Interstitial lung diseases (ILDs) represent a challenging frontier in pulmonary medicine, often fraught with diagnostic uncertainty and complex treatment pathways. For years, the management of ILDs such as idiopathic pulmonary fibrosis (IPF) and other forms of idiopathic interstitial pneumonias (IIPs) has been beset by the limitations of traditional diagnostic procedures. However, a recent editorial by experts in the field, Fabien Maldonado and Jonathan A. Kropski, has reignited the debate about the role of transbronchial lung cryobiopsy as a potential initial diagnostic tool for ILDs. This article delves into the rationale behind advocating for cryobiopsies, as presented in the May 2019 issue of Chest journal, and explores its implications for the clinical landscape of ILD diagnosis.
DOI: 10.1016/j.chest.2019.02.331
The article, published under the title “POINT: Should Transbronchial Cryobiopsies Be Considered the Initial Biopsy of Choice in Patients With a Possible Interstitial Lung Disease? Yes.” presents a compelling argument for the adoption of transbronchial cryobiopsies (TBC) over traditional methods when diagnosing ILDs. Maldonado and Kropski argue that TBC offers superior sensitivity and specificity, with a lower risk profile than surgical lung biopsies (SLB), which have long been considered the diagnostic gold standard.
For decades, lung biopsies have been the cornerstone of ILD diagnosis, providing critical histopathological evidence to distinguish between the myriad presentations of lung fibrosis and inflammation. However, the procedure carries significant risks, including substantial morbidity and even mortality. TBC presents an attractive alternative, employing a cryoprobe passed through the bronchoscope to freeze and extract a sample of lung tissue. This technique is minimally invasive, can be performed under moderate sedation, and has been shown to provide ample tissue for diagnosis, with fewer complications compared to SLBs.
References
1. Maldonado, F., & Kropski, J. A. (2019). POINT: Should Transbronchial Cryobiopsies Be Considered the Initial Biopsy of Choice in Patients With a Possible Interstitial Lung Disease? Yes. Chest, 155(5), 893-895. https://doi.org/10.1016/j.chest.2019.02.331
2. Romagnoli, M., Colby, T. V., & Berthet, J. P. (2019). Poor Concordance Between Sequential Transbronchial Lung Cryobiopsy and Surgical Lung Biopsy in the Diagnosis of Diffuse Interstitial Lung Diseases. American Journal of Respiratory and Critical Care Medicine, 199(10), 1249-1256. https://doi.org/10.1164/rccm.201810-1892OC
3. Troy, L. K., Grainge, C., Corte, T. J., Williamson, J. P., Vallely, M. P., Cooper, W. A., … & Mahar, A. (2020). Cryobiopsy versus Open Lung biopsy in the Diagnosis of Interstitial lung disease alliance (COLDICE) Investigators. American Journal of Respiratory and Critical Care Medicine, 201(9), 1083-1092. https://doi.org/10.1164/rccm.201905-1014OC
4. Hetzel, J., Maldonado, F., Ravaglia, C., Wells, A. U., Colby, T. V., & Tomassetti, S. (2020). Transbronchial cryobiopsy increases diagnostic confidence in interstitial lung disease: a prospective multicenter trial. Chest, 158(3), 1030-1041. https://doi.org/10.1016/j.chest.2020.04.026
5. Gershman, E., & Maldonado, F. (2021). Diagnosis of Interstitial Lung Diseases via Transbronchial Lung Cryobiopsy. Journal of Clinical Medicine, 10(5), 853. https://doi.org/10.3390/jcm10050853
Keywords
1. Interstitial Lung Disease diagnosis
2. Transbronchial Cryobiopsy
3. Lung cryobiopsy in ILD
4. Non-invasive lung biopsy
5. Cryobiopsy vs Surgical Biopsy
The impetus for this shift towards TBC is not merely a matter of procedural convenience. Maldonado and Kropski point out that the diagnostic yield of TBC, that is, its ability to provide sufficient and quality tissue samples for a definitive diagnosis, rivals that of SLB. Studies cited in their editorial have documented the high diagnostic confidence and histological agreement between TBC and SLB, underscoring its reliability. Additionally, TBC’s complication rates, notably pneumothorax and bleeding, are significantly lower than those associated with SLBs. This is a crucial consideration, particularly for patients with advanced lung disease and comorbid conditions, for whom the risks of surgery pose a considerable deterrent.
The call for change in practice is predicated on a growing body of evidence. Clinical studies have shown that in skilled hands, TBC can safely be incorporated into the diagnostic algorithm for ILDs, thus allowing many patients to avoid the more invasive SLB. It is important to note, however, that the endorsement of TBC does not negate the necessity of SLB in certain clinical scenarios. Experts acknowledge that there are instances where cryobiopsies may be inconclusive or when the risk of TBC is deemed too high. In such cases, SLB retains its role in providing a definitive histopathological diagnosis.
The ramifications of this endorsement for clinical practice are substantial. A broader utilization of TBC as the initial biopsy choice means that more patients can receive timely diagnoses with reduced risk and discomfort. Furthermore, the healthcare system stands to benefit from the cost efficiencies associated with TBC’s minimally invasive nature, as it can be performed on an outpatient basis or with a shorter hospital stay.
Critically, Maldonado and Kropski’s support for TBC is not unilateral. They recognize the importance of a multidisciplinary approach in ILD diagnosis, involving pulmonologists, radiologists, and pathologists. The histopathological specimens obtained by TBC must be interpreted within the clinical context, compounded by radiological imaging and the patient’s clinical history. Only then can an accurate diagnosis of ILD be achieved.
The future of ILD diagnosis may very well rest in the balance between innovation and prudence. As the field continues to evaluate new methods like TBC, it must do so rigorously, assessing risks, benefits, and limitations through the lens of evidence-based medicine. The endorsement by Maldonado and Kropski is a clarion call for a measured yet decisive step towards a new paradigm in ILD diagnostics—one that prioritizes patient safety, diagnostic accuracy, and procedural efficiency. As with any emerging medical technology, the evolution of its use will be a testament to the agility and commitment of the medical community in its quest to improve patient outcomes.