Transbronchial Lung Biopsy (A Technical Contribution)

Tran sbron chial Lung Biopsy (A Techn ical Contri bution ) B.

LEONC INI, M.D'-x, AND

et ar·' HAVE RECEN TLY PERformed transbr onchia l lung biopsies with diffuse pulmo nary diseases. on ~atients ?unng a bronchoscopic examin ation they mtrod.uced flexible forceps, of the Holing er type, rnto one of the segmental bronch i of either the lower lobe or middle lobe and ~ushed it forward until the patien t felt pain In the thorax; it was then ass u m e d the pleura ~ad been touched. Then the forceps were wIthdrawn slightly and lung biopsy was performed. The results attained are remark able'. 27 relrable b' . . IOpSIes In 32 cases, 25 of which . and theraverv useful for d'Iagnostlc were. ' peutrc purposes. . arise (six Though Some compI"Icatrons dId . d pneumothora ces an two cases of medias tinal em no. fatal episod e occUrred . f:ys~ma), Smart; . ~ 4 lung bIopsies perform ed by Wit the same techniq ue produc ed ANDER SEN

n

the Section

Hf PALATR £SI, M.D.-

Siena, Italy

Pisa, Italy

*Fr~m

R.

..

the follow ing results: 12 successful biopsies, four positiv e histologic diagno es, one complicati on (pneum othora x). 1'vIATE RIALS AXl)

fETHOD S

Transb ronchi al luno- biopsy a described by Anders en el at was fir t perform ed by us in dogs enablin
. Fie 'bl f FIGURE IA (upper) ' Metras catheter s (right and cUITcd) wirh a cuff at their t>nnina', end X} e o.rcfKs, HolInge r tYP7> and . (lower) : FleXIble forceps protrud ing from thc tip of rhe calheter ICURE .

736

Volume 5" No.6 June, 1968

TRANSBRONCHIAL LUNG BIOPSY

case to case. The relatively high percentage of pneumothoraces ( 1B.5 per cent) reported by the authors tends to prove our considerations. Bronchoscopic examination must be performed with the patient supine and, unless one has special radiologic equipment, it does not permit the fluoroscopic exploration of all views. Thus, the advantages offered by fluoroscopic vision are for the most part negated. On the basis of these can. iderations and in order to simplify the procedure and make it less hazardous, we introduced fiexible forceps into the bronchial tree through a Metras catheter with a cuff at its terminal end, internal diameter 3-3.5 mm (Fig 1A

FIGUIn; 210.: lobe. FICURE

737

and B). The catheter was fluoroscopically controlled while introduced either into the upper or into the lower bronchi, under topical anesthesia, and held in position by inflating the terminal cuff. The flexible forceps were then introduced into the catheter and pushed towards the peripheral region until resi tance was met, taking great care not to touch the pleura (Fig 2A and B). ow the patient was asked to inspire deeply and hold his breath while the operator conti n ued pus h i n g the forceps forward, Often a snapping sensation was felt. The increased thickness of the lung peripheral layer caused by inspiratory apnea makes lung biopsy rather easy. Once the biopsy was performed, the forceps were withdrawn

FlO

2B

The forceps have been introduced into the lateral segment (axillary area~

of the right upper 2B: The forceps have been introduced into the posterior segment of the nght lower lobe.

LEONCINI AND PALATRESI TABLE I-EIGHT PATIENTS WITH CLINICALLY ASCERTAINED DIFFUSE LUNG DISEASES

No. 8 5

Biopsies Quantitatively successful biopsies Sufficiently informatil,:e histologic findings correspond!ng to the clinical diagnosIs Complications a) Minimal hemoptysis* b) Negligible hemoptysist

Di,else, of rhe Chest

clinical, radiolouic and laboratory findings only afforded presumptive diagnosis. The results arc resumed in Table 1 and 2. To define the diagnostic value of the biopsies we have u 'ed the term "histologic

4

4

3 1

*Not more than 20 mI of blood. tSputum with traces of blood.

while the catheter was left in to control any possible hemorrhagic complication. I.

TABLE 2-THIRTEEN PATIENTS WITH DETERMINATE DIFFUSE LUNG DISEASES

Biopsies Quantitatively successful biopsies Histologic findings of sure interpretation Sufficiently informative histologic findings Insufficiently infonnative histologic findings Complications a) Minimal hemoptysis* b) Negligible hemoptysist c) Pneumothorax

No. 19 13

5 3

4 9 6 9

I

*Not more than 20 ml of blood. tSputum with traces of blood. RESULTS

We have performed 27 biopsies on 21 patients with diffuse lung disea')es. All the biopsies were successful; we had to repeat the biopsy only seven times during the same session. . Eight patients did not present any particular diagnostic problems and therefore the biopsies were made only to enable us to .~erify the value of their diagnostic reliabILity and above all, to check the incidence of. complications in lung diseases with reSpIratory failure and pulmonary hypertenSIOn. 'The clinical diagnosis of this group o~. pa.tIents were the following:

SIlICOSIS with cavitary tuberculosis Chronic. miliary tuberculosis with fibrOSIS and emphysema Fjbrono~luJar tuberculosis and chromc emphysematous bronchitis Chronic pneumonia with chronic emphysematous bronchitis

3 Cases

2 " 2 " 1 "

Thirteen patients instead underwent biopsy for diagnostic purposes because the

3A (upper): X-ray evidence of compact density in the left upper lung field with diffuse micmnoduJal' and linear densities of the remaining ar- as of both lungs. FICURE 3B (center): Ivficroscopic evidence of far advanced diffuse interstitial fibr'osis withollt any specific features (hematoxylin and cosin x 70). FIGURE 3C (lower): Microscopic evidence of the sallie pat hoi og i c manifestations present in the bioptic sample obtained fmm the Jeft lower lobe (hematoxylin and eosin x 190). FIGURE

Volume 53. No.6 June. 1968

TRA)< SBROK CHIAL

findings of sure interpr etation " when the pathologist was able to make a 'ertain diagnosis even withou t the clinica l data. W . have used the term "suffic iently inform ative histologic findings" when the diao-nosis was possible with the aid of all th clinica l data. "Insufficiently inform ative histolo o'ic findings" ar tho. e which did not give any useful diagnostic d a t a. There fore, in the la~t group of patient s, there were 13 u. eful biopsies; they secm'd a definit e diagno si in ten patients, as shown in Table 3. The complications encou ntered in our 27 biopsies were of little conseq uence and did not require any particu lar treatm ent. Their incidence, too, wa. extrem ely low: one pneumonectomy (at the beginn ing of our practice), eight ases of minim al hemop tysis and four ca.<;es of negligible hemop tysis. This last event in fact 'hould not be considered as a compli cation becaus e the laceration of the b 1'0 n chi 0 1a l' wall and the TAIlLI; 3-CORRF.LA TIO~ DIAGNO SIS OF THE

13

LU~C

hi optic cuttin g of the lung tissue are bound to cause the ruptur e of mall vessels even when the biopsy i made in the most peripher al . ite po. sible. Howev er, in such peripher al areas the occasi onal hemor rhagic pheno mena were neO'lio-ible e\'en in patient s with pulmo nary hypert en ion. ,\SE REPORT S

1 A rC1ir d railway man, aged 68 years, was adlIlincd from anothc r hospita l with a diagnos is of eptemb er 24, 1966. On pulmon ary cancer on cxamin ation, he appear ed very thin and asthenic with cough, mucop urulent sputum , fever and dyspnc a gl'owin g into orthopn ea; there were diminish ed breath sounds over two-thi rds of the uppcr left hemith orax where the vesicula r murmm had a blowin g sound. On the right, the ycsicul ar JnurmU l' was coarse. Chest roentgen ogram (Fig 3A) 'howed compa u density in the left upper lung field; micron odular and linear densiti c' in the left lower lung field and in the whole area of the right lung. Sputum examina tion for acid-fa st bacilli and for neoplas tic cells was negativ e. All other routine tests gave negative

CASE

SIS AND HISTOLO GIC IlETWEE >I PRI;SUl \lPTlVE CLINICA L DIAGNO E LUKG DISEA 'ES PAT\\;>l TS WITH !:-
Sex

Age

M

68

2

2 3

F

64 60

I

M

4

F

54

2

5

F

70

Numbe r and Site of Biopsie s Right posterio r basal segmen t* Left posterio r basal segmen t* Lingllla * Right inferior apical scgmen tt Right posterio r basal segment:\: Left inferior apical segmen tt Right posterio r basal segmen t* Lingula t Left posterio r basal segmen tt

6

M

48

Right posterio r basal segment:!:

7

M

57

Right posterio r basal segmen t*

8

M

56

9

M

40

10

F

62

Left anterio r-latera l basal segmen t Right axillary area:\: Right inferior apical segment:!: Middle lobe:!:

II

M

57

12

M

65

Right posterio r basal segment:\: Right inferior apical segmen t* Right posterio r basal segmen t*

13

M

54

Left posterio r basal segmen t*

Case

3

2

2

739

BIOPSY

Clinical Diagnos is

Histolog ic Diagnos is

Sclerod erma Sarcoid osis

Nonspec ific diffuse fibrosis Sclerod erma Adenom atosis

Sarcoid osis

Sarcoido sis

Metasta tic carcino ma

Undiffe rentiate d large cell carcinom a Normal tissue

Carcino matosis

Silicosis (early stage) Silicosis (early stage) Silicosis (early stage) odular tubercul osis Interstit ial pneumo nia Carcino matosis Sarcoid osis Silicosis (early stage)

Scleroti c areas with vessel hyperpla sia Fibrosis with emphys ema N on-diagnost~c abnorm al \Issue Non-dia gnostic abnorm al tissue Diffuse fibrosis Fibrosis with pseudo- nodular features Pseudo- nodular fibrosis with vessel hyperpla sia

of sure interpre tation; :l:Insuffi*Suffici ently informa tive histolog ic finding: tHistolo gic finding cicntly informa tive histolog ic finding.

74°

LEONC INI AND PALAT RESI

results. Bronchoscopy revealed atrophi c chronic bronchitis with mucopu rulent secretio n from the upper lobe bronchu s and dense mucouS secretio n from the lower lobe bronchu s. Transb ronchia l biopsy in the left posterio r basal segmen t w~s perform ed first; microsc opic section reveale d dIffuse nonspecific fibrosis (Fig 3B). Biopsy in the right posterior basal segmen t perform ed five days later gave the same histolog ic results (Fig 3C). CASE 3 A man, aged 60 years, was admitte d to our hospital on Decemb er 9, 1966 with a histol'y of diabetes mellitus, cough with abunda nt mucouS sputum and fever. Previous chest roentge nogram s showed nonhomogenous density ill the left parahilar area with diffuse reticula r densitie s in the mid and lower fields of the contrala teral lung. All the tests carried out, includin g broncho scopy, gave negative results. For two months, he had undergo ne antitub erculosis treatmen t, but only slight improv ement was noted. After discharg e from the hospita l, he went on wi~h therapy, but cough, abunda nt sputum, asthellJa and occasional rise in tempera ture never disappeared. He was admitte d because of these respiratory symptoms. Chest film (Fig 4A)

4A (upper): X-ray evidence of nonhomogenous densities in the right and left parahilar areas (so-called butterfly wings figure). FIGURE 4B (lower): Adenomatous structures consisting of atypical columnar and cuboidal cells sistent with alveolar cell carcinoma (hematoxylin and eosin x 200).

FIOURE

Diseases

or

the Chest

showed nonhom ogenou s densitie in the right and left parahil ar al'cas (so-call d butterAy· wing figure); in the lateral view such images chiefly seemed to concern th apical segmell l of the lower lobes. Sputum examin ation for acid-fas t bacilli wa' negative . Tub rculin skin test IVa' slightlr positive . Al broncho scopy a d forming atrophic bronchi tis with scarce IIlUCOUS secretio n from the right lower lobe bron 'hus was noted. Biop ies of the carinas gave negativ · results. Transbr onchial lung biopsy in the right lower apical segmen t was done. Micro copic cxamin ation (Fig 4B) showcd tissuc with adenom atou' structur es at diff rent stages of develop ment consistent with a diagnos is of alv alar cell carcino ma. Biopsy in the posterio r right ba al scgmen t wanat signific ant (abnorm al nondiag nostic tissue) while with a biopsy in the inferior left api al segmen t tissuc having th salllc patholo gic characterist ics noted as the first biopsy was obtaine d. CASE

4

A housew ifc, aged 54 years, pre ented on August 4, 1967 with the history of onsct of disease

X-ray evidenc e of diffuse FIGURE SA (upper) : bilatera l fibrosis with enlarge ment of the mediastinal shadow and bilatera l basal thicknes s of the pleura. FIGURE 5B (lower) : Multipl e noncase ating granulo mas consiste nt with sa rc 0 i d granulo mas (hemato xylin and eosin x 100).

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1968

No.6

TR.-\:-':SBRO~CHIAL

three years hefore, wh 11 sh' nf)\cd dry cough. slight persistcIH f vcr, a~thcnia and dyspnca on exenion. Che t x-ray ('xaminaliol1 suggcsted \liberculosis and Iher ·for(' the paticl1\ entered a sanatorium wher' shc relllained for a few In JlIhs and returned lwice. On pre~ 'Iltation, she had slight temperaturc elevation. dry cough. and d\'spnea on exenion. Chest film (Fig 5A) showed diffuse bilat ral fibrosis mostly in the mid ami upper fi Ids with enlargement of lhe mediastinal shadow and wilh many hyperlucenl image' well c\'id nc d by laminography. SPUIUIll xaminalion fo\' acid-fast bacilli and tuberculin skin tCSl w rc negati\' for tuherculosis. Bronchoscopy with biopsy of the carina was of no significance. Transbronchial lung biopsy in lhe right posterior basal segmeIH was done. l\1icro 'copic section showed diffme nonspecific fibrosis. Biopsy of the lingula was pl'rformed a week latel' and microscopic section (Fig 5B) 'howed granulomatous tissue consistenl with sarcoidosis, DISCUSSION

LU~G

74 1

BIOPSY

Tran. bronchial lung biopsy is widely indi ated for diffu e lung disea e which cannot b· diagno ed by routine procedures; contmindications are hemorrhagic diathesis and, obviou ly the vascular pathology. The great'st disadvantage is the smallne:s of the biopsy sam pies (2 mm x 1 mm) ; however, the biop. y may be repeated easily and with no ri:·k. larger experience will be necessary to define the value of this in\' tilYtltion in the diagnosis of the diffuse pathology of the lung.

Transbronchiallung biopsy performed by our technique does not present any. ;:,lYreater difficulty than bronchography, Usually the patient feels no pain and therefore he'does not fear other biopsies. In addition, it is pas.sible to avoid touching the pleura and consequently provoking pneumothorax, the most frequently occurring complication. The only case of pneumothorax in our experience occurred in the early days of our practice. Fluoroscopic control of the biop y procedure makes it easier to obtain tissue from the peripheral areas without injuring vessels which might cause abundant hemorrhage; nevertheles.<;, the use of a catheter with a cuff at its terminal end could prove useful to arrest the eventually great hemorrhagic complications. Not provoking cough during and after the biopsy procedure aids in avoiding all complications, interstitial and media tinal emphysema included (two cases reported by Andersen et al), Curved catheters make it possible to perform biopsies both in the upper and lower lobes. Lung tissue can therefore be obtained from every region of the lungs where the pathologic proccs.<; is more 'ev re and consequently morc exprc:sivc.

SUMMARY

In 21 patients with diffuse lung disease, 27 transbronchial lung biopsies have been perfonned by means of flexible forceps introduced into the bronchial tree through a Metra radiopaque catheter with a cuff at it terminal end. In eight patients with clinically ascertained diffuse pulmonary Ie ion, biopsies helped to confirm their diagnostic reliability and to e\ aluate complications both in respiratory insufficiency and in pulmonary hypertension. Thirteen patients instead underwent 19 biopsies for diagno tic purposes; 13 were useful and prO\ ided definitive re!':ults in ten ca es. Complications were minor and did not require treatment. RESUMEN

Mediante una pinza flexible introducida en los bronquio a traves de una sonda radiopaca de Metras se han efectuado 27 biopsias pulmonares cn 21 pacientes afectados de neumopatias difundidas, En 8 paciellles la enfennedad pulmonar era evidente y la finalidad de Ia biopsia era 1a de omrolar el valor diagno tico y la incidencia de las complicaciones en la insuficiencia respiratoria y en la hipenension pulmonar. En 13 pacientes la biopsia se ha practicado 19 veces con finalidad de diagnoslico: las relaciones (Itiles resultaron 13 y han consentido un conneto enfoque de la neu1l10patia en 10 pacientcs, Las complicaciones que se han verificado son de entidad minima. Las vcntajas que la metodologia compona son aqui indicadas. ZUSAl\lMENFA'S 'NG

Bci 27 Patientcn mit diffusen Lungcnerkrankungen wurden 27 transbronchiale Lungcnbiopien mitt I cineI' flexiblen Zange vorgenommen, die in den Bron hialbautn durch eincn konnast-

Diseas
LEONCINI AND PALATRESI

gebenden Mctras-katheter mit cincr terminalen Manschette eingefiihrt wurde. Bei acht Patienten mit klinisch sichercn diffusen LungenHisionen verhalfen die Biopsien daw, ihre diagnostische Zuverlassigkeit zu bcstatigcn und Komplikationen sowohl hinsichtilch respiratorischer Insuffizienz als auch pulmonalen I-lochdrucks abzuschiitzen. Dreizehn Patientcn andererseits wurden 19 Biopsien au s diab'l10stischcn Grunden unterzogen; niitzlich warcn 13 Biopsicn, durch die definitive Resultate in zchn Fallcn erzielt wurden. Komplikationen warcn von geringer Bedeutung und erfordcrten keinerlei besonderc Behandlung.

ein offener Ductus aneriosu', Truncus arterio'us setzen 'ines Pu!monalartericllteilprothcse ein. REFERE:"CES ANDERSEN, H. A., FONTA:"A, R. RISO=-, E. G., JR.: Transbron~llOscoP1C

S..AND

lung bIopsy in diffuse pulmonary dlscase, DIs. Chest, 48: 187, 1965. 2 ANDERSEN, H. A. Ar-;D HARRISON, E. G., JR.: Transbronchoscopic lung biopsy in diffuse monary discase, Ann. OlolariTlg., 74: \113, 196J. 3 SMART, J.: Transbronchial pulmonary biopsy, Thorax, 2 J : 444, 1966. For reprints, please write: .Dr. B. Leoncini, Hospital S. Chiara, Cisanell o Plsa, Italy.

PULMONARY FUNCTION TESTI. G BY INFRARED ANALYZER .The co~centratlon of carbon diOXide in expired air was contmuously determined b red. capnograph in ten health y means of an infrapatIents with chronic lu . y subjects and In 34 firm that cha ng diseases. The results con(lack of lhe ~e:~I: gpu/atrIY observed In pa ti en ts a eau in the capnogr m Important increase or th a , an e rate of rise of the alveolar

PCa) point to an impaircd venilation-per!usion

" ratio.

N A TSUZM"R, T, S., V/NITSKAYA. R. S. AND KAGANOVA.. . .: Testin~ of pulmonHY {uOtlion by 11rIlle"ns of ,n mfr"ed ou .'n.'IY''''r for c'.rl,on dioxide, c.x/'· 5 8· (//1l1 AlItJ/lJm l gy .. .. ., {USSR}, 3:22, 1967.

SWEAT TEST IN ADUL1S ' WITH CHRONIC BRONCHOPULMONARY DISORDERS spectively. The lack of uniformity of. resul~S.

The authors analYze th performed on 117 ti e results or the sweat test chronic bronehoPUlr:oana~nts ,with various types of controls. No significant ~iiratholOgy and 40 normal tween the two group Th erences were round beof chlorine In each s. e average concen lra lion grOUP was 36 and 33 mEq/L re-

make this test an interesting but unreliable diagnostic lool. MIGUHIWS, J" LAYSSOL. M.. JOV"II, r\., l.EVY, P. AND AlII/A, G.: Etude du lest de h sueur 'u (ours des bron, I' 1 I" lull I. 1''''11. Md. (I thopncumopathlcs (" HOnlqUCS (. I.: ..(,. , o

0

Chir., 21:675, 1967.

PULMONARY RESECTION FOR CYSTIC FIBROSIS IN INFANTS

The authors report a t cystic fibrosis seen in lh s udy of 120 infants wilh ~963 and 1967. In three ~2 four-year period between mtervention was deCided uper cenl) cases, surgical tens!ve medical treatment r~~ln wh~n the usual Intomlcs were performed ed. RIght pneumonec '. on all thr Itmlled Improvement In t ee and resulted in wo cases and a marked

improvement in one. It is recommended th~t .the parents should always be informed of the palliative, not curative, nature of the surl,:ieal procedure. GILLY, R.. JAUllERT D" IIE,'")/Hl, M., HHMt"R, M.,. Mo:, u I.ARD. 1'., RAv"Au, J, AND CAMeo-I'AYSM, A.: La c1ur rg.c thor"ique ,bns I. mu(oviscit!ose ,Ie I'enfant, f. F"III. Md. 'I

Chir., 21 :685, 1967.