Year : 2023 | Volume
: 3 | Issue : 1 | Page : 3--4
Interstitial lung diseases and lung biopsies… more, less, or nothing…
Department of Pulmonary Medicine, Lisie Hospital, Kochi, Kerala, India
Dr. A R Paramez
Department of Pulmonary Medicine, Lisie Hospital, Kochi
|How to cite this article:|
Paramez A R. Interstitial lung diseases and lung biopsies… more, less, or nothing….J Adv Lung Health 2023;3:3-4
|How to cite this URL:|
Paramez A R. Interstitial lung diseases and lung biopsies… more, less, or nothing…. J Adv Lung Health [serial online] 2023 [cited 2023 May 28 ];3:3-4
Available from: https://www.jalh.org//text.asp?2023/3/1/3/365495
Interstitial lung diseases (ILDs) are a heterogeneous group of diseases that are classified together because of common clinical, radiological, physiological, or pathological manifestations. They are also known as diffuse parenchymal lung diseases (DPLDs). It comprises a group of over 200 disorders of variable etiologies and course of disease.
An accurate diagnosis of the exact disease is paramount as the course of most ILDs can only be altered if diagnosed at an early stage. A comprehensive clinical history and examination along with good radiological correlation may help in arriving at a diagnosis in many cases of DPLD such as idiopathic pulmonary fibrosis (IPF), hypersensitivity pneumonitis, and pulmonary Langerhans cell histiocytosis. However, there may be instances where the clinic radiological and laboratory investigations may not yield an accurate diagnosis. Advancements in the quality of high-resolution computed tomography (HRCT) has revolutionized the lung biopsy with multidisciplinary discussion (MDD) involving pulmonologist, radiologist, and pathologist may be necessary in cases with conflicting clinical and radiological findings. Surgical lung biopsy (SLB) remains the gold standard invasive test for the pathological evaluation of ILDs, especially in IPF, nonspecific interstitial pneumonia and lymphocytic interstitial pneumonia. Video-assisted thoracic surgery (VATS) is minimally invasive procedure with low morbidity and mortality; if performed by the surgeons familiar with techniques required for ILD diagnosis. The complications of VATS include prolonged air leak, infections, bleeding, and incision site pain. Patient should be able to tolerate one lung ventilation for undergoing VATS. Patients with type 2 respiratory failure and severe pulmonary arterial hypertension may also be considered against VATS. International IPF registry data reveal VATS biopsy rates of 13%–24%, which is abysmally low. This is attributed to the complications, high risk-benefit ratio, lack of accessibility to surgical facility, etc.
Videobronchoscopic-guided transbronchial lung biopsy (TBLB) and transbronchial lung cryobiopsy (TBLC) offer a less invasive option for those who are unfit for VATS. TBLB is a procedure routinely done by interventional pulmonologists globally. When coupled with fluoroscopy guidance, the yield of good quality tissue is improved and chances of pneumothorax are reduced; if done by a skilled bronchoscopist.
Transbronchial biopsy is safe, with risk for pneumothorax of approximately 1% and significant bleeding <2%. Compared to SLB, diagnostic information in certain forms of ILD is particularly amenable to diagnosis by bronchoscopy despite having relatively smaller specimen, especially granulomatous diseases such as sarcoidosis, hypersensitivity pneumonitis, and drug toxicity. The small samples are susceptible to sampling error and reduced ability to detect scattered histological features such as granulomas. The diagnostic yield of TBLB in detected ILDs is around 36% and SLB may be avoided in those. It also means that majority (64%) remains undiagnosed after TBLB. Hence, TBLB is not included in the standard practice guidelines for the diagnosis of IPF by ATS because of the above reasons. It may be considered as the first choice in resource-limited settings where good quality surgical procedures are difficult to access.
TBLC is better in procuring samples as compared to TBLB. There are many potential advantages of TBLC over VATS, including faster recovery time and lower risk of adverse events. The impact of prolonged chest wall pain following VATS is under-recognized and can be largely avoided with the TBLC. Although no direct comparison has been made, the risk of death with TBLC appears favorable over VATS, with respective reported mortality rates of 0.3% and 1.7% for elective procedures. It follows that the better safety profile could potentially translate into lower healthcare utilisation and cost savings.
The risk for TBLC, however, is not negligible, with a number of meta-analyses showing bleeding rates of 14%–39% and pneumothoraces in 10%–12%. Poor patient selection and operator inexperience are likely to be important contributing factors, highlighting the need for further evidence and standardized practice before general implementation of TBLC.
A MDD is essential in establishing an early accurate diagnosis, thereby helps in avoiding incorrect therapies and unnecessary diagnostic tests. MDD consists of an interaction between pulmonologist/rheumatologist, radiologist, and a pathologist. The benefit of MDD is greatest when the HRCT pattern is probable usual interstitial pneumonia (UIP), indeterminate for UIP, or an alternative diagnosis, or when there exist discordant clinical, radiologic, and/or histologic data. A comprehensive approach including the clinical history, laboratory testing, and radiographic appearance can help assess if pathologic information is needed for accurate diagnosis.
The emergence of artificial intelligence and machine learning is likely to revolutionize the radiological and pathological diagnosis in a more objective way. AI has the potential to contribute to the radiologic diagnosis and classification of ILD. However, the accuracy performance is still not satisfactory, and more well-defined prospective controlled studies are needed to assess the value of the existing AI tools.
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