TBLB in DX of lung cancer

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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_at_yahoo.com

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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

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Indications of TBBX
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 Langerhans cell
   histiocytosis, lymphangioleiomyomatosis, and
   cryptogenic organizing pneumonia.
7. Assessment of rejection and infectious
   complications following lung transplantation.

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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.

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Contraindications for TBBx

1. Refractory hypoxemia
2. Uncorrected coagulopathy.
3. Uncontrolled cardiac arrhythmia
4. Active myocardial ischemia
5. Severe pulmonary hypertension
6. Uncontrolled bronchospasm
7. Uncooperative patient
8. Inability to control cough
9. Lack of adequate facilities for patient
   resuscitation
10. Abnormal platelet counts (lt50 K or gt1 million)

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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

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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.

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TBBx from peripheral and diffuse lung cancer

• Methods.
• Forceps.
• Cryobiopsy.
• TBNA.
• Guidance.
• Yield.
• Complications.
• Case presentation.

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Rt central bronchial carcinoma
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Left central br carcinoma
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Left central br carcinoma with left lung collapse
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Left ll malignant abscess
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Rt peripheral upper lung cancer
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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.

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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

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Transbronchial lung biopsy forceps
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Guidance with C -arm screen
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Guidance with C- arm screen
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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.

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Cryoprobe
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Cryobiopsy
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TBNA
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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.

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Diagnostic yield of TBBx

• According to an evidence-based review, FB
  provided diagnostic specimen in 3688 , 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. 2007132131S48.

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Diagnostic yield of TBBx

• The average diagnostic yield from TBBx is 57
  with a range of 1777 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. 20022313758.

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Complications of TBLB

• Pneumothorax.
• Hemothorax.
• Hemopneumothorax.
• Infections as pneumonia.
• Hemoptysis.

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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.

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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.

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• 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.
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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.
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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.
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• 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.
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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.
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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
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Yield of bronchoscopic procedure (BAL TBLB)
among the studied 23 patients
Bronchoscopic procedure No
Confirmed pulmonary TB Malignancy 14 6 60.9 26.1
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