Chest
Volume 157, Issue 4, April 2020, Pages 1030-1042
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Thoracic Oncology: Guidelines and Consensus Statements
Transbronchial Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: CHEST Guideline and Expert Panel Report

https://doi.org/10.1016/j.chest.2019.10.048Get rights and content

Background

Transbronchial cryobiopsy (TBC) is increasingly recognized as a potential alternative to surgical lung biopsy (SLB) for the diagnosis of interstitial lung disease (ILD). The goal of this analysis was to examine the literature on TBC as it relates to diagnostic utility and safety to provide evidence-based and expert guidance to clinicians.

Methods

Approved panelists developed key questions regarding the diagnostic utility and safety of TBC for the evaluation of ILD using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus.

Results

The systematic review and critical analysis of the literature based on four PICO questions resulted in six statements: two evidence-based graded recommendations and four ungraded consensus-based statements.

Conclusions

Evidence of the utility and safety of TBC for the diagnosis of ILD is limited but suggests TBC is safer than SLB, and its contribution to the diagnosis obtained via multidisciplinary discussion is comparable to that of SLB, although the histological diagnostic yield appears higher with SLB (approximately 80% for TBC vs 95% for SLB). Additional research is needed to enhance knowledge regarding utility and safety of TBC, its role in the diagnostic algorithm of ILD, and the impact of technical aspects of the procedure on diagnostic yield and safety.

Section snippets

Summary of Recommendations

1. In patients with suspected interstitial lung disease (ILD), we suggest that transbronchial cryobiopsy (TBC) can be used to provide histopathologic findings for multidisciplinary discussion diagnosis (Weak Recommendation, Very Low-Quality Evidence).

Remarks: The choice between TBC and surgical lung biopsy (SLB) should be based on local availability and expertise, benefit-risk assessments, and patient preference following informed consent. In some instances, a nondiagnostic TBC may be followed

Background

Interstitial lung diseases (ILDs) are a heterogeneous group of diffuse parenchymal lung diseases characterized by varying histopathologic patterns of inflammation and fibrosis.1 These distinct histopathologic patterns are associated with a variety of clinical contexts with specific clinical implications regarding course of disease, management strategies, and prognosis.2 The most commonly encountered pattern, usual interstitial pneumonia (UIP), is the defining histological finding in idiopathic

Expert Panel Composition

The co-chairs of the panel (F. M. and L. B. Y.) were reviewed for potential conflicts of interest (COIs) and approved by CHEST’s Professional Standards Committee. Additional panelists were nominated by the co-chairs based on their expertise relative to potential guideline questions. The panel consisted of the guideline co-chairs, nine panelists (S. K. D., T. V. C., A. U. W., J. H. R., M. L., V. P., J. H., F. H., and O. B. R.), a methodologist (L. B. F.), and an additional panelist (M. M. W.)

Diagnostic Yield

1. In patients with suspected interstitial lung disease (ILD), we suggest that transbronchial cryobiopsy (TBC) can be used to provide histopathologic findings for multidisciplinary discussion diagnosis (Weak Recommendation, Very Low-Quality Evidence).

Remarks: The choice between TBC and surgical lung biopsy (SLB) should be based on local availability and expertise, benefit-risk assessments, and patient preference following informed consent. In some instances, a nondiagnostic TBC may be followed

Further Research

The data on TBC in the diagnosis of ILD remain limited and accordingly recommendations are necessarily provisional and contingent upon future research findings. Specifically, the results of several studies evaluating the concordance between TBC and SLB in the same patient are expected in the near future and may further clarify the histological yield of TBCs. There is a prospective trial in the United States (NCT01972685) directly comparing SLB to cryobiopsy for ILD which has completed

Conclusions

Data on the utility and safety of TBC for the diagnoses of ILD remain limited. Conversely, a substantial body of evidence suggests that SLB, with an estimated 12,000 procedures performed annually for ILD in the United States alone, is associated with significant morbidity and mortality.8 While the use of SLB is increasingly questioned in the ILD community, recent guidelines on IPF continue to recommend SLB as a possible option in patients with possible UIP/IPF when the diagnosis cannot be

Acknowledgments

Financial/nonfinancial disclosures: The COIs are given in e-Table 1.

Additional information: The e-Appendix, e-Figures, and e-Tables can be found in the Supplemental Materials section of the online article.

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    DISCLAIMER: CHEST Guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://www.chestnet.org/Guidelines-and-Resources.

    FUNDING/SUPPORT: This study was funded in total by internal funds from the American College of Chest Physicians.

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