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Correspondence |

Are Transbronchial Cryobiopsies Living Up to Expectations? FREE TO VIEW

Fabien Maldonado, MD, FCCP
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN

CORRESPONDENCE TO: Fabien Maldonado, MD, FCCP, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Ave S, T-2220 MCN, Nashville, TN 37232-2650


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


Chest. 2017;151(3):722. doi:10.1016/j.chest.2016.10.045
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I read with great interest the retrospective study by Mayo Clinic researchers Ussavarungsi and colleagues, on transbronchial cryobiopsies for the diagnosis of diffuse parenchymal lung diseases (DPLDs), in a recent issue of CHEST (February 2017). Transbronchial cryobiopsies have emerged as an exciting diagnostic alternative for patients with DPLD, being less invasive than surgical lung biopsies but with a reported safety profile similar to that of conventional transbronchial biopsies. While the yield reported by the Mayo Clinic investigators is lower than those reported in previous studies, diagnostic yield remains an elusive end point in the absence of the comparative “gold standard” of surgical lung biopsy.

I am, however, intrigued by the absence of usual interstitial pneumonia (UIP) as a histologic diagnosis, one of the most common diagnoses in previous studies on cryobiopsies. Three possible explanations may be suggested: this observation is due to chance, to a distinctive patient selection, or a specific technique. The authors suggest that selection bias may have played a role as patients with suspected UIP could have been referred directly to surgical lung biopsy. Justified or not, this would be somewhat at odds with the downward nationwide trend, and it would be interesting to know how many patients indeed underwent surgical lung biopsy for DPLD in the same time period. In addition, some data on high-resolution CT imaging would have been useful, offering some insight into the type of patients selected for cryobiopsies. Aside from chance, then, the other possibility is of course a difference in technique. As pointed out in the authors’ own review, previous studies included more UIP diagnoses, but also more pneumothoraces. Cryobiopsy samples obtained closer to the pleura (including the periphery of the secondary pulmonary lobule) could have allowed a UIP diagnosis in some of these cases. It is also noteworthy that cryobiopsy samples were obtained in only one lobe in 80% of these cases. Given the interlobar heterogeneity of UIP, these results are perhaps not all that surprising.

There is considerable variability in methodology, patient selection, and clinical outcomes in the published literature on transbronchial cryobiopsies. This has hampered widespread adoption of the technique, and calls for continued quality comparative research efforts. I agree with the authors that while promising, the place of cryobiopsies in the diagnostic algorithmic approach to DPLD remains to be determined.

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]
 
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]
 
Patel N.M. .Borczuk A.C. .Lederer D.J. . Cryobiopsy in the diagnosis of interstitial lung disease. a step forward or back? Am J Respir Crit Care Med. 2016;193:707-709 [PubMed]journal. [CrossRef] [PubMed]
 
Poletti V. .Casoni G.L. .Gurioli C. .Ryu J.H. .Tomassetti S. . Lung cryobiopsies: a paradigm shift in diagnostic bronchoscopy? Respirology. 2014;19:645-654 [PubMed]journal. [CrossRef] [PubMed]
 
Flaherty K.R. .Travis W.D. .Colby T.V. .et al Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med. 2001;164:1722-1727 [PubMed]journal. [CrossRef] [PubMed]
 

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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]
 
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]
 
Patel N.M. .Borczuk A.C. .Lederer D.J. . Cryobiopsy in the diagnosis of interstitial lung disease. a step forward or back? Am J Respir Crit Care Med. 2016;193:707-709 [PubMed]journal. [CrossRef] [PubMed]
 
Poletti V. .Casoni G.L. .Gurioli C. .Ryu J.H. .Tomassetti S. . Lung cryobiopsies: a paradigm shift in diagnostic bronchoscopy? Respirology. 2014;19:645-654 [PubMed]journal. [CrossRef] [PubMed]
 
Flaherty K.R. .Travis W.D. .Colby T.V. .et al Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med. 2001;164:1722-1727 [PubMed]journal. [CrossRef] [PubMed]
 
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