Download chapter 48 – ROLE OF LUNG BIOPSY IN INTERSTITIAL LUNG

– Diffuse Lung Disease
chapter 48 – ROLE OF LUNG BIOPSY IN INTERSTITIAL LUNG DISEASE
Vitaliy Poylin,
Malcolm M. DeCamp Jr.
Key Points
▪
Thoracic surgeons evaluate two distinct patient populations with interstitial lung disease:
those with acute respiratory illness, often with impaired immunity, and those with progressive
dyspnea and an insidious decline in lung function.
▪
The goal of a surgical lung biopsy is to define pathology leading to revised therapy that in
turn leads to improved outcome. The goal is not to merely make a diagnosis.
▪
Surgical lung biopsy has greater utility in classifying the disorder and leading to effective
therapy if it is performed early in the acute or chronic illness.
▪
Thoracoscopic and open lung biopsy techniques provide equivalent diagnostic information.
▪
Thoracoscopy facilitates sampling of divergent areas of the same lung and results in less
trauma and faster recovery compared with a limited thoracotomy.
Interstitial lung disease (ILD) is a heterogeneous group of lung conditions of both known and unknown
etiology. There are more than 200 different diseases in the group, which broadly can be divided into
infectious, occupational, iatrogenic, granulomatous, malignant, autoimmune/connective tissue
disorder–related, and idiopathic categories (Table 48-1) (Kim et al, 2006).[1] Despite disparate
etiologies, they often have similar clinical features, including dyspnea and hypoxemia, restrictive
spirometry, depressed diffusion capacity, and a diffusely abnormal interstitium on lung imaging.
Patients with ILD present a therapeutic conundrum for clinicians because these varied disorders with
similar clinical presentations often require radically different therapies (e.g., antimicrobial therapy
versus augmented immunosuppression).
TABLE 48-1 -- Classification of Interstitial Lung Disease
Infectious
Idiopathic Occupational Iatrogenic
Granulomatous Malignant
Autoimmune/CTD
Bacterial
UIP
Asbestos
Radiation
Sarcoidosis
Lymphoma
Scleroderma
Fungal
DIP
Silica
Bleomycin
Histiocytosis
Lymphangitic Polymyositis
carcinomatosis
Viral
NSIP
Coal
Amiodarone Hypersensitivity
Dermatomyositis
Infectious
Idiopathic Occupational Iatrogenic
Mycobacterial COP
Organic
Protozoan
Heavy metal
RB-ILD
Methotrexate
Granulomatous Malignant
Autoimmune/CTD
Rheumatoid
arthritis
SLE
Adapted from Kim DS, Collard HR, King TE Jr: Classification and natural history of the idiopathic
interstitial pneumonias. Proc Am Thorac Soc 3:285-292, 2006.
COP, cryptogenic organizing pneumonia; CTD, connective tissue disorder; DIP, desquamative
interstitial pneumonitis; NSIP, nonspecific interstitial pneumonitis; RB-ILD, respiratory bronchiolitis–
associated interstitial lung disease; SLE, systemic lupus erythematosus; UIP, usual interstitial
pneumonitis.
CLINICAL PRESENTATION
When patients with ILD are encountered by a surgeon, they are usually symptomatic with progressive
dyspnea, nonproductive cough, occasional weight loss, and fever. Known environmental exposure, a
prior malignancy, or a detailed drug history may suggest a cause in a fraction of these cases.
Insidious onset is the most common presentation, although fulminant onset is more common in
patients who are immunocompromised. Physical examination often reveals nonspecific findings
consistent with hypoxemia (clubbing, tachypnea, and tachycardia), wheezing, and/or fine or coarse
crackles. Extrapulmonary manifestations of collagen-vascular disease, as are seen in scleroderma or
systemic lupus erythematosus (SLE), may help narrow the differential diagnosis. Pulmonary
hypertension with a fixed split second heart sound, peripheral edema, and/or ascites speaks to the
chronicity of the underlying process. Spirometry usually shows a nonspecific restrictive pattern with
symmetrical reduction in both forced vital capacity (FVC) and forced expiratory volume in 1 second
(FEV1) as ILD progresses. Worsening diffusing capacity of the lung for carbon monoxide (D LCO) is
perhaps the most sensitive measure to detect disease progression.
From a surgical standpoint, the issue with such a nonspecific presentation is that too few patients get
referred for biopsy early in the disease, when a specific diagnosis can potentially make a difference.
By the time a surgeon encounters these patients, many have progressed significantly toward endstage fibrotic disease, with mature collagen replacing and expanding the air-blood barrier. At such a
time, the utility of an invasive, diagnostic surgical intervention and even the subsequent institution of
potentially toxic pharmacologic therapy is questionable.
IMAGING
Routine chest radiographs contribute little to the timely diagnosis of ILD. Radiographic changes are
not obvious early in the process. As disease progresses, diffuse linear and reticular infiltrates are
seen and are commonly more pronounced in the lower lobes. High-resolution computed tomography
(HRCT) provides a detailed image of lung parenchyma and differentiates areas of active disease with
ground-glass opacification (Fig. 48-1) from areas of the common end-stage so-called honeycomb
changes of fibrosis and scarring (Fig. 48-2). These distinctions become critical when choosing a
biopsy site if one is needed.
FIGURE 48-1 Axial image with lung windowing from an HRCT. Slice taken at the level of the inferior pulmonary
veins. Note the diffuse areas of ground-glass opacification suggestive of active inflammation affecting both lungs.
FIGURE 48-2 Axial image with lung windowing from an HRCT of a patient with advanced interstitial lung disease.
Slice taken below the level of the inferior pulmonary veins depicts extensive peripheral fibrosis with honeycomb
changes affecting the left lower lobe more than the right.
AMBULATORY DIAGNOSTIC MODALITIES
Routine sputum cultures are usually obtained but are likely to be relevant only in patients with
predisposing comorbidities or historical factors such as active immunosuppression, unique
occupational or environmental exposures, or exotic travel. The low diagnostic yield from sputum
cultures can be marginally improved by fiberoptic bronchoscopy with bronchoalveolar lavage (BAL)
for microbiology and cytology studies. These two modalities are useful in identifying certain infectious
sources, such as Pneumocystis jiroveci (Pneumocystis carinii) pneumonia (PCP) and fungal
infections.
Transbronchial biopsy has been reported to have a success rate of 25% to 59% in establishing a
specific histologic diagnosis.[2] The low complication rate of about 3% makes this a useful addition to
bronchoscopy and BAL. This technique is very successful in accurately diagnosing such conditions as
sarcoidosis and lymphangitic carcinomatosis. Yet, small sample size and the limited number of
accessible sites limits its use in most cases of ILD. Despite its ambulatory application and less
invasive profile, flexible fiberoptic bronchoscopy with BAL and transbronchial biopsy remains inferior
to surgical lung biopsy if the end point is a discrete histologic diagnosis. [3]
SURGICAL LUNG BIOPSY
The debate regarding the role of surgical lung biopsy for the patient with ILD centers on three
questions:
1. Is a biopsy necessary to establish a diagnosis?
2. Will establishing a histologic diagnosis change therapy?
3. Will biopsy-driven therapy change outcome?
Historical reports failed to delineate changes in therapy and overall outcome. These studies were
largely retrospectiveand included patients with diverse presentations, including those who were
severely ill and already confined to an intensive care unit alongside other patients who remained
ambulatory and otherwise functional.[4]
A more timely and relevant debate asks whether the diagnosis can be established by noninvasive
means alone. The ubiquitous availability of HRCT has made this a feasible concept. Two recent
prospective studies have validated a noninvasive diagnostic strategy for selected patients, but both
emphasized the importance of surgical biopsy for establishing diagnosis in clinically unclear cases.
Hunninghake and colleagues[5] reported that, when evaluating clinical and radiologic data, an
experienced pulmonologist and radiologist were accurate in diagnosing usual interstitial pneumonitis
(UIP) in 90% and 77% of cases, respectively. However, when asked for a definitive diagnosis, the
accuracy dropped to 75% to 77%. Raghu and colleagues[6–8] similarly found that the accuracy of
radiologic, clinical, and transbronchial diagnosis was 90% to 97% specific for interstitial pulmonary
fibrosis (IPF), but sensitivity remained low at 50% to 78%. For non-IPF ILD, sensitivity and specificity
were both low at 62% to 70%. Both studies concluded that, although surgical biopsy may not be
necessary for some cases of IPF (especially UIP), it remains essential in more than one third of
patients. It is also important to point out that these studies surveyed only experienced pulmonologists
and radiologists from centers of recognized authority in ILD. Overall, it is clear that lung biopsy
increases the chance of definitive tissue diagnosis in almost all patient populations.
The next question is whether establishing the diagnosis will make a difference in patient management
or outcome. Historical reports noted that surgical lung biopsy achieves a discrete diagnosis in 37% to
93% of cases.[2–4] Although it is difficult to derive useful information from these retrospective analyses,
if we try to tease out the effects on the specific patient groups, a few distinct patterns emerge. For
immunocompetent patients, two recent reports found that a discrete diagnosis caused a change in
therapy in 57% to 63% of cases (Kramer et al, 1998).[9,10] In the few studies that reported overall
benefit and survival, change in therapy for immunocompetent patients resulted in moderate likelihood
of patient benefit (18%–26%).[9,10] At the same time, the overall operative morbidity and mortality
relative to the actual procedure for these patients remained sufficiently low to make lung biopsy a
rational and safe addition to management. Overall, in immunocompetent patients without respiratory
distress whose HRCT shows minimal end-stage fibrotic change, biopsy is likely to change or guide
therapy, and there is some evidence of improvement in survival (Tables 48-2 and 48-3).
TABLE 48-2 -- Characteristics of Idiopathic Forms of Interstitial Lung Disease
Characteristic
UIP
NSIP
COP
RB-ILD
Mean age at presentation (yr) 57
49
42
Onset
Insidious
Subacute Subacute Insidious
Smoking-related
Increased risk No
No
Required
Steroid-responsive
No
Yes
Yes
Slightly
Complete recovery
No
Possible Yes
Yes
Mortality (%)
90
30
0
5
36
Adapted from Kim DS, Collard HR, King TE Jr: Classification and natural history of the idiopathic
interstitial pneumonias. Proc Am Thorac Soc 3:285-292, 2006.
COP, cryptogenic organizing pneumonia; NSIP, nonspecific interstitial pneumonitis; RB-ILD,
respiratory bronchiolitis–associated interstitial lung disease; UIP, usual interstitial pneumonitis.
TABLE 48-3 -- Effect of Lung Biopsy (VATS and Open) on Change in Therapy and Outcome
Author (Year)
No.
Patient Status
% Change of
% Change in
Patients
Therapy
Outcome
Lee et al[21]
(2005)
196
Immunocompromised and
immunocompetent
84
63
Kramer et al[9]
103
Immunocompromised
59
46[*]
Author (Year)
No.
Patients
Patient Status
% Change of
Therapy
% Change in
Outcome
Immunocompetent
18
18
(1998)
White et al[16]
(2000)
63
Immunocompromised
57
26
Temes et al[10]
(1999)
75
Immunocompetent
77
39
VATS, video-assisted thoracic surgery.
* The
mortality rate of this group was 39%.
This pattern does not hold true for elderly or immunocompromised patients or those with end-stage
disease. Patients with end-stage fibrosis on top of poor overall status have a higher rate of
complications from anesthesia and the procedure itself, resulting in higher mortality and important
morbidity, such as extra days of mechanical ventilation and prolonged air leak. [11,12]
For ventilated immunocompetent patients, the rates of diagnosis and changes in therapy seem to be
compatible with studies of ambulatory patients (approximately 46%). This ventilated group did
experience significantly higher mortality (approaching 60%), calling into question the therapeutic index
for lung biopsies once a patient is intubated.
Timing of biopsy has also been debated. Delaying the biopsy may be related to some degree of
therapeutic nihilism, given the absence of effective remedies for UIP (see Table 48-2)[1,11] or the
pattern of diffuse alveolar damage seen frequently on specimens from critically ill patients. Performing
biopsy late in the course of the disease decreases the chance of diagnosis due to coalescence of
heavy indiscriminant fibrosis (honeycombing). These patients also are more likely to be in respiratory
distress, which, as described earlier, reduces the likelihood that a tissue diagnosis will change the
overall outcome and is certainly accompanied by much higher morbidity and mortality. In patients with
fulminant forms of the disease, choosing the appropriate time may not be possible. This group of
patients needs urgent or emergent lung biopsy if there is any clinical likelihood of a reversible process.
IMMUNOCOMPROMISED PATIENTS
Immunocompromised hosts comprise a large patient cohort affected by diffuse lung disease. Unlike
patients with fibrotic lung disease, these hosts have a much higher risk of developing infectious
complications. They are usually acutely ill with fever, cough, dyspnea, and progressive hypoxemia.
They have often been exposed to other potential lung-damaging therapies, such as
immunosuppressive drugs, chemotherapy, and irradiation. The prognosis for immunocompromised
patients with pulmonary infiltrates is grim, especially if mechanical ventilation is required. In these
circumstances, prompt diagnosis may be critical for survival. Because opportunistic infections can be
a common cause of ILD, the workup for these patients begins with expeditious sputum culture,
bronchoscopy, and BAL. Microbiologic examination of expectorated sputum and/or lavaged airway
secretions has successfully identified a discrete diagnosis in 40% of immunocompromised
patients.[13,14]
For the balance of the patients in whom the diagnosis remains unclear, a more invasive approach is
controversial. Many reports suggest that patients in whom lung biopsy is pursued do not fare better
than those treated empirically.[12,15,16] Rano and colleagues[17] examined patients with hematologic
malignancies and solid organ transplantation who presented with fever, dyspnea, and pulmonary
infiltrates. Their overall mortality rate after surgical lung biopsy was 39% (see Table 48-2). Although
prolonged time to diagnosis (>5 days) was predictive of the need for mechanical ventilation and of
higher mortality, patients who underwent lung biopsy experienced outcomes similar to those
diagnosed by less invasive methods. Despite a higher rate of finding a specific diagno-sis with biopsy
than in immunocompetent patients, the extra information did not translate into salutary clinical
outcomes.
VIDEO-ASSISTED THORACIC SURGERY VERSUS OPEN BIOPSY
For decades, open biopsy via a limited thoracotomy has been a gold standard for the surgical
diagnosis of ILD. However, this approach is associated with increased pain, some limitation in
accessible biopsy sites, and, in some uncontrolled studies, increased mortality. The emergence of
video-assisted thoracic surgery (VATS) has proved to be an attractive alternative to the open
technique. In largely retrospective studies, VATS has been shown to decrease the length of hospital
stay and postoperative analgesic requirements, with better preservation of shoulder strength and
range of motion and faster return to baseline pulmonary function.[18] There are also intriguing reports
of a decrease in surgery-associated immunosuppression when patients undergoing VATS procedures
were compared with those having open thoracotomy.[19] Direct comparisons between open and
minimally invasive approaches suggest equivalency in diagnostic efficacy. Miller and coworkers
(Miller et al, 2000),[20] in a prospective randomized study of 42 patients, found no clinical or statistical
differences between the two techniques with regard to diagnostic yield, operating time, duration of
chest tube drainage, postoperative length of stay, pain scores, complications, or spirometry measured
both preoperatively and postoperatively.
Ultimately, the choice between an open or VATS approach to lung biopsy is a clinical one based on
patient anatomy, physiology, and the surgeon's facility with minimally invasive techniques. For
ambulatory patients referred for biopsy to define ILD, VATS has largely supplanted thoracotomy as
the procedure of choice, both for patients and for their referring physicians. These patients almost
uniformly tolerate single-lung ventilation, which is a practical requirement for VATS lung biopsy. The
need to convert VATS to a thoracotomy is rare and in most series is limited to 0% to 5.3%. This is
usually related to the patient's inability to tolerate single-lung ventilation, pleural adhesions, or
iatrogenic lung injury (Lee et al, 2005; Miller et al, 2000).[20–25]
In contrast, the critically ill, severely dyspneic, oxygen-dependent or mechanically ventilated patient
with a clear indication for surgical lung biopsy cannot tolerate single-lung ventilation. This
necessitates the use of a thoracotomy (albeit limited) and brief intermittent periods of apnea to
successfully biopsy the affected lung.
LOCATION OF THE BIOPSY AND NUMBER OF SITES
Contemporary imaging modalities such as HRCT guide the surgeon and represent an invaluable
resource in performing high-yield biopsy. HRCT allows the surgeon to avoid areas of high fibrosis
(see Fig. 48-2), the common end stage for multiple lung disorders, and guide biopsy to areas of active
disease, which often appear as ground-glass opacifications (see Fig. 48-1). The site for biopsy in
generalized disease remains controversial. Traditionally, the lingula was considered a poor site for the
biopsy because the location was believed to be akin to the basilar aspects of the lower lobes, where
fibrosis is usually more advanced.[26] More recent studies by Ayed, Miller, and Blewett and their
colleagues have found that lingular (and right middle lobe) biopsies provide a diagnostic yield similar
to that obtained from tissue sampled from the other areas of either lung. [24,26,28]
The optimal number of samples is also debated. In a study of 100 patients with ILD, Qureshi and
Soorae[25] demonstrated that a single biopsy from an active disease area is adequate for diagnosis. In
their study, the site, size, number, or laterality of the biopsy specimen had no statistical influence on
diagnostic yield, although there was a trend favoring two or more biopsies on the right lung. They and
others have also confirmed that obtaining multiple biopsies does not increase postoperative morbidity.
Given these data and the lack of evidence that multiple biopsies engender increased risk, we
recommend two wedge biopsy samples from separate lobes when investigating idiopathic ILD in an
ambulatory patient. The anatomic separation of such samples may assist the pathologist in
classification of the underlying process and its severity.
For the acutely ill, hospitalized, immunocompromised, or febrile patient, the underlying process is
more likely to be diffuse. Multiple biopsies in this clinical scenario are not necessary as long as
lesional tissue is obtained and confirmed by either gross examination or frozen section. Moreover,
multiple biopsies in these more fragile patients are associated with important morbidity, including
bleeding and prolonged air leaks. The more critical technical issue for these patients is to obtain
sufficient tissue in a single wedge resection to allow for both histology and microbiologic analysis for
bacteria, mycobacteria, fungi, viruses, and parasites.
TECHNIQUE
Surgical lung biopsy, whether performed via VATS or thoracotomy, is done with the patient under
general anesthesia in the lateral decubitus position. Selective bronchial intubation and single-lung
ventilation are mandatory for VATS. For left-sided biopsies, a bronchial blocker can be used, but it
limits anesthetic maneuvers such as continuous positive airway pressure (CPAP) if intraoperative
hypoxemia becomes problematic. Many ambulatory patients who present with hypoxemia requiring
supplemental oxygen actually tolerate single-lung ventilation well. Similarly, the acutely ill patient with
a focal lung process may tolerate selective ventilation for a brief procedure if the more diseased lung
is the target for biopsy. If intraoperative hypoxia creates instability, brief periods of ventilation of the
deflated lung or low levels of CPAP (5 cm H2 O) may allow the procedure to be completed without
progressing to thoracotomy.
The ipsilateral arm is abducted and strapped to an ether screen or arm holder to open the axilla and
provide port access to the upper thorax (Fig. 48-3). This also facilitates a minithoracotomy low in the
axilla if the patient cannot tolerate single-lung ventilation or extensive pleural adhesions are
encountered. It is helpful to extend the operating table or flex the patient's hip to widen the lower
intercostal spaces and deflect the hips down and away from the field.
FIGURE 48-3 Proper positioning for surgical lung biopsy. The operative-side arm is abducted and secured with
appropriate padding to an ether screen or arm holder to provide access to the axilla for either a utility thoracotomy or
more apical port sites. If a video-assisted thoracic surgery (VATS) approach is planned, suggested camera
positioning and port site options are indicated.
(REPRINTED WITH THE PERMISSION OF THE CLEVELAND CLINIC FOUNDATION.)
Three access ports are used (see Fig. 48-3). The camera port is usually placed in the seventh
intercostal space in themidaxillary line. A 5- or 10-mm telescope with a 30-degree lens allows the
camera to visualize the entire thorax. The lung is inspected, and the proposed site for biopsy (based
on HRCT) is identified. The other two ports are usually placed under thoracoscopic guidance in the
sixth or seventh intercostal spaces, posteriorly below the scapular tip and anteriorly below or
immediately lateral to the breast. Attractive targets for biopsy include the upper lobe apices, the
superior segment of the lower lobes, the basilar edges of the lower lobes, and any of the lobes along
the fissures. The broad surfaces of the lung must be approached with care if there is underlying
fibrosis or induration because the lung may not be compressible, resulting in malformed staples and
air leak. The lung adjacent to the biopsy target is gently grasped with a ringed forceps, and an
endomechanical stapler with a thick tissue cartridge is introduced and fired via the opposing port site.
The instruments are reversed and a second staple firing is made, completing the wedge resection
with intersecting staple lines. Remove all specimens from the chest in an impenetrable bag to prevent
dissemination of disease within the pleura or seeding/contamination of the chest wall. Staple lines and
each port site are inspected for hemostasis. This may necessitate relocating the camera to any or all
port sites used. All staple lines should intersect to ensure pneumostasis. A single, small chest tube is
placed via the original camera port and positioned in the posterior gutter with its tip in the apex. The
lung is reinflated in a controlled fashion under thoracoscopic visualization to ensure re-expansion of
all lobes and segments. The remaining port sites are reapproximated in layers with absorbable suture,
including a subcuticular skin closure.
Surgical lung biopsy for the intubated patient who requires high levels of inspired oxygen (Fio 2 ≥0.6)
or positive end-expiratory pressure (PEEP ≥10) is best accomplished via a limited lateral or axillary
thoracotomy. These patients are unlikely to tolerate single-lung ventilation, and manipulation of the
airway to place a bronchial blocker or double-lumen endotracheal tube may precipitate a crisis. Again,
the patient is positioned laterally with the arm abducted (see Fig. 48-3). A muscle-sparing approach
lateral to the pectoralis major and anterior to the latissimus dorsi in front of the scapular tip exposes
either lung along the fissure. The serratus anterior fibers can be split, with care taken not to divide the
long thoracic nerve. Either the upper or the lower lobe can be biopsied through this exposure. We
prefer to use the thick tissue cartridges and the endomechanical stapler even during open biopsies.
Use of a more inferiorly placed chest tube incision to pass the stapler for one or several firings may
facilitate the geometry of the biopsy. Very brief episodes of apnea during application of the stapler
may help decrease pleural injury and subsequent air leak. A hemostatic survey, chest tube placement,
and wound closure are standard as for any thoracotomy.
Specimen handling depends on the immune status of the patient. Although a frozen section is rarely
definitive, it often confirms the adequacy of the biopsy as representative of lesional tissue.
Examination of fresh tissue by the pathologist may also guide further investigation, such as
immunohistochemistry, fungal stains, flow cytometry, or electron microscopy. Granulomas are readily
identified by frozen section. Although these lesions can be infective or noninfective, such tissues must
always be cultured for fungal and mycobacterial organisms. In the immunocompromised patient, in
addition to histology, tissue is routinely assayed for bacterial, fungal, acid-fast, viral, and protozoan
organisms (especially PCP).
Procedure-related morbidity and mortality are uncommon for VATS lung biopsy. The risk of death
after an elective biopsy for ILD is reported at 0% to 2%, whereas the need to convert to open
thoracotomy ranges from 0% to 5.3%. Other complications include hemothorax (0%–5%), persistent
leak requiring prolonged chest tube drainage (1%–8%), and bleeding requiring re-exploration (1%–
2%). As described earlier, in immunocompromised patients or in clinical crises where intubation has
occurred or is eminent, complication rates (especially respiratory failure, need for mechanical
ventilation, and air leak) tend to be higher and are less likely to be caused by errors in technique.
Operative mortality in this population may approach 40% to 60%, similar to that experienced by any
critically ill patient in whom respiratory distress deteriorates into multisystem organ failure. [9, 11, 12, 16, 20–
25, 28]
COMMENTS AND CONTROVERSIES
Current CT imaging techniques and relatively noninvasive bronchoscopic biopsy strategies have
lessened the need for surgical biopsy in patients with ILD. Opportunistic infections and sarcoidosis
can usually be diagnosed by BAL and transbronchial biopsy, respectively. The CT imaging pattern of
UIP is typical in its early stages. In many cases, surgical biopsy can be avoided.
As the authors correctly point out, the goal of surgical biopsy is not only to establish a diagnosis but,
more importantly, to effect a change in management to the patient's benefit. If this latter goal is
unlikely to be achieved, the biopsy is of questionable utility, especially in a critically ill patient. VATS
has proved to be an effective strategy for lung biopsy, but only in the elective situation of a stable
patient. Adequate multifocal biopsies can be obtained by VATS, but use of a double-lumen tube and
an arterial line and a more expensive operative setup are required. This commentator does not
believe that VATS offers benefit over minimal anterolateral thoracotomy in terms of pain,
postoperative morbidity, and operative time. This anterolateral approach is definitely superior in the
critically ill patient.
KEY REFERENCES
Kim DS, Collard HR, King Jr TE: Classification and natural history of the idiopathic interstitial
pneumonias. Proc Am Thorac Soc 2006; 3:285-292.
▪ This paper led off a contemporary international symposium on ILD. The authors clearly define the
distinct differences in clinical, radiologic, and histologic features; treatment; and prognosis for the
noninfectious types of ILD.
Kramer MR, Berkman N, Mintz B, et al: The role of open biopsy in the management and outcome of
patients with diffuse lung disease. Ann Thorac Surg 1998; 65:198-202.
▪ In one of the first papers to emphasize the clinical utility of the biopsy for more than a diagnosis,
these authors remind us to exercise judgment when considering risks and benefits of surgical lung
biopsy. They documented an alarming operative mortality in the immunocompromised group,
especially if the decision to proceed to biopsy was made late.
Lee YC, Wu CT, Hsu HH, et al: Surgical lung biopsy for diffuse pulmonary disease: Experience of 196
patients. J Thorac Cardiovasc Surg 2005; 129:984-990.
▪ In this large recent series, the investigators report a high rate of change in both therapy and
outcome based on the surgical biopsy. Unfortunately, it is difficult to tease apart the results between
immunocompetent and immunosuppressed hosts.
Miller JD, Urschel JD, Cox G, et al: A randomized, controlled trial comparing thoracoscopy and limited
thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000; 70:1647-1650.
▪ One of two small, prospective, randomized trials comparing open to thoracoscopic lung biopsy for
ILD. The patients selected were largely ambulatory; critically ill, severely hypoxic, and ventilated
patients were excluded. Given these restrictions, there were no differences in any of the measured
surgical, pathologic, or clinical outcomes of the two groups. It is doubtful that the study was
adequately powered to detect meaningful differences based on choice of incision. That the
procedures yielded comparable results underscores the need for surgeons contemplating lung biopsy
to select an approach that best meets the patient's needs.
White DA, Wong PW, Downey R: The utility of open lung biopsy in patients with hematologic
malignancies. Am J Respir Crit Care Med 2000; 161:723-729.
▪ Thoracic surgeons are often asked to evaluate patients whose bone marrow is failing because of
disease or therapy. The authors, from Memorial Sloan Kettering Cancer Center, report that, although
therapy changed in more than half of patients biopsied, the outcome changed only one quarter of the
time.