Lung cancer. Making the diagnosis

Sequential use of bronchial aspirates, biopsies and washings in the preoperative management of lung cancers

BACKGROUND

The combination of cytology and biopsies improves the recognition and typing of small cell (SCLC) versus non small cell (NSCLC) lung cancers in the fiberoptic bronchoscopy assessment of centrally located tumours.

METHODS

We studied whether bronchial aspirates performed before biopsies (BA) and washings performed after biopsies (BW) could increase the diagnostic yield of fiberoptic bronchoscopy. A series of 334 consecutive samples taken in patients with suspicious fiberoptic bronchoscopy findings was studied. Two hundred primary tumours were included in the study. The actual diagnosis was based on surgical tissue specimen analysis and/or imaging techniques. The typing used was that of the 1999 WHO/IASLC classification.

RESULTS

The diagnosis of malignancy and tumour typing were analyzed according to the sequential (combined) or single use of tests. Malignancy was assessed by cytology in 144/164 (87.8%) positive biopsy cases and in 174/200 tumour cases (87.0%). BA before biopsies allowed 84.0% of cancers to be diagnosed, whereas BW after biopsies allowed 79.0% of cancers to be found (p = ns). However, combining biopsies with BW allowed 94.0% of cancers to be diagnosed, whereas 82.0% were diagnosed by biopsies alone (p < 0.001). The highest diagnostic yield was obtained with the combination of BA, biopsies and BW, with 97.0% sensitivity. Exact concordance in typing was obtained in 83.8% of cases. The six surgically resected cases (3.0%) with negative cytology and biopsy results included four squamous cell carcinomas with necrotizing or fibrous surface and two adenocarcinomas, pT1 stage.

CONCLUSION

Fiberoptic bronchoscopy may reach a yield of close to 100% in the diagnosis and typing of centrally located, primary lung cancers by combining bronchial aspirates, biopsies and washings.

Neglected lung cancer

Pulmonary nodules of unknown nature may be cancerous and are best treated by early resection. During the past 20 years we have seen 65 patients in whom asymptomatic pulmonary nodules from 5 to 20 mm in diameter were discovered on routine roentgenograms between 1 and 4 years prior to their referral to surgery. These patients have not been investigated for cancer. Instead, they had been 'observed' or treated with antibiotics while their nodules increased in size. At the time of referral, 29 patients had widespread metastases, 28 had locally invasive State III lung cancer, eight had Stage I or Stage II lesions. Only 16 patients had their tumors resected. Sixteen patients (24.6%) survived 1 year or longer; six patients (9.3%) survived more than 2 years. Early resection of all undiagnosed pulmonary nodules is essential. 'Expectant' or antibiotic treatment of these lesions should be condemned. Educational programs for family physicians are urged.