Tom Gildea, MD: Biopsy Tools in Bronchoscopy

There’s a diversity of resources, tools, and even personnel available for bronchoscopies. But is there an optimal strategy?

In an interview with MD Magazine® while at the CHEST 2019 Annual Meeting in New Orleans, Tom Gildea, MD, head of Bronchoscopy at the Cleveland Clinic, detailed recent research from his team which assessed the impact of biopsy tool selection and methods such as rapid on-site evaluation on bronchoscopy accuracy and safety.

Gildea: Today I was talking about an analysis of the NAVIGATE registry. The NAVIGATE registry was a multicenter trial that looked at 1200 patients who had navigational bronchoscopy, and it was really a study based around safety.

This was a secondary analysis of the biopsy tools used in the study, recognizing that, although we talk a lot about the technology being an important part of the procedure, at the end of the day, it's about obtaining the tissue.

So when you're doing a diagnostic bronchoscopy, in addition to using navigation systems or whatever to get to the lesion, you have to obtain tissue and see if that tissue was valuable in terms of making a clinical diagnosis. What was interesting about our findings were all bronchoscopies were local.

Although we may use the same technology to get to lesions, there's a very vast difference of how people obtain tissue. In our particular study, we decided to look at 3 things. One was safety. Anytime you do a biopsy on someone, we're looking at safety. And we broke it down into 2 groups. We defined an extended biopsy tool group, which is standard biopsy forceps, cytology brushes, and a wash. Then, extended strategy, which was peripheral needle biopsy, triple needle brush, needle biopsy—a number of different new tools.

And we looked to see if the yields were similar between the 2 groups, and if the complication rates were similar. And we also looked at the general utility of rapid onsite cytologic evaluation, which is the procedure where during it we will obtain specimens and do a rapid stain on the material, and then pathologists would give us a read-back immediately about adequacy.

The first thing we learned was that there were certainly far more diagnostic procedures in the individuals that use extended strategies. They use needles, forceps, brushes, and different biopsy tools during the procedure—compared to individuals who did use a more limited biopsy strategy.

And then we learned that even though they may use a more extended strategy, they did make the procedures significantly longer. So just because you're using a smaller number of instruments, it didn't necessarily save you a lot of time. So you couldn't do a lot more biopsies in the extended strategy.

We also learned that adding the cytopathology steps—taking the actual slide and sending to a pathologist to read right there in the room, it didn't necessarily add a lot of time to the procedure. That may be local stuff—that may be they're not waiting for the answers, that they're just continuing to move on.

Nevertheless, it didn't add anything to the length of the procedure.

Of course, the third part was safety. Even though we used needles and additional complex biopsy techniques, it didn't significantly increase the risk of the procedure in any way.

So although there is a wide variation in the way people use tools, which tools they use first, the mere fact that using multiple tools in a procedure is associated with a higher yield, with same safety and no impact on time. So that's the general gist of it.

There's way more to it than that, really, in that we looked at people whose strategies are different. Some people have a very strict regimen to how they do the procedures; other centers have no specific strategy—they seem to adjust to the leisure of the procedures.

There's a lot to be said about the technologies, but there's also a lot to be said and learned about the basic procedure, where getting tissue is very different.