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Transbronchial biopsy interpretation in the patient with diffuse
parenchymal lung disease. Arch
Pathol Lab Med. 2007 Mar;131(3):407-23.
CONTEXT: The most
common lung tissue samples seen by pathologists worldwide are obtained
with the flexible bronchoscope. Specimens taken for examination of
diffuse or multifocal parenchymal lung abnormalities pose special
challenges for the general surgical pathologist, and these challenges
are often compounded by high clinical expectations for accurate and
specific diagnosis. OBJECTIVE: To present and discuss the most common
histopathologic patterns and diagnostic entities seen in
transbronchial biopsy specimens in the setting of diffuse or
multifocal lung disease. Specifically, acute lung injury, eosinophilic
pneumonia, diffuse alveolar hemorrhage, chronic cellular infiltrates,
organizing pneumonia, alveolar proteinosis, sarcoidosis, Wegener
granulomatosis, intravenous drug abuse-related microangiopathy,
Langerhans cell histiocytosis, and lymphangioleiomyomatosis are
presented. Clinical and radiologic context is provided for the more
specific diagnostic entities. DATA SOURCES: The published literature
and experience from a consultation practice. CONCLUSIONS: The
transbronchial biopsy specimen can provide valuable information for
clinical management in the setting of diffuse or multifocal lung
disease. Computed tomographic scans are useful for selecting
appropriate patients to undergo biopsy and in limiting the
differential diagnosis. Knowledge of the clinical context, radiologic
distribution of abnormalities, and histopathologic patterns is
essential. With this information, the surgical pathologist can
substantially influence the diagnostic workup and help guide the
clinician to an accurate clinical/radiologic/pathologic diagnosis.
Mortality and
risk factors for surgical lung biopsy in patients with idiopathic
interstitial pneumonia.Eur
J Cardiothorac Surg. 2007
Jun;31(6):1115-9. Epub 2007 Apr 5.
Background: The
overall safety of surgical lung biopsy in patients with idiopathic
interstitial pneumonia (IIP) remains controversial. This study was
performed to investigate the mortality and complication rate and
identify the risk factors for surgical lung biopsy in patients with
IIP. Methods: A total of 200 patients with IIP who underwent surgical
lung biopsy at the Asan Medical Center, Korea, from April 1990 to
August 2003, were enrolled. Complications and mortality were analyzed
retrospectively. Results: (1) The mortality rate 30 days after the
surgical lung biopsy was 4.3%, which was significantly higher than the
control group. Biopsy performed at the time of acute exacerbation (AE)
resulted in higher 30-day mortality (28.6%) compared to non-AE (3.0%;
p<0.05). AE was followed by biopsy itself in three cases. (2)
Univariate analysis indicated that lower FVC, lower DL(CO), and
presence of AE were significant risk factors for 30-day mortality
(p<0.05). However, multivariate analysis revealed that only AE (OR:
11.334, 95% CI: 1.727-74.365, p=0.011) was an independent risk factor.
(3) The patients with low DL(CO) (<50% predicted) had higher mortality
and complication rate than high DL(CO) group. Conclusion: Our data
suggested that the presence of acute exacerbation at the time of
biopsy and lower DL(CO) were predictors of higher mortality after the
surgical lung biopsy.
Low-Dose
CT-Guided Transthoracic Lung Biopsy for Evaluation of Non-Infectious
Chronic Interstitial Lung Disease in Children.
Pneumologie.
2007 May 25.
BACKGROUND:
Children with interstitial pneumonitis (IP) of unknown origin often
have to undergo open lung biopsy to establish a final diagnosis. Open
lung biopsy is an invasive procedure with major potential
complications. In the meantime, CT-guided transthoracic lung biopsy (TLB)
has become a common diagnostic procedure in adults. OBJECTIVE: The aim
of this study was to retrospectively evaluate the efficacy and
radiation exposure of low-dose CT-guided TLB in children with
non-infectious IP of unknown origin. METHODS: Twelve children
(7-males, age range: 7 months-15 years) with non-infectious IP of
unknown origin and inconclusive clinical tests underwent CT-guided TLB
with a 20-gauge biopsy instrument. A low-dose protocol with
acquisition of single slices was used on a 16-row CT scanner: 80 kVp,
20 mAs, slice thickness 10 mm. Biopsy specimens were processed by
standard histopathological and immunohistochemical techniques and
effective doses were individually calculated. RESULTS: All biopsies
were performed without major complications. Two children (17 %)
developed a small pneumothorax/pulmonary haemorrhage that resolved
spontaneously. A final diagnosis could be established in 9/12 patients
(75 %) by CT-guided TLB. In 2 patients (17 %) the results of TLB were
inconclusive; however, the clinical suspicion could be disproved. Open
lung biopsy was performed in 1 patient (8 %), which demonstrated
idiopathic pulmonary fibrosis. On average, the effective dose of
CT-guided TLB was 0.78 mSv (0.4 - 1.1 mSv). CONCLUSION: Low-dose
CT-guided TLB can be a helpful method for investigating children with
non-infectious IP of unknown origin thus making open lung biopsy
unnecessary. Application of a low-dose protocol leads to a significant
reduction of radiation exposure in CT-guided TLB.
Complications of
video-assisted thoracoscopic lung biopsy in patients with interstitial
lung disease.Ann
Thorac Surg. 2007 Mar;83(3):1140-4.
BACKGROUND:
Current guidelines recommend surgical lung biopsy for diagnosis of
interstitial lung diseases (ILDs) in selected patients. To shed light
on the risk-benefit ratio for this recommendation, we examined the
morbidity and mortality associated with video-assisted thoracoscopic
surgical (VATS) lung biopsy in a group of outpatients. METHODS: A
retrospective cohort study was conducted of 68 consecutive ambulatory
patients with radiographically apparent interstitial lung disease (ILD)
referred for VATS biopsy during a 6-year period. Incidence of
postoperative mortality, prolonged air leaks, pneumonias, and
re-admissions were calculated. Risk factors for complications of
surgery were examined. RESULTS: Three deaths occurred within 60 days
after biopsy for a mortality rate of 4.4% (95% confidence interval
[CI], 1% to 12%), and 19.1% (95% CI, 11% to 31%) experienced one or
more complications of surgery. Risk factors for morbidity included
preoperative dependence on oxygen therapy and pulmonary hypertension.
The three patients who died had usual interstitial pneumonia on their
biopsy specimen and were reintubated postoperatively for acute lung
injury. Aggregation of articles published over the past 10 years
reporting on surgical lung biopsy for the diagnosis of ILD yielded a
postoperative mortality rate of 2% to 4.5%. CONCLUSIONS: VATS lung
biopsy for diagnosis of ILD, even in ambulatory patients, is not an
entirely benign procedure. Biopsy rarely may trigger an acute
exacerbation of usual interstitial pneumonitis. The risk of
postoperative complications appears to be greatest in those dependent
on oxygen and those who have pulmonary hypertension. This information
may be used in weighing the risk-benefit ratio of biopsy in individual
patients.
Diffuse
interstitial lung disorders in systemic diseases.Verh
K Acad Geneeskd Belg. 2003;65(6):350-65.
Diffuse
parenchymal lung disorders (DPLD) can develop in a variety of systemic
disorders. Schematically grouped, these include connective tissue
disorders, vasculitis, neoplastic disorders, sarcoidosis and a group
of inherited or other rare miscellaneous disorders. This overview
focuses on sarcoidosis, systemic sclerosis and Churg Strauss
vasculitis. Pulmonary involvement occurs in more than 90% of all
patients with sarcodosis. Grading into 4 stages is based on the chest
radiograph. Forms characterised by an acute clinical onset or a low
grade lung involvement have the highest spontaneous remission rate.
The cause of sarcoidosis remains unknown. The diagnosis therefore is
descriptive, based on the combination of clinical observations, chest
X ray, and the histological documentation of non-caseating epitheloid
granulomas in tissue biopsies. Treatment with steroids is only
indicated if organ involvement leads to functional impairment. Lung
fibrosis is the most important complication of both the "limited" and
"diffuse cutaneous form" of systemic sclerosis, involving 90% of all
patients. The histological pattern is that of "Usual Interstitial
Pneumonia" (UIP) or "Non-specific Interstitial Pneumonia" (NSIP). The
pathogenesis of the disorder is thought to consist of an abnormal,
excessive regenerative response to an auto-immune mediated lung
injury. Churg Strauss vasculitis is characterised by asthma, blood
eosinophilia and vasculitis of the small vessels. The affected vessels
wall shows signs of fibrinoid necrosis and are infiltrated by
eosinophils. pANCA (anti-myeloperoxidase) is considered to play a role
in the pathogenesis of the disease. Concern has risen that CysLT1
receptor antagonists might induce production of pANCA. To date, this
has not been substantiated.
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