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ORIGINAL ARTICLE
Year : 2021 | Volume
: 70
| Issue : 1 | Page : 107-112
Medical thoracoscopic lung biopsy in diffuse parenchymal lung diseases: safety and usefulness
Hesham E Abdel-Ati, Ahmed A Khames, Amr M Allama, Sami S El-Dahdouh, Bishoy B Tawadros Los, Maha Yousif
Department of Chest Diseases and Tuberculosis, Faculty of Medicine, Menoufia University, Menoufia, Egypt
Correspondence Address:
MBBCh Bishoy B Tawadros Los
Department of Chest Diseases and Tuberculosis, Faculty of Medicine, Menoufia University, Quesna, Menoufia University Hospital, Menoufia, 12345
Egypt
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ejcdt.ejcdt_77_20
Background Diffuse parenchymal lung diseases (DPLD) compromise heterogeneous subtypes. Establishing an accurate diagnosis is paramount. Lung tissue biopsy is the gold standard diagnostic tool.
Aim To assess the role of medical thoracoscopy with electrocautery in the diagnosis of DPLD.
Patients and methods A total of 20 patients who had undiagnosed DPLD on chest high-resolution computed tomography were randomly selected from Menoufia Chest Department from March 2017 to March 2019. Lung biopsy was taken by medical thoracoscopy under conscious sedation with the aid of electrocautery device.
Results A total of 12 (60%) patients were males, and seven (35%) patients were smokers. The mean age was 58.1±10.5 years. High-resolution computed tomography patterns were reticulonodular (65%), ground glass (35%), miliary shadow (15%), and consolidation (15%). Diagnoses were granulomatous lung disease (40%), idiopathic interstitial pneumonias (30%), malignant lung disease (15%), and interstitial lung disease secondary to rheumatoid disease (10%). One (5%) case remained undiagnosed. The mean duration of hospital stay for the studied group was 1.95 days, ranging from 1 to 6 days. Recorded complications were air leak (5%), wound infection (5%), and surgical emphysema (5%). There were no reported mortalities.
Conclusions Medical thoracoscope is a safe, effective, and feasible method to obtain lung biopsies for diagnosis of DPLD.
Keywords: diffuse parenchymal lung diseases, electrocautery, medical thoracoscope
There are many disease subtypes under the umbrella of diffuse parenchymal lung diseases (DPLDs). Sometimes, the diagnosis is obvious by the clinical and radiological findings. In other instances, a lung biopsy is required especially if that could alter the treatment plan or the prognosis of the patient [1].
The gold standard of diagnosis is surgical lung biopsy done via open surgery (thoracotomy) or video-assisted thoracoscopy (VATS). Surgical thoracoscopy has the upper hand now, as it is minimally invasive with fewer complications and less hospital stay [2].
Medical thoracoscopy with electrocautery forceps could be a practical alternative for VATS to obtain lung biopsies in a safe and cheap method [3]. Therefore, the aim of this study was to assess the safety, effectiveness, and feasibility of this method to obtain lung biopsies in patients with DPLD.
Patients and methodsThis prospective study was conducted on 20 patients with undiagnosed DPLD on high-resolution computed tomography (HRCT) chest who were admitted to Menoufia Chest Department from March 2017 to March 2019. Exclusion criteria included patients with type II respiratory failure, pulmonary hypertension more than 40 mmHg on echocardiography, coagulopathy (prothrombin concentration <50% or platelet count <70 000/ml), recent cardiac disorders (significant arrhythmia, myocardial infarction, unstable angina), any end-stage systemic disease, and diffuse end-stage lung fibrosis as traction bronchiectasis and honeycombing on HRCT. All patients had full clinical, laboratory, and radiological assessment including HRCT and pulmonary function test.
Medical thoracoscopic lung biopsy
Technique
The patient was placed in the lateral decubitus position with the desired lung above. A small incision was made (about 1 cm). Blunt dissection with round-ended scissors was carefully performed through the chest wall. The single puncture, TEKNO thoracoscope was passed through the trocar to obtain biopsies. A diathermy unit (ERB VIO 300 D) was connected to the forceps of the biopsy as needed.
The forceps was dipped in the lung surface in an open position then closed to obtain lung biopsies. Short pulses of diathermy (60 W coagulation) were applied. This was important to close the lung breach and prevent air leak or bleeding. Usually two to three biopsies were obtained from different lobes. Lastly, an intercostal drainage (28 or 32 Fr gauge) catheter was placed connected to an underwater seal.
ResultsThe demographic characteristics and smoking habits are represented in [Table 1]. Regarding pulmonary function tests, many of the patients (65%) showed a restrictive abnormality (forced vital capacity ranged from 60 to 83%).
There was a statistically highly significant decrease in postbiopsy oxygen saturation compared with its prebiopsy values (P=0.004) ([Table 2]).
Table 2 Oxygen saturation before and after biopsy among the studied groupThe predominant parenchymal shadow among the studied group was the reticulonodular pattern, appearing in 65% of the HRCT scans. The second common pattern was the ground-glass appearance, constituting 35%. The miliary shadow and consolidation pattern were equal by 15% for each ([Table 3]).
Table 3 Predominant high-resolution computed tomography parenchymal findings among the studied groupIn this study, medical thoracoscopy provided definitive diagnosis in 19 (95%) of 20 patients. The different diagnoses reached in the study are illustrated in [Table 4].
There was a statistically significant correlation between some radiological shadows and specific types of DPLD. For example, reticulonodular shadow in HRCT was present in 87.5% of granulomatous lung diseases, 66.7% of idiopathic pneumonias, and 100% of ILDs secondary to rheumatoid disease. Other relations are clarified in [Table 5].
Table 5 Relation between final diagnosis and high-resolution computed tomography findings among the studied groupRegarding complications, 17 (75%) patients did not encounter any complications. Three (25%) patients had complications, which were air leak (5%), wound infection (5%), and surgical emphysema (5%). The mean values of hospital stay for the studied group were 1.95±1.53. There was a statistically significant correlation between complications and prolonged hospital stay (P=0.028) ([Figure 1]).
Figure 1 Relation between hospital stay and complications among the studied group.In this study, there was a statistically highly significant correlation between final diagnosis and follow-up after 6 months. Patients with malignant disease had the worst prognosis ([Table 6]).
Table 6 Relation between patients’ follow-up and final diagnosis among the studied group (prognosis) Discussion DPLDs compromise a wide scale of heterogeneous subtypes. The decision to perform lung biopsy is based on the likelihood that results of the biopsy could alter the treatment being received by the patient [4].
The aim of this study was to assess the role of medical thoracoscopic lung biopsy in the diagnosis of DPLD. The safety, feasibility, and complications of the procedure were also assessed.
This study showed male predominance: 12 males representing 60% of patients and eight females representing 40% of patients. This was in contrary with Ahmed et al. [5], Magdy et al. [6], and Elhadidy et al. [7] whose studies showed female predominance (80, 66.7, and 58.2%, respectively). This study was in agreement with Xaubet et al. [8], Danes et al. [9], and Jain et al. [10], which showed male predominance (71.8, 66.4, and 64.8%, respectively). In this study, the mean age of the studied population was 58.1±10.5 years. This was in agreement with the study of Morell et al. [11] and in contrary to Ahmed et al. [5] who reported a mean age of 56.2±16.3 and 39.96±13.31 years, respectively. The difference of sex and age between studies is owing to random selection of the patients and different etiologies of interstitial lung diseases.
Regarding the HRCT patterns, the predominant parenchymal shadow among the studied group was the reticulonodular pattern (65%) followed by ground-glass appearance (35%). The miliary shadow and consolidation pattern were equal by 15% for each. In contrary, the study of Akl et al. [12] showed that 36.7% patients showed diffuse reticulation patterns, eight (26.7%) patients showed nodular patterns, and two (6.7%) patients showed ground-glass pattern. These findings agree with the study of Magdy et al. [6] which showed that the commonest presentation of the studied cases were reticulonodular infiltrate (52%) and the second common shadow was ground-glass appearance (26.6%).
The most common diagnoses were hypersensitivity pneumonitis (25%) and usual interstitial pneumonia (UIP) (25%). Two patients with UIP pattern were associated with rheumatoid disease. The other three patients were diagnosed as IPF. This was in agreement with Ahmed et al. [5] who found that among the most common diagnoses were UIP in nine (16.4%) cases and hypersensitivity pneumonitis in five (9.1%) cases. In concordance with our results, Nitin et al. [13] reported that UIP presented 59.3% of all cases they studied. Elnady et al. [14] found that the commonest diagnosis in their studied group was UIP pattern constituting 38.9% of cases. They carried out their study using VATS rather than medical thoracoscope. This was in contrary to Akl et al. [12] who found that the most frequent histological diagnoses were IIP (40.0%) and seven (23.3%) patients showed granulomatous lung disease. However, their study was on non-UIP DPLD.
In our study, sarcoidosis was found in two (10%) patients. This almost matches with Ahmed et al. [5] who found the percentage of sarcoidosis among the cases was 7.3%. Moreover, Akl et al. [12] found that sarcoidosis represented 7% of their study. Nonspecific interstitial pneumonia was found in two (10%) patients. This coincides with Elnady et al. [14] who found NSIP in one patient out of 10 patients. One case was diagnosed as miliary tuberculosis. This is in agreement with Magdy et al. [6] who found one case out of 15 with tuberculosis. Ahmed et al. [5] diagnosed two patients out 55 with tuberculosis. Cryptogenic organizing pneumonia was diagnosed in one (5%) case in our study. This agrees with the study of Ahmed et al. [5] who diagnosed three (5.5%) patients with cryptogenic organizing pneumonia.
One case was diagnosed as military tuberculosis. This is in agreement with Magdy et al. [6] who found one case out of 15 with tuberculosis. Ahmed et al. [5] diagnosed two patients out 55 with tuberculosis ([Figure 2]).
Figure 2 (a) HRCT chest (pulmonary window), shows miliary shadow. (b) Forceps biopsy grasping lung tissue via medical thoracoscope. The histopathological diagnosis was tuberculosis. HRCT, high-resolution computed tomography.Three (15%) patients in this study were diagnosed with malignant lung diseases. Two of them were diagnosed as metastatic adenocarcinoma and one as adenocarcinoma in situ ([Figure 3]). This matches with Elnady et al. [14] who found three cases as metastatic adenocarcinoma out of 10 patients. However, these results were in contrary with the study by Andrew et al. [15] which included 62 patients, and the most common diagnoses were neoplasm in 25 (40%) patients.
Figure 3 (a) HRCT chest shows diffuse infiltrations with micronodules and multiple areas of consolidations. (b) Lung biopsy specimen obtained by thoracoscopy. The histopathological diagnosis was adenocarcinoma in situ (AIS). HRCT, high-resolution computed tomography.The variations between our study and others regarding types of pathology and final diagnoses reached may be owing to the random way of cases selection and the different patterns of exposures in different communities. The exposure to organic agents in rural community makes hypersensitivity pneumonitis more common.
In this study, medical thoracoscopy provided adequate lung tissue samples which were highly diagnostic. The definitive diagnosis was made in 95% of the cases. This finding was in agreement with the studies performed by Nitin et al. [13], Elnady et al. [14], and Akl et al. [12] who found that the diagnostic yield in their studies was 98.3, 90, and 91, and 100%, respectively.
Regarding complications from the procedure, 17 (75%) patients did not encounter any complications. Three (25%) patients had complications which were air leak (5%), wound infection (5%), and surgical emphysema (5%). There was statistically nonsignificant correlation between the final diagnosis and the complication (P=0.327).The results of this study were in agreement with Ahmed et al. [5] who reported no mortality, major complication, or prolonged postthoracoscopic hospital stay. Our results disagreed with Nitin et al. [13] who encountered air leak in 26% of cases (eight cases out of 30). This was almost in agreement with Magdy et al. [6] who did not have any infection as a complication. In this study, no residual pneumothorax was encountered after removal of the intercostal chest tube. This result disagreed with Elnady et al. [14] who founded that 20% of patients had residual pneumothorax.
One (5%) case had surgical emphysema. This was in agreement with the results found by Vansteenkiste et al. [16] and Boutin et al. [17] who did not find major complications such as important bleeding or persistent bronchopleural fistula.
The mean and SD values of hospital stay for patients without complications were 1.35±0.49. There was a statistical significant correlation between complications and prolonged hospital stay. Hospital stay for the patient with air leak was 6 days. Both patients who encountered wound infection and surgical emphysema stayed for 5 days in hospital. This was in agreement with the study of Mary et al. [18] and Jeon et al. [19].
However, the current study should be interpreted in light of the following limitations: small number of the studied group, and not including other types of DPLD, such as lymphangitic carcinoma, eosinophilic pneumonia, and histiocytosis X.
ConclusionsMedical thoracoscopy with electrocautery is a safe and effective method to obtain lung biopsies and diagnose DPLD of unknown etiology. Proper selection of cases is mandatory to avoid complications and unnecessary maneuvers.
Limitations of the study
Small number of the studied population, so not all types of DPLD were presented in the study.
Many patients were excluded from the study like those with advanced respiratory failure, coagulopathy, advanced fibrosis on HRCT, significant comorbidities, so the study was limited to early stages of DPLD. This may have altered the results.
The procedure should be compared with other methods of obtaining lung biopsies like transbronchial lung biopsy and CT-guided biopsy, regarding safety and usefulness.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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