Bronchoscopic lung cryobiopsy increases diagnostic confidence in the multidisciplinary diagnosis of idiopathic pulmonary fibrosis. Sara Tomassetti, Athol U Wells, Ulrich Costabel, Alberto Cavazza, Thomas V Colby, Giulio Rossi, Nicola Sverzellati, Angelo Carloni, Elisa Carretta, Matteo Buccioli, Paola Tantalocco, Claudia Ravaglia, Christian Gurioli, Alessandra Dubini, Sara Piciucchi, Jay H Ryu, and Venerino Poletti ONLINE DATA SUPPLEMENT
on line Supplement 1 Materials and Methods Clinical assessment We collected data following a prospective clinical protocol at the time of the first visit of patients at our Institution, during which the diagnosis of ILD was established. Complete clinical information (including onset, symptoms, detailed history of exposure, family history, past medical history and medications), pulmonary function data, laboratory tests (including blood cell count, LDH, CRP, ESR, liver and kidney function profile, serum protein ELF, autoimmunity ANA ENA ANCA), and good quality HRCT were available in all cases. Precipitins were performed only in selected cases and among the 117 cases of this study were available in the vast majority (113/117, 97%; 87 negative and 26 positive). BAL and follow-up at our institution were performed whenever possible as a prospective clinical intention. BAL were performed in 114/117 (97%), confirming a rigorous clinical protocol at diagnosis. Follow-up data were available in 36 (62%) cases of BLC and in 47 (80%) cases of SLB. During the multidisciplinary meeting clinical data were reviewed by two radiologists (AC and NS), two clinicians (AUW and UC) and two pathologists (AC and GR) in a sequential manner, from step 3 to step 8 (Fig 1). Radiological assessment HRCT images performed within 12 months prior to biopsy and during follow-up were reviewed by two radiologists (AC and NS). Radiologists recorded their diagnostic impressions during the multidisciplinary meeting, from step 1 to step 8 (Fig. 1). 1 or 1.5-mm collimation sections were obtained at 10-mm intervals or volumetrically on multi-detector CT scanners with 0.6- or 1-mm collimation and 1-mm reconstruction. All images were de-identified and reviewed at window settings optimized for lung parenchyma (width, 1500 1600 HU; level, -500 to -600 HU). All patients included in this study had an HRCT pattern of fibrotic DPLD defined as possible UIP or E2
inconsistent with UIP according to current guidelines (3). The radiologic pattern was also inconsistent with sarcoidosis, Langerhans cell histiocytosis or other patterns of cystic or nodular diseases. E3
etable 1 Flowchart for inclusion of patients in the prospective ILD-database and in this study. etable 2 - Changes in confidence levels after addition of biopsy informations in the MDD process. etable 3 Diagnosis of each participant through each step of the study etable 4 From pathologists impressions to multidisciplinary diagnosis of IPF. etable 5 Cases in which BAL changed the participants confidence level etable 6 Cases in which BAL changed the initial clinical-radiologic diagnostic impression. etable 7 Cases in which follow-up (step 8) changed the initial multidisciplinary diagnosis (step 6). E4
etable 1 Flowchart for inclusion of patients in the prospective database and in this study. A proportion of older cases in the SLB (surgical lung biopsy) group were not invited to participate in the prospective interstitial lung diseases database (ILD-database) and were not assessed for eligibility (N=29). Among the total 129 patients recruited in the ILD-database, were used for this study all 58 cryobiopsy cases, and 59 out of 71 surgical lung biopsy cases. 12 old cases diagnosed by surgical lung biopsy were excluded from this study because of UIP pattern on HRTC. The final 117 cases selected for this study are consecutive cases of fibrotic ILD without UIP pattern on HRCT followed at out Institution. E5
etable 2. Changes in confidence levels after addition of biopsy informations in the MDD process. Clinical review (step 2) Clinical review plus BLC (step 6) Clinical review (step 2) Clinical review plus SLB (step 6) p value 3 IPF- H 3 IPF-H 2 IPF- H 2 IPF-H 1 11 IPF-I 10 IPF-H 5 IPF-H 0.596 1 IPF-I 6 IPF-I 1 IPF-L 4 IPF-L 3 IPF-H 1 IPF-I 5 IPF-L 5 IPF-H 0.444 31 non-ipf 9 no consensus 2 IPF-H 1 IPF-H 0.848 3 IPF-I 3 IPF-I 3 IPF-L 2 IPF-L 34 non-ipf 22 non-ipf 23 non-ipf 0 no consensus 4 no consensus 1 unclassifiable 1 unclassifiable 1 IPF-H 2 IPF-H 0.914 0 IPF-I 1 IPF-I 2 IPF-L 1 IPF-L 11 no consensus 2 non-ipf 4 non-ipf 3 no consensus 2 no consensus 1 unclassifiable 1 unclassifiable 0 unclassifiable NA 1 unclassifiable 1 no-ipf - E6
etable 3 Diagnosis of each participant through each step of the study BLC SLB Clinician Radiologist Pathologist Clinician Radiologist Pathologist UC AUW AC NS AC GR UC AUW AC NS AC GR STEP 1 IPF 24 19 18 17 NA NA 15 16 12 14 NA NA NSIP 13 11 13 12 NA NA 13 8 9 7 NA NA HP 8 12 11 15 NA NA 12 17 13 15 NA NA DIP/RB-ILD 2 3 2 2 NA NA 4 2 2 2 NA NA OTHER 11 13 14 12 NA NA 14 16 21 20 NA NA UNCLASS 0 0 0 0 NA NA 1 0 2 1 NA NA STEP 2 IPF 22 20 21 21 NA NA 14 16 15 16 NA NA NSIP 10 13 11 12 NA NA 12 9 9 7 NA NA HP 12 12 11 12 NA NA 14 16 15 16 NA NA DIP/RB-ILD 3 3 3 2 NA NA 4 2 2 2 NA NA OTHER 11 10 12 11 NA NA 14 14 16 16 NA NA UNCLASS 0 0 0 0 NA NA 1 2 2 2 NA NA STEP 3 IPF 22 17 19 19 20 20 16 16 18 16 16 18 NSIP 14 12 12 10 8 12 10 10 8 7 7 10 HP 7 11 10 13 14 10 11 13 11 15 12 10 DIP/RB-ILD 2 4 4 3 2 2 5 3 2 2 3 3 OTHER 11 12 11 11 12 12 15 14 17 16 15 16 UNCLASS 0 0 0 0 0 0 1 2 2 2 5 1 STEP 4 IPF 22 20 23 21 23 22 16 16 17 17 17 18 NSIP 12 13 11 11 10 12 9 10 8 8 8 7 HP 9 11 9 10 10 9 11 11 11 12 11 11 DIP/RB-ILD 2 2 2 2 2 2 5 4 4 4 4 5 OTHER 11 10 11 12 11 11 16 16 17 16 15 16 UNCLASS 0 0 0 0 0 0 1 1 1 1 3 1 STEP 5 IPF 28 29 28 27 31 31 22 22 21 25 27 31 NSIP 8 9 8 7 6 8 7 5 5 2 3 3 HP 10 8 9 11 8 6 12 13 14 15 13 10 DIP/RB-ILD 3 2 3 2 3 3 4 4 5 3 3 4 OTHER 8 9 9 11 9 9 12 13 12 13 11 10 UNCLASS 1 1 1 0 1 1 2 2 2 1 2 1 STEP 6 IPF 30 29 30 30 31 31 24 24 24 23 25 25 NSIP 8 9 8 8 7 7 6 6 6 6 5 6 HP 7 7 6 7 7 7 11 11 12 12 12 11 DIP/RB-ILD 2 2 2 2 2 2 4 4 4 4 4 4 OTHER 9 9 10 9 9 9 12 12 11 12 11 11 UNCLASS 2 2 2 2 2 2 2 2 2 2 2 2 STEP 7 E7
IPF 20 20 19 20 22 22 21 23 22 24 24 23 NSIP 6 6 6 5 4 4 4 4 4 4 4 4 HP 4 4 5 5 4 4 8 6 7 6 6 6 DIP/RB-ILD 0 0 0 0 0 0 3 2 2 3 2 3 OTHER 6 6 6 6 6 6 10 11 11 9 10 10 UNCLASS 0 0 0 0 0 0 1 1 1 1 1 1 STEP 8 IPF 20 20 20 21 21 21 24 26 24 23 24 24 NSIP 5 5 5 4 4 4 4 3 4 4 4 4 HP 5 5 5 5 5 5 6 5 6 6 6 6 DIP/RB-ILD 0 0 0 0 0 0 3 3 3 3 3 3 OTHER 6 6 6 6 6 6 9 9 9 10 9 9 UNCLASS 0 0 0 0 0 0 1 1 1 1 1 1 E8
etable 4 From pathologists impressions to multidisciplinary diagnosis of IPF. The table shows how blind pathologic impression of UIP cases, translated into multidisciplinary diagnosis of IPF (step 6). Pathologic diagnosis of UIP are stratified in two groups according to pathologists confidence level in their blind assessment (UIP-H, high confidence; UIP-L, low confidence). Bronchoscopic Lung Cryobiopsy Surgical Lung Biopsy Pathologic Pathologic Impression MDD (step 6) Impression MDD (step 6) N N (%) diagnosis N N (%) diagnosis 21 UIP-H 19 (90) IPF 22 (63) IPF 2 (10) Other* 35 UIP-H 8 (23) Other 5 (14) No Consensus 19 UIP-L 10(53) IPF 1(17) IPF 5(26) Other^ 4(67) Other 6 UIP-L 3(16) No Consensus 1(17) No Consensus 1(5) Unclassifiable * 2 cases of ILDs related to connective tissue diseases. ^ 3 cases of HP, 1 case of insip and 1 case of ILD related to connective tissue disease. 6 cases of HP, 1 case of ILD related to connective tissue disease and 1 case of DIP (in this case DIP and UIP pattern were coexistent in the biopsy) 1 case of HP, 1 case of idiopathic pleuro-parenchymal fibroelastosis, 2 cases of insip. E9
etable 5 - Cases in which BAL increased the observers confidence level. Change of confidence levels between step 2 (clinical-radiologic) and 4 (BAL). Data were collected in two subgroups of 56 patients among BLC and 58 patients among SLB, in whom BAL had been performed. All diagnosis made at step 4 here reported were subsequenty confirmed by biopsy, except for the two cases reported below *^ Observers Confidence Level Diagnosis (step 4 - BAL) from Intermediate to High 5 IPF; 1 DIP; 1 LIPOID PN.; 1 EOSIN.PN.; 1 GRANULOMATOSIS RELATED TO COMMON VARIABLE IMMUNODEFICIENCY from Low to High 1 LIPOID PN.*; 1 RB-ILD; 1 HP from Low to Intermediate 3 IPF; 3 NSIP; 1 AIP^ * the diagnosis of LIPOID PN. was changed into IPF-LIPOID PNEUMONIA after biopsy revision. ^ the diagnosis of AIP was changed into acute-exacerbation of IPF after biopsy. E10
etable 6 Cases in which BAL changed the initial clinical-radiologic diagnostic impression. Change of diagnostic impression between step 2 (clinical-radiologic), 4 (BAL) and 6 (biopsy). Data were collected in two subgroups of 56 patients among BLC and 58 patients among SLB, in whom BAL had been performed. ID # BIOPSY STEP 2 (clinical-radiologic) STEP 4 (BAL) STEP 6 (biopsy) 5 SLB IPF-NSIP IPF IPF 13 SLB NSIP-HP NSIP HP 21 SLB NSIP-IPF-LIPOID PNEUMONIA LIPOID PNEUMONIA IPF-LIPOID PNEUMONIA 54 SLB NSIP-SARCOIDOSIS SARCOIDOSIS SARCOIDOSIS 73 SLB UNCLASSIFIABLE-RB-ILD RB-ILD RB-ILD 89 SLB HP-DIP DIP NSIP/IPF 14 BLC IPF-HP HP IPF 24 BLC insip IPF IPF 32 BLC HP NSIP IPF 78 BLC NSIP-IPF IPF IPF E11
etable 7 Cases in which follow-up (step 8) changed the initial multidisciplinary diagnosis (step 6). ID # BIOPSY STEP 6 (MDD after biopsy) STEP 8 (follow-up) 23 BLC IPF-NSIP IPF 34 BLC IPF HP 1 SLB IPF ILD-CVD 47 SLB HP-IPF IPF 97 SLB HP IPF 116 SLB IPF HP E12
Supplementary Figure Legends efig 1. Interobserver agreement measured as Kappa coefficient. Was evaluated the interobserver agreement among the two radiologists, the two clinicians and the two pathologists, and the overall Kappa among all six observers for the discrimination between IPF and non-ipf cases (any confidence level). efig 2. Pathologists independent interpretations of SLB and BLC specimens. Biopsy specimens were considered adequate when containing at least one alveolated fragment and diagnostic when containing features sufficient to define a pathologic pattern. Pathologists confidence levels in their blind identification of UIP were stratified into two groups, high (H) and low (L). Kappa value measures the interobserver agreement among the three pathologists for the discrimination between UIP and non-uip cases. E13
efigure 1 E14
efigure 2. STEPS CLINICIANS RDIOLOGISTS PATHOLOGISTS OVERALL BLC Kappa 95%CI Kappa 95%CI Kappa 95%CI Kappa 95%CI 1 0.58 0.36 0.80 0.34 0.07 0.61 - - 0.47 0.36 0.58 2 0.93 0.82 1.00 0.93 0.82 1.00 - - 0.90 0.79 1.00 3 0.66 0.47 0.86 0.92 0.81 1.00 0.85 0.70 0.99 0.79 0.72 0.86 4 0.82 0.66 0.97 0.93 0.83 1.00 0.89 0.77 1.00 0.89 0.82 0.96 5 0.76 0.59 0.93 0.90 0.78 1.00 0.93 0.84 1.00 0.84 0.77 0.91 6 0.97 0.90 1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.96 0.89 1.00 7 0.83 0.67 0.99 0.94 0.84 1.00 1.00 1.00 1.00 0.90 0.82 0.98 8 1.00 1.00 1.00 0.94 0.83 1.00 1.00 1.00 1.00 0.97 0.89 1.00 SLB Kappa 95%CI Kappa 95%CI Kappa 95%CI Kappa 95%CI 1 0.46 0.20 0.72 0.52 0.24 0.79 - - 0.42 0.32 0.52 2 0.82 0.65 0.99 0.96 0.87 1.00 - - 0.87 0.77 0.97 3 0.91 0.80 1.00 0.92 0.81 1.00 0.84 0.68 0.99 0.88 0.95 0.81 4 0.91 0.80 1.00 1.00 1.00 1.00 0.96 0.88 1.00 0.94 0.87 1.00 5 0.86 0.72 0.99 0.65 0.45 0.84 0.80 0.65 0.95 0.74 0.67 0.81 6 0.93 0.83 1.00 0.96 0.90 1.00 0.93 0.84 1.00 0.93 0.86 1.00 7 0.89 0.74 1.00 0.92 0.84 1.00 0.96 0.88 1.00 0.87 0.80 0.94 8 0.91 0.80 1.00 0.96 0.88 1.00 1.00 1.00 1.00 0.96 0.89 1.00 E15
These four videos show a bronchoscopic lung cryobiopsy (BLC) in a case of interstitial lung disease (ILD) Video #1 The tools In this video we show the bronchoscopy trays ready for the BLC procedure. In the first tray, from left to right: the rigid bronchoscope (Storz 14), the Fogarty balloon, the tooth-shield and the syringe for laryngeal anesthesia (the laryngoscope used to perform the local laryngeal anesthesia is not shown). In the second tray is the cryoprobe ready for use. Video # 2 Intubation with rigid bronchoscope, Storz 14. Video #3 The Fogarty balloon. The Fogarty balloon and the flexible bronchoscope are both inserted by the bronchoscopist into the rigid bronchoscope. The Fogarty is positioned by the bronchoscopist into the previously chosen segmental bronchus (RB 9) and then is inflated. The Fogarty in then fixed to the rigid bronchoscope with a patch. Video # 4 The cryobiopsy First, the cryoprobe is tested in saline water to ascertain that an ice ball properly freezes around the tip. Then the probe is inserted in the operative channel of the flexible bronchoscope. A nurse holds the cryoprobe with the right hand and holds the rigid bronchoscope with the left hand. The Fogarty balloon is deflated and the cryoprobe is inserted into bronchus RB9. Under fluoroscopic guidance, the tip of the probe is positioned perpendicular to the chest wall and approximately 1cm beneath the pleura. After freezing for 5-6 seconds, the flexible bronchoscope and the cryoprobe are pulled out. The nurse inflates the Fogarty balloon, then helps the bronchoscopist to gently defrost and remove the lung fragment from the tip of the probe into saline solution. The Fogarty balloon is deflated under direct visualization using the bronchoscope. As there is no bleeding, the bronchoscopist perform the second biopsy in the same segment. Once again, before extubating the patient, the bronchoscopist deflates the Fogarty and checks that there is no significant bleeding. Clinical case The patient: 48 year old gentlemen, former smoker (quit in 2013, pack years: 33), without any relevant history of environmental/occupational exposure, or familial ILD. No relevant past medical history, no comorbidities. The patient does not take medications. Reason for referral to our center: evaluation of an ILD diagnosed after a 7 month history of mild dyspnea on exertion, no signs or symptoms of connective tissue disease, unremarkable chest examination. Pulmonary function is normal except for a mild reduction in DLco (FVC 117%, FEV1 119%, DLco 61%). No oxygen desaturation after 6 min walking test. Unremarkable laboratory findings except for ENA anti Jo1 29.0 KUI/L (pos >10). The high resolution computed tomography of the thorax shows a mixed organizing pneumonia and nonspecific interstitial pneumonia (OP-NSIP) pattern (Figure 1). The BAL in the middle lobe (not shown) shows a marked lymphocytosis, microbiology is negative. BLC is taken from the latero-basal segment of the right lower lobe (RB 9), as shown in Figure 1c and in the video #3. The two lung fragments are 6x4mm and 5x5mm (Figure 2). BLC confirms the presence of OP in the E16
context of NSIP with uniform interstitial infiltrate with predominant lymphocytosis, minimal interstitial fibrosis, and numerous lymphoid follicles (Figure 3). Figure 1. High resolution computed tomography of the thorax. The red circle in Figure 1c shows the radiologic features of the area where cryobiopsies are taken. a) b) c) d) Figure 2. BLC fragments. (H&E, low power). Figure 3. OP-NSIP pattern with lymphoid follicles E17