| The role of
transbronchial lung biopsy in the treatment of lung transplant
recipients. An analysis of 200 consecutive procedures.Chest.
1992 Oct;102(4):1049-54.
STUDY
OBJECTIVE: The purposes of this study were as follows: (1) to
establish the positivity rate and complication rate of
transbronchial lung biopsies in the treatment of lung transplant
recipients; (2) to determine the sensitivity of transbronchial lung
biopsy specimens for the diagnosis of clinically suspected acute
rejection and cytomegalovirus pneumonia; and (3) to examine the
results of surveillance transbronchial lung biopsies in clinically
and physiologically stable recipients. DESIGN: Retrospective review
and analysis of 203 consecutive procedures. SETTING: Washington
University Lung Transplantation Program, Washington University
School of Medicine and Barnes Hospital, St. Louis, Mo. PATIENTS:
Fifty-five lung transplant recipients. INTERVENTIONS: Biopsies were
done with 2-mm fenestrated forceps using fluoroscopic guidance. Two
hundred three bronchoscopies with transbronchial lung biopsy were
performed for clinical indications (n = 88), routine surveillance (n
= 90), or follow-up of a previous biopsy (n = 25). Biopsy specimens
showing acute allograft rejection were classified according to the
scheme recommended by the Lung Rejection Study Group. MEASUREMENTS
AND RESULTS: The positivity rate and complication rate were
determined for the procedures. In procedures performed for clinical
indications, the sensitivity for the diagnosis of acute rejection
and cytomegalovirus pneumonia was calculated by a decision-to-treat
analysis. A specific histologic diagnosis was detected in 69 percent
of the clinical procedures, 57 percent of the surveillance
procedures, and 64 percent of the follow-up procedures. For clinical
indications, the sensitivity of transbronchial lung biopsy was 72
percent for the diagnosis of acute rejection and 91 percent for the
diagnosis of cytomegalovirus pneumonia. Surveillance biopsy
specimens often showed clinically inapparent rejection or
cytomegalovirus pneumonia. The overall complication rate was 8.9
percent; none of the complications were life threatening.
CONCLUSIONS: Transbronchial lung biopsy is a useful and safe
procedure in the treatment of lung transplant recipients. When
performed for clinical indications, the procedure proved to be
sensitive for the diagnosis of acute rejection and cytomegalovirus
pneumonia. When performed for surveillance in clinically and
physiologically stable recipients, the incidence of rejection and
cytomegalovirus pneumonia was unexpectedly high; the potential
clinical implications of these findings will require further study.
Transbronchial biopsy in heart and lung transplantation:
clinicopathologic correlations.J
Heart Lung Transplant. 1995 Jul-Aug;14(4):761-73
BACKGROUND AND
METHODS: We reviewed and correlated the histologic and clinical
records for the 1027 transbronchial biopsies performed, as
clinically indicated, in 313 heart and lung transplant recipients in
the Harefield Transplant Unit from 1988 through 1991. Three pieces
of lower lobe or radiologically abnormal lung were routinely sent
for histologic diagnosis. Clinical diagnoses of rejection and
infection were based on symptomatologic, radiologic, and
bacteriologic findings and response to appropriate therapy. Standard
histopathologic technology and diagnostic criteria were used,
including the Working Formulation for the standardization of
nomenclature in the diagnosis of heart and lung rejection grading.
RESULTS: Rejection was the most common finding (22.2%) and showed
good clinicopathologic correlation. With unequivocal histologic
features of rejection (Working Formulation grade A1 or above),
specificity (clinical agreement with biopsy diagnosis) was 93.1% and
sensitivity (clinical rejection confirmed by transbronchial biopsy)
was 61%. Sensitivity increased to 77% if unsatisfactory specimens
were excluded. Possible/probable rejection only was reported in 83
specimens; there were technically unsatisfactory, showed only
minimal perivascular infiltrates, or had infiltrates limited to one
vessel; 71% of these did have clinical rejection. Infection,
excluding opportunistic, was reported in 18.5% of biopsy specimens;
specificity was 70.5% and sensitivity 51.3% (both rising by 9%),
with unsatisfactory specimens excluded. Histologic features of both
rejection and infection were seen in 47 transbronchial biopsy
specimens (4.7%). Where both components appeared definite
specificity was 66.7%, but where either had been doubtful the
clinical diagnosis was most often rejection. Sensitivity was also
66.7%. Cytomegalovirus inclusions were identified in 12.1% of biopsy
specimens, with specificity of 91% and sensitivity of 83.5%.
Sensitivity (88%) and specificity (100%) were both high for the 17
cases with pneumocystis infections. Sensitivity for the 25
transbronchial biopsy specimens from fungal infections was only 20%.
Sensitivity was also poor (27.7%) in obliterative bronchiolitis,
although specificity was 75%. Almost a third of transbronchial
biopsy specimens from patients with obliterative bronchiolitis were
unsatisfactory. Pneumonitis was the only change noted in 68 biopsy
specimens. Most correlated with clinical status, but 26.5% were from
patients with active rejection. Nonspecific changes or no
significant pathologic condition was seen in 278 transbronchial
biopsy specimens; over a third of these were from patients with
clinical rejection (17.7%) or infection (18%) and 6.5% were from
obliterative bronchiolitis cases. Excluding 78 technically
unsatisfactory specimens reduced the proportion of false negative
findings in rejection and infection by 6% and 4%, respectively.
CONCLUSIONS: We found that transbronchial biopsies consisting of
three adequate pieces of lung parenchyma correlated well with
clinical rejections and infections other than fungal but was of
limited value in confirming a diagnosis of obliterative
bronchiolitis or fungal infection.
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