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: profkhairy2008@yahoo.com

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