Pathologic comparison of conventional video-assisted thoracic surgical (VATS) biopsy versus non-intubated/“awake” biopsy in fibrosing interstitial lung diseases

Surgical lung biopsy remains the standard procedure for the subset of patients with fibrosing interstitial lung disease (F-ILD) who require a lung biopsy to secure a confident diagnosis. Little is known about the pathologic features of samples obtained via non-intubated/"awake" surgical lung biopsy and the diagnostic accuracy of awake biopsy in patients with F-ILD. Two expert thoracic pathologists blinded to the type of lung biopsy compared the clinical-pathologic features of 120 conventional VATS biopsies with those of 21 consecutive non-intubated/"awake" VATS biopsies. No statistically significant differences between the two procedures were observed with regard to identification of histopathological features. Biopsy length, average of sampled lobes and mean number of slides were similar with the two procedures, while the width of the biopsies was significantly deeper with conventional VATS (31.5 mm versus 25.6 mm; p = 0.01). By contrast, the mean age of patients (69.5 versus 64.5 years; p = 0.02) and the level of diagnostic confidence (100% versus 75%; p = 0.007) were significantly higher among patients undergoing the "awake" procedure. Diagnostic yield was 100% in both groups, with a similar distribution of ILD diagnoses. Non-intubated/"awake" biopsy has the potential to become the standard surgical procedure in patients with F-ILD requiring a histological confirmation of their diagnosis. However, larger prospective studies are needed to validate the safety and diagnostic yield of "awake" compared to conventional VATS.