TBLB in DX of peripheral and diffuse lung cancer
By
Prof Mohammad Khairy EL Badrawy MDProf and head of chest medicine
department.Mansoura university Egypt
March 2014Email: [email protected]
Introduction
• Transbronchial Lung biopsy (TBBx) also known as “Bronchoscopic Lung Biopsy” is one of the most important sampling procedures performed during FOB
• In majority of cases, TBBx is performed under conscious sedation in an outpatient setting.
• TBBx is performed for obtaining tissue specimen from peripheral lung masses and focal or diffuse lung infiltrates.
Prasoon Jain, Sarah Hadique, and Atul C. Mehta. Interventional Bronchoscopy. 2013
Indications of TBBX
1. Suspected lung cancer,2. Fungal and mycobacterial lung infections, 3. Unexplained infiltrates in ICH.4. Suspected pulmonary sarcoidosis,5. Lymphangitic carcinomatosis, 6. Selected cases of pulmonary Langerhan’s cell
histiocytosis, lymphangioleiomyomatosis, and cryptogenic organizing pneumonia.
7. Assessment of rejection and infectious complications following lung transplantation.
Indications of TBBx
• Forceps TBBx is not useful for histological diagnosis of IPF or for distinguishing histological subtypes of idiopathic interstitial pneumonia. (cryobiopsy is more valuable than forceps biopsy)
• The diagnostic yield is also suboptimal in lung nodules smaller than 2 cm in diameter.
• Several recent techniques such as radial probe endobronchial ultrasound with guide sheath, electromagnetic navigation bronchoscopy, and virtual bronchoscopy navigation have been devised to improve the diagnostic yield of TBBx for solitary lung nodule.
Drawbacks of TBBx
Contraindications for TBBx
1. Refractory hypoxemia2. Uncorrected coagulopathy.3. Uncontrolled cardiac arrhythmia4. Active myocardial ischemia5. Severe pulmonary hypertension6. Uncontrolled bronchospasm7. Uncooperative patient8. Inability to control cough9. Lack of adequate facilities for patient resuscitation10. Abnormal platelet counts (<50 K or >1 million)
Distribution of lung cancer
• Central bronchial carcinoma: it is the tumor that can be seen via FOB.
• Peripheral bronchial carcinoma : it is the tumor that can not be seen via FOB.
• Diffuse lung cancer: as bronchoalveolar cell carcinoma
Samples used for diagnosis of lung cancer
• Samples for DX of the centrally situated lung tumors:1. Sputum.2. BAL.3. Brush.4. Tumor forceps biopsy.5. Tumor cryobiopsy.
• Samples for DX of the peripherally situated and diffuse lung tumors:1. Percutaneous ultrasound or CT-guided biopsies.2. BAL.3. TBNA.4. TBLB lung biopsies.
TBBx from peripheral and diffuse lung cancer
• Methods.1. Forceps.2. Cryobiopsy.3. TBNA.
• Guidance.• Yield.• Complications.• Case presentation.
Rt central bronchial carcinoma
Left central br carcinoma
Left central br carcinoma with left lung collapse
Left ll malignant abscess
Rt peripheral upper lung cancer
Guidance for TBLB
• C- arm screen.• Ultrasonography.• CT screen.• CT localization of the segment or the lobe
affected before TBLB.• No guidance if it is diffuse.
TBLB forceps
• With plastic cover makes it semi rigid to bypass resistance.
• Steps:1. Introduction through FOB with closed blades.2. Withdraw the forceps with open blades.3. Introduce the forceps with open blades.4. Close forceps to get lung tissue in between the
blades.5. Withdraw the forceps with tumor tissue in between
the blades
Transbronchial lung biopsy forceps
Guidance with C -arm screen
Guidance with C- arm screen
• Cryoprobe is introduced into the bronchus in direction to the peripheral lung cancer till you feel resistance.
• Contact time of 2-4 seconds.• Extraction of the probe and FOB en toto.
TBLB cryoprobe
Cryoprobe
Cryobiopsy
TBNA:
Sample processing after TBLB
TBBx: 1. Pathological examination; biopsies preserved in
formalin 10%.2. Silver and Giemsa stain; preserved in saline.3. ZN stain; preserved in saline..4. Culture for TB; preserved in saline.5. Culture for bacteria; preserved in saline.6. Culture for fungi; preserved in saline.
• According to an evidence-based review, FB provided diagnostic specimen in 36–88 %, with an average of 78 % in 16 studies of patients with peripheral lung cancers
Rivera MP, Mehta AC. Initial diagnosis of lung cancer. ACCP evidence-based clinical practice guidelines. 2nd edition. Chest. 2007;132:131S–48.
Diagnostic yield of TBBx
• The average diagnostic yield from TBBx is 57 % with a range of 17–77 % in patients with peripheral lung cancers.
• When performed in conjunction with bronchial washing and brushing, TBBx provides exclusive diagnosis in up to 19 % of the patients.
Mazzone P, Jain P, Arroliga AC, Matthay RA. Bronchoscopic and needle biopsy techniques for diagnosis and staging of lung cancer. Clin Chest Med. 2002;23:137–58.
Diagnostic yield of TBBx
Complications of TBLB
• Pneumothorax.• Hemothorax.• Hemopneumothorax.• Infections as pneumonia.• Hemoptysis.
Differences between forceps biopsy and cryobiopsy
• Forceps biopsies:1. Relatively small size.2. Crushing effect.3. Less incidence of pneumothorax.4. More complications of bleeding.
• Cryobiopsies:1. Relatively large size.2. Spatial presentation.3. Less incidence of bleeding.4. More incidence of pneumothorax.
Case presentation• A female patient 29 years old presented with dry cough and
dyspnea for one month.• O/E: the patient was tacypneic, chest examination: NAD • CXR, CT of the chest were done and showed bilateral
diffuse miliary shadows.• TST: negative.• Sputum ZN: negative for AFB.• FOB: no endobronchial abnormaities were found.• TBLB was taken from RT middle lobe: 3 forceps biopsies
and one cryobiopsy.• Final diagnosis: bronchoalveolar cell carcinoma.
• Hetrogenous opacities in right middle and lower lung zones.
• FOB: no endobronchial abnormalities
• TBLB with forceps.
TBLB; Malignant epithelial cells with glandular attempt. These show abundant
eosinophilic cytoplasm with vesicular nucle. Diagnosed as adenocarcinoma.
Non-homogenous opacities are seen in the left upper and middle zones. TBLB taken with cryobiopsy from the anterior segment.
TBLB; Malignant epithelial cells with glandular attempt. These show abundant
eosinophilic cytoplasm with vesicular nucle. Diagnosed as adenocarcinoma.
Multiple variable-sized, well defined thin walled cavities are seen in RT upper lung zones and rt paratracheal opacity.FOB and TBLB taken from posterior segment with cryobiopsy.
TBLB; Sheets of malignant epithelial cells showing abundant eosinophilic
cytoplasm with vesicular nuclei. Diagnosed as squamous cell
carcinoma.
• Right upper and middle zone hetrogenous opacities.
• TBLB taken with biopsy forceps
BAL (Z.N): +ve
BAL, Langhan giant cell with histiocytes.
Higher magnification of previous case.
Langhan giant cell
Left upper and mid-zonal hetrogenous opacities.
BAL (Z.N): +ve
TBLB; Multiple epithelioid granulomas with one showing
central caseation necrosis. Diagnosed as tuberculosis.
Higher magnification of previous case showing the
caseation necrosis.
Transbronchial lung biopsy (TBLB)
results among the studied 23 patients
TBLB No%
Undiagnosed
TB granuloma
Tumour:
- Sq.cell carcinoma
- Adenocarcinoma
- Mucoepidermoid carcinoma
9
8
6
3
2
1
39.1
34.8
26.1
13
8.7
4.3
Yield of bronchoscopic procedure (BAL
+ TBLB) among the studied 23 patients
Bronchoscopic procedure No%
Confirmed pulmonary TB
Malignancy
14
6
60.9
26.1
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