Transbronchial Biopsy for the Diagnosis of Lung Transplant Rejection Comparison with Needle and Open Lung Biopsy Techniques in Canine Lung Allografts'- 3
SPENCER K. KOERNER, JACK W.C. HAGSTROM, and FRANK J. VEITH
SUMMARY __________________________________________________________ The accurate diagnosis of lung transplant rejection requires histologic examination of the grafted lung. Because transbronchial lung biopsy has been advocated as an effective diagnostic procedure for a varietY of lung diseases, it was elected to assess this technique in rejecting transplanted lungs. Twenty-two dogs received allografts and underwent simultaneous lung biopsy by 3 techniques when signs of rejection occurred. Open lung biopsy was diagnostic of rejection in all instances. Transthoracic needle biopsy correlated with the open biopsv in 59 per ce:>t of the cases. No specimen obtained by transbronchial lung biopsy provided sufficient material to permit fulfillment of the strict histologic criteria needed to diagnose allograft rejection. Although transbronchial lung biopsy is successful in many pulmonary infiltrative processes, it appears to be inadequate for the diagnosis of lung allograft rejection.
Introduction Becauoe lung allograft rejection and pneumonia can present in identical fashion, differentiation between them can be made with certainty only by histologic examination of pulmonary tissue obtained by biopsy (l-3). In the clinical situation, with acutely ill patients, obtaining lung (Received for publication Apri/26, 1976) 1 From the James Hilton Manning and Emma Austin Manning Laboratory, Departments of Medicine and Surgery, Montefiore Hospital, and the Albert Einstein College of Medicine and the Department of Pathology, Columbia University College of Physicians and Surgeons, New York, N.Y. 2 Supported in part by grants from the U.S. Public Health Service (HL 17417 and HL 16476), the Stony Wold-Herbert Corporation, the New York Lung Aswciation, and the Manning Foundation. 3 Requests for reprints should be addressed to Spencer K. Koerner, M.D., Montefiore Hospital and Medical Center, Ill East 210th Street, Bronx, N. Y. 10467.
tissue is freyuently attendant with high risk or not feasible at all, so that methods of diagnosis of rejection must be indirect. These involve the recognition of deteriorating pulmonary function in the presence of radiologic infiltrates in the absence of clinical evidence of infection (1). Although this indirect method of diagnosing rejection can be relatively accurate, it is by no means absolute (2, 3), and, in addition, rejection and infection may exist concurrently (4). Lung biopsy is, therefore, the only way to differentiate definitively between these 2 major causes of pulmonary infiltration after lung transplantation. The 3 commonly used biopsy procedures are open lung biopsy, transthoracic needle biopsy, and transbronchial lung biopsy. Open lung biopsy is the best procedure in terms of the diagnostic yield in diffuse lung disease because a large representative piece of tissue can be obtained (5, 6). It is a rather drastic procedure, however, especia:ly in view of the frequent need for histologic material. Transthoracic need:e biopsy has been advocated for the diag-
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 114, 1976
575
576
KOERNER, HAGSTROM, AND VEITH
nosis of diffuse as well as localized lesions of the lung (7, 8) but is associated with sufficient morbidity and mortality to make this procedure dangerous if performed serially (8-10). Recent reports of low morbidity and high diagnostic yield of transbronchial lung biopsy (11, 12) stimula ted a study of this procedure as a possible aid in the diagnosis of lung allograft rejection.
Materials and Methods Twenty-two mongrel dogs underwent left lung allotransplantation and were then treated with azathioprine (2 mg per kg), rabbit antithymocyte globulin (30 rng per kg), and prednisone (2 mg per kg) daily. Chest roentgenograms were obtained daily. When an infiltrate was present in the allograft, the animal was lightly anesthetized with sodium pentobarbital and the allografted lung was biopsied by the 3 different techniques. Transbronchial lung biopsy was performed via a fiberoptic bronchoscope. Under fluoroscopic control, th e tip of a flexible biopsy forceps was advanced to an area of pulmonary infiltrate. The forceps was then opened and wedged into the infiltrate until it could not be advanced any further. The forceps was then closed, removing a piece of tissue approximately 1.5 mm in diameter. Three such biopsies were obtained in all cases. A transthoracic needle biopsy of the same region of lung was then obtained using a Vim Trucut needle (Travenol Laboratories, Inc., Morton Grove, Ill.), again under fluoroscopic control. After this procedure a thoracotomy was performed and an open lung biopsy from the area immediately adjacent to the previous biopsies was obtained. The tissue from all biopsy procedures was paraffin fixed, stained with hematoxylin and eosin, and examined by light microscopy. The triple biopsy procedure was performed between the fifth and twentieth day after transplant, which coincided with the initial appearance of a pulmonary infiltrate. In 18 of the animals the biopsies were done on the sixth, seventh, or eighth day after
TABLE 1 RESULTS OF COMPARATIVE LUNG BIOPSIES IN 22 CANINE ALLOGRAFT RECIPIENTS TransOpen Lung Biopsy Histologic diagnosis of rejection Histologic diagnosis of infiltrates other than rejection Diagnostic yield
18
4
22/22
thoracic TransNeedle bronchial Biopsy Biopsy
10
3 13/22
0
0 0/22
Fig. I. Open lung biopsy obtained during rejection crisis showing interstitial and perivascular lymphocytic infiltration. (Hematoxylin and eosin stain; original magnification: X 50.) tra nsplanta tion. After the open lung biopsy, intensive immunosuppressiv e therapy was i.nstituted with the addition of methyl prednisolone sodium succinate (30 mg per kg) administered intravenously twice daily until there was regression of the radiologic infiltrate or the animal died. Sixteen animals died within a f ew days of the diagnosis and autopsy was performed with multiple sections of the trans planted lung. The 6 surviving animals were used for other studies of lung allograft function. The histologic criteria of lung allograft rejection are lymphocytic infiltration of the interstitium of the lung and perivascular cuffing by round cells (13, 14), both of which had to be present for the diagnosis of rej ection to be applied to any specimen.
Results As seen in table I, 18 of the 22 biopsy specimens obtained by the open chest technique demonstrated histologic evidence of rejection. The remaining 4 specimens showed evidence of other infiltrative processes, including hemorrhage, infarction, and parasitic infection. The open lung biopsy was, therefore, diagnostic in all cases. Postmortem examination of the lungs in the 16 animals that died revealed histologic findings
TRANSBRONCHIAL BIOPSY IN LUNG TRANSPLANT REjECTION
577
mented rejection showing sparse infiltration with lymphocytes. Discussion
Fig. 2. Transthoracic needle biopsy of the same ani· mal in figure l obtained just before the open lung biopsy. There are interstitial lymphocytes and peri· vascular round cell infiltrates. (Hematoxylin and eosin stain; original magnification: X 50.) similar to the open lung biopsy. A typical open lung biopsy specimen in an animal with a rejection crisis is shown in figure l. In the IS animals with rejection, 10 of the transthoracic needle biopsy specimens were also diagnostic of rejection, revealing histologic findings similar to the open lung biopsy. In the 4 animals with infiltrates not secondary to rejection, the needle biopsy was diagnostic in 3. Therefore, the n eedle biopsy correlated with the open biopsy in 13 of 22 instances (59 per cent). Figure 2 shows the needle biopsy specimen obtained on the same animal as in figure I, demonstrating findings similar to the open lung biopsy. In no case was the transbronchial lung biopsy adequate to allow the diagnosis of rejection or infection. There was evidence of inflammatory disease in all the specimens, including diffuse round cell infiltrates, but these findings were nonspecific and were considered insufficient to permit the diagnosis of rejection. Perivascular cuffs of mononuclear cells were not observed. Figure 3 is a transbronchial lung biopsy of the same animal as in figures I and 2, with docu-
The inability to diagnose lung allograft rejection by means of transbronchial lung biopsy is certainly unexpected in view of the favorable results obtained in the diagnosis of a variety of other pulmonary infiltrative diseases. We fully expected to obtain a comparable diagnostic yield with this method that could then be applicable to the difficult clinical differentia tion of rejection from infection. All 5 patients who have undergone lung tran splantation at this institution developed pulmonary infiltrates and clinically deteriorated within 10 days of surgery (1, 4). In 2 of these p atients we indirectly diagnosed rejection because of pulmonary infiltrates, fever, and a decrease in arterial oxygen tension during a period when the sputum smear was unchanged. In one patient there was total absence of bacteria or fungi, and examination of the sputum in the other patient revealed the same bacterial flora on serial Gram-stained specimens that were present before the febrile episode (1 ).
Fig. 3. Transbronchial lung biopsy from the same animal in figures I and 2 obtained via fiberoptic bronchoscope with scattered lymphocytes but without perivascular cuffing. (Hematoxylin and eosin stain; original magnification: X 50.)
578
KOERNER, HAGSTROM, AND VEITH
In these patients the rejection crisis was successfully reversed by increasing the dose of immunosuppressive drugs without the addition of antimicrobial drugs. In 2 other patients who survived for more than one week we were unable to differentiate rejection from infection by clinical means (2, 3). Because histologic examination of lung tissue is necessary for an accurate differentiation between rejection and infection, we compared 2 closed-chest biopsy procedures with open lung biopsy. Although the open procedure is accurate in all instances, it is certainly too extreme a diagnostic procedure to contemplate in the clinical situation, because human lung allograft recipients will probably have severe respiratory impairment when pulmonary infiltrates are present. Furthermore, the necessity for differentiating rejection from other causes of infiltration may arise on a number of occasions, thereby requiring several thoracotomies. Transthoracic needle biopsy of the lung has been shown to correlate with open biopsy in approximately 75 per cent of cases of diffuse lung disease other than rejection (7, 8). In certain conditions, such as discrete pulmonary nodules, the diagnostic yield is higher (15). The major drawbacks to transthoracic lung biopsy are the limited amount of tissue obtained and the number of complications. Pneumothorax occurs in approximately 22 to 35 per cent of the cases and bleeding in 17 per cent (7, 8). The incidence of these complications is far less when an aspiration technique is used, but this t~ch nique supplies tissue for only cytologic examination and is therefore not applicable for our purposes. The cutting needle used for obtaining tissue has been associated with a low mortality, but Norenberg and co-workers (9) have recently reported 2 deaths due to intrapulmonary hemorrhage after needle biopsy of the lung. These investigators recommended abandonment of the use of the cutting needle for lung biopsy. Our interest in transbronchial lung biopsy was stimulated by the report of Andersen and Fontana (16) of their experience with this tech nique in 450 patients. They obtained adequate pulmonary tissue in 84 per cent of patients, with an over-all incidence of pneumothorax of 14 per cent and only one death, which occurred 70 minutes after the procedure. Their cases were almost exclusively diffuse lung disease, and procedures were not done under fluoroscopic visualization. Transbronchiallung biopsy during fiberoptic bronchoscopy has been performed in di£-
fuse and localized lesions with fluoroscopic guidance (12, 17). The diagnostic yield in peripheral malignant lesions, not visualized bronchoscopically, is high (17). In a recent series of 22 patients with sarcoidosis seen at this institution (II), 21 had transbronchial lung biopsies that revealed noncaseating granulomas consistent with the clinical diagnosis of sarcoidosis, a diagnostic yield of 95 per cent. More than 200 patients have had this procedure at this institution, with only one pneumothorax and no mortality. Ellis (12) reported a 79 per cent diagnostic yield in diffuse lung diseases with this technique. The extremely low morbidity, absence of mortality, and high diagnostic yield suggested that this procedure might be applicable to lung allograft recipients with parenchymal infiltrates that could not be diagnosed accurately by clinical means. It was surprising that, although the transthoracic needle biopsy did correlate fairly well with the material obtained by the open chest method, the diagnosis of rejection could not be made in any of the transbronchial specimens. Because other diffuse diseases such as interstitial pneumonitis and sarcoidosis are frequently diagnosed by this method, it is disturbing that we were unable to make a diagnosis of rejection in any instance. Although the parenchyma of the lung did contain inflammatory cells that were predominantly lymphocytes in all cases, this is certainly insufficient for a diagnosis of rejection. Because such a diagnosis is dependent on the presence of perivascular round cell infiltrates as well as interstitial lymphocytic infiltration, a biopsy specimen must contain enough tissue for examination of pulmonary parenchyma and vasculature as well. Even with open lung biopsy specimens, there are regions with little or no perivascular lymphocytic infiltrates interspersed with areas of marked perivascular cuffing. The biopsy specimens obtained by transbronchial lung biopsy are small and contain a small number of arterioles and venules. Because the perivascular cuffing and interstitial infiltrates that occur in rejection are not uniform, examination of relatively large portions of lung must be done to observe the histologic findings necessary to diagnose rejection. Because bacterial pneumonia was not present in any of the animals studied, we are unable to comment on the efficacy of the closed biopsy procedures in the differentiation of rejection from bacterial infection. Since pneumonia of bacterial origin is characterized by a polymorphonuclear cellular infiltrate, transbronchial lung hi-
TRANSBRONCHIAL BIOPSY IN LUNG TRANSPLANT REJECTION
opsy could be of some importance by determining the presence of such an infiltrate as contrasted with the lymphocytic cellular reaction characteristic of rejection or a viral infection. Although our experience with transbronchial lung biopsy for the diagnosis of other pulmonary lesions has been favorable, it is apparent that allograft rejection cannot be diagnosed on the limited amount of material obtained by this method.
8.
9.
10.
Acknowledgment The writers thank Ms. Marisa Sokolow and Mr. Michael Torres for their technical assistance. References 1. Veith, F. J., Koerner, S. K., Siegelman, S. S., Kawakami, M., Kaufman, S., Attai, L., Hagstrom, J. W. C., and Gliedman, M. L.: Diagnosis and reversal of rejection in experimental and clinical lung allografts, Ann Thorac Surg, 1973, 16, 172. 2. Veith, F. J., Koerner, S. K., Siegelman, S. S., Torres, M., Bardfeld, P. A., Attai, L. A., Boley, S. J., Takara, T., and Gliedman, M. L.: Single lung transplantation in experimental and human emphysema, Ann Surg, 1973,178,463. 3. Veith, F. J., Koerner, S. K., Hagstrom, J. W. C., Attai, L., Bloomberg, A., Jacobson, E., Nagashima, H., Boley, S. J., and Gliedman, M. L.: Experience in clinical lung transplantation, JAMA, 1972,22,779. 4. Veith, F. J., and Koerner, S. K.: The present status of lung transplantation, Arch Surg, 1974, 109,734. 5. Gaensler, E. A., Moister, M. V. B., and Hamm, J.: Open lung biopsy in diffuse pulmonary disease, N Engl J M, 1964, 270, 1319. 6. Andrews, N.C., and Klassen, K. P.: Eight years experience with pulmonary biopsy, JAMA, 1957, 164, 1061. 7. Zavala, D. C., and Bedell, G. N.: Percutaneous
11.
12.
13.
14.
15.
16.
17.
579
lung biopsy with a cutting needle: An analysis of 40 cases and comparison with other biopsy techniques, Am Rev Respir Dis, 1972,106, 186. Tukiainen, P.: Needle biopsy in diffuse lung diseases, Scand J Respir Dis [Suppl], 1974, 89, 167. Norenberg, R., Claxton, C. P., Jr., and Takara, T.: Percutaneous needle biopsy of the lung: Report of two fatal complications, Chest, 1974, 66,216. Pearce, J. G., and Patt, N. L.: Fatal pulmonary hemorrhage after percutaneous aspiration lung biopsy, Am Rev Respir Dis, 1974,110, 346. Koerner, S. K., Sakowitz, A. J ., Appleman, R. I., Becker, N. H., and Schoenbaum, S. W.: Transbronchial lung biopsy for the diagnosis of· sarcoidosis, N Eng! J Med, 1975,293,268. Ellis, J. H., Jr.: Transbronchial lung biopsy via the fiberoptic bronchoscope, Chest, 1975, 68, 524. Veith, F. J., Sinha, S. B. P., Dougherty, J. C., Becker, N. H., Seigelman, S. S., Blumcke, S., and Hagstrom, J. W. C.: Nature and evolution of lung allograft rejection with and without immunosuppression, J Thorac Cardiovasc Surg, 1972, 63,509. Veith, F. J., and Hagstrom, J. W. C.: Alveolar manifestations of rejection: An important cause of the poor results with human lung transplantation, Ann Surg, 1972,175,336. Zelch, J. V., Lalli, A. F., McCormack, I. J., and Belovich, D. M.: Aspiration biopsy in diagnosis of pulmonary nodule, Chest, 1973,63, 149. Andersen, H. A., and Fontana, R. S.: Transbronchoscopic lung biopsy for diffuse pulmonary diseases: Technique and results in 450 cases, Chest, 1972, 62, 125. Schoenbaum, S. W., Koerner, S. K., Ramakrishna, B., and Goldman, M. L.: Transbronchial biopsy of peripheral lesions with fluoroscopic guidance: Use of the fiberoptic bronchoscope, J Can Assoc Radio!, 1974,25,39.
SPENCER K. KOERNER, JACK W.C. HAGSTROM, and FRANK J. VEITH
SUMMARY __________________________________________________________ The accurate diagnosis of lung transplant rejection requires histologic examination of the grafted lung. Because transbronchial lung biopsy has been advocated as an effective diagnostic procedure for a varietY of lung diseases, it was elected to assess this technique in rejecting transplanted lungs. Twenty-two dogs received allografts and underwent simultaneous lung biopsy by 3 techniques when signs of rejection occurred. Open lung biopsy was diagnostic of rejection in all instances. Transthoracic needle biopsy correlated with the open biopsv in 59 per ce:>t of the cases. No specimen obtained by transbronchial lung biopsy provided sufficient material to permit fulfillment of the strict histologic criteria needed to diagnose allograft rejection. Although transbronchial lung biopsy is successful in many pulmonary infiltrative processes, it appears to be inadequate for the diagnosis of lung allograft rejection.
Introduction Becauoe lung allograft rejection and pneumonia can present in identical fashion, differentiation between them can be made with certainty only by histologic examination of pulmonary tissue obtained by biopsy (l-3). In the clinical situation, with acutely ill patients, obtaining lung (Received for publication Apri/26, 1976) 1 From the James Hilton Manning and Emma Austin Manning Laboratory, Departments of Medicine and Surgery, Montefiore Hospital, and the Albert Einstein College of Medicine and the Department of Pathology, Columbia University College of Physicians and Surgeons, New York, N.Y. 2 Supported in part by grants from the U.S. Public Health Service (HL 17417 and HL 16476), the Stony Wold-Herbert Corporation, the New York Lung Aswciation, and the Manning Foundation. 3 Requests for reprints should be addressed to Spencer K. Koerner, M.D., Montefiore Hospital and Medical Center, Ill East 210th Street, Bronx, N. Y. 10467.
tissue is freyuently attendant with high risk or not feasible at all, so that methods of diagnosis of rejection must be indirect. These involve the recognition of deteriorating pulmonary function in the presence of radiologic infiltrates in the absence of clinical evidence of infection (1). Although this indirect method of diagnosing rejection can be relatively accurate, it is by no means absolute (2, 3), and, in addition, rejection and infection may exist concurrently (4). Lung biopsy is, therefore, the only way to differentiate definitively between these 2 major causes of pulmonary infiltration after lung transplantation. The 3 commonly used biopsy procedures are open lung biopsy, transthoracic needle biopsy, and transbronchial lung biopsy. Open lung biopsy is the best procedure in terms of the diagnostic yield in diffuse lung disease because a large representative piece of tissue can be obtained (5, 6). It is a rather drastic procedure, however, especia:ly in view of the frequent need for histologic material. Transthoracic need:e biopsy has been advocated for the diag-
AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 114, 1976
575
576
KOERNER, HAGSTROM, AND VEITH
nosis of diffuse as well as localized lesions of the lung (7, 8) but is associated with sufficient morbidity and mortality to make this procedure dangerous if performed serially (8-10). Recent reports of low morbidity and high diagnostic yield of transbronchial lung biopsy (11, 12) stimula ted a study of this procedure as a possible aid in the diagnosis of lung allograft rejection.
Materials and Methods Twenty-two mongrel dogs underwent left lung allotransplantation and were then treated with azathioprine (2 mg per kg), rabbit antithymocyte globulin (30 rng per kg), and prednisone (2 mg per kg) daily. Chest roentgenograms were obtained daily. When an infiltrate was present in the allograft, the animal was lightly anesthetized with sodium pentobarbital and the allografted lung was biopsied by the 3 different techniques. Transbronchial lung biopsy was performed via a fiberoptic bronchoscope. Under fluoroscopic control, th e tip of a flexible biopsy forceps was advanced to an area of pulmonary infiltrate. The forceps was then opened and wedged into the infiltrate until it could not be advanced any further. The forceps was then closed, removing a piece of tissue approximately 1.5 mm in diameter. Three such biopsies were obtained in all cases. A transthoracic needle biopsy of the same region of lung was then obtained using a Vim Trucut needle (Travenol Laboratories, Inc., Morton Grove, Ill.), again under fluoroscopic control. After this procedure a thoracotomy was performed and an open lung biopsy from the area immediately adjacent to the previous biopsies was obtained. The tissue from all biopsy procedures was paraffin fixed, stained with hematoxylin and eosin, and examined by light microscopy. The triple biopsy procedure was performed between the fifth and twentieth day after transplant, which coincided with the initial appearance of a pulmonary infiltrate. In 18 of the animals the biopsies were done on the sixth, seventh, or eighth day after
TABLE 1 RESULTS OF COMPARATIVE LUNG BIOPSIES IN 22 CANINE ALLOGRAFT RECIPIENTS TransOpen Lung Biopsy Histologic diagnosis of rejection Histologic diagnosis of infiltrates other than rejection Diagnostic yield
18
4
22/22
thoracic TransNeedle bronchial Biopsy Biopsy
10
3 13/22
0
0 0/22
Fig. I. Open lung biopsy obtained during rejection crisis showing interstitial and perivascular lymphocytic infiltration. (Hematoxylin and eosin stain; original magnification: X 50.) tra nsplanta tion. After the open lung biopsy, intensive immunosuppressiv e therapy was i.nstituted with the addition of methyl prednisolone sodium succinate (30 mg per kg) administered intravenously twice daily until there was regression of the radiologic infiltrate or the animal died. Sixteen animals died within a f ew days of the diagnosis and autopsy was performed with multiple sections of the trans planted lung. The 6 surviving animals were used for other studies of lung allograft function. The histologic criteria of lung allograft rejection are lymphocytic infiltration of the interstitium of the lung and perivascular cuffing by round cells (13, 14), both of which had to be present for the diagnosis of rej ection to be applied to any specimen.
Results As seen in table I, 18 of the 22 biopsy specimens obtained by the open chest technique demonstrated histologic evidence of rejection. The remaining 4 specimens showed evidence of other infiltrative processes, including hemorrhage, infarction, and parasitic infection. The open lung biopsy was, therefore, diagnostic in all cases. Postmortem examination of the lungs in the 16 animals that died revealed histologic findings
TRANSBRONCHIAL BIOPSY IN LUNG TRANSPLANT REjECTION
577
mented rejection showing sparse infiltration with lymphocytes. Discussion
Fig. 2. Transthoracic needle biopsy of the same ani· mal in figure l obtained just before the open lung biopsy. There are interstitial lymphocytes and peri· vascular round cell infiltrates. (Hematoxylin and eosin stain; original magnification: X 50.) similar to the open lung biopsy. A typical open lung biopsy specimen in an animal with a rejection crisis is shown in figure l. In the IS animals with rejection, 10 of the transthoracic needle biopsy specimens were also diagnostic of rejection, revealing histologic findings similar to the open lung biopsy. In the 4 animals with infiltrates not secondary to rejection, the needle biopsy was diagnostic in 3. Therefore, the n eedle biopsy correlated with the open biopsy in 13 of 22 instances (59 per cent). Figure 2 shows the needle biopsy specimen obtained on the same animal as in figure I, demonstrating findings similar to the open lung biopsy. In no case was the transbronchial lung biopsy adequate to allow the diagnosis of rejection or infection. There was evidence of inflammatory disease in all the specimens, including diffuse round cell infiltrates, but these findings were nonspecific and were considered insufficient to permit the diagnosis of rejection. Perivascular cuffs of mononuclear cells were not observed. Figure 3 is a transbronchial lung biopsy of the same animal as in figures I and 2, with docu-
The inability to diagnose lung allograft rejection by means of transbronchial lung biopsy is certainly unexpected in view of the favorable results obtained in the diagnosis of a variety of other pulmonary infiltrative diseases. We fully expected to obtain a comparable diagnostic yield with this method that could then be applicable to the difficult clinical differentia tion of rejection from infection. All 5 patients who have undergone lung tran splantation at this institution developed pulmonary infiltrates and clinically deteriorated within 10 days of surgery (1, 4). In 2 of these p atients we indirectly diagnosed rejection because of pulmonary infiltrates, fever, and a decrease in arterial oxygen tension during a period when the sputum smear was unchanged. In one patient there was total absence of bacteria or fungi, and examination of the sputum in the other patient revealed the same bacterial flora on serial Gram-stained specimens that were present before the febrile episode (1 ).
Fig. 3. Transbronchial lung biopsy from the same animal in figures I and 2 obtained via fiberoptic bronchoscope with scattered lymphocytes but without perivascular cuffing. (Hematoxylin and eosin stain; original magnification: X 50.)
578
KOERNER, HAGSTROM, AND VEITH
In these patients the rejection crisis was successfully reversed by increasing the dose of immunosuppressive drugs without the addition of antimicrobial drugs. In 2 other patients who survived for more than one week we were unable to differentiate rejection from infection by clinical means (2, 3). Because histologic examination of lung tissue is necessary for an accurate differentiation between rejection and infection, we compared 2 closed-chest biopsy procedures with open lung biopsy. Although the open procedure is accurate in all instances, it is certainly too extreme a diagnostic procedure to contemplate in the clinical situation, because human lung allograft recipients will probably have severe respiratory impairment when pulmonary infiltrates are present. Furthermore, the necessity for differentiating rejection from other causes of infiltration may arise on a number of occasions, thereby requiring several thoracotomies. Transthoracic needle biopsy of the lung has been shown to correlate with open biopsy in approximately 75 per cent of cases of diffuse lung disease other than rejection (7, 8). In certain conditions, such as discrete pulmonary nodules, the diagnostic yield is higher (15). The major drawbacks to transthoracic lung biopsy are the limited amount of tissue obtained and the number of complications. Pneumothorax occurs in approximately 22 to 35 per cent of the cases and bleeding in 17 per cent (7, 8). The incidence of these complications is far less when an aspiration technique is used, but this t~ch nique supplies tissue for only cytologic examination and is therefore not applicable for our purposes. The cutting needle used for obtaining tissue has been associated with a low mortality, but Norenberg and co-workers (9) have recently reported 2 deaths due to intrapulmonary hemorrhage after needle biopsy of the lung. These investigators recommended abandonment of the use of the cutting needle for lung biopsy. Our interest in transbronchial lung biopsy was stimulated by the report of Andersen and Fontana (16) of their experience with this tech nique in 450 patients. They obtained adequate pulmonary tissue in 84 per cent of patients, with an over-all incidence of pneumothorax of 14 per cent and only one death, which occurred 70 minutes after the procedure. Their cases were almost exclusively diffuse lung disease, and procedures were not done under fluoroscopic visualization. Transbronchiallung biopsy during fiberoptic bronchoscopy has been performed in di£-
fuse and localized lesions with fluoroscopic guidance (12, 17). The diagnostic yield in peripheral malignant lesions, not visualized bronchoscopically, is high (17). In a recent series of 22 patients with sarcoidosis seen at this institution (II), 21 had transbronchial lung biopsies that revealed noncaseating granulomas consistent with the clinical diagnosis of sarcoidosis, a diagnostic yield of 95 per cent. More than 200 patients have had this procedure at this institution, with only one pneumothorax and no mortality. Ellis (12) reported a 79 per cent diagnostic yield in diffuse lung diseases with this technique. The extremely low morbidity, absence of mortality, and high diagnostic yield suggested that this procedure might be applicable to lung allograft recipients with parenchymal infiltrates that could not be diagnosed accurately by clinical means. It was surprising that, although the transthoracic needle biopsy did correlate fairly well with the material obtained by the open chest method, the diagnosis of rejection could not be made in any of the transbronchial specimens. Because other diffuse diseases such as interstitial pneumonitis and sarcoidosis are frequently diagnosed by this method, it is disturbing that we were unable to make a diagnosis of rejection in any instance. Although the parenchyma of the lung did contain inflammatory cells that were predominantly lymphocytes in all cases, this is certainly insufficient for a diagnosis of rejection. Because such a diagnosis is dependent on the presence of perivascular round cell infiltrates as well as interstitial lymphocytic infiltration, a biopsy specimen must contain enough tissue for examination of pulmonary parenchyma and vasculature as well. Even with open lung biopsy specimens, there are regions with little or no perivascular lymphocytic infiltrates interspersed with areas of marked perivascular cuffing. The biopsy specimens obtained by transbronchial lung biopsy are small and contain a small number of arterioles and venules. Because the perivascular cuffing and interstitial infiltrates that occur in rejection are not uniform, examination of relatively large portions of lung must be done to observe the histologic findings necessary to diagnose rejection. Because bacterial pneumonia was not present in any of the animals studied, we are unable to comment on the efficacy of the closed biopsy procedures in the differentiation of rejection from bacterial infection. Since pneumonia of bacterial origin is characterized by a polymorphonuclear cellular infiltrate, transbronchial lung hi-
TRANSBRONCHIAL BIOPSY IN LUNG TRANSPLANT REJECTION
opsy could be of some importance by determining the presence of such an infiltrate as contrasted with the lymphocytic cellular reaction characteristic of rejection or a viral infection. Although our experience with transbronchial lung biopsy for the diagnosis of other pulmonary lesions has been favorable, it is apparent that allograft rejection cannot be diagnosed on the limited amount of material obtained by this method.
8.
9.
10.
Acknowledgment The writers thank Ms. Marisa Sokolow and Mr. Michael Torres for their technical assistance. References 1. Veith, F. J., Koerner, S. K., Siegelman, S. S., Kawakami, M., Kaufman, S., Attai, L., Hagstrom, J. W. C., and Gliedman, M. L.: Diagnosis and reversal of rejection in experimental and clinical lung allografts, Ann Thorac Surg, 1973, 16, 172. 2. Veith, F. J., Koerner, S. K., Siegelman, S. S., Torres, M., Bardfeld, P. A., Attai, L. A., Boley, S. J., Takara, T., and Gliedman, M. L.: Single lung transplantation in experimental and human emphysema, Ann Surg, 1973,178,463. 3. Veith, F. J., Koerner, S. K., Hagstrom, J. W. C., Attai, L., Bloomberg, A., Jacobson, E., Nagashima, H., Boley, S. J., and Gliedman, M. L.: Experience in clinical lung transplantation, JAMA, 1972,22,779. 4. Veith, F. J., and Koerner, S. K.: The present status of lung transplantation, Arch Surg, 1974, 109,734. 5. Gaensler, E. A., Moister, M. V. B., and Hamm, J.: Open lung biopsy in diffuse pulmonary disease, N Engl J M, 1964, 270, 1319. 6. Andrews, N.C., and Klassen, K. P.: Eight years experience with pulmonary biopsy, JAMA, 1957, 164, 1061. 7. Zavala, D. C., and Bedell, G. N.: Percutaneous
11.
12.
13.
14.
15.
16.
17.
579
lung biopsy with a cutting needle: An analysis of 40 cases and comparison with other biopsy techniques, Am Rev Respir Dis, 1972,106, 186. Tukiainen, P.: Needle biopsy in diffuse lung diseases, Scand J Respir Dis [Suppl], 1974, 89, 167. Norenberg, R., Claxton, C. P., Jr., and Takara, T.: Percutaneous needle biopsy of the lung: Report of two fatal complications, Chest, 1974, 66,216. Pearce, J. G., and Patt, N. L.: Fatal pulmonary hemorrhage after percutaneous aspiration lung biopsy, Am Rev Respir Dis, 1974,110, 346. Koerner, S. K., Sakowitz, A. J ., Appleman, R. I., Becker, N. H., and Schoenbaum, S. W.: Transbronchial lung biopsy for the diagnosis of· sarcoidosis, N Eng! J Med, 1975,293,268. Ellis, J. H., Jr.: Transbronchial lung biopsy via the fiberoptic bronchoscope, Chest, 1975, 68, 524. Veith, F. J., Sinha, S. B. P., Dougherty, J. C., Becker, N. H., Seigelman, S. S., Blumcke, S., and Hagstrom, J. W. C.: Nature and evolution of lung allograft rejection with and without immunosuppression, J Thorac Cardiovasc Surg, 1972, 63,509. Veith, F. J., and Hagstrom, J. W. C.: Alveolar manifestations of rejection: An important cause of the poor results with human lung transplantation, Ann Surg, 1972,175,336. Zelch, J. V., Lalli, A. F., McCormack, I. J., and Belovich, D. M.: Aspiration biopsy in diagnosis of pulmonary nodule, Chest, 1973,63, 149. Andersen, H. A., and Fontana, R. S.: Transbronchoscopic lung biopsy for diffuse pulmonary diseases: Technique and results in 450 cases, Chest, 1972, 62, 125. Schoenbaum, S. W., Koerner, S. K., Ramakrishna, B., and Goldman, M. L.: Transbronchial biopsy of peripheral lesions with fluoroscopic guidance: Use of the fiberoptic bronchoscope, J Can Assoc Radio!, 1974,25,39.
