Asian Cardiovasc Thorac Ann 2004;12:65-68
© 2004 Asia Publishing EXchange Ltd
Elective Video-Assisted Thoracoscopic Lung Biopsy for Interstitial Lung Disease
Masafumi Yamaguchi, MD,
Ichiro Yoshino, MD,
Ryuichi Suemitsu, MD,
Atsushi Osoegawa, MD,
Toshifumi Kameyama, MD,
Tetsuzo Tagawa, MD,
Seiichi Fukuyama, MD,
Yoshihiko Maehara, MD
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
For reprint information contact: Masafumi Yamaguchi, MD Tel: 81 92 642 5466 Fax: 81 92 642 5482 Email: masafumi{at}surg2.med.kyushu-u.ac.jp Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan.
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ABSTRACT
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Lung biopsy is often required for the definitive subtype classification of interstitial lung disease. The video-assisted thoracoscopic approach has been advocated as an alternative to standard open lung biopsy because it is less invasive; however, whether it makes a positive contribution to treatment strategy remains contentious. We investigated the safety and efficacy of the video-assisted approach in a retrospective review of 30 consecutive patients who underwent the procedure in an elective setting after being diagnosed with interstitial lung disease by chest radiography and computed tomography. The mean age of the patients was 56.7 years. The preoperative vital capacity and forced expiratory volume in 1 second were 80.0% and 83.6%, respectively. There was no operative mortality, but 2 cases of respiratory failure and 1 of prolonged air leak occurred. The diagnostic yield was 100%, and treatment was changed in 57% of the cases as a result of the histological diagnosis. The rate of treatment change was higher for patients with nonspecific interstitial pneumonia than for those with idiopathic pulmonary fibrosis. We conclude that video-assisted biopsy is effective in the subtyping of interstitial lung disease and is a safe procedure when performed electively at the early stage of the disease.
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INTRODUCTION
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Surgical biopsy is usually required to confirm the diagnosis of interstitial lung disease (ILD) and to classify the subtype in order to decide on the best treatment strategy. However, lung biopsy sometimes results in deterioration of the disease,1 especially in urgent cases.2 Video-assisted thoracoscopic lung biopsy (VATLB) has recently been introduced. If deterioration after lung biopsy is associated with inflammatory stress, VATLB would be preferable as it is less invasive than open lung biopsy (OLB). Furthermore, similar rates of diagnosis have been found with the 2 methods: 95% to 100% with VATLB compared to 100% with OLB.3–5 While VATLB might readily contribute to an accurate diagnosis of ILD, its safety and contribution to therapy decision are still unclear.
We report our experience with elective VATLB in 30 ILD patients with a stable condition, as well as evaluate the safety and diagnostic efficacy of the procedure.
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PATIENTS AND METHODS
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From June 1994 to July 2002, 30 consecutive patients with ILD underwent VATLB for the definitive subtype classification of the disease. We reviewed retrospectively the medical records and investigated the safety and efficacy of VATLB in terms of postoperative course, impact on treatment strategy, and prognosis. There were 18 males and 12 females, aged 17 to 75 years (mean, 56.7 years). Most of the patients were referred to our department because of the presence of clinical symptoms related to ILD or features of ILD on chest radiography and chest computed tomography. The symptoms were cough in 12 patients and dyspnea on exertion in 16, while 2 patients had no symptoms. None were immunocompromised or required ventilatory support. Pulmonary function tests showed a mean vital capacity of 80.0% (range, 34.8% to 117.8%) and a mean forced expiratory volume in 1 second of 83.6% (range, 36.9% to 115.0%).
Intraoperatively, all patients tolerated systemic anesthesia with differential lung ventilation. VATLB involved making 2 thoracic ports of 11.5 mm, one for the thoracoscope and the other for the mechanical linear stapler, and a 5.5-mm thoracic port for the lung forceps. The contraindication for this procedure was radiographically apparent excessive pleural adhesion.
Operative morbidity included respiratory failure that required mechanical ventilation and prolonged air leak requiring pleurodesis or reoperation. A change in treatment was defined as the initiation of a new treatment as a result of the histological diagnosis. Simple observation without treatment or withdrawal of the preceding therapy after confirmation of the diagnosis was not considered as a beneficial outcome of VATLB.
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RESULTS
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We performed a total of 45 biopsies (single biopsy in 17 patients, double biopsies in 11, and triple biopsies in 2), all of which by wedge resection using a mechanical stapler. Biopsy was done on the right lung in half of the cases and on the left lung in the other half. The mean operating time was 100 minutes (range, 32 to 225 minutes), with mean blood loss of 35.3 g (range, 0 to 200 g). Minithoracotomies were required for 8 patients (27%) owing to intrathoracic adhesion in 4 cases, lung injury during VATLB in 2 cases, and incomplete lobulation and bleeding from the resected lung margin in 1 case each. A bolus infusion of methylprednisone was given to 9 patients (30%) during and immediately after operation. Operative morbidity was experienced in 3 cases (10%), 2 of acute respiratory failure and 1 of prolonged air leak, but there was no mortality. No reoperation was needed. Chest tube drainage was required for a mean of 1.9 days (range, 1 to 4 days). Diagnosis was confirmed histologically in all cases. Table 1
shows the diagnoses and the data on treatment change.
A treatment change was made in 17 cases (57%). Oral steroid therapy was started in 5 of 12 cases of idiopathic pulmonary fibrosis (IPF) (42%) and 5 of 7 cases of nonspecific interstitial pneumonia (NSIP) (71%). A patient with acute interstitial pneumonia was also treated with intensified steroid therapy. The other 6 cases involving treatment change included 2 patients with collagen vascular disease and 1 patient each with chronic graft versus host disease (due to bone marrow transplantation), hypersensitive pneumonia, diffuse panbronchiolitis, and drug-induced interstitial pneumonia. The patients with eosinophilic granuloma and pulmonary alveolar proteinosis were placed under observation without medication, since their pulmonary function was preserved and they were clinically stable at the time of diagnosis. The 5-year survival rate in this series was 78.8%, and no significant deterioration was experienced with the therapeutic change (Table 1
).
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DISCUSSION
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The reported morbidity and mortality rates of lung biopsy in ILD patients are relatively high at 9% to 50% and 0% to 27%, respectively.2–9 On the other hand, VATLB showed lower morbidity and mortality rates in the present study (10% and 0%) as well as in the study by Zegdi and associates6 (11% and 4.7%). Temes and coworkers2 reported no operative death in 25 patients who received elective lung biopsy among a total of 75 patients in their series, while there were 3 deaths in 17 urgent cases (18%) and 14 deaths in 26 emergency cases (54%). All of the patients in our series had good pulmonary function and underwent elective surgery, so our favorable results might be attributed to the choice of patients as well as to the use of the minimally invasive approach. Since histology is least helpful when obtained late in the course of an illness or after the commencement of treatment,10 biopsy should be done in the early stage of ILD when there is still good pulmonary function, through a thoracoscopic approach for safety.
Histological diagnosis was made in all of the patients in our series. Diagnostic rates varied from 34% to 100% in other studies, as shown in Table 2. It has been reported that there was no difference in the diagnostic rate between standard OLB and VATLB,3–5 thus VATLB is preferable to OLB as it is less invasive. The site and frequency of lung biopsy appear to be important. For a more accurate diagnosis, it has been suggested that biopsy samples should be taken from a representative region of the lobe that is shown radiographically to be the most involved and a biopsy from the other lobe is unnecessary.11 In our series, the majority of the procedures were single biopsies, with the samples taken from a border site between the interstitial lesions and the normal parts seen on computed tomographic scans.
Therapeutic change was made in 57% of cases in our series, more frequently in NSIP than in IPF cases. The clinical course of IPF is likely to be gradual deterioration with a median survival time of 3.2 years,12 whereas that of NSIP may show various patterns.13 The role of treatment for these subtypes remains unclear. In our series, treatment change for these conditions was decided on the basis of the clinical course in addition to the histological diagnosis. Of the 10 patients diagnosed with diseases other than IPF or NSIP, 7 had underlying diseases (such as graft versus host disease, collagen disease, and drug-induced disease), and treatment change was made in 6 of them based on the clinical course of the underlying disease.
In conclusion, VATLB as a diagnostic tool is safe when performed electively for ILD patients whose pulmonary function is preserved, and it contributes to treatment decision. It is recommended for patients in whom the diagnosis is likely to lead to a beneficial therapeutic change, especially at the early stage of the disease.
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REFERENCES
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- Utz JP, Ryu JH, Douglas WW, Hartman TE, Tazelaar HD, Myers JL, et al. High short-term mortality following lung biopsy for usual interstitial pneumonia. Eur Respir J
2001;17:175–9.[Abstract/Free Full Text]
- Temes RT, Joste NE, Qualls CR, Allen NL, Crowell RE, Dox HA, et al. Lung biopsy: is it necessary? J Thorac Cardiovasc Surg
1999;118:1097–100.[Abstract/Free Full Text]
- Bensard DD, McIntyre RC Jr, Waring BJ, Simon JS. Comparison of video thoracoscopic lung biopsy to open lung biopsy in the diagnosis of interstitial lung disease. Chest
1993;103:765–70.[Abstract/Free Full Text]
- Ferson PF, Landreneau RJ, Dowling RD, Hazelrigg SR, Ritter P, Nunchuck S, et al. Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease. J Thorac Cardiovasc Surg
1993;106:194–9.[Abstract]
- Carnochan FM, Walker WS, Cameron EW. Efficacy of video assisted thoracoscopic lung biopsy: an historical comparison with open lung biopsy. Thorax
1994;49:361–3.[Abstract/Free Full Text]
- Zegdi R, Azorin J, Tremblay B, Destable MD, Lajos PS, Valeyre D. Videothoracoscopic lung biopsy in diffuse infiltrative lung diseases: a 5-year surgical experience. Ann Thorac Surg
1998;66:1170–3.[Abstract/Free Full Text]
- Walker WA, Cole FH Jr, Khandekar A, Mahfood SS, Watson DC. Does open lung biopsy affect treatment in patients with diffuse pulmonary infiltrates? J Thorac Cardiovasc Surg
1989;97:534–40.[Abstract]
- Bove P, Ranger W, Pursel S, Glover J, Bove K, Bendick P. Evaluation of outcome following open lung biopsy. Am Surg
1994;60:564–70.[Medline]
- Kramer MR, Berkman N, Mintz B, Godfrey S, Saute M, Amir G. The role of open lung biopsy in the management and outcome of patients with diffuse lung disease. Ann Thorac Surg
1998;65:198–202.[Abstract/Free Full Text]
- American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med
2002;165:277–304.[Free Full Text]
- Chechani V, Landreneau RJ, Shaikh SS. Open lung biopsy for diffuse infiltrative lung disease. Ann Thorac Surg
1992;54:296–300.[Abstract]
- Douglas WW, Ryu JH, Schroeder DR. Idiopathic pulmonary fibrosis: impact of oxygen and colchicine, prednisone, or no therapy on survival. Am J Respir Crit Care Med
2000;161(Pt 1):1172–8.[Abstract/Free Full Text]
- Katzenstein AL, Fiorelli RF. Nonspecific interstitial pneumonia/fibrosis. Histologic features and clinical significance. Am J Surg Pathol
1994;18:136–47.[Medline]
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ABSTRACT
INTRODUCTION
