly shorter than in group A . Multivariate analysis showed a significant difference in complications favoring group B (odds ratio, 1.88). A high postoperative air leakage rate was observed in a simple case series using an unsecured harmonic scalpel after a randomized trial of the same method in the same institute with a diametrically opposite outcome. The medium complication rate of 3 in 16 cases is unacceptable for a minor procedure such as lung biopsy. The two groups differed only in their thromboembolic prophylaxis protocol. Therefore, it is hypothesized that the recent introduction of low-molecular-weight heparin from day 1 may influence the complication rate. The authors' observation calls for caution in use of the harmonic scalpel on lung tissue without reinforcing maneuvers (i.e., stitches or clips). To avoid unnecessary complications, operative technique adjustment is recommended.

Invasive pulmonary aspergillosis and pulmonary cryptococcosis really coexist in immunocompromised host

Fungal infections develop slowly in immunocompetent patients and rarely a severe disease, however, they progress rapidly and usually prove fatal in immunocompromised patients. Early diagnosis and treatment of fungal infections is essential to survival of immunocompromised patients. We report a 33-year-old woman with systemic lupus erythematosus undergoing immunotherapy infected with combined invasive pulmonary aspergillosis and pulmonary cryptococcosis diagnosed by video-assisted thoracic surgery lung biopsy and she was successfully treated as a result of early diagnosis and treatment.