Value of flexible bronchoscopy in the pre-operative work-up of solitary pulmonary nodules

Development and Validation of a Prediction Model for Positive Findings of Preoperative Flexible Bronchoscopy in Patients with Peripheral Lung Cancer

(1) Background: It has yet to be determined whether preoperative flexible bronchoscopy (FB) should be routinely performed in patients with peripheral lung cancer. The aim of this study was to construct a model to predict the probability of positive FB findings, which would help assess the necessity of preoperative FB. (2) Methods: A total of 380 consecutive patients with peripheral lung cancer who underwent preoperative FB were recruited for this study. A prediction model was developed through univariate and multivariate logistic regression, with predictors including gender, age, body mass index (BMI), smoking, history of chronic lung diseases, respiratory symptoms, lesion size, lesion type, lesion location in the bronchi, and lesion location in the lobe. The predictive performance of the model was evaluated by validation using 1000 iterations of bootstrap resampling. Model discrimination was assessed using the area under the receiver operating characteristics curve (AUC), and calibration was assessed using the Brier score and calibration plots. (3) Results: The model suggested that male patients with respiratory symptoms, decreased BMI, solid lesions, and lesions located in lower-order bronchi were more likely to have positive FB findings. The AUC and Brier score of the model for internal validation were 0.784 and 0.162, respectively. The calibration curve for the probability of positive FB findings showed convincing concordance between the predicted and actual results. (4) Conclusions: Our prediction model estimated the pretest probability of positive FB findings in patients with peripheral lung cancers. Males and patients with lower BMI, the presence of respiratory symptoms, larger lesions, solid lesions, and lesions located in lower-order bronchi were associated with increased positive FB findings. The use of our model can be of assistance when making clinical decisions about preoperative FB.

Is flexible bronchoscopy necessary in the preoperative workup of patients with peripheral cT1N0 subsolid lung cancer? -a prospective multi-center cohort study

Background

Necessity of flexible bronchoscopy (FB) examination as a routine preoperative work-up for peripheral clinical T1N0 subsolid lung cancer was unknown.

Methods

This was a prospective, multi-center clinical trial (NCT03591445). Patients with peripheral GGO nodules (GGNs) who were candidates for surgical resection were enrolled. FB examination was performed preoperatively. Surgical plan could be changed if any aberrant histologic and anatomic findings were detected by FB examination. Primary endpoint was the rate that surgical plan was changed by positive FB findings. Secondary endpoints were rate of positive FB findings and rate of procedural complications.

Results

Six hundred and fifteen patients with peripheral subsolid nodules detected by thoracic CT were enrolled. There were 187 (30.4%) male and 428 (69.6%) female patients, mean age was 54.85±10.41 y (range, 26-78). 262 (42.6%) patients had pure GGNs and 353 (57.4%) patients had part-solid nodules. Mean size of nodules was 13.87±6.37 mm (range, 5-30). FB examinations confirmed one (0.16%) adenocarcinoma, seven (1.14%) bronchial variations, one (0.16%) segmental bronchostenosis, one (0.16%) segmental bronchial occlusion and one (0.16%) bronchial inflammation. No complications of FB examinations occurred. 568 (92.35%) thoracoscopic and 47 (7.65%) open surgeries were performed. No established surgical plan was changed by positive FB findings. Final pathologies revealed 26 (4.2%) adenocarcinoma in situ (AIS), 240 (39%) minimal invasive adenocarcinomas (MIAs), 343 (55.8%) invasive adenocarcinomas (IADs), one (0.2%) adenosquamous cell carcinoma, one (0.2%) squamous cell carcinoma, two (0.3%) atypical adenoid hyperplasia and two (0.3%) inflammations.

Conclusions

FB examination was unnecessary in the preoperative assessment of peripheral clinical T1N0 subsolid lung cancer.

Multivariate Analysis Of The Diagnostic Yield Of Conventional Bronchoscopy In Peripheral Lung Adenocarcinoma

Background

The new subtypes of lung adenocarcinoma reflect local invasive growth, pulmonary alveoli, and intraluminal spreading, while the effective improvement of the diagnostic yield of bronchoscopy still remains unclear. This study aims to explore whether the subtypes of lung adenocarcinoma and other factors affect the diagnostic yield of bronchoscopy.

Methods

All patients were performed 64-row CT examination and bronchoscopy.

Results

The bronchus cutoff sign in 48 cases and the endoscopic diagnostic yield was 60.4%. The lumen of the lobes and segments was invaded in 59 cases, and the endoscopic diagnostic yield was 54.2%.The lymph node metastasis was detected in 46 cases, and the endoscopic diagnostic yield was 60.9%. In addition, 42 cases showed acinar type-predominant, and the endoscopic diagnostic yield was 28.6%. Eighteen cases showed solid type-predominant, and the endoscopic diagnostic yield was 33.3%. The micropapillary type-predominant was noted in 17 cases, with the endoscopic diagnostic yield as 94.1%. The papillary type-predominant was in 14 cases, and the endoscopic diagnostic yield was 42.9%. The lepidic type-predominant was seen in 13 cases, and the endoscopic diagnostic yield was 7.7%. The mean diameter of tumors with a positive endoscopic diagnostic yield was 4.34±2.65cm, and the mean diameter of tumors with a negative diagnostic yield was 2.83±1.47cm. Multivariate analysis showed that micropapillary lung adenocarcinoma affected the endoscopic diagnostic yield (OR=37.594, 95% CI: 4.074-346.94) .Tumor diameter affects endoscopic diagnostic yield (OR=1.39, 95% CI: 1.073-1.802), bronchus cutoff sign is easy to obtain endoscopic diagnostic yield (OR=4.86, 95% CI: 1.606-14.704), and lymph node metastasis affects the endoscopic diagnostic yield (OR=3.696, 95% CI: 1.255-10.883).

Conclusion

The micropapillary subtype lung adenocarcinoma has a certain influence on the diagnostic yield of bronchoscopy. When the lung adenocarcinoma has a large tumor diameter, bronchus cutoff sign and lymph node metastasis, it is easy to obtain a diagnostic yield of bronchoscopy.

Reasons for prolonged time for diagnostic workup for stage I-II lung cancer and estimated effect of applying an optimized pathway for diagnostic procedures

BACKGROUND

Minimizing the time until start of cancer treatment is a political goal. In Norway, the target time for lung cancer is 42 days. The aim of this study was to identify reasons for delays and estimate the effect on the timelines when applying an optimal diagnostic pathway.

METHODS

Retrospective review of medical records of lung cancer patients, with stage I-II at baseline CT, receiving curative treatment (n = 100) at a regional cancer center in Norway.

RESULTS

Only 40% started treatment within 42 days. The most important delays were late referral to PET CT (n = 27) and exercise test (n = 16); repeated diagnostic procedures because bronchoscopy failed (n = 15); and need for further investigations after PET CT (n = 11). The time from referral to PET CT until the final report was 20.5 days in median. Applying current waiting time for PET CT (≤7 days), 48% would have started treatment within 42 days (p = 0.254). "Optimal pathway" was defined as 1) referral to PET CT and exercise test immediately after the CT scan and hospital visit, 2) tumor board discussion to decide diagnostic strategy and treatment, 3) referral to surgery or curative radiotherapy, 4) tissue sampling while waiting to start treatment. Applying the optimal pathway, current waiting time for PET CT and observed waiting times for the other procedures, 80% of patients could have started treatment within 42 days (p < 0.001), and the number of tissue sampling procedures could have been reduced from 112 to 92 (- 16%).

CONCLUSION

Changing the sequence of investigations would significantly reduce the time until start of treatment in curative lung cancer patients at our hospital and reduce the resources needed.

Management of pulmonary nodules

Pulmonary nodules are frequently detected during clinical practice and require a structured approach in their management in order to identify early lung cancers and avoid harm from over investigation. The article reviews the 2015 British Thoracic Society guidelines for the management of pulmonary nodules and the evidence behind them.

Malignant central airway obstruction

This review comprehensively describes recent advances in the management of malignant central airway obstruction (CAO). Malignant CAO can be a dramatic and devastating manifestation of primary lung cancer or metastatic disease. A variety of diagnostic modalities are available to provide valuable information to plan a therapeutic intervention. Clinical heterogeneity in the presentation of malignant CAO provides opportunities to adapt and utilize endoscopic technology and tools in many ways. Mechanical debulking, thermal tools, cryotherapy and airway stents are methods and instruments used to rapidly restore airway patency. Delayed bronchoscopic methods, such as photodynamic therapy (PDT) and brachytherapy can also be utilized in specific non-emergent situations to establish airway patency. Although data regarding the success and complications of therapeutic interventions are retrospective and characterized by clinical and outcome measure variability, the symptoms of malignant CAO can often be successfully palliated. Assessment of risks and benefits of interventions in each individual patient during the decision-making process forms the critical foundation of the management of malignant CAO.

Electromagnetic navigation bronchoscopy: clinical utility in the diagnosis of lung cancer

Electromagnetic navigation bronchoscopy (ENB) is one of several technological advances which have broadened the indications for bronchoscopy in the diagnostic workup of lung cancer. The technique facilitates bronchoscopic sampling of peripheral pulmonary nodules as well as mediastinal lymph nodes, although wide availability and expertise in endobronchial ultrasonography has limited its application in routine clinical practice to the former. ENB in this setting is quite versatile and may be considered an established alternative to more invasive techniques, especially in selected patients with underlying pulmonary disease or comorbidities at high risk for complications from computer topography-guided fine needle aspiration or surgical resection. Nodule sampling may be performed with a variety of instruments, including forceps, cytology brushes, and transbronchial needles. Although samples are generally small, they are often suitable for molecular analysis.

Comparison of the accuracy of 99mTc-3P4-RGD2 SPECT and CT in diagnosing solitary pulmonary nodules

The aim of the present study was to compare technetium-99m-(polyethylene glycol-4)₃-(Arg-Gly-Asp)₂ (99mTc-3P₄-RGD₂) single-photon emission computed tomography (SPECT) and computed tomography (CT) in the noninvasive differentiation of solitary pulmonary nodules (SPNs). The present study prospectively investigated a consecutive series of 24 patients with SPN, who were newly diagnosed using radiography between September 2012 and January 2014. All patients underwent 99mTc-3P₄-RGD₂ SPECT and CT scans using a dual-head variable-angle γ-camera equipped with high-resolution collimators. A blinded panel of two thoracic radiologists for CT and three nuclear physicians for SPECT analyzed the images using a 5-grade scale. The SPECT images were also semi-quantitatively evaluated using tumor to non-tumor localization ratios (T/NT). The results were verified by pathological examination of the biopsy material obtained from each patient with SPN, and receiver operating characteristic (ROC) curves were generated from these results. The present results revealed that there were 17 malignant and 7 benign SPNs among the 24 patients with SPN. The mean size of the SPN was 2.1±0.6 cm. Sensitivity of visual analysis for SPECT and CT were 100.0 and 82.4%, respectively, and specificity was 71.4% for the two methods. When the T/NT SPECT semiquantitative analysis (ratio, 1.64) was used as a cut-off, the sensitivity and specificity of SPECT were 100.0 and 71.4%, respectively. The areas under the ROC curves were 0.840 for visual analysis of SPECT [95% confidence interval (CI), 0.600–1.000], 0.849 for semiquantitative analysis of SPECT (95% CI, 0.618–1.000) and 0.815 for CT (95% CI, 0.626–1.000). In conclusion, the present results suggest that 99mTc-3P₄-RGD₂ SPECT is more accurate than CT in the detection of malignant SPN, and visual analysis appears to be sufficient for the characterization of SPN.

Transbronchial needle aspirations vs. percutaneous needle aspirations

Over the last decade, the increasing diffusion of innovative and more powerful imaging guided techniques has further broadened the bronchoscopist's horizons in the diagnostic work-up of peripheral pulmonary nodules/masses (PPN/M). However, in most of institutions worldwide, due to the lack of resources and specific skills, the routinely diagnostic approach to PPN/M is still represented by imaging-guided transbronchial needle aspirations (TBNA) and percutaneous needle aspirations (PCNA). So far, no randomized clinical trials directly comparing the accuracy of the two procedures are available, and a standardized strategy that defines the proper role of each technique has yet to be established. In fact, the choice between these procedures is mostly influenced by "environmental" factors, such as operator's experience and local resources, rather than by an established algorithm, based on selected clinical scenarios. Data from literature indirectly suggest a higher sensitivity of PCNA compared to transbronchial approach, especially when lesions are peripheral and less than 2 cm. On the other hand, the transbronchial approach has been shown to have a better safety profile. Moreover, it offers the advantages to provide, during a single examination, a pathological diagnosis of nodules, information on mediastinal staging and airways involvement, and to identify potential synchronous lesions. In this context, it would be reasonable to firstly perform flexible bronchoscopy with TBNA, and, in case of inconclusive results, PCNA. In conclusions, both the techniques have been shown to be useful in the diagnostic pre-operative work-up of PPN/M. In order to optimize the diagnostic yield and to minimize the risk of patients they should not to be considered as two alternative options, but, rather, as two complementary techniques integrated in a standardized algorithm.

Transbronchial Catheter Aspiration and Transbronchial Needle Aspiration in the Diagnostic Workup of Peripheral Lung Lesions

PURPOSE

Increasingly frequent, it is clinically indicated to obtain tissue from a peripheral lung lesion (PLL) to yield a pathological diagnosis. The aim of the present study was to evaluate the diagnostic sensitivity of transbronchial needle aspiration (TBNA) and transbronchial catheter aspiration (TBCA) in addition to transbronchial forceps biopsy (TBB) at conventional bronchoscopy.

METHODS

Eligible patients showing a PLL on computed tomography scans were included in the study. In all patients, following TBB, TBNA and TBCA were employed in randomised order under fluoroscopy.

RESULTS

Fourty-eight patients were enrolled, of whom 46 patients with 46 PLLs were included in the analysis. The mean ± SD diameter of the PLL was 27.0 ± 13.3 mm. The overall sensitivity for all modalities was 69.6%; PLL ≤20 or >20 and ≤30 mm in diameter showed a sensitivity of 60.0 and 72.2%, respectively. For malignant PLL (n = 33), the combined sensitivity of TBNA + TBCA versus TBB was significantly higher (63.6 vs. 33.3%, p ≤ 0.05), and could not further be improved by TBB. For benign PLL, TBB was superior to TBNA + TBCA (76.9 vs. 38.5%).

CONCLUSIONS

TBB, TBNA and TBCA are complementary to one another. Combining the three techniques, even allows transbronchial specimen collection of PLL <3 cm in diameter at conventional bronchoscopy.

Improvements to bronchoscopic brushing with a manual mapping method: A three-year experience of 1143 cases

Background

Conventional bronchoscopy with brushing alone for diagnosing peripheral pulmonary lesions (PPLs) is of low sensitivity. A manual mapping method was introduced and evaluated in this study, which could be routinely applied with bronchoscopic brushing to improve the sensitivity for malignant PPLs.

Methods

This mapping method involves the bronchoscopist drawing the route with a series of bronchial opening sketches and marking the leading bronchus at every bifurcation point based on thin‐section computed tomography. This map is then used to guide bronchoscope insertion for brushing. A cross‐sectional study on the evaluation of this method for the diagnosis of malignant PPLs was conducted on patients from July 2010 to June 2013.

Results

The sensitivity for malignant PPLs of conventional brushing, conventional brushing with mapping on a portion of patients, and conventional brushing with mapping method increased from 17.0% to 25.8% to 31.5% (P < 0.001), respectively. For lesion sizes over 3 cm, the rate of these three groups increased from 25.1% to 38.6% to 50.9% (P < 0.001), respectively. The sensitivity of this mapping method for malignant PPLs was statistically associated with lesion size, lesion character, relationship between the lesion and the leading bronchus, linear distance between the targeted bronchus and the opening of the lobe bronchus, and accessibility (P < 0.001, P = 0.039, P < 0.001, P = 0.031, and P = 0.020, respectively).

Conclusions

The manual mapping method greatly increased the bronchoscopic brushing sensitivity for malignant PPLs compared to the conventional brushing method. During routine clinical work, it is economical and convenient for guiding bronchoscope insertion.

Preoperative flexible bronchoscopy in patients with persistent ground-glass nodule

There are no accurate data on the diagnostic value of preoperative flexible bronchoscopy (FB) for persistent ground-glass nodule (GGN) of the lung. We evaluated the value of preoperative FB in patients with suspected GGN-type lung cancer. We retrospectively searched a database for subjects who had ‘ground-glass opacity’, ‘non-solid nodule’, ‘part-solid nodule’, or ‘sub-solid nodule’ on chest computed tomography reports between February 2004 and March 2012. Patients who had infiltrative ground-glass opacity lesions, mediastinal lymphadenopathy, or pleural effusion, focal ground-glass opacity lesions >3 cm, and were lost to follow-up were excluded. We assessed the diagnostic value of preoperative FB in patients with persistent GGNs who underwent surgical resection. In total, 296 GGNs were evaluated by FB in 264 patients with persistent GGNs who underwent preoperative FB and surgical resection. The median size of the GGNs was 18 mm; 135 (46%) were pure GGN and 161 (54%) were part-solid GGN. No visible tumor or unsuspected endobronchial metastasis was identified by preoperative FB. Only 3 (1%, 3/208) GGNs were identified preoperatively as malignant by bronchial washing cytology; all were part-solid GGNs. No other etiology was identified by FB. Of the GGNs, 271 (91%) were subsequently confirmed as malignant and 25 (9%) were confirmed as benign at surgical resection. Consequently, the overall diagnostic sensitivity and negative predictive value of preoperative FB on a per-nodule basis was 1% (3/271) and 8% (25/293), respectively. The preoperative FB did not change the surgical strategy. Preoperative FB did not add much to the evaluation of persistent GGNs of the lung. Routine preoperative FB may have limited value in surgical candidates with small persistent pure GGNs.

Is bronchoscopy necessary in the preoperative workup of a solitary pulmonary nodule?

OBJECTIVE

This study evaluated the role of conventional bronchoscopy in the preoperative workup of patients with solitary pulmonary nodules (SPNs).

METHODS

Patients with SPNs of unknown origin were enrolled for preoperative bronchoscopy at our institution. Bronchoscopic findings were prospectively collected, and their impact on planned therapy was analyzed.

RESULTS

A total of 1026 patients were included. Bronchoscopy identified unsuspected findings in 80 (7.8%) of them, with a total of 826 (80.5%) malignant nodules. Referent values for bronchoscopic detection of malignant SPNs were: accuracy, 24.3% (95% confidence interval [CI]: 21.7%-27.0%); sensitivity, 5.9% (95% CI: 4.5%-7.4%); specificity, 100%; and negative predictive value, 20.5% (95% CI: 18.0%-22.9%). Malignant bronchoscopic findings were more common in male patients (odds ratio [OR] = 2.1, 95% CI: 1.1-3.9, P = .021) and large nodules (OR = 2.3, 95% CI: 1.6-3.3, P < .001). Surgery was cancelled in 2 (0.2%) patients and modified in 36 (3.5%) patients because of bronchoscopic findings. In all, for 268 (26.1%) SPNs that presented with ground-glass opacity, the bronchoscopy was unrevealing.

CONCLUSIONS

In the preoperative evaluation of SPN, bronchoscopy is most likely to reveal malignancy in larger SPNs and in male patients. Bronchoscopy is not indicated in SPNs that present with ground-glass opacity on computed tomography scan.

[Clinical experience of the treatment of solitary pulmonary nodules with Da Vinci surgical system]

背景与目的

肺孤立结节（solitary pulmonary nodule, SPN）定义为一个圆形的直径小于3 cm的肺实质内的病变，不伴有肺不张和淋巴结病变。本研究旨在探讨达芬奇机器人治疗SPN的临床体会。

方法

2011年11月-2014年3月，沈阳军区总医院应用达芬奇机器人治疗SPN 9例，其中男性3例；女性6例；年龄41岁-74岁，平均（51±9.9）岁；患者多数无明显临床症状（健康体检发现7例，咳嗽咳痰2例）；病史时间4天-3年（中位数12个月）；病变均为周围型肺结节病灶，直径为0.8 cm-2.8 cm，平均（1.4±0.6）cm；术中切取病变送冰冻病理检查，证实为恶性病变者行肺叶切除或楔形切除并常规清除肺门和纵隔淋巴结。手术采用全麻、双腔管气管插管，患者健侧卧位，胸部垫高，双手屈曲抱枕于头前，折刀位。孔位为腋后线第8肋间为进镜孔，肩胛线第8肋间、腋前线与锁中线间第5肋间为器械孔，腋中线第7肋间为辅助口。

结果

术后病理为良性病变4例（炎性假瘤3例，错构瘤1例），恶性病变5例，均为腺癌。手术包括楔形切除4例，右肺中叶切除+淋巴结清除术2例，左肺上叶切除+淋巴结清除术1例，其余2例肺癌患者因为心肺功能差，病变小于2 cm，行楔形切除+淋巴结清除术。9例均顺利完成机器人手术，所有患者无严重术后并发症，均顺利出院。随访时间为0.1个月-18.5个月（中位数11个月），无复发、转移。

结论

SPN病变应该予以积极手术治疗，提高早期肺癌的诊断率和治愈率，达芬奇机器人手术对于SPN的治疗是一种安全、微创的手术方法，在SPN病变的诊治中具有较高的价值。