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					          Dr Göksel Kıter
Pamukkale University, Medical Faculty
  Pulmonary Medicine Department
 Plan
 Transthoracic way
   Fine neddle aspiration
   Tru-cut biopsy
 Bronchoscopic techniques
   Bronchial mucosa biopsy
   BAL
   Transbronchial lung biopsy
      New techniques included
 In which ILD, which one have the priority
   (with case presentations)
Tru-cut Fine Neddle Comparison
 Histopathology - Cytology
 149 thoracic tm (29 mediastinal, 120 lung)
 Malign tm: %97 vs %59
 Benign tm: %85 vs %32
 Metastatic nodules: %90 vs %33
 Mediastinal tm: %100 vs %46
 77 primary lung tm: via FNB %88 positive; %70 accurate
  histological type and via tru-cut %97 confirmed histological
  diagnosis

               Tang PC et al. USG guided biopsy of thoracic tumours. Tru-cut vs FNB. Cancer 1992; 69(10): 2553-60
NT, 58/M, cultivated mushroom grower
   Dry cough, left-sided chest pain, weight loss: 6 weeks
   PA chest X-ray and thorax CT
   Transthoracic fine needle aspiration biopsy: Suspicious for
    malignancy, cytology
   Sent to Thoracic surgeon
   Frozen biopsy examination: benign- wedge excision of the
    mass
   Sent to pulmonologist with histopathological result
AA, 57/F, retired teacher
   Cough, fatigue, sleepiness, sweat
   Short period of exertion dyspnoe; 1 year ago .
   Physical exam, PFT, PA chest X-ray: Normal
   Diabetes mellitus, hypertension
   10 pac.year smoking history
   Bibasilar, dominant at right basis, velcro crackles
   Romathological tests: Negative
   BAL; microbiological culture: Strep. pneumonia
   Transbronchial biopsy: non-diagnostical
   Transthoracic tru-cut biopsy: Organized pneumonia
April 2008
October 2008
ATS/ERS IIP Consensus reprort.AJRCCM 2002; 1658(2): 277-304
Specific diagnosis: 29-79%
 Distribution of lesions (focal-diffuse)
 Immunological status of the patient
 Size of samples (insufficient)
 Crush artefact
 Inaddequecy of passing through peribronchial bundle
TBB: Diagnostic spectrum
   Bronchoalveolar carsinoma                       90%
   Sarcoidozis                                     84%
   Lymphangitis carsinomatosa                      80%
   Tuberculosis                                    64%
   BOOP                                            63%
   Eosinophilic pneumonia                          60%
   Alveolar proteinozis                            50%
   LAM                                             40%
   Langerhans cell histiositozis                   20%



                              Poletti V et al. Personal experience 1988-1997
    Studies from Turkey
Study                     In focal lesions (%)      In diffuse lesions (%)   Total (%)


Uçar E et al                       51                         59                48

Çetinkaya E et al                  33                         59                57

Oğul SE et al                                                 72

Başoğlu ÖK et al                   30                         60                51


                    Uçar E et al; Gülhane Tıp Dergisi; 2005
                    Çetinkaya E et al; Tüberküloz ve Toraks Dergisi; 2001
                    Oğul SE et al; Solunum Hastalıkları Dergisi; 1999
                    Başoğlu ÖK et al; Solunum Dergisi 1993
  Is TBB clinically useful?
 Did the biopsy result change the clinical management?
 2 years. 603 patients with 651 Flouroscopy-guided
  bronchoscopic lung biopsy
 Utility: 75.9%
    resulted in a specific clinical diagnosis
    specific management decision was made based on the biopsy
     result
    certain pathologic processes were excluded on the basis of the
     biopsy result
 In 16.4 %: no diagnostic abnormality: Useful in 55 %
 In 9% : no lung parenchyma
      Ensminger and Prakash. Is bronchoscopic lung biopsy helpful in the management of patients with diffuse lung disease?ERJ 2006; 28: 1081–1084
ILDs with bronchocentric distrubition
  In selected situations, diagnostic value for 65-90%
  Especially, for
     Sarcoidozis,
     lymphangitis carsinomatosa
  First biopsy choice
BÖ, 39/F, Medical doctor
 Cough
     6 months, flu-like syndrome, dry, no response to
       antibiotics and montelukast sodium treatment
      Alergic rhinitis
   Dyspnoea
      Climbing 2 flight of stairs and uphill road
   Left mastectomized for breast carcinoma; 2.5 years ago
   Last chemotherapy 2 years ago, Erceptin treatment was
    stopped 1 year ago
   RT: 2 years ago
   Hypothyroid
   Thorax CT control: 1 year ago; normal.
 20 pac.year smoking history
 No exposure

 Physical examination: Normal

 PFT: Moderate obstruction

 Blood analyses: Normal. CRP=1.1mg/dL
Bronchoscopy
No endobronchial lesion
Samples:
 Transbronchial biopsy from left lower lobe (superior
  segment)
 BAL; from lingular segment
 Bronchoschopic lavage from left lower lobe


BAL and lavage fluid cytology: Malignant smear
Parenchimal biopsy
 Macroscopy: 0,3x0,2x0,1 cm , 2 biopsy samples
 Pathological diagnosis: Metastasis of carsinoma
 Immunohistochemistry:
   Eustrogen (-),
   Progesteron (-),
   Cerb-B2 skor 3 (+)
   Lung metastasis of breast carsinoma
In Sarcoidosis diagnosis
 Transbronchial lung biopsy
 Bronchial mucosa biopsy
 Transcarinal lymph node biopsy
 Transbronchial lymph node biopsy


 BAL
    Lymphocytosis
    Increase in CD4/CD8
TTS Clinical Problems Working Group




                     Kıter G et al. Tuberk Toraks. 2011; 59(3): 248-58
VM, 51/F, house wife
 Fatigue(excessive)
 Sarcoidosis diagnosis in 2006 (via mediastinoscopic lymph
    node biopsy)
   Corticotherapy for 2 years; no treatment for 1 year.
   Sent for progression in Thorax BT
   No accompanying disease
   Ex-smoker for 3 years, had 15pac.years smoking history
   Physical examination: Normal except eczema like palmer
    lesions
   Tuberculin test: negative
   PFT: Normal
2010
Bronchoscopy
 BAL from medial segment of medial lobe: given 240cc –
  taken 120cc SF
 Right upper lobe bronchus: no obstruction; the carina
  between apical and posterior segments were widen and the
  mucosa here has fine granullar appearance : Biopsy

 Result: Chronical granulomatous inflamatory findings
Bronchoalveolar lavage fluid
 BAL CD4/CD8: 7


 BAL PCR negative, ARB smear negative
 BAL: 70% alveolar macrophage, 28% lymphocyte, 2%
  granulocyte
 BAL cytology: Benign
ILDs without bronchocentric distribution

 COP, less frequently HP (EAA)
    Eosinophilic pneumonia, alveolar hemorrhagy, alveolar
     proteinozis
 When compatibility with clinical, radiological and other
  laboratory findings exists
   i.e. BAL
 For the assurance of diagnosis
GA, 54/F, house wife
 For 3 months: dry cough, dyspnoea ar excertion (2 flights
    of stair, uphill road)
   No response to antibiotherapy: 10 days ago
   Medical history: Corticotherapy for elevation in ESR, 1
    year ago
   Never smoker
   No exposure
   No rheumatical disease
   Bibasilar, and also at middle zones, velcro crackles
 PA Chest X-ray: Consolidation at both lower zones
 Thorax CT was obtained
 PFT: mild restriction
 Rheumathological tests: Negative
 BAL: 17% lymphocytosis
 Transbronchial biopsy was performed
MÇ, 62/M, farmer
 Dyspnoea(for e few years in uphill roads, progression in
  last 2 months, even at rest for last week), rare cough
 No respones to inhaler treatments
 Occupational specific history for farmer’s lung; 3 years
  (hay storage)
 Coronary artery disease, gastritis
 Exsmoker for 19 years. 20pac.years smoking history
 Enviromental asbestosis exposure (childhood)
 Bibasilar, dominant at left side, velcro crackles and squake
  at left lower zone
 PFT: Normal


 DLco             3.76 (53%)
 Kco              0.93 (53%)
 TLC              4.20 (68%)
 RV/TLC           39%



 BAL cytology: Benign, right middle lobe bronchus
 BAL: 70% macrophage, 25% lymphocyte, 5% granulocyte
BAL
 When specific findings exist, BAL may replace biopsy


 Cell distcrimination of BAL is not specific: Unless
  appropriate clinical presentation

 Value of evaluation in the diagnosis and efficacy of
  treatment: Controversial
           BAL: diagnostic
   (high sensitivity and specificity)

Alveolar filling disorders
  (CT: ground glass opacities, alveolar consolidation)

 Alveolar proteinozis
 Pneumocystis jerovicii
 Eosinophilic lung disease
 Alveolar hemorrhagy
 Bronchoalveolar carcinoma
Idiopathic Interstitial Pneumonias
 i.e. Idiopathic Pulmonary Fibrosis (IPF)
 Nonspecific Interstitial Pneumonia-fibrotic (NSIP-f)
 Desquamative Interstitial Pneumonia (DIP)
TBB for UIP diagnosis
 21 patients with UIP confirmed by surgical lung biopsy
  and/or lung explant, and 1 patient with UIP confirmed by
  clinical and radiographic findings
 Retrospective
 Interstitial fibrosis in a patchwork pattern along with
  fibroblast foci and/or honeycomb change
 In 7/22 patients TBB “diagnostic” (30%)
    Hypersensitivity pneumonia, collagen vascular
     diseases, sarcoidozis cases? False positivity? “non-
     blind” pathologists..
                        Berbescu EA et al. Transbronchial biopsy in UIP. Chest 2006; 129: 1126-31
                        Churg A, Schwarz M. Editorial. Chest 2006; 129: 1117-18
İG, 27/M, stained glass blasting

 Cough, fatigue for 20 days
 Occupational history: After age 15, stained glass blasting
  for 4 years
 Last 8 years, pencil factory worker
 PA chest X-ray: Diffuse nodular lesions
 Thorax CT: progressive massive fibrosis at upper lobes,
  diffuse cetrlobular and subpleural nodules
Thomas Nicolai, Munique, Germany - SGKA-APA-Meeting 2004
     Jumbo forceps

         In 2 years; 95 TBB
         74/95 diagnostic (78%)
         Via small forceps: 62/95
          diagnostic (65%)
         p=0.001
         1.4 x 1.0 mm vs 2.5 x 1.9
          mm (p< 0.005)



Casoni G et al. The value of transbronchial lung biopsy using jumbo forceps via rigid bronchoscope in diffuse lung disease. Monaldi Arch Chest Dis.2008;69:59-64.
Transbronchial criobiopsy




       Babiak A et al. Transbronchial Cryobiopsy: A New Tool for Lung Biopsies. Respiration. 2009;78:203-12.
       Pajares V et al. Transbronchial Lung Biopsy Using Cryoprobes. Arch Bronconeumol. 2010;46:111-5.
Pajares V et al. Transbronchial Lung Biopsy Using Cryoprobes.
Arch Bronconeumol. 2010;46:111-5.
     Biopsy/Cytology Comparison

                         BAL     TBB     Open lung
Invasiveness             +      ++        +++
Hospitalisation (days)   0      0-1       3-5
Mortality (%)            0     0.1-0.2   0.4-1.8
 Interobserver compatibility between pathologists
   No data on TBB
   Moderate even for open lung biopsies
 Sampling error
   Accompanying NSIP-like findings
   Need for showing
       Bronchocentric distrubition and poorly formed granuloma in
        HP
       Lymphoid follicules in Rheumatoid lung

				
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