The diagnostic yield of bronchoscopy

Diagnosis of Diffuse Lung Disease by Cutting Needle Biopsy

The results of 15 consecutive automated cutting needle (1.2 mm, n = 14; 2.0 mm, n = 1) biopsies of diffuse lung manifestations are presented. Sufficient material for histologic analysis was obtained in 13 of 15 specimens (87%) and a specific diagnosis was obtained in 11 of 14 patients (79%). The tissue specimen confirmed the clinically probable lung disease in 6 patients, gave a new, unsuspected, diagnosis in 2, and resolved a differential diagnostic problem in 3 patients. One pneumothorax after a 2.0-mm needle biopsy necessitated catheter drainage. We conclude that percutaneous lung biopsy with the automated biopsy device mounted with a 1.2-mm needle yields a histologic diagnosis with high accuracy in interstitial and alveolar lung changes, reducing the need for more invasive methods such as open lung biopsy.

Image-Guided Fine Needle Aspiration Strategies for Staging of Lung Cancer

Image-guided transthoracic, bronchoscopic, and endoscopic ultrasound fine needle aspiration (FNA) greatly facilitates lung cancer staging by having the potential to precisely biopsy lung lesions and virtually all mediastinal lymph node stations. Imaging modalities alone, including chest x-ray, computed tomography (CT), magnetic resonance imaging, and positron emission tomography identify lesions suspicious for cancer but cannot make a tissue diagnosis. We describe an algorithm for the diagnosis and tumor-node-metastasis staging of lung cancer that uses procedures with the least invasiveness and cost with the highest diagnostic yields. For the anterior mediastinum, fluoroscopic-, ultrasound-, or CT-guided transthoracic FNA (which has a greater yield than bronchoscopy and is less invasive than mediastinoscopy) should be the primary technique for lymph node sampling. In the middle mediastinum, CT-guided transthoracic FNA is preferred for all nodal stations except subcarinal. Endoscopic ultrasound-guided FNA (EUS-FNA), which enables real-time biopsies within 5 cm of the esophagus, is preferred for sampling subcarinal and posterior mediastinal nodes because the yield is similar to CT-guided transthoracic FNA, with minimal risk of pneumothorax. The posterior mediastinum is also accessed by fluoroscopic- or CT-guided transthoracic FNA or video-assisted thoracic surgery. Sampling of the aorticopulmonary window depends on lymph node size; if the nodes are large enough to displace the aortic arch and pulmonary vein, then EUS-FNA is attempted, and if the nodes are not sufficiently enlarged, CT-guided transthoracic FNA should be performed prior to thoracoscopy or thoracotomy.

Ultrasound-guided fine-needle aspiration cytology of non-palpable supraclavicular lymph nodes in sarcoidosis

PURPOSE

The aim of this prospective study was to determine the incidence of enlarged supraclavicular lymph nodes by US and the diagnostic yield of US-guided aspiration cytology in the diagnosis of sarcoidosis.

METHODS

During a 54-month period, all consecutive patients with a clinical suspicion of sarcoidosis underwent supraclavicular US at the Kiljava Hospital, Finland. All patients with enlarged supraclavicular lymph nodes underwent US-guided fine-needle aspiration biopsy (FNAB) of the lymph node.

RESULTS

Of a total of 250 patients, 27 (10.8%) had enlarged supraclavicular lymph nodes at US. All these were non-palpable at clinical examination. The cytological specimen was quantitatively sufficient in 25 of the 27 cases (93%). In 22 (88%) of these, the cytological diagnosis was granulomatous inflammation suggestive of sarcoidosis. Three aspirates yielded reactive hyperplasia and 2 specimens were insufficient. No complications occurred. The patients were followed for 2-42 months (mean 19 months), and the diagnosis of sarcoidosis was confirmed clinically in all cases.

CONCLUSION

Supraclavicular US detects non-palpable enlarged lymph nodes in 1/10 of the patients with suspected sarcoidosis. In this subgroup of patients, US combined with aspiration cytology may give cytological evidence of granulomatous disease similar to sarcoidosis and more invasive diagnostic methods can be avoided.

Fine-needle aspiration as the initial diagnostic modality in malignant lung disease

Cytologic detection of lung cancer is accepted, accurate, and time-honored. Typically, cytologic workup of a radiologic abnormality proceeds sequentially from sputum to bronchoalveolar cytology, and, if necessary, to fine-needle aspiration biopsy (FNA). Initial use of FNA in lung cancer diagnosis is controversial, but increasingly popular. We therefore decided to objectively assess current practice in cytologic lung cancer diagnosis at our institution. All pulmonary cytologic diagnoses for 1993 and the first half of 1994 were retrieved. Positive diagnoses were then used to access all patient data. Patients were stratified according to the specimen from which the first positive diagnosis was obtained. Of 542 pulmonary cytology specimens, 15% were sputa, 65% were bronchoalveolar, and 20% were FNAs. One hundred sixty-one of 172 malignant diagnoses were first diagnoses. Three percent of first malignant diagnoses were made from sputa, 47% were from lavages, and 50% were from FNAs. Although FNAs comprised just 20% of all pulmonary cytologies, 50% of all new malignant cytologic diagnoses were made by FNA. Initial use of FNA is successful, has a high diagnostic yield and low complication rate, and offers the most direct approach to diagnosis.

Hemoptysis: prospective high-resolution CT/bronchoscopic correlation

The precise roles of fiberoptic bronchoscopy (FOB) and computed tomography (CT) of the chest in the evaluation of patients presenting with hemoptysis have not been clearly defined. On the assumption that both procedures would likely provide unique and complementary information, a prospective study with blinded interpreters using a modified high-resolution CT technique (HRCT) and FOB was designed to evaluate 57 consecutive patients admitted to Bellevue Hospital with hemoptysis. Etiologies included bronchiectasis (25 percent), tuberculosis (16 percent), lung cancer (12 percent), aspergilloma (12 percent), and bronchitis (5 percent): in an additional 5 percent of cases, hemoptysis proved to be due miscellaneous causes, while in 19 percent hemoptysis proved to be cryptogenic. Patients with lung cancer all were at least 50 years old, smoked an average of 78 pack-years, and had less severe hemoptysis but of longer duration. All had conditions diagnosed both by HRCT and FOB. High-resolution CT proved of particular value in diagnosing bronchiectasis and aspergillomas, while FOB was diagnostic of bronchitis and mucosal lesions such as Kaposi's sarcoma. Fiberoptic bronchoscopy localized bleeding in only 51 percent of cases. The high sensitivity of CT in identifying both the intraluminal and extraluminal extent of central lung cancers in conjunction with its value in diagnosing bronchiectasis suggest that CT should be obtained prior to bronchoscopy in all patients presenting with hemoptysis.