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Part 3A: Endobronchial BiopsyPart 3A: Endobronchial Biopsyvolume 1volume 1

Bronchoscopy InternationalBronchoscopy International

Strategy and Planning

Execution

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When to perform endobronchial biopsyWhen to perform endobronchial biopsy

Visible airway mucosal abnormalitiesVisible airway mucosal abnormalities Visible airway nodules or massesVisible airway nodules or masses In case of suspected sarcoidosis (even if In case of suspected sarcoidosis (even if

airway mucosa appears normal)airway mucosa appears normal) In case of abnormal autofluorescence to In case of abnormal autofluorescence to

diagnose intraepithelial lesions (dysplasia, diagnose intraepithelial lesions (dysplasia, metaplasia, carcinoma in-situ)metaplasia, carcinoma in-situ)

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Training is essential in order toTraining is essential in order to

Learn proper techniques and indicationsLearn proper techniques and indications Avoid procedure-related complications.Avoid procedure-related complications. Learn to protect the equipment and the Learn to protect the equipment and the

patientpatient To obtain adequate tissue for diagnosisTo obtain adequate tissue for diagnosis To avoid damaging the working channelTo avoid damaging the working channel To avoid excess patient discomfort (cough, To avoid excess patient discomfort (cough,

anxiety, shortness of breath).anxiety, shortness of breath). To avoid bleeding, that might also prompt To avoid bleeding, that might also prompt

cough and patient agitation.cough and patient agitation.

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Endobronchial BiopsyEndobronchial Biopsy

IndicationsIndications Visible intraluminal or mucosal Visible intraluminal or mucosal

abnormalityabnormality Suspected Sarcoidosis (even if mucosa Suspected Sarcoidosis (even if mucosa

appears normal)appears normal) Early lung cancer detection (based on Early lung cancer detection (based on

findings of autofluorescence and other findings of autofluorescence and other imaging modalities)imaging modalities)

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Biopsy instrumentsBiopsy instruments Small reduction in bleeding using hot forceps: 39 Small reduction in bleeding using hot forceps: 39

patients with 6 biopsies each (Eur Respir J 2007; patients with 6 biopsies each (Eur Respir J 2007; 29:108-11129:108-111

Forceps with spike can be used Forceps with spike can be used to anchor forceps on lesionto anchor forceps on lesion..

Open cupOpen cup

Alligator Alligator (serrated)(serrated)

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Serrated forceps and cup forceps

Cup forceps with central tooth

Examples of biopsy forcepsExamples of biopsy forceps

Forceps may be single use or reusable

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Endobronchial biopsy:Endobronchial biopsy:EElectrocautery forceps can be usefullectrocautery forceps can be useful

Hot biopsy forceps in the Hot biopsy forceps in the diagnosis of endobronchial diagnosis of endobronchial lesionslesions 39 patients with 6 biopsies each 39 patients with 6 biopsies each

(hot and cold)(hot and cold) Pathologic concordance between Pathologic concordance between

hot and cold biopsies was 92.5% hot and cold biopsies was 92.5% and 87% (2 pathologists)and 87% (2 pathologists)

Small reduction in mild bleeding Small reduction in mild bleeding episodes with hot forceps (at 40-episodes with hot forceps (at 40-60-80-100 W)60-80-100 W)

Authors: routine use not warranted Authors: routine use not warranted – can use as cold with set up for – can use as cold with set up for EC if significant bleeding occursEC if significant bleeding occurs

(from Olympus America)

Eur Respir J 2007; 29:108-111Eur Respir J 2007; 29:108-111

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Approach Open forceps Close and biopsy

Biopsy techniquesBiopsy techniques Engage as much tissue as possibleEngage as much tissue as possible Keep scope as close to target tissue as possibleKeep scope as close to target tissue as possible May feel tugging sensation as forceps retractedMay feel tugging sensation as forceps retracted

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Obtaining the best specimen Obtaining the best specimen possiblepossible

Use forceps with central tooth, especially if Use forceps with central tooth, especially if lesion is along lateral wall of trachea or lesion is along lateral wall of trachea or bronchi.bronchi.

Obtain deep submucosal biopsies to increase Obtain deep submucosal biopsies to increase yield for small cell carcinoma, Amyloidosis, yield for small cell carcinoma, Amyloidosis, Sarcoidosis and other infiltrating processes.Sarcoidosis and other infiltrating processes.

Get close to the target area with the Get close to the target area with the bronchoscope.bronchoscope.

Click here for video

AA BB

Deep, submucosal biopsyDeep, submucosal biopsy

Wedge the forceps onto the target area, push on the forceps to dig into the tissues, then close forceps

Grade 4 Squamous Cell Carcinoma in LMBGrade 4 Squamous Cell Carcinoma in LMB

Use cup forceps or forceps with central tooth Use cup forceps or forceps with central tooth

to anchor forceps onto lateral wall lesionsto anchor forceps onto lateral wall lesions

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Yield of endobronchial Yield of endobronchial biopsybiopsy

Respir Med 1998;92:1110-5 82% yield for malignancy if disease visible82% yield for malignancy if disease visible Best yield probably with combination of Best yield probably with combination of

brushings, washings, and biopsy materialbrushings, washings, and biopsy material Optimum sequence of procedures unknownOptimum sequence of procedures unknown

Thorax 1982;37:684-7 4-5 biopsy samples from visible lesion 4-5 biopsy samples from visible lesion

achieves at least a 90% positive rate for achieves at least a 90% positive rate for malignancymalignancy22

EBNA and TBNA probably superior to forceps EBNA and TBNA probably superior to forceps biopsy in submucosal and peribronchial biopsy in submucosal and peribronchial carcinomacarcinoma

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Diagnosis of Lung Diagnosis of Lung CancerCancer

Endobronchial Endobronchial Biopsy:Biopsy:

3-5 biopsies for 90 – 100 3-5 biopsies for 90 – 100 sensitivity in lung cancersensitivity in lung cancer

Variable yield 67 – 100% Variable yield 67 – 100% d/t:d/t: Sampling error, Sampling error, crush artifacts, surface crush artifacts, surface

necrosis, inadequate necrosis, inadequate tissuetissue

submucosal disease submucosal disease extrinsic compressionextrinsic compression

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Endobronchial biopsy:Endobronchial biopsy:Biopsy or wash first ?Biopsy or wash first ?

Yield: Effect of different bronchial washing sequences Yield: Effect of different bronchial washing sequences on diagnostic yield in endoscopically visible lung cancer on diagnostic yield in endoscopically visible lung cancer 75 patients underwent washing pre/post 75 patients underwent washing pre/post

endobronchial biopsy and brushingendobronchial biopsy and brushing

Arch Bronconeumol. 2006;42(6):278-82

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Endobronchial biopsy:Endobronchial biopsy:SarcoidosisSarcoidosis

Yield: Endobronchial biopsy (EBB) for sarcoidYield: Endobronchial biopsy (EBB) for sarcoid 34 patients underwent TBBX and EBB34 patients underwent TBBX and EBB If airways appeared normal – biopsies from main If airways appeared normal – biopsies from main

and a secondary carinaand a secondary carina EBB positive in 62%EBB positive in 62% TBBX positive in 59%TBBX positive in 59% Addition of EBB increased yield by 21%Addition of EBB increased yield by 21% EBB positive in 30% of patients with normal airwayEBB positive in 30% of patients with normal airway No additional complications from EBBNo additional complications from EBB

CHEST 2001;120:109-114

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False negatives do occurFalse negatives do occur

Due to necrotic surface Due to necrotic surface or if process 2-3 mm or if process 2-3 mm below mucosal surfacebelow mucosal surface Absence of blood Absence of blood

suggests necrosissuggests necrosis Therefore, take Therefore, take

biopsies until the core biopsies until the core is reachedis reached

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Case example: 72 year old with Case example: 72 year old with hemoptysishemoptysis

72 year old, non-72 year old, non-smoker female smoker female with Diabetes, on with Diabetes, on 50 mg/d 50 mg/d Prednisone Prednisone presents with presents with hemoptysis, fever hemoptysis, fever and wheezing.and wheezing.

ANCA negativeANCA negative ANA negativeANA negative PPD negativePPD negative

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Your diagnosis is ?Your diagnosis is ?

A.A. Endobronchial Endobronchial Wegener'sWegener's

B.B. Endobronchial Endobronchial tuberculosistuberculosis

C.C. Tracheobronchitis Tracheobronchitis from inflammatory from inflammatory bowel diseasebowel disease

D.D. Squamous cell Squamous cell carcinomacarcinoma

E.E. Endobronchial Endobronchial CryptococcosisCryptococcosis

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The answer is Endobronchial The answer is Endobronchial CryptococcosisCryptococcosis

Rare, Incidence Rare, Incidence unknownunknown

Presentation: Presentation: Mass, plaque, Mass, plaque, sub-mucosal sub-mucosal infiltration, Ulcerinfiltration, Ulcer

From: JOB 2005; 12(4): From: JOB 2005; 12(4): 236-238236-238

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Complications of endobronchial Complications of endobronchial biopsybiopsy

Chest 1991;100:1141-7 Profuse bleeding less likely than in Profuse bleeding less likely than in

Transbronchial biopsies Transbronchial biopsies Increased risk in Uremia, pulmonary Increased risk in Uremia, pulmonary

hypertension, liver disease, hypertension, liver disease, thrombocytopenia and immunosuppressionthrombocytopenia and immunosuppression

Superior vena cava syndrome – no Superior vena cava syndrome – no literature on risk of biopsy bleedingliterature on risk of biopsy bleeding

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Complications of endobronchial Complications of endobronchial biopsybiopsy

Thorax 2001;56(suppl I)i1-i21 British Thoracic Society guidelines Routine PT/PTT/platelet counts not Routine PT/PTT/platelet counts not

indicated unless known risk factorsindicated unless known risk factors It is unclear whether there is a safe level It is unclear whether there is a safe level

of INR or plateletsof INR or platelets

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This presentation is part of a This presentation is part of a comprehensive curriculum for comprehensive curriculum for

Flexible Bronchoscopy. Our Flexible Bronchoscopy. Our goals are to help health care goals are to help health care

workers become better at what workers become better at what they do, and to decrease the they do, and to decrease the burden of procedure-related burden of procedure-related

training on patients.training on patients.

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Step by Step©

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All efforts are made by Bronchoscopy All efforts are made by Bronchoscopy International to maintain currency of online International to maintain currency of online information. All published multimedia slide information. All published multimedia slide

shows, streaming videos, and essays can be shows, streaming videos, and essays can be cited for reference as:cited for reference as:

Bronchoscopy International: Art of Bronchoscopy, an Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2007 (Please add “Date Accessed”).Published 2007 (Please add “Date Accessed”).

Thank you

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Prepared with the expert assistance of Udaya Prepared with the expert assistance of Udaya Prakash M.D. (Mayo Clinic, USA), and Atul Mehta Prakash M.D. (Mayo Clinic, USA), and Atul Mehta M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Virginia Commonwealth University, USA)M.D. (Virginia Commonwealth University, USA)

www.bronchoscopy.org