Editorial
Transbronchial Cryobiopsy in Interstitial Lung Disease: Advantageous Costs to Benefits Ratio
La criobiopsia transbronquial en la enfermedad pulmonar intersticial: excelente relación coste/beneficio
M. Ángeles Montero Fernández
Royal Brompton and Harefield NHS Trust Foundation and Imperial College, London, United Kingdom
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Ángeles Montero Fernández" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M. Ángeles" "apellidos" => "Montero Fernández" "email" => array:1 [ 0 => "m.monterofernandez@rbht.nhs.uk" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Royal Brompton and Harefield NHS Trust Foundation and Imperial College, London, United Kingdom" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La criobiopsia transbronquial en la enfermedad pulmonar intersticial: excelente relación coste/beneficio" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Interstitial lung disease (ILD) comprises a group of pathologies characterized histologically by different degrees of pulmonary parenchymal inflammation and fibrosis. So far, around 150 causes of ILD have been identified. Idiopathic pulmonary fibrosis (IPF), the prototype of ILD, is diagnosed in one-third of all cases. Despite advances in diagnosis and therapy, ILD prognosis continues to be as poor as that of lung cancer.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">International diagnostic guidelines for ILD accept that in around half of all cases the disease can be diagnosed using high-resolution chest computed tomography (HRCT) in a suitable clinical setting, without the need for open lung biopsy (OLB), with the proviso that multidisciplinary committees determine definitive diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> Situations in which more information can be gained from lung biopsy than from HRCT are defined in the latest version of the guidelines, although OLB is still the only biopsy considered suitable for identifying the histological patterns by which clinicians can determine the possible causes of the disease.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Nevertheless, 2 large studies found that OLB was performed as a diagnostic procedure in 22% and 54% of IPF patients, respectively.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> Complications associated with acquiring tissue samples for biopsy in patients with compromised lung function, problems with the tissue sample, the slight but ever present risk of mortality,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and high surgery and hospitalization costs have considerably undermined this practice.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Some clinicians believe that the technical and clinical complications presented by each patient, along with the lack of an effective treatment for IPF, have made histological diagnosis from lung biopsy redundant in this disease. Despite this, histological diagnosis continues to be an important factor in the multidisciplinary assessment of a considerable number of cases. In ILD, a definitive diagnosis is essential for clinicians to determine the causative agent, provide the best possible treatment, and determine prognosis, which can vary according to etiology. Interestingly, the findings of a recent study<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> confirmed the effectiveness of pirfenidone in stabilizing IPF, suggesting that early HRCT diagnosis of atypical IPF and administration of pirfenidone or some other new therapy may achieve greater disease stabilization.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Transbronchial biopsy is discouraged in ILD, mainly because the possibility of artefacts and the small size of the sample obtained using this procedure prevent a detailed study of tissue architecture. The first diagnostic guidelines for ILD were based on fibrosis and inflammation patterns seen on OLBs, which enabled pathologists to define the extent of the disease. However, microscopic study is at best complex and at worst impossible in the case of tiny specimens that have been crushed by conventional forceps. These problems, however, can be avoided if ILD diagnostic protocols include the use of cryobiopsy. Transbronchial cryobiopsy has been used successfully for the removal of endobronchial tumors for 27 years,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> and the use of cryobiopsy in ILD has been the focus of many recent studies.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In <span class="elsevierStyleItalic">Archivos de Bronconeumología</span>, Hernández-González et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> described their experience with this technique, and also estimated the economic cost of using cryobiopsy techniques in ILD. Although theirs was not the largest cohort (33 patients), they reported a diagnostic yield similar to that obtained in other studies (79%). Incidence and type of complications associated with the procedure, such as pneumothorax and bleeding, vary between studies. Fruchter et al.,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> in the largest cohort (75 patients), reported 4% mild to moderate bleeding and 2.6% pneumothorax. These figures are far below those described by Pajares et al. (56.4% and 7.7%)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and Hernández-González et al. (30% and 12%),<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> although the authors stress that both pneumothorax and bleeding improve with routine clinical strategies. Only 1 study reports worsening of the patient's condition following cryobiopsy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> An observation common to all studies is the larger size of the specimen obtained compared to transbronchial biopsy (4–43.11<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>)<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,10</span></a> and the absence of crush artefacts. The series studied by Hernández-González, however, is the first to give a detailed analysis of the cost of cryobiopsy in ILD.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This aspect is particularly important in situations in which cost-effectiveness is prioritized over other considerations. The authors conclude that cryobiopsy is €953.09 more economical per patient than OLB when performed on an outpatient basis, and €1925.29 more economical in the case of a 48-h hospital stay.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although further research is needed to compare the cost-effectiveness of OPB and cryobiopsy, all studies published so far highlight the indisputable advantage of cryobiopsy and the almost total absence of complications. On this basis, the technique should be included in ILD diagnostic protocols.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montero Fernández MÁ. La criobiopsia transbronquial en la enfermedad pulmonar intersticial: excelente relación coste/beneficio. Arch Bronconeumol. 2015;51:257-258.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prednisone, azathioprine, and N-acetylcysteine for pulmonary fibrosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Raghu" 1 => "K.J. Anstrom" 2 => "T.E. King Jr." 3 => "J.A. Lasky" 4 => "F.J. 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| 2019 July | 17 | 13 | 30 |
| 2019 June | 27 | 8 | 35 |
| 2019 May | 47 | 22 | 69 |
| 2019 April | 44 | 14 | 58 |
| 2019 March | 48 | 21 | 69 |
| 2019 February | 41 | 24 | 65 |
| 2019 January | 64 | 20 | 84 |
| 2018 December | 43 | 21 | 64 |
| 2018 November | 98 | 24 | 122 |
| 2018 October | 143 | 21 | 164 |
| 2018 September | 55 | 14 | 69 |
| 2018 May | 26 | 0 | 26 |
| 2018 April | 30 | 7 | 37 |
| 2018 March | 71 | 7 | 78 |
| 2018 February | 54 | 12 | 66 |
| 2018 January | 48 | 9 | 57 |
| 2017 December | 41 | 9 | 50 |
| 2017 November | 30 | 8 | 38 |
| 2017 October | 29 | 11 | 40 |
| 2017 September | 38 | 13 | 51 |
| 2017 August | 31 | 20 | 51 |
| 2017 July | 27 | 18 | 45 |
| 2017 June | 42 | 33 | 75 |
| 2017 May | 42 | 30 | 72 |
| 2017 April | 30 | 16 | 46 |
| 2017 March | 30 | 23 | 53 |
| 2017 February | 22 | 10 | 32 |
| 2017 January | 40 | 15 | 55 |
| 2016 December | 38 | 13 | 51 |
| 2016 November | 46 | 18 | 64 |
| 2016 October | 51 | 26 | 77 |
| 2016 September | 47 | 21 | 68 |
| 2016 August | 46 | 13 | 59 |
| 2016 July | 42 | 9 | 51 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 34 | 2 | 36 |
| 2015 September | 15 | 10 | 25 |
| 2015 August | 0 | 1 | 1 |
| 2015 July | 0 | 3 | 3 |
| 2015 June | 0 | 1 | 1 |
Show all
