A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma

Bronchoscopic sampling techniques in the era of technological bronchoscopy

Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.

Health state dependent multiphoton induced autofluorescence in human 3D in vitro lung cancer model

Lung diseases pose the highest risk of death and lung cancer is a top killer among cancers with a mortality rate up to 70% within 1 year after diagnosis. Such a fast escalation of this cancer development makes early diagnosis and treatment a highly challenging task, and currently there are no effective tools to diagnose the disease at an early stage. The ability to discriminate between healthy and tumorous tissue has made autofluorescence bronchoscopy a promising tool for detection of lung cancer; however, specificity of this method remains insufficiently low. Here, we perform autofluorescence imaging of human lung cancer invading a human functional airway using an in vitro model of Non Small Cell Lung Cancer which combines a reconstituted human airway epithelium, human lung fibroblasts and lung adenocarcinoma cell lines, OncoCilAir™. By using two-photon laser induced autofluorescence microscopy combined with spectrally resolved imaging, we found that OncoCilAir™ provides tissue's health dependent autofluorescence similar as observed in lung tissue in patients. Moreover, we found spectral and intensity heterogeneity of autofluorescence at the edges of tumors. This metabolic related heterogeneity demonstrates ability of tumor to influence its microenvironment. Together, our result shows that OncoCilAir™ is a promising model for lung cancer research.

Pre- and postoperative care for stage I-III NSCLC: Which quality of care indicators are evidence-based?

Identification of evidenced-based Quality of Care (QoC) indicators for lung cancer care is essential to quality improvement. The aim of this review was to identify evidence-based quality indicators for the pre- and postoperative care of stage I-III Non Small Cell Lung Cancer (NSCLC) provided by the lung physician. To obtain these indicators, a search in PubMed, Embase and the Cochrane library database was performed. English literature published between 1980 and 2012 was included and search terms regarding 'lung neoplasms', 'quality of care', 'pathology', 'diagnostic methods', 'preoperative and postoperative treatment' were used. The potential indicators were categorized as structure, process or outcome measures and the indicators supported by literature with high evidence level were selected. Five QoC indicators were identified. The use of the positron emission tomography-computed tomography (PET-CT) results in more accurate mediastinal staging compared to the CT scan. Endoscopic Ultrasound-Fine Needle Aspiration and Endobronchial Ultrasound-Fine Needle Aspiration are sensitive diagnostic tools for mediastinal staging and reduce futile thoracotomies. Pathological conformation of lung cancer can best be obtained by a combination of cytological and histological diagnostics used during bronchoscopy. For patients with clinical stage III NSCLC, preoperative multimodality treatment (i.e. preoperative chemoradiation) results in superior survival and increased mediastinal downstaging compared to single modality treatment (i.e. preoperative chemotherapy or radiotherapy). After surgery, the addition of chemotherapy results in a significant survival benefit for patients with pathological stage II and III NSCLC. These five QoC indicators can be used for benchmarking and ultimately quality improvement of lung cancer care.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Transbronchial needle aspiration cytology (TBNA) in endobronchial lesions: a valuable technique during bronchoscopy in diagnosing lung cancer and it will decrease repeat bronchoscopy

BACKGROUND

Lung cancer is the leading cause of cancer deaths around the world. Globally, lung cancer is the largest contributor to new cancer diagnosis and to death from cancer. Various conventional diagnostic techniques (CDTs) such as endobronchial forcep biopsy (FB), bronchial washing (BW) and bronchial brushing (BB), and transbronchial needle aspiration cytology (TBNA) are employed during fiber-optic bronchoscopy.

METHODS

This is a prospective study conducted between June 2012 and September 2013 at Bronchoscopy unit of MIMSR Medical College Latur, India, to find the role of TBNA in exophytic endobronchial lesions in confirming the diagnosis of lung cancer and to find additive yield over other techniques such as BB, BW and FB, and included 150 patients on the basis of clinical and radiological features of malignancy. In exophytic endobronchial lesions, predominant endoscopic findings were cauliflower, polypoidal-like or nodular or multinodular endobronchial growth. TBNA, FB, BB and BW were performed in all the cases during FOB. Histopathological and cytological examinations of specimens were performed at Pathology department. The statistical analysis was done using chi-square test.

RESULTS

Total 150 patients, between age group 24-80 years, mean age was 57.93 years, male population constitutes 86.17 % of total. 76.14 % cases were smoker of them 61.87 % cases having history of >40 pack years. Commoner symptoms were cough (91.33 %), hemoptysis (54.00 %) and chest pain (46.66 %), and mass lesion (40.66 %), hilar opacity (31.33 %) and collapse segmental/lobar (29.33 %) were commoner radiological abnormalities. Yield of TBNA, CDT and TBNA plus CDT in exophytic lesions is 60.66, 79.33 and 84.66 %, respectively, in diagnosis of lung malignancies (P < 0.001). Sensitivity of forcep biopsy and TBNA in diagnosing lung malignancy was 88.18 and 71.65 %, respectively (P < 0.01). FOB-related hypoxemia documented in two cases and minor bleeding in six cases. Other complications such as significant bleeding, pneumothorax and death were not seen. Minor bleeding was seen with forcep biopsy mainly in 4.0 % cases. TBNA has decreased repeat procedure, decreases cost for diagnosis. IHC on TBNA specimens had increased histological-type confirmation.

CONCLUSION

Transbronchial needle aspiration is a beneficial, safe and minimally invasive bronchoscopic technique with insignificant side effect in the diagnosis bronchogenic carcinoma. TBNA considered safe, especially when fleshy vascular endobronchial growth is present and risk of bleeding is high with forcep biopsy. Inadequate tissue sampling due to the presence of necrosis, blood clot over the lesion and formation of crush artifacts by FB makes TBNA valuable in these lesions. TBNA will definitely decrease need for repeat bronchoscopy.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Diagnosis of lung cancer: a bronchoscopist's perspective

BACKGROUND

Guidelines recommend multiple types of cytologic and tissue samplings in the diagnosis of lung cancer by bronchoscopy, but differences of opinion exist as to the relative value of bronchial brushings and endobronchial or transbronchial biopsies. Our objective was to determine concordance of these procedures by a test of symmetry in a historical cohort referred to the pulmonary diagnostic laboratory.

METHODS

From 1988 to 2001, patients with pathologic confirmation of primary lung cancer were examined by standard bronchoscopic techniques of that period. An electronic medical record system was used, with statistical analysis of symmetry between brushings and biopsies establishing the diagnosis.

RESULTS

Of 968 patients, 98% had bronchoscopy for 624 central and 322 peripheral suspect lesions. Bronchial brushings from 915 patients confirmed pulmonary malignancy in 811 (89%) patients. Endobronchial or transbronchial biopsies from 739 patients showed lung cancer in 603 (82%) cases. Bronchial washings in 16 patients and transthoracic needle biopsies in 30 patients established diagnosis. Transbronchial needle aspiration of mediastinal nodes identified metastases in 94 patients. Only 14 patients required a surgical procedure for diagnosis, but 188 received surgical excision as primary treatment. Statistical evaluation used only patients with both bronchial brushings and endobronchial or transbronchial biopsies. Analysis by a test of symmetry showed a significant difference (P<0.0001).

CONCLUSIONS

Positive, suspicious, and negative specimens were consistent, with bronchial brushings being more sensitive with a lower false-negative rate than endobronchial or transbronchial biopsies. Multiple techniques are recommended for bronchoscopic confirmation of lung cancer, but bronchial brushings should be collected initially, as technical or patient limitations might preclude diagnostic tissue biopsies.

Rapid on-site evaluation improves needle aspiration sensitivity in the diagnosis of central lung cancers: a randomized trial

BACKGROUND

Few prospective studies have evaluated the role of endobronchial needle aspiration in diagnosing central airways neoplasms. Rapid on-site evaluation has long been used in transbronchial needle aspiration of adenopathies and peripheral lesions, but its role in sampling central malignancies has not been substantiated yet.

OBJECTIVES

In this study we evaluated if endobronchial needle aspiration may increase the sensitivity of bronchoscopy for diagnosing central airways neoplasms when added to conventional diagnostic methods (forceps biopsy, brushing and bronchial washing), and if rapid on-site evaluation may be beneficial in patients undergoing endobronchial needle aspiration.

METHODS

125 patients (77% males, aged 70 ± 7 years; mean ± SD) with central lung cancers were randomized to undergo bronchoscopy including conventional diagnostic methods and needle aspiration, with or without rapid on-site evaluation, stratifying the patients on the basis of the neoplasm growth pattern (exophytic and submucosal/peribronchial disease).

RESULTS

Needle aspiration significantly increased the sensitivity of bronchoscopy when added to conventional methods (from 76 to 91%; p < 0.001), primarily resulting from differences in submucosal/peribronchial diseases (68 vs. 90%; p < 0.001) and independently from the presence of rapid on-site evaluation; needle aspiration guided by rapid on-site evaluation guaranteed a higher improvement in bronchoscopy sensitivity than conventional needle aspiration (98 vs. 84%, respectively; p = 0.004). Needle aspiration guided by rapid on-site evaluation showed a significantly higher sensitivity than the conventional method (97 vs. 76%, respectively; p = 0.001).

CONCLUSIONS

Needle aspiration increases the sensitivity of bronchoscopy in diagnosing central airways malignancies when added to conventional diagnostic methods, with a further significant improvement when guided by rapid on-site evaluation.

Subtyping of non-small cell lung carcinoma: a comparison of small biopsy and cytology specimens

BACKGROUND

There is growing evidence that lung adenocarcinoma and squamous cell carcinoma (SQCC) have distinct oncogenic mutations and divergent therapeutic responses, which is driving the heightened emphasis on accurate pathologic subtyping of non-small cell lung carcinoma (NSCLC). The relative feasibility and accuracy of NSCLC subtyping by small biopsy versus cytology is not well established, particularly in current practice where immunohistochemistry (IHC) is becoming routinely used to aid in this distinction.

METHODS

Concurrent biopsy and cytology specimens obtained during a single procedure and diagnosed as NSCLC during a 2-year period (n = 101) were reviewed. Concordance of diagnoses in the two methods was assessed. Accuracy was determined based on subsequent resection or autopsy diagnosis (n = 21) or IHC for thyroid transcription factor 1 and p63 on a subset of cases (n = 43).

RESULTS

The distribution of definitive versus favored versus unclassified categories (reflecting the degree of diagnostic certainty) was similar for biopsy (71% versus 23% versus 6%, respectively) and cytology (69% versus 19% versus 12%, respectively), p = 0.29. When results from paired specimens were combined, the rate of definitive diagnoses by at least one method was increased to 84% and the unclassified rate was decreased to 4%. NSCLC subtype concordance between biopsy and cytology was 93%. Kappa coefficient (95% confidence interval) for agreement between methods was 0.88 (0.60-0.89) for adenocarcinoma and 0.76 (0.63-0.89) for SQCC. In pairs with discordant diagnoses (n = 7) the correct tumor type was identified with a similar frequency by biopsy (n = 4) and cytology (n = 3). Factors contributing to mistyping were poor differentiation, necrosis, low cellularity, and lack of supporting IHC. All concordant diagnoses for which verification was available (n = 57) were correct. IHC was used more frequently to subtype NSCLC in biopsy than cytology (32% versus 6%; p = 0.0001).

CONCLUSIONS

Small biopsy and cytology achieve comparable rates of definitive and accurate NSCLC subtyping, and the optimal results are attained when the two modalities are considered jointly. The lower requirement for IHC in cytology highlights the strength of cytomorphology in NSCLC subtyping. Whenever clinically feasible, obtaining parallel biopsy and cytology specimens is encouraged.

Flexible bronchoscopy and its role in the staging of non-small cell lung cancer

Technologic advances in bronchoscopy continue to improve the ability to perform minimally invasive, accurate evaluations of the tracheobronchial tree and to perform an ever-increasing array of diagnostic, staging, therapeutic, and palliative interventions. The role of both old and new diagnostic bronchoscopy will continue to evolve as further improvements are made in bronchoscopes, accessory equipment, and imaging technologies. The major challenge is the adoption of the many new bronchoscopic techniques into routine clinical practice. There is a need for well-designed studies to delineate the appropriate use of these interventions and to better define their limitations and cost effectiveness.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer

PURPOSE

We performed this study to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the pathologic diagnosis of lung cancer including lung masses as well as lymph nodes as targets.

METHODS

We retrospectively reviewed 126 patients who underwent EBUS-TBNA to diagnose radiologically suspected lung cancer. The patients had masses or lymph nodes that were highly suspicious for malignancy and accessible by EBUS-TBNA.

RESULTS

EBUS-TBNA was performed on 195 lesions (lymph nodes, n=151; lung masses, n=44). In 61 cases, other diagnostic methods had failed previous to EBUS-TBNA. In 118 patients, no definite endobronchial mucosal tumor invasion was observed. In eight patients with endobronchial tumor invasion, EBUS-TBNA was chosen due to tumor bleeding, necrosis, or difficult location for endobronchial biopsy. EBUS-TBNA confirmed 105 lung cancers, five other malignancies and six specific benign cases, demonstrating a diagnostic yield of 92.1% (116/126). Nine cases were diagnosed by other methods (lung cancer, n=2; other malignancies, n=2; benign cases, n=5). One case that was not confirmed by any diagnostic method was considered false negative. The sensitivity and diagnostic accuracy of EBUS-TBNA in the diagnosis of lung cancer were 97.2% (105/108) and 97.6% (123/126), respectively.

CONCLUSIONS

EBUS-TBNA targeting lymph nodes or masses highly suspicious for malignancy demonstrated high diagnostic value in the diagnosis of lung cancer. EBUS-TBNA is recommended for these cases, especially when other diagnostic methods have failed or are difficult.

Cryoprobe biopsy increases the diagnostic yield in endobronchial tumor lesions

OBJECTIVE

Forceps biopsy is the standard method to obtain specimens in endoscopically visible lesions. It is common to combine forceps biopsy with cytology methods to increase the diagnostic yield. Although the flexible cryoprobe has been established for bronchoscopic interventions in malignant stenosis, the obtained biopsies, called "cryobiopsies," have not been investigated in a large cohort of patients. The aim of this feasibility study was to prospectively evaluate the diagnostic yield and safety of cryobiopsy and forceps biopsy.

METHODS

During a 6-year period, 296 patients with visible endoluminal tumor lesions were included in the study at the bronchoscopy unit of a university hospital. In the first consecutively conducted 55 cases, both techniques, forceps biopsy and cryobiopsy, were applied simultaneously. Pathologic and quantitative image analyses were performed to evaluate the size and quality of the obtained specimens. We evaluated the safety and diagnostic yield to describe the feasibility of cryobiopsy.

RESULTS

Comparative analysis of the first conducted and randomly assigned 55 cases revealed a significantly higher diagnostic yield for cryobiopsy compared with forceps biopsy (89.1% vs 65.5%, P < .05). In this cohort, quantitative image analysis showed significantly larger biopsies regarding size and artifact-free tissue sections for cryobiopsy compared with forceps biopsy (P < .0001). The overall diagnostic yield of cryobiopsy was 89.5%. Mild bleeding occurred in 11 cases (3.7%), moderate bleeding occurred in 3 cases (1.0%), and severe bleeding occurred in 1 case (0.3%).

CONCLUSION

Cryobiopsy is safe and increases the diagnostic yield in endobronchial tumor lesions. The method also is feasible under routine conditions.

Initial Diagnosis of Lung Cancer

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

Bronchial washing yield before and after forceps biopsy in patients with endoscopically visible lung cancers

BACKGROUND AND OBJECTIVE

The need for routine use of bronchial washing in addition to forceps biopsy has been debated in the diagnosis of endoscopically visible lung tumours. Moreover, the optimal sequence for obtaining bronchial washing and forceps biopsy specimens from endoscopically visible tumours through a flexible bronchoscope has not been well established.

METHODS

A multicentre 13-month prospective randomized study was performed. Two hundred and thirty consecutive patients with endoscopically visible tumours were randomly assigned into a bronchial washing before forceps biopsy (pre-biopsy) group and a bronchial washing after forceps biopsy (post-biopsy) group. Bronchial washing and forceps biopsy were performed according to the assigned sequence.

RESULTS

Two hundred and seven patients with a definite cytological or histological diagnosis of lung cancer were included in the analyses. One hundred and three were in the pre-biopsy group and 104 were in the post-biopsy group. The diagnostic yield of bronchial washing was 57.3% (59/103) in the pre-biopsy group and 55.8% (58/104) in the post-biopsy group (P = 0.88). In addition, bronchial washing provided the diagnosis in six patients without definite diagnosis from forceps biopsy, and its addition to forceps biopsy significantly increased the overall diagnostic yield of bronchoscopy from 93.7% to 96.6% (P = 0.03).

CONCLUSION

The sequence for performing bronchial washing before or after forceps biopsy did not affect the diagnostic yield of bronchial washing in patients with endoscopically visible lung cancers. However, bronchial washing led to a significant increase in the overall diagnostic yield of bronchoscopy in patients with lung cancers.

Measuring the success of transbronchial needle aspiration in everyday clinical practice

BACKGROUND

Trans-bronchial needle aspiration (TBNA) is a simple, safe technique that can be performed without additional resources in any centre with a bronchoscopy service. It provides rapid diagnostic information in malignant and benign conditions and staging information in non-small cell lung cancer (NSCLC) and may avoid the delays, risks, in-patient stay and financial implications associated with surgical exploration of the mediastinum. Despite this, centres have been slow to adopt the technique. This may be due to the lack of clarity about the clinical success of TBNA in everyday clinical practice and the absence of a single valid measurement of clinical utility for TBNA against which to audit.

METHODS

We undertook a retrospective analysis of all TBNA carried out at Nottingham City Hospital since the service began. "Success" was carefully and strictly defined. The influences of various factors on the likelihood of a successful outcome were analysed.

RESULTS

Fifty percent (71/142) of patients undergoing TBNA received an exact histological diagnosis whilst in 72% (97/134) of patients in whom a final diagnosis was made, TBNA results correctly predicted malignant versus benign conditions. We defined the former, more stringent, outcome measure as "success--exact". This outcome was not significantly affected by patient age or gender, lesion size or position, experience of the bronchoscopist or number of aspiration attempts. Final diagnosis strongly influenced "success--exact" with NSCLC 6.5 times and small cell lung cancer 28.5 times more likely to yield a diagnostic sample than benign conditions.

CONCLUSIONS

TBNA should be used as a standard first line invasive investigation for diagnosis of mediastinal lymphadenopathy or submucosal endobronchial disease. The stringent outcome defined in this study as "success--exact" is simple for clinicians and patients to understand and would be a useful definition to standardise audit and future research.

Effectiveness of transbronchial needle aspiration in the diagnosis of exophytic endobronchial lesions and submucosal/peribronchial diseases of the lung

The role of transbronchial needle aspiration (TBNA) in diagnosing endobronchial lung cancers has not been elucidated. The definitive combination of procedures that offers the best diagnostic yield following fiberoptic bronchoscopy remains controversial. This study was designed to investigate the diagnostic yield of transbronchial needle aspiration and other cytologic and histologic diagnostic procedures (i.e., forceps biopsy, brushing, and washing) and to assess the optimal combination for diagnosing endobronchial lung cancers. This prospective study included 95 patients presenting with visible tumors detected during bronchoscopic procedure as either an exophytic endobronchial lesion (EEL) or submucosal-peribronchial disease (SPD). Transbronchial needle aspiration, forceps biopsy, brushing, and washing were performed in all patients, and 91 patients were diagnosed. Rates of positive results were 75.8% for needle aspiration, 71.6% for forceps biopsy, 61.1% for brushing, and 32.6% for washing. Needle aspiration was used as the sole diagnostic method in 11, forceps biopsy was the sole diagnostic method in 5, and brushing was the sole diagnostic method in 4 patients. Washing was not used as the sole diagnostic method in any case. Forceps biopsy yielded the highest diagnostic rate for an EEL (86.4%); however, when compared with needle aspiration (77.9%), no significant difference was observed between these two procedures (P = 0.302). In patients with a diagnosis of SPD, needle aspiration was determined to be the sole diagnostic method in eight patients. In this group of patients, the highest rate of diagnosis was achieved with needle aspiration (72.2%), and when compared with forceps biopsy (47.2%), a significant difference between the two procedures (forceps biopsy versus needle aspiration) was observed (P = 0.049). By adding transbronchial needle aspiration to the conventional diagnostic methods (forceps biopsy, brushing, and washing), the rate of diagnosis increased from 82.1% to 95.8% (P = 0.001), and in patients with a diagnosis of SPD, this rate increased from 69.4% to 94.4% (P = 0.008). In patients with a diagnosis of an EEL, addition of needle aspiration led to an increase in diagnostic yield but this difference was not statistically significant (89.8% versus 96.6%, P = 0.250). In endobronchial lung cancers, transbronchial needle aspiration is a safe method that can be used together with conventional diagnostic procedures to increase the diagnostic yield and should be considered a valuable diagnostic tool, particularly in cases of SPD. The highest rate of diagnostic yield in this study was obtained using a combination of forceps biopsy, transbronchial needle aspiration, and brushing; washing did not contribute to this high rate.

Transbronchial needle aspiration in the diagnosis of endobronchial malignant lesions: a 3-year experience

STUDY OBJECTIVES

To establish the diagnostic yield of transbronchial needle aspiration (TBNA) and its contribution to conventional diagnostic techniques (CDT) such as forceps biopsy, bronchial washing, and bronchial brushing in the diagnosis of malignant endobronchial lesions.

DESIGN

Retrospective clinical study.

PATIENTS

One hundred fifteen lung cancer patients

MEASUREMENT AND RESULTS

We reviewed files of 115 lung carcinoma cases diagnosed in our clinic from 2001 to 2003 with endobronchial lesions sampled by CDT and TBNA. The lesions were classified into three groups: exophitic mass lesion (EML), submucosal disease, and peribronchial disease. The diagnostic yield of TBNA and CDT was compared to that of the combination of CDT and TBNA with respect to the type and location of the lesion and the histopathologic subgroups. Of the 115 cases, histology findings were confirmed by TBNA in 91 cases (79%), CDT in 75 cases (65%), and TBNA plus CDT in 105 cases (91%). The difference of the diagnostic yield of CDT vs TBNA plus CDT was statistically significant (p < 0.001). In peribronchial disease, the sensitivity of TBNA plus CDT was significantly better than CDT (87% vs 52%, p < 0.001). In EML and submucosal disease, addition of TBNA to CDT improved sensitivity from 85 to 100% and from 84 to 97%, respectively (p > 0.05). Regarding localization, the addition of TBNA to CDT increased sensitivity in the trachea and main bronchi, and in right upper and middle lobe lesions (p < 0.05). By the addition of TBNA to CDT, small cell lung cancer and non-small cell lung cancer cases demonstrated improvements in sensitivity from 74 to 100% and 61 to 87%, respectively. This significant difference (p < 0.05) was attributed to the peribronchial disease group.

CONCLUSION

In the case of peribronchial disease, the addition of TBNA to CDT improves the diagnostic yield of the bronchoscopic examination.

Utility of Rapid On-Site Evaluation of Transbronchial Needle Aspirates

BACKGROUND

Rapid on-site evaluation has been proposed as a method to improve the yield of transbronchial needle aspiration.

OBJECTIVES

This study investigated whether on-site analysis facilitates routine diagnostic bronchoscopy in terms of sampling, yield and cost.

METHODS

Patients with lesions accessible for transbronchial needle aspiration on computed tomography were investigated. A cytopathologist screened the needle aspirates on site for the presence of diagnostic material. The bronchoscopic sampling process was adjusted according to the results. In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung tumours or lymph node sites (mediastinal: 7%; tracheobronchial: 68%; other: 25%). In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung lesions (paratracheal tumours or lymph nodes: 7%; tracheobronchial lymph nodes: 68%; other: 25%).

RESULTS

The diagnostic yield of needle aspiration was 77 and 25% in patients with neoplastic and non-neoplastic lesions, respectively. Sampling could be terminated in 64% of patients after needle aspiration had been performed as the only diagnostic modality, and on-site analysis identified diagnostic material from the first site aspirated in 50% of patients. Only in 2 patients (2%) diagnostic aspirates were not recognized on site. On-site analysis was cost effective due to savings for disposable diagnostic tools, which exceeded the extra expense for the on-site cytology service provided.

CONCLUSIONS

Rapid on-site analysis of transbronchial aspirates is a highly useful, accurate and cost-effective addition to routine diagnostic bronchoscopy.

[Transbronchial needle aspiration in bronchogenic carcinoma with visible lesions: diagnostic yield and cost]

BACKGROUND

Transbronchial needle aspiration (TBNA) is a bronchoscopic technique whose usefulness in diagnosing endobronchial lesions has not yet been clearly established.

OBJECTIVE

We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased, without a negative impact on diagnostic costs, if TBNA were used in combination with conventional diagnostic techniques (bronchial washings and bronchial brushings and forceps biopsy).

PATIENTS AND METHODS

The cases of 130 patients diagnosed with bronchogenic carcinoma with endoscopically visible lesions were analyzed retrospectively. All had undergone conventional diagnostic procedures; TBNA was also performed if the bronchoscopist considered it was indicated. The final cost was calculated in euros for each diagnosis as the sum of the cost of the procedures needed to reach the diagnosis, including both endoscopic procedures and others (transthoracic needle aspiration, lymph node biopsy). Diagnostic yield and costs in cases diagnosed using only conventional techniques were compared to the yield and costs in cases in which both conventional techniques and TBNA were used.

RESULTS

TBNA was performed in 49 patients and provided the diagnosis in 85.7%. Conventional techniques led to cytological and histological diagnosis in 80.2% of the cases, and the combination of conventional techniques and TBNA gave a diagnosis in 89.7% (P=.01). Significant differences were observed in extrinsic compression (conventional 37.5%; conventional+TBNA 100%; P=.01), submucosal infiltration (conventional 54.6%; conventional+TBNA 85%; P=.03), and exophytic mass with necrosis (conventional 80%; conventional+TBNA 100%; P=.01). The mean (SD) cost of diagnosis was euros 381.60 (euros 156.53) using conventional techniques and euros 413.25 (euros 112.91) for conventional techniques in combination with TBNA. By adding TBNA, costs decreased for diagnoses of submucosal infiltration, exophytic mass with necrosis and extrinsic compression, although the saving was significant only for extrinsic compression.

CONCLUSION

The diagnostic yield of TBNA is high for endoscopically visible bronchial anomalies suggesting neoplasm, particularly when the lesion is due to extrinsic compression, submucosal infiltration, or exophytic mass with necrosis.

Cytologic approach to tumors of the tracheobronchial tree

Cytologic testing is an integral part of the workup of patients suspected of having lung cancer. These tests are less invasive than other tissue procurement methods, with minimal risk of complications. In experienced hands, the tests are highly accurate and reliable. To achieve good results and avoid diagnostic errors, clinicians must be educated in proper collection and fixation methods and the pathologist should be cognizant of clinical and radiologic data. Close communication between the clinician and pathologist should be encouraged.

Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence

STUDY OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

A systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer.

MEASUREMENT AND RESULTS

For sputum cytology, the pooled specificity was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central lesions than for peripheral lesions (0.71 vs 0.49, respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69. Peripheral lesions < 2 cm or > 2 cm in diameter showed sensitivities of 0.33 and 0.62, respectively. Updating a previous meta-analysis with 19 studies revealed a pooled sensitivity of 0.90 for TTNA. A trend toward lower sensitivity was noted for lesions that were < 2 cm in diameter. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive and false-negative rates were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions that are < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease. The distinction between small cell lung cancer and non-small cell lung cancer by cytology appears to be accurate.

Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer

Lung cancer is the leading cause of cancer deaths in the United States. The individual therapeutic approach and prognosis depends on accurate diagnosis and staging. Flexible bronchoscopy (FB) and transthoracic needle biopsy (TNB) are the most widely used techniques for this purpose. This article provides a critical overview of indications, diagnostic yield, and limitations of bronchoscopy and TNB in the diagnosis of lung cancer.