TBLB in DX of peripheral and diffuse lung cancer

2. TBLB in DX of peripheral and diffuse lung cancer By Prof Mohammad Khairy EL Badrawy MD Prof and head of chest medicine department. Mansoura university Egypt March 2014 Email: profkhairy2008@yahoo.com

3. 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

4. Indications of TBBX Indications of TBBx • Suspected lung cancer, • Fungal and mycobacterial lung infections, • Unexplained infiltrates in ICH. • Suspected pulmonary sarcoidosis, • Lymphangitic carcinomatosis, • Selected cases of pulmonary Langerhan’s cell histiocytosis, lymphangioleiomyomatosis, and cryptogenic organizing pneumonia. • Assessment of rejection and infectious complications following lung transplantation.

5. Drawbacks 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.

6. Contraindications for TBBx • Refractory hypoxemia • Uncorrected coagulopathy. • Uncontrolled cardiac arrhythmia • Active myocardial ischemia • Severe pulmonary hypertension • Uncontrolled bronchospasm • Uncooperative patient • Inability to control cough • Lack of adequate facilities for patient resuscitation • Abnormal platelet counts (<50 K or >1 million)

7. 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

8. Samples used for diagnosis of lung cancer • Samples for DX of the centrally situated lung tumors: • Sputum. • BAL. • Brush. • Tumor forceps biopsy. • Tumor cryobiopsy. • Samples for DX of the peripherally situated and diffuse lung tumors: • Percutaneous ultrasound or CT-guided biopsies. • BAL. • TBNA. • TBLB lung biopsies.

9. TBBx from peripheral and diffuse lung cancer • Methods. • Forceps. • Cryobiopsy. • TBNA. • Guidance. • Yield. • Complications. • Case presentation.

10. Rt central bronchial carcinoma

11. Left central br carcinoma

12. Left central br carcinoma with left lung collapse

13. Left ll malignant abscess

14. Rt peripheral upper lung cancer

21. 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.

22. TBLB forceps • With plastic cover makes it semi rigid to bypass resistance. • Steps: • Introduction through FOB with closed blades. • Withdraw the forceps with open blades. • Introduce the forceps with open blades. • Close forceps to get lung tissue in between the blades. • Withdraw the forceps with tumor tissue in between the blades

24. Transbronchial lung biopsy forceps

25. Guidance with C -arm screen

26. Guidance with C- arm screen

27. TBLB cryoprobe • 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.

28. Cryoprobe

29. Cryobiopsy

30. TBNA:

32. Sample processing after TBLB TBBx: • Pathological examination; biopsies preserved in formalin 10%. • Silver and Giemsa stain; preserved in saline. • ZN stain; preserved in saline.. • Culture for TB; preserved in saline. • Culture for bacteria; preserved in saline. • Culture for fungi; preserved in saline.

33. Diagnostic yield of TBBx • 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.

34. 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.

35. Complications of TBLB • Pneumothorax. • Hemothorax. • Hemopneumothorax. • Infections as pneumonia. • Hemoptysis.

36. Differences between forceps biopsy and cryobiopsy • Forceps biopsies: • Relatively small size. • Crushing effect. • Less incidence of pneumothorax. • More complications of bleeding. • Cryobiopsies: • Relatively large size. • Spatial presentation. • Less incidence of bleeding. • More incidence of pneumothorax.

37. 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.

39. 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.

40. 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.

41. 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.

42. Right upper and middle zone hetrogenous opacities. • TBLB taken with biopsy forceps BAL (Z.N): +ve Langhan giant cell BAL, Langhan giant cell with histiocytes. Higher magnification of previous case.

43. Left upper and mid-zonal hetrogenous opacities. BAL (Z.N): +ve Higher magnification of previous case showing the caseation necrosis. TBLB; Multiple epithelioid granulomas with one showing central caseation necrosis. Diagnosed as tuberculosis.

44. Transbronchial lung biopsy (TBLB) results among the studied 23 patients

45. Yield of bronchoscopic procedure (BAL + TBLB) among the studied 23 patients