Surgical lung biopsy

A medical history, physical examination, PFTs, and HRCT should be performed on all patients with suspected DPLD. In many cases, this will provide sufficient data for a diagnosis. In others, the diHerential diagnosis will require additional ancillary testing. The most common of these procedures are bronchoscopy, serologies, and surgical lung biopsy. 

Collard HR, King TE Jr. The clinical significance of histopathologic subgroups in idiopathic interstitial pneumonia is surgical lung biopsy essential Semin Respir Crit Care Med 2001 22 347-356. 

When CT features are classical for UIP, the accuracy of a confident diagnosis by CT by experienced observers is 90% to 1(X)% (12,14,17,20,21). In this context, surgical biopsy is not warranted. However, less than two-thirds of patients with histological UIP display classical features of UIP on CT (2,12-14,22). In these patients, surgical lung biopsies should be performed to substantiate a specific histological diagnosis (2,12,14). 

Parambil JG, Meyers JL, Ryu JH. Histopathologic feamres and outcome of patients with acute exacerbation of idiopathic pulmonary fihrosis undergoing surgical lung biopsy. Chest 2005 128 3310-3315. 

Surgical lung biopsy is rarely required to diagnose sarcoidosis. However, when the above procedures are not definitive, biopsy of mediastinal lymph nodes and/or lung may be warranted. This can be done with cervical mediastinoscopy, the Chamberlain procedure (a parasternal mini-thoracotomy to biopsy aortopulmonary window or para-aortic nodes), or video-assisted thoracoscopic surgical biopsy (VATS) (28,108). 

Monaghan H, Wells AU, Colby TV, et al. Prognostic implications of histologic patterns in multiple surgical lung biopsies from patients with idiopathic interstitial pneumonias. Chest 2004 125(2) 522-526. 

Figure 3 HRTC scan from a 47-year-old female. (A) The upper lobes show peripheral reticular thickening. (B) The lower lobes show GGO. The HRCT picture was felt to be consistent with NSIP however, the surgical lung biopsy showed UIP. Abbreviations HRCT, high-resolution computed tomography GGO, ground-glass opacities NSIP, nonspecific interstitial pneumonia UIP, usual interstitial pneumonia.

Kondoh Y, Taniguchi H, Kitaichi M, et al. Acute exacerbation of interstitial pneumonia following surgical lung biopsy. Respir Med 2006 100 1753-1759. 

Organizing Diffuse Alveolar Damage on surgical lung biopsy... 

With the publication of two international consensus statements on the IIP, the American Thoracic Society and the European Respiratory Society formally recognized AIP as a distinct IIP with cardinal features of rapid symptom onset, unknown causation, and the presence of a DAD pattern on surgical lung biopsy (8,9). As these same clinical and pathologic features are present in patients with known causes of lower respiratory tract disease, in particular the acute respiratory distress syndrome (ARDS) and overwhelming lower respiratory tract infection, AIP is by necessity, a diagnosis of exclusion (Table 1). 

The underlying cause of AIP is by definition unknown, and while an understanding of the pathobiology would provide the template for treatment, only hypotheses are available. As with most of the interstitial lung diseases, these hypotheses are driven by the pathologic pattern seen on surgical lung biopsy. 

Parambil JG, Myers JL, Aubry MC, et al. Causes and prognosis of diffuse alveolar damage diagnosed on surgical lung biopsy. Chest 2007 132(l) 50-57. 

The diagnostic evaluation requires samples from the lower respiratory tract. While some individuals have advocated a surgical lung biopsy, most practitioners will perform bronchoscopy with bronchoalveolar lavage (BAL). The BAL is sent for cultures for bacteria, mycobacteria, and fungi. A ceU count in acute lupus pneumonitis is typically neutrophil predominant. Exclusion of pulmonary emboli is usually performed, particularly if the patient has circulating antiphospholipid antibodies. 

Maldonado F, Daniels CE, Hoffman EA, et al. Focal organizing pneumonia on surgical lung biopsy causes, clinicoradiologic features, and outcomes. Chest 2007 132 1579-1583. 

Xhe triad of pulmonary arterial hypertension, radiographic evidence of pulmonary edema, and normal pulmonary artery occlusion pressure suggests PVOD. Xhe definitive diagnosis of PVOD requires surgical lung biopsy or necropsy. Xhere is no proven therapy for PVOD. Xhere are case reports of steroid therapy in BMX recipients with PVOD, with conflicting results (1). 

Renal biopsies are more common than lung biopsies, probably reflecting the higher complexity of a surgical lung biopsy. Also, the IF staining seen in a lung biopsy may be technically inferior to that of a renal biopsy (84). Nevertheless, IF... 

BAL is a good noninvasive surrogate of lung biopsy for the diagnosis of eosinophilic pneumonias, and surgical lung biopsy is rarely necessary, although... 

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