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Kamonpun Ussavarungsi, MD; Eric S. Edell, MD; Jay H. Ryu, MD
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FINANCIAL/NONFINACIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN

CORRESPONDENCE TO: Kamonpun Ussavarungsi, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(3):722-723. doi:10.1016/j.chest.2016.10.046
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We appreciate the insightful comments by Dr Maldonado regarding our study. As reported, our study demonstrated a diagnostic yield of 51%, which was lower than those reported previously. The diagnostic yield of transbronchial cryobiopsy has varied in studies published to date. This likely reflects the experience of bronchoscopists and pathologists as well as the technique used (ie, size of cryoprobe, freezing time, site and number of biopsy samples, etc.). Aside from the size of cryobiopsy specimens, pathologists likely have differing thresholds in diagnosing histopathologic patterns such as usual interstitial pneumonia (UIP) on bronchoscopic biopsy specimens. Thus, some authors have employed terms such as “possible UIP” and “probable UIP” in the interpretation of cryobiopsy specimens. Furthermore, it is notable that the portion of transbronchial cryobiopsy specimens that were interpreted to show a UIP pattern has varied widely in prior studies.,,,, Substantial interobserver variability among pathologists has been demonstrated even in the interpretation of surgical lung biopsies in patients with idiopathic interstitial pneumonias.,

Dr Maldonado wonders about the absence of UIP as a histopathologic diagnosis in our study. Our study subjects manifested various radiologic patterns of diffuse parenchymal infiltrates encountered in clinical practice and not enriched for those with fibrotic interstitial pneumonias as in some other studies. Our cryobiopsy technique differed from those of other investigators who placed the cryoprobe more distally (< 10 mm from the thoracic wall) in order to obtain subpleural lung tissue at the cost of an increased rate of pneumothorax. In addition, it is our impression, as we mention in our article, that pulmonologists at our medical center tend to proceed directly to surgical lung biopsy for patients suspected of having UIP. For the period of our transbronchial cryobiopsy study (June 2013 to September 2015), 57 patients at our institution underwent surgical lung biopsies for undiagnosed diffuse parenchymal lung disease, and 21 of these biopsy samples (37%) demonstrated UIP.

We agree with Dr Maldonado that there is currently considerable variability in transbronchial cryobiopsy technique and patient selection. Clearly, we need more data and consensus on the optimal technique and use of this modality in the diagnostic evaluation of patients with diffuse parenchymal lung disease.

References

Ussavarungsi K. .Kern R.M. .Roden A.C. .Ryu J.H. .Edell E.S. . Transbronchial cryobiopsy in diffuse parenchymal lung disease: retrospective analysis of 74 cases. Chest. 2017;151:400-408 [PubMed]journal. [CrossRef] [PubMed]
 
Hagmeyer L. .Theegarten D. .Treml M. .Priegnitz C. .Randerath W. . Validation of transbronchial cryobiopsy in interstitial lung disease: interim analysis of a prospective trial and critical review of the literature. Sarcoidosis Vasc Diffuse Lung Dis. 2016;33:2-9 [PubMed]journal. [PubMed]
 
Kropski J.A. .Pritchett J.M. .Mason W.R. .et al Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease. PLoS One. 2013;8:e78674- [PubMed]  :- [PubMed]journal. [CrossRef] [PubMed]
 
Fruchter O. .Fridel L. .El Raouf B.A. .Abdel-Rahman N. .Rosengarten D. .Kramer M.R. . Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy. Respirology. 2014;19:683-688 [PubMed]journal. [CrossRef] [PubMed]
 
Pajares V. .Puzo C. .Castillo D. .et al Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014;19:900-906 [PubMed]journal. [CrossRef] [PubMed]
 
Tomassetti S. .Wells A.U. .Costabel U. .et al Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2016;193:745-752 [PubMed]journal. [CrossRef] [PubMed]
 
Nicholson A.G. .Addis B.J. .Bharucha H. .et al Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax. 2004;59:500-505 [PubMed]journal. [CrossRef] [PubMed]
 
Flaherty K.R. .King T.E. Jr..Raghu G. .et al Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med. 2004;170:904-910 [PubMed]journal. [CrossRef] [PubMed]
 
Ravaglia C. .Bonifazi M. .Wells A.U. .et al Safety and diagnostic yield of transbronchial lung cryobiopsy in diffuse parenchymal lung diseases: a comparative study versus video-assisted thoracoscopic lung biopsy and a systematic review of the literature. Respiration. 2016;91:215-227 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Ussavarungsi K. .Kern R.M. .Roden A.C. .Ryu J.H. .Edell E.S. . Transbronchial cryobiopsy in diffuse parenchymal lung disease: retrospective analysis of 74 cases. Chest. 2017;151:400-408 [PubMed]journal. [CrossRef] [PubMed]
 
Hagmeyer L. .Theegarten D. .Treml M. .Priegnitz C. .Randerath W. . Validation of transbronchial cryobiopsy in interstitial lung disease: interim analysis of a prospective trial and critical review of the literature. Sarcoidosis Vasc Diffuse Lung Dis. 2016;33:2-9 [PubMed]journal. [PubMed]
 
Kropski J.A. .Pritchett J.M. .Mason W.R. .et al Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease. PLoS One. 2013;8:e78674- [PubMed]  :- [PubMed]journal. [CrossRef] [PubMed]
 
Fruchter O. .Fridel L. .El Raouf B.A. .Abdel-Rahman N. .Rosengarten D. .Kramer M.R. . Histological diagnosis of interstitial lung diseases by cryo-transbronchial biopsy. Respirology. 2014;19:683-688 [PubMed]journal. [CrossRef] [PubMed]
 
Pajares V. .Puzo C. .Castillo D. .et al Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014;19:900-906 [PubMed]journal. [CrossRef] [PubMed]
 
Tomassetti S. .Wells A.U. .Costabel U. .et al Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2016;193:745-752 [PubMed]journal. [CrossRef] [PubMed]
 
Nicholson A.G. .Addis B.J. .Bharucha H. .et al Inter-observer variation between pathologists in diffuse parenchymal lung disease. Thorax. 2004;59:500-505 [PubMed]journal. [CrossRef] [PubMed]
 
Flaherty K.R. .King T.E. Jr..Raghu G. .et al Idiopathic interstitial pneumonia: what is the effect of a multidisciplinary approach to diagnosis? Am J Respir Crit Care Med. 2004;170:904-910 [PubMed]journal. [CrossRef] [PubMed]
 
Ravaglia C. .Bonifazi M. .Wells A.U. .et al Safety and diagnostic yield of transbronchial lung cryobiopsy in diffuse parenchymal lung diseases: a comparative study versus video-assisted thoracoscopic lung biopsy and a systematic review of the literature. Respiration. 2016;91:215-227 [PubMed]journal. [CrossRef] [PubMed]
 
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