|ORIGINAL ARTICLE - INTERVENTION PULMONOLOGY
|Year : 2020 | Volume
| Issue : 2 | Page : 364-370
Comparative study between medical thoracoscopic, bronchoscopic transbronchial, and ultrasound-guided transthoracic lung biopsies in diagnosis of peripheral pulmonary lesions
Mohamed El-Hoffy, Emad Ibrahim, Rasha Daabis, Mohamed El-Shafey, Haytham Emam
Departments of Chest Diseases and Radiodiagnosis, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||08-Jun-2019|
|Date of Decision||22-Jul-2019|
|Date of Acceptance||30-Jul-2019|
|Date of Web Publication||14-May-2020|
MSc Haytham Emam
Departments of Chest Diseases and Radiodiagnosis, Faculty of Medicine, Alexandria University, Alexandria
Source of Support: None, Conflict of Interest: None
Background Peripheral pulmonary lesions are common clinical problems which need to be diagnosed through techniques less invasive than surgical biopsies.
Objectives To compare safety and diagnostic yield of fiberoptic transbronchial, medical thoracoscopic, and ultrasound (US)-guided transthoracic lung biopsies in assessment of peripheral lung disorders.
Patients and methods We recruited 45 patients with peripheral lung lesions. In 19 patients pathology was solitary and it was diffuse in 26 patients. Patients were randomly divided into three groups 15 patients each: Group A: patients underwent flexible bronchoscopy. The biopsy instrument was advanced under fluoroscopic guidance to reach the target lesion. Group B: patients underwent medical thoracoscopy and lung biopsies were taken using coagulating forceps. Group C: patients underwent US-guided transthoracic needle.
Results Symptoms, investigations, findings, and hazards related to each technique were recorded. A conclusive diagnosis was achieved in 34 patients: 15 patients were diagnosed as bronchogenic carcinoma and 12 patients had metastatic lesions. Seven patients had benign pathology. Transbronchial, medical thoracoscopic, and US-guided biopsies had a sensitivity of 67.7, 87.7, and 73.7%, respectively for the diagnosis of peripheral lung disorders. Transbronchial biopsies showed less diagnostic accuracy than thoracoscopy in solitary lesions. 73.3%, of both bronchoscopy and medical thoracoscopy patients and 40% of US-guided patients had minor complications. The diagnostic performance of transbronchial lung biopsy under fluoroscopic guidance, thoracoscopic lung biopsies, and US-guided transthoracic biopsies are comparable. However, risk of potential complications makes US-guided method preferred in cases of respiratory insufficiency.
Keywords: lung biopsy, peripheral parenchymal lesions, transbronchial, medical thoracoscopy, US-guided transthoracic
|How to cite this article:|
El-Hoffy M, Ibrahim E, Daabis R, El-Shafey M, Emam H. Comparative study between medical thoracoscopic, bronchoscopic transbronchial, and ultrasound-guided transthoracic lung biopsies in diagnosis of peripheral pulmonary lesions. Egypt J Chest Dis Tuberc 2020;69:364-70
|How to cite this URL:|
El-Hoffy M, Ibrahim E, Daabis R, El-Shafey M, Emam H. Comparative study between medical thoracoscopic, bronchoscopic transbronchial, and ultrasound-guided transthoracic lung biopsies in diagnosis of peripheral pulmonary lesions. Egypt J Chest Dis Tuberc [serial online] 2020 [cited 2020 Aug 4];69:364-70. Available from: http://www.ejcdt.eg.net/text.asp?2020/69/2/364/284295
| Introduction|| |
Reaching diagnosis of the peripheral lung lesions is a diagnostic challenge. New guidelines for bronchogenic carcinoma screening state that detection of pulmonary nodules will become more common  efficient and less invasive diagnostic approaches are needed.
Transbronchial biopsy: this technique is done by wedging the bronchoscope in the segmental bronchus determined, and then passing the biopsy forceps through the working channel. Fluoroscopy can guide the forceps reaching the needed lesion .
For peripheral lesions, radial endobronchial ultrasound (US)-guided biopsy and electromagnetic navigation guidance are beneficial if present and transthoracic needle biopsy is also a diagnostic approach for many patients with peripheral lung disorders . However, the use of nonguided bronchoscopy in peripheral disorders is not well recommended .
Bronchus sign on computed tomography (CT) means the finding of a bronchus leading directly to or contained within the peripheral lung mass . The diagnostic yield of bronchoscopy for peripheral lesions is 0–44% when the bronchus sign is not present, as compared with 60–82% when it is positive ,,,,.
Medical thoracoscopy was used for diagnosis of diffuse lung diseases previously, and was recently indicated when a final diagnosis could not be achieved by a noninvasive approach. Many diseases, such as granulomatous lesions  have been included especially sarcoidosis and invasive fungal infections, some types of interstitial lung diseases like idiopathic interstitial pneumonias, Langerhans cell histiocytosis, and lymphangitic carcinomatosis.
Transthoracic needle biopsy
The percutaneous transthoracic core biopsy of lung lesions can be done under fluoroscopic, US, or CT guidance. Choice of imaging technique depends on the diameter and site of the lesion, availability of modalities, and personal experience and preference ,.
US is the most commonly used imaging modality for reaching the peripheral, pleural-based lesions producing acoustic window as US beam does not pass through air. It allows real-time visualization with multiplanar ability of the needle introduction, allowing precise placement of the needle ,. It is a safe with no radiation, time saving, and cheap modality . It should be used whenever possible and appropriate.
Open lung biopsies are a significant diagnostic modality ,. Although their associated hazards and mortality have restricted most of its uses to the failure of other less invasive procedures, or to clinical scenarios when large biopsies are needed.
| Patients and methods|| |
Our study recruited 45 patients with peripheral lung diseases admitted in the Department of Chest Diseases, Alexandria main university hospital between January 2017 and May 2018. This research is approved by the ethical committee of faculty of medicine, alexandria university. informed consent was taken from all cases of the study before the research. The procedures were contraindicated in cases with one of the following findings: bleeding diathesis (prothrombin level <50% or platelets <70 000 cells/mm, severe respiratory failure) arterial carbon dioxide tension (PaCO2) (>60 mmHg); mechanical ventilation; radiological features suggesting significant pleural fibrosis or extensive bullae.
They were randomly allocated into three equal groups.
Group A: 15 patients had transbronchial lung biopsy.
All the patients underwent flexible bronchoscopy (PENTAX FB-18V fiberoptic bronchoscopy, Tokyo, Japan).
Transbronchial forceps lung biopsy
Fifteen patients were subjected to transbronchial forceps lung biopsy. The procedure was performed under conscious sedation using Midazolam (3–7 mg intravenous). Transbronchial lung forceps biopsies were taken from selected segment previously chosen according to high-resolution computed tomography (HRCT) with a distance of ∼2 cm from the thoracic wall under radiological guidance using real-time fluoroscopy (Mobile C-arm, Siemens Healthcare GmbH, Munich, Germany).
Group B: 15 patients had medical thoracoscopy.
Thoracoscopic examination was done under conscious sedation using rigid thoracoscopy (Karl Storz Hopkins Straight Forward Tele-scope 0 with parallel eyepiece diameter 10 mm, length 27 cm.) Trocar size 11 mm consisting of trocar only with blunt tip cannula, click line Blakesley dissecting and biopsy forceps, rotating, with connector pin for electrocautry coagulation, and videoscopy unit [camera (Karl Storz Endoskope Telecam Pal 20211020), light source (Henke-Sass Wolf Gmbh D-7200 Tuttingen)], computer, and LCD.
When there was no pleural effusion, we used Butin technique. Artificial pneumothorax was done through a smooth tipped pleural needle prior to skin incision.
Coagulating forceps connected to electrocautery was used to take lung biopsies from lung surface and seal the cut sites.
Group C: 15 patients had US-guided transthoracic needle biopsies.
This technique was done in the intervention unit of radiodiagnosis department in Alexandria Main University hospitals under local anesthesia using lidocaine 2%. The procedure was explained to the patient and it was done using an US machine (Accuson X300; Siemens) using a semiautomatic cutting needle (18 G) either uniaxial (Eigmen, Turkey) or Coaxial (Stericut TSK Laboratory, Hirayanagi-Cho, Tochigi-ShiCity, Tochigi-Ken, Japan) using a semiautomatic cutting needle (18 G) either uniaxial (Eigmen) or Coaxial (Stericut TSK Laboratory).
| Results|| |
Statistical analysis of the data
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0. Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median
As shown in [Table 1], there is no statistical difference between the three studied groups as regard baseline characteristics.
[Table 2] shows that there is no significant difference between the three studied groups as regarded radiological findings of cases.
As shown in [Table 3], all cases of medical thoracoscopy were performed under local anesthesia and conscious sedation. While during bronchoscopy 80% of cases were done general anesthesia. All cases of US group were done under local anesthesia.
Number of biopsies varied between one and three biopsies in the three groups. As well there is no statistical difference between the three groups as regard size of lesions.
As shown in [Table 4], malignancy was found in 46.6, 73.4, and 60% of bronchoscopy, thoracoscopy, and US-guided groups respectively. Interstitial lung diseases were encountered in 20% of bronchoscopy group and in 13.3% of thoracoscopy and US-guided groups while 33.3, 13.3, and 26.7% of bronchoscopy, thoracoscopy, and US-guided groups, respectively, showed inconclusive results.
|Table 4 Represents histopathological diagnosis of lung biopsies in the studied group of cases|
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[Table 5] shows complications of the three groups. Local wound infection, subcutaneous emphysema, and pain were encountered more in thoracoscopy group while transient hypoxemia and hemoptysis were more frequent in bronchoscopy group.
|Table 5 Complications of the procedure in each the studied group of patients|
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[Table 6] shows statistically significant positive correlation between diameter of biopsies and diagnostic yield in bronchoscopy group only (P=0.014).
[Table 7] describes correlation between lesion distribution and histopathological yield in the three groups.
| Discussion|| |
As regard size of lesions, mean maximum diameter was 5.61, 4.77, and 6.37 cm in bronchoscopy, thoracoscopy, and US groups, respectively, which is comparable with study of Guo et al.  in which mean diameter was 4.20 cm. We found no positive correlation between inconclusive cases and size of lesions in the three groups of our study. This is maybe due to inefficient sampling in small lesions and lower diagnostic accuracy in larger lesions, it can be explained by the presence of necrosis. Yeow et al.  concluded that the incidence of lesion necrosis as 10% for lesions less than 5 cm to 29% for lesions more than 5 cm.
As regard anesthesia in medical thoracoscopy, it could be done using local or general anesthesia according to the European Respiratory society  as determined by cause and duration of the technique, general condition of the patient as well as the preference of the operator and institutional biases. In the current study, medical thoracoscopy was done using local anesthesia and conscious sedation. While during bronchoscopy 80% of cases were done general anesthesia. The use of general anesthesia could theoretically reduce the danger of iatrogenic complications (less patient movement and coughing) and improve pathological yield. The remaining 20% were done under conscious sedation. In the present study we considered Poletti and Hetzel  standards for transbronchial biopsy and consistent with study of Shafiek et al. . In US-guided biopsies were done using local anesthesia and this is consistent with other studies ,,,. As well, high pressure in case of using general anesthesia may facilitate the occurrence of persistent air leak in cases of thoracoscopic lung biopsies . It could be related to insufficient sealing of the cut site of the visceral pleura during electrocoagulation as due to high pressure.
Concerning number of lung biopsies, we found no positive correlation between number of biopsies and positive histopathological results in our study. There is limited data on the best number of transbronchial or thoracoscopic biopsies. Generally, in transbronchial biopsies four to six biopsies are enough in most of cases with diffuse pulmonary lesions . In one study, in 53% of cases diagnosis was achieved with the first biopsy, and 33% of diagnoses were achieved with the second biopsy .
The mean size of biopsies in bronchoscopy group was found comparable with that of Griff et al. , and in medical thoracoscopy cases comparable with the study of Hatata et al.  and that of Vansteenkiste et al. . We observed that size of biopsies was strongly correlated with positive diagnostic yield in bronchoscopy group (P<0.05). In US group size of biopsies was not correlated with positive yield possibly due to limited size variation as a result of fixed true cut needle used 18 or 20 gauge in all cases of the group.
Regarding histopathology of lung biopsies in our work. diagnostic accuracy in our study was 67.7, 87.7, and 73.3% in bronchoscopy, thoracoscopy, and US-guided groups, respectively. Our results as regard transbronchial lung biopsies are comparable with many other studies. Iftikhar et al.  meta-analysis found a comparable diagnostic yield (84% with transbronchial lung cryobiopsy vs. 64% with conventional-forceps biopsy). Other researches achieved greater accuracy in taking biopsies from these lesions using fluoroscopy (Hanson et al.  71% and Ellis  up to 81% success, according to the size of the lesion).
In accordance to our results, other previous studies reported diagnostic accuracy of 75–93% for medical thoracoscopic lung biopsies in the diagnosis of lung diseases  however the procedure is not widely done and few studies have been done in the literature .
Results of thoracoscopy group are comparable with Hatata et al. study  which found diagnostic accuracy of 80% of medical thoracoscopy in diagnosis of peripheral lung lesions.
Our results in the US group are comparable with previous studies with diagnostic accuracy ranging from 80 to 92% in diagnosis of peripheral lung lesions through US-guided lung biopsies ,,,.
While surgical lung biopsies are still needed for the conclusive diagnosis of DPLD of unknown cause, especially when idiopathic pulmonary fibrosis is probable, the risks are significant. Possible causing factors include drawbacks of volume-induced injury due to single-lung ventilation, possible aspiration after surgery and postoperative complications (atelectasis or hospital acquired pneumonia). As a result, surgical lung biopsies, even by VATS are not a completely safe technique .
As regard lesion distribution, we found highest diagnostic accuracy of solitary lesions in thoracoscopy group. We found statistically significant higher diagnostic accuracy of solitary lesions in thoracoscopy group in relation to bronchoscopy group (P≤0.05) while there is no statistically significant difference in relation to US group (P>0.05). In cases with diffuse lesions there is no statistically significant difference among the three groups.
Diagnostic yield in our study differed among the three groups according to radiographic description of lesions in HRCT. Diagnostic yield in the presence nodules was 100% in both thoracoscopy and US groups in comparison to 25% in bronchoscopy group. We found weak statistically significant correlation between the presence of nodules in HRCT and negative histopathological yield in bronchoscopy group (P=0.07).
Bronchus sign on CT means the presence of a bronchus that leads directly to or contained within the peripheral lung mass. The diagnostic yield of bronchoscopy for peripheral masses is 0–44% when the bronchus sign is negative, in comparison to 60–82% when it is present. We found that diagnostic yield in bronchoscopy cases having bronchus sign in HRCT was 100% in comparison with 50% in both thoracoscopy and US groups ,,,,.
As well cases who had pleural effusion showed better diagnostic accuracy in thoracoscopy group (100%) in comparison to 50% in both bronchoscopy and US groups
In our study, few minor complications occurred in the studied cases. Wound infection was observed in three (20%) patients in thoracoscopy group only. Subcutaneous emphysema was met in four (26.7%) patients only in thoracoscopy group, it may be due to large pleural opening (P=0.027).
Pneumothorax was encountered only in one (6.7%) patient of each of bronchoscopy and US groups. persistent air leak was not encountered in any of the three groups. Many precautions were taken to avoid persistent air leak. Exclusion of cases with advanced bullous degeneration from the three groups as well as use of coagulating forceps and avoiding positive pressure ventilation in thoracoscopy group helped us to avoid such complication. Injection of saline over the sites of biopsies helped us greatly to recognize air leak at these sites and so the use of repeated coagulation after biopsies.
Compared to our results, study of Hatata et al.  reported a single case of persistent air leak. In the study of Boutin et al.  who did medical thoracoscopic lung biopsies in cases with interstitial lung disease, persistent air leak (>5 days) was encountered in three out (15%) of 20 patients As well, incidence of pneumothorax in US-guided biopsy in our study is comparable to other previous studies. As regard the safety of image-guided lung biopsies, the rates of, pneumothorax reported in the literature was 4–34.5% ,,,.
In our study, we found strong positive correlation between transbronchial biopsies and hemoptysis (P=0.002). Hemoptysis was mild and self-limited in 1–2 days in all cases and in addition we did not encounter significant bleeding in any of the three groups.
In comparison to previous transbronchial studies, Shafiek et al.  reported mild bleeding occurred in 6% after transbronchial forceps biopsy. Pajares et al. , reported grade 2 bleeding (not statistically significant) occurred in the cryobiopsy group (56.4%) rather than in the conventional-forceps group (34.2%) among their 77 patients underwent transbronchial lung biopsy for evaluation of ILD, which is higher in incidence compared to the present study despite being insignificant. This could be attributed to negative effect of pulmonary hypertension (even mild degree) which may predispose to bleeding after transbronchial biopsies. Incidence of hemoptysis in US group in our study is comparable with previous studies in which incidence ranging from 1.0 to 27% ,,,.
In conclusion, our study demonstrates that in the evaluation of peripheral lung lesions, the diagnostic performance of transbronchial lung biopsy under fluoroscopic guidance, thoracoscopic lung biopsies and US-guided transthoracic biopsies are comparable. However, many factors can give priorities to certain techniques. transbronchial biopsy is not the preferred tool in localized peripheral disease or nodular lesions. However it is preferred in cases of mass lesions with positive bronchus sign. On the other hand, thoracoscopic lung biopsy is preferred to other techniques in cases associated with pleural effusion. Risk of potential procedural complications such as persistent air leak, mild, to moderate bleeding and transient hypoxemia need to be weighed while taking biopsies in cases of relative respiratory insufficiency in which transthoracic US-guided biopsies are the preferred initial tool. Further studies on a larger scale are needed to compare the three techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]