Transbronchial needle aspiration of peripheral pulmonary nodules

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Historical eye: from traditional to endobronchial ultrasound-guided needle aspiration and beyond

PURPOSE OF REVIEW

In the history of bronchoscopy, the advent of flexible transbronchial needle aspiration (TBNA) before and, subsequently, of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), have represented fundamental events, as they have significantly and definitively changed interventional pulmonology's role in diagnostic and therapeutic work-up of most of thoracic diseases.Purpose of this historical review is to retrace the main stages that have contributed to the development of these two techniques.

RECENT FINDINGS

TBNA allowed the bronchoscopists to overcome the barrier of the tracheobronchial wall and to obtain samples from hilar-mediastinal lesions. With this additional method, bronchoscopy has become an essential procedure for staging of lung cancer.The advent of echo-bronchoscopes, allowing to perform TBNA under direct ultrasound guidance in real time, further increased the diagnostic yield of this technique. Furthermore, the insertion of the echo-bronchoscope through the oesophagus allowed to extend the landscape of targets to sample, including also para-esophageal lesions, liver metastases, celiac nodes and left adrenal glands.EBUS-TBNA has shown its usefulness not only in the approach to mediastinal lesions, but also in other clinical conditions, such as lung nodules or masses adjacent to the tracheobronchial tree.

SUMMARY

Despite the obvious advantages of EBUS-TBNA, this technology is not yet available in many centres and countries worldwide. For this reason, TBNA remains a basic technique that must complete the technical background of bronchoscopists and it should not be forgotten.

Efficacy and safety of virtual bronchoscopic navigation with fused fluoroscopy and vessel mapping for access of pulmonary lesions

BACKGROUND AND OBJECTIVE

Virtual bronchoscopic navigation (VBN) with fused fluoroscopy and vessel mapping provides a point of entry (POE) for puncturing airway wall to biopsy lesions. The study was designed to evaluate the safety and efficacy of this technology to diagnose peripheral pulmonary lesions.

METHODS

It was a prospective, single-arm, multicentre study. Patients underwent lesions biopsy with the Archimedes® VBN System via a POE using one of the two techniques: (1) bronchoscopic transparenchymal nodule access (BTPNA) and (2) guided transbronchial needle aspiration (TBNA). Biopsy yield, sampling yield and diagnostic yield were mainly determined in lesions biopsy attempted.

RESULTS

One hundred and thirty patients underwent anaesthesia and constituted the intention-to-treat population. One hundred and four patients with 114 lesions had biopsy attempted. Mean lesion size was 2.4 ± 1.13 cm. Sufficient tissue samples were obtained from 86 lesions with a biopsy yield of 75.4%. Nevertheless, sufficient samples for diagnosis based on histology ± cytology were obtained from 107 lesions with a sampling yield of 93.9%. Follow-up was conducted for more than 1 year, with a diagnostic yield of 75.4% and 72.8%, respectively, on high and low estimate with consideration of three lesions without follow-up. Two (1.9%) pneumothoraxes and one (1.0%) mild bleeding occurred.

CONCLUSION

BTPNA and guided TBNA contribute to safe and effective sampling of peripheral pulmonary lesions. A relatively high biopsy yield was obtained independent of the presence or absence of a bronchus sign (BS), and high sampling yield and diagnostic yield were obtained independent of location, lesion size and presence or absence of a BS.

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.

Technologies for targeting the peripheral pulmonary nodule including robotics

Bronchoscopic sampling of PPL was significantly advanced by the development of the endobronchial ultrasound guide sheath method in the 1990s. Since then, a range of technical and procedural techniques have further advanced diagnostic yields. These include the use of thinner bronchoscopes with better working channel diameters, understanding the importance of peripheral transbronchial needle aspiration, and virtual bronchoscopic assistance. These have enabled better sampling of smaller and more technically challenging lesions including ground-glass nodules. Most recently, robotic bronchoscopy has been developed which, among other refinements, allows fine control of visual bronchoscopic navigation by replacing movements directed by the hand with electronic consoles and trackballs, and innovatively integrate virtual with real bronchoscopic pathways. The requirement for PPL diagnosis and treatment is expected to increase with more chest CT performed as part of CT screening programmes.

Radial probe endobronchial ultrasound assisted conventional transbronchial needle aspiration in the diagnosis of solitary peribronchial pulmonary lesion located in the segmental bronchi

Background: The diagnosis of peribronchial pulmonary lesions located in the tertiary bronchi, also known as segmental bronchi, as well as, the 4th order and 5th order segmental bronchi is very difficult. Histopathological specimens cannot be easily obtained by endobronchial biopsies (EBBX) due to the patent but small segmental bronchial lumen. The aim of the present study was to evaluate the diagnostic accuracy and safety of the novel technique with radial probe endobronchial ultrasound (R-EBUS) assisted conventional transbronchial needle aspiration (C-TBNA) in the diagnosis of solitary peribronchial pulmonary lesions located in segmental bronchi from 3th to 5th order. Methods: From December 2014 to December 2015, 16 patients with solitary peribronchial pulmonary lesions in the segmental bronchi from 3th to 5th order confirmed by computed tomography (CT) were enrolled. The lesions were located using radial probe endobronchial ultrasound (R-EBUS) to determine the sites of conventional transbronchial needle aspiration (C-TBNA), then, histopathological specimens were obtained using the technique of C-TBNA. The final pathological diagnosis was made based on the findings from the surgical specimens. Statistical analyses were performed for specimen results and complications. Results: On pathological evaluation, 14 of the 16 specimens were malignant, including 8 adenocarcinomas, 4 squamous cell carcinomas, and 2 small cell carcinomas, while 2 were non-malignant diseases. The diagnostic accuracy rate, sensitivity and missed diagnosis rates were 87.5%, 87.5% and 12.5%, respectively. When Combined the results of cytology with histologic samples obtained from C-TBNA the total diagnostic accuracy rate, sensitivity and missed diagnosis rate were 93.75%, 93.75% and 6.25%, respectively. There were 2 cases of bleeding complications >5 mL after C-TBNA, and both were resolved with endobronchial management. Conclusions: The combination of R-EBUS with C-TBNA was advantageous and safe for the diagnosis of solitary peribronchial pulmonary lesions located in the segmental bronchi. However, possible bleeding complications should be anticipated with needle aspiration. Further verification of this combined application should be investigated in larger clinical trials.

The efficacy of transbronchial needle aspiration with endobronchial ultrasonography using a guide sheath for peripheral pulmonary lesions suspected to be lung cancer

BACKGROUND

The efficacy of transbronchial needle aspiration (TBNA) with endobronchial ultrasonography using a guide sheath (EBUS-GS) for cases of peripheral pulmonary lesions (PPLs) has not been well established. The purpose of this study was to evaluate the efficacy of TBNA with EBUS-GS for PPLs.

METHODS

We evaluated 130 patients suspected to have lung cancer who underwent transbronchial brushing (brushing), transbronchial biopsy (TBB), and TBNA with EBUS-GS. The pathological diagnostic yields of TBNA were compared to that of TBB and brushing. The histological diagnosis of TBNA was compared to that of surgical specimens. The results of epidermal growth factor receptor (EGFR) gene mutation in TBNA samples were compared to that in TBB or surgical specimens.

RESULTS

The diagnostic yields of this study were 62.9% for brushing, 80.0% for TBB, and 77.1% for TBNA. Histological diagnosis was 84.8% for TBB and/or TBNA and pathological diagnosis was 86.7% for all the procedures. TBB and TBNA had significance higher than brushing (p < 0.05). TBB and TBNA had a tendency of higher diagnostic yields than brushing if EBUS probe was adjacent to PPLs (p = 0.058). Histological evaluations were obtained from TBNA specimens from 50 of 105 patients (47.6%) and these were identical to those of surgical specimens from 29 of 32 patients (90.6%). The results of EGFR gene mutation in TBNA specimens were identical to the same tissue obtained by surgery or TBB.

CONCLUSIONS

TBNA with EBUS-GS for PPLs was a useful tool for accurate diagnosis and EGFR gene mutation analysis. This method may improve diagnostic accuracy and be useful for molecular testing. This study was approved by the institutional review board (Date of approval: May 27, 2013, approval number: 2816) of Tokyo Women's Medical University Hospital.

Role of radial endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of pulmonary nodules: Case report and literature review

The diagnosis of pulmonary nodules can be made using several methods including computed tomography (CT)-guided fine-needle aspiration (FNA), radial endobronchial ultrasound (EBUS)-guided sampling techniques (transbronchial lung biopsy [TBLB], transbronchial brush, bronchoalveolar lavage, or transbronchial needle aspiration [TBNA]), or occasionally with convex probe (CP) EBUS-TBNA. While CT-guided FNA is associated with a high (25%) rate of pneumothorax, the CP-EBUS cannot reach lesions beyond the interlobar region. Radial EBUS-guided TBLB and transbronchial brushing are excellent modalities in the evaluation of peripheral pulmonary lesions. However, these techniques cannot access lesions that are located adjacent to the proximal segmental bronchus, due to the presence of a cartilaginous wall. Herein, we describe a 58-year-old man, who presented with a lung nodule in the right middle lobe, wherein radial EBUS-guided TBNA proved to be the most appropriate diagnostic modality. We also discuss the current utility of radial EBUS-guided TBNA in day-to-day practice.

Usefulness of conventional transbronchial needle aspiration in the diagnosis, staging and molecular characterization of pulmonary neoplasias by thin-prep based cytology: experience of a single oncological institute

BACKGROUND

Conventional transbronchial needle aspiration (c-TBNA) contributed to improve the bronchoscopic examination, allowing to sample lesions located even outside the tracheo-bronchial tree and in the hilo-mediastinal district, both for diagnostic and staging purposes.

METHODS

We have evaluated the sensitivity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the c-TBNA performed during the 2005-2015 period for suspicious lung neoplasia and/or hilar and mediastinal lymphadenopathy at the Thoracic endoscopy of the Thoracic Surgery Department of the Regina Elena National Cancer Institute, Rome. Data from 273 consecutive patients (205 males and 68 females) were analyzed.

RESULTS

Among 158 (58%) adequate specimens, 112 (41%) were neoplastic or contained atypical cells, 46 (17%) were negative or not diagnostic. We considered in the analysis first the overall period; then we compared the findings of the first [2005-2011] and second period [2012-2015] and, finally, only those of adequate specimens. During the overall period, sensibility and accuracy values were respectively of 53% and 63%, in the first period they reached 41% and 53% respectively; in the second period sensibility and accuracy reached 60% and 68%. Considering only the adequate specimens, sensibility and accuracy during the overall period were respectively of 80% and 82%; the values obtained for the first period were 68% and 72%. Finally, in the second period, sensibility reached 86% and accuracy 89%. Carcinoma-subtyping was possible in 112 cases, adenocarcinomas being diagnosed in 50 cases; further, in 30 cases molecular predictive data could be obtained.

CONCLUSIONS

The c-TBNA proved to be an efficient method for the diagnosis/staging of lung neoplasms and for the diagnosis of mediastinal lymphadenopathy. Endoscopist's skill and technical development, associated to thin-prep cytology and to a rapid on site examination (ROSE), were able to provide by c-TBNA a high diagnostic yield and molecular predictive data in advanced lung carcinomas.

Transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

Fluoroscopy-guided transbronchial needle aspiration (TBNA) has long been used in the diagnosis of peripheral pulmonary lesions (PPLs), although its diagnostic performance varies considerably.We conducted a systematic review and meta-analysis evaluating the accuracy of TBNA in the diagnosis of PPLs, comparing its diagnostic yield with transbronchial biopsy (TBB) and assessing the main predictors of a successful aspirate.In 18 studies, the overall TBNA yield was 0.53 (95% CI 0.44-0.61). TBNA showed a higher accuracy when directly compared to TBB (0.60 (95% CI 0.49-0.71) versus 0.45 (95% CI 0.37-0.54)). The subgroup analyses documented a higher TBNA yield when the computed tomography (CT) bronchus sign was present (0.70 (95% CI 0.63-0.77) versus 0.51 (95% CI 0.38-0.64)), when rapid on-site evaluation (ROSE) was performed (0.62 (95% CI 0.43-0.79) versus 0.51 (95% CI 0.42-0.60)), in the case of malignant lesions (0.55 (95% CI 0.44-0.66) versus 0.17 (95% CI 0.11-0.24)) and for lesions >3 cm (0.81 (95% CI 0.73-0.87) versus 0.55 (95% CI 0.47-0.63)).Conventional TBNA is a useful sampling technique for the diagnosis of PPL, with a higher diagnostic yield than TBB. The presence of CT bronchus sign, an underlying malignant process, lesion size >3 cm and ROSE employment are predictors of a higher yield.

Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry

RATIONALE

Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy.

OBJECTIVES

To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations.

METHODS

We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions.

MEASUREMENTS AND MAIN RESULTS

Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16).

CONCLUSIONS

Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

Evolution of transbronchial needle aspiration technique

Transbronchial needle aspiration (TBNA) is an established technique to collect cell and tissue specimens from lesions outside the airway wall, generally guided by flexible bronchoscope under the direct visualization of the puncture site. TBNA has been utilized for 30 years, and now there is renewed interest in utilizing it in conjunction with endobronchial ultrasound. Although the basic operational principles have remained the same, conventional TBNA (cTBNA) and endobronchial ultrasound-guided TBNA (EBUS-TBNA) have been greatly improved over the years with the increased application in clinic and the advance of new technology. In this article we briefly discussed the evolution of TBNA technique and its future.

Insight into the differences in classification of mediastinal and hilar lymph nodes between Wang's lymph node map and the International Association for the Study of Lung Cancer lymph node map

Lung cancer is the leading cause of malignant-tumor-related morbidity and mortality worldwide. Transbronchial needle aspiration (TBNA) has for the past 30 years been an effective technique for the diagnosis and staging of lung cancer. Understanding the anatomy of mediastinal and hilar lymph nodes is essential to improve the yield of TBNA. Wang's lymph node map is based on the lymph node map of the American Thoracic Society (ATS), and on the TBNA technique; it was published in 1994, and has promoted the development of both conventional TBNA (cTBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In 2009, the International Association for the Study of Lung Cancer (IASLC) developed a new chest lymph node map to reconcile the differences between the Naruke and The Mountain-Dresler (MD)-ATS lymph node maps. The IASLC lymph node map was incorporated into the seventh edition of the tumor, node, metastasis (TNM) staging system for lung cancer, which directly affected the treatment and prognosis of lung cancer. There are significant differences between Wang's lymph node map and the IASLC lymph node map in TNM staging, and it is imperative to understand these differences and correlate these maps for the prognosis and staging of lung cancer using cTBNA or EBUS-TBNA.

Transbronchial needle aspiration: development history, current status and future perspective

BACKGROUND

Transbronchial needle aspiration (TBNA) technology was underutilized by clinicians because it is "blind". Recent development of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) renewed the interest and confident of TBNA. TBNA without EBUS is referred as conventional transbronchial needle aspiration (C-TBNA).

METHODS

This paper focuses on C-TBNA technology development history, present situation and future development to do a detailed introduction.

RESULTS

TBNA is a simple, cost effective and minimally invasive technique for diagnosing disease of the mediastinum and lung in adult as well as children patients.

CONCLUSIONS

More improvements of TBNA technology should be made, including employing technological advances to perfect the instruments and techniques, focusing on patient comfort, optimizing yield, simplifying instruments, maximizing ease of use and minimizing training requirements for the pulmonologist. The ideal TBNA scope deserves further evaluation and study.

Evolution of transbronchial needle aspiration - a hybrid method

Conventional Transbronchial Needle Aspiration (C-TBNA) has been around for three decades, however it is still underutilized. Recent development of Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) renewed the interest and confident of TBNA. In short five years, it has proven to be a more attractive and reliable method than standard TBNA. Without adequate C-TBNA training is a key factor to make this useful technique to lose its competitive edge. This paper shared a junior pulmonary fellow's C-TBNA learning experience to summarize the indication, anatomy, instruments and technique, and our improvement of current and the future of TBNA. With systemic training program including slides presentation, video demonstration and hands on practice on a bronchial tree model, the correct lymph nodes of every stations would be able to punctured successfully. More importantly, this is the first time to describe a hybrid method of C-TBNA inspired by EBUS-TBNA, which will make the conventional technique more reliable and dependent in the future.

Transbronchial needle aspiration with or without endobronchial ultrasound

Transbronchial needle aspiration (TBNA) has been used for over three decades in the diagnosis and staging of mediastinal adenopathy and masses. Although first described in Argentina in 1949 by Dr. Eduardo Schieppati, this rigid bronchoscope technique received very little attention until 1978 at Johns Hopkins Hospital where Wang and colleagues described in detail the diagnosis of a paratracheal mass by TBNA biopsy through a rigid bronchoscope using a 25-gauge esophageal variceal needle. In 1983, a novel flexible needle that could be used with the flexible bronchoscope to perform TBNA was developed and introduced for diagnosis and staging of bronchogenic carcinoma. Immediately to follow was the expansion of its use in the diagnosis of peripheral pulmonary nodules and benign mediastinum and hilar disorders by obtaining histological core specimens. Recent development of the endobronchial ultrasound-guided TBNA is most exciting and promising. Whether this will enhance the result of TBNA and spread the TBNA technique as a standard lung cancer staging procedure is yet to be seen. TBNA is simpler and easier. Endobronchial ultrasound-guided TBNA currently is more complicated and more difficult. Its future relies on a hybrid instrument and methodology to be widely applied to the diagnosis and staging of bronchogenic carcinoma.

Management of an incidentally discovered pulmonary nodule

The incidental finding of a pulmonary nodule on computed tomography (CT) is becoming an increasingly frequent event. The discovery of such a nodule should evoke the possibility of a small bronchogenic carcinoma, for which excision is indicated without delay. However, invasive diagnostic procedures should be avoided in the case of a benign lesion. The objectives of this review article are: (1) to analyze the CT criteria defining benign nodules, nodules of high suspicion of malignancy and indeterminate nodules, (2) to analyze the diagnostic performances and limitations of complementary investigations requested to characterize indeterminate lung nodules, (3) to review the criteria permitting to assess the probability of malignancy of indeterminate nodules and (4) to report on the new guidelines provided by the Fleischner Society for the management of small indeterminate pulmonary nodules, according to their prior probability of malignancy.

Transbronchial needle aspiration: initial experience in routine diagnostic bronchoscopy

BACKGROUND

Transbronchial needle aspiration (TBNA) has been shown to be useful not only for the diagnosis and staging of lung cancer, its most widely studied indication, but also for many of other clinical indications. Despite this, it remains largely underutilized, mainly because of concerns with poor yield, safety, lack of experience of the bronchoscopist, and lack of cytopathological support.

OBJECTIVE

To study the clinical utility and yield of TBNA as an adjunct to other conventional procedures in diagnostic bronchoscopy at a centre that was relatively inexperienced with this technique, but where there was availability of rapid on-site evaluation (ROSE). Most of the major indications for TBNA in both malignant as well as benign disease were included.

SETTING

University Teaching Hospital naïve to the procedure.

PATIENT AND METHODS

Forty-five consecutive patients who underwent TBNA as part of diagnostic bronchoscopy during a 2-year study period.

RESULTS

TBNA gave a yield of 65% for evaluation of mediastinal disease, both benign and malignant. The overall diagnostic utility for all indications was 71% and there were no complications.

CONCLUSIONS

We conclude that TBNA is a useful and safe adjunct to diagnostic bronchoscopy in routine clinical practice. It has a satisfactory yield even with an inexperienced team, if used with ROSE.

Lung cancer in elderly patients

Lung cancer is one of the most common causes of death in elderly patients in the United States. Treatment advances have improved survival in selected patients. The available treatments carry the risk of morbidity and mortality but the benefit in most patients far outweighs the risks, given the dismal prognosis of untreated disease. Elderly patients with lung cancer need careful attention during pretreatment assessment. Advanced age alone, however, should not contraindicate aggressive treatment. In the high-risk groups it is important to involve a team of physicians including surgeons, radiation oncologists, medical oncologists, and pulmonologists, who are familiar with current treatment options and their risks.

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.

Role of computed tomographic scanning of the thorax prior to bronchoscopy in the investigation of suspected lung cancer

BACKGROUND

Fibreoptic bronchoscopy (FOB) is the usual initial investigation of choice in patients with suspected endobronchial carcinoma, but it is often non-diagnostic. Once a positive diagnosis has been made, many patients undergo staging by computed tomographic (CT) scanning to assess the extent of the disease and its suitability for radical treatment. To determine whether initial CT scanning before FOB is a cost effective way of reducing subsequent unnecessary or unhelpful invasive diagnostic procedures, a study was undertaken in 171 patients with suspected endobronchial carcinoma.

METHODS

A randomised two group study was performed with all patients undergoing an initial CT staging scan. In group A the CT scans were reviewed before FOB, allowing cancellation or a change to an alternative invasive procedure if considered appropriate. In group B all patients proceeded to FOB with the bronchoscopist blinded to the result of the CT scan until after the procedure.

RESULTS

In group A six of 90 patients (7%) required no further investigations as the CT scan was either normal, consistent with benign disease, or consistent with widespread metastatic disease. Of the remainder, bronchoscopy was diagnostic in 50 of 68 (73%) in group A compared with 44 of 81 (54%) in group B (p = 0.015). Overall, a positive diagnosis was made after a single invasive investigation in 64 of 84 patients (76%) in group A compared with only 45 of 81 patients (55%) in group B (p = 0.005). Only seven of 90 patients (8%) in group A required more than one invasive investigation compared with 15 of 81 patients (18.5%) in group B. In patients with malignancy, bronchoscopy was more likely to be diagnostic in group A (50 of 56 patients (89%)) than in group B (44 of 62 (71%); p = 0. 012), and the diagnosis was more frequently made on the initial invasive investigation (group A, 63 of 70 (90%); group B, 44 of 62 (71%); p = 0.004). Because of the lower number of invasive procedures performed in group A than in group B, the cost of performing CT scans before FOB in all patients in group A would have equated to a projected cost of performing CT scans in 60% of patients after FOB in group B.

CONCLUSIONS

Performing initial CT thoracic scans before bronchoscopy in patients with suspected endobronchial malignancy is a cost effective way of improving diagnostic yield from invasive diagnostic procedures and occasionally may obviate the need for any further investigation.

Utility of on-site cytopathology assessment for bronchoscopic evaluation of lung masses and adenopathy

STUDY OBJECTIVES

To determine the extent to which on-site cytopathology assessment improves diagnostic yield when sampling lung nodules or masses and/or hilar or mediastinal lymphadenopathy by fiberoptic bronchoscopy (FOB).

DESIGN

Prospective cohort study.

SETTING

Two teaching hospitals in Baltimore, MD.

PATIENTS

Consecutive adult patients (>/= 18 years) undergoing FOB for evaluation of lung nodules or masses and/or hilar or mediastinal lymphadenopathy.

INTERVENTION

Prospective collection of data on patient factors and details of the procedure on standardized report forms.

MEASUREMENTS AND RESULTS

The primary outcome measure was a new diagnosis obtained by FOB. On-site assessment was used in 81 of 204 cases (40%), and overall diagnostic yield was 62%. Yield was greater when on-site cytopathology assessment was used, in unadjusted analysis (81% vs 50%, p < 0.001) and in a multivariate model (odds ratio, 4.5; 95% confidence interval, 2.1 to 10.0). Other significant predictors of a new diagnosis included older patient age, higher dose of narcotic used during FOB, and shorter procedure time.

CONCLUSIONS

We conclude that diagnostic yield was greater when on-site cytopathology was used to assist FOB evaluation of intrathoracic adenopathy and/or lung nodules or masses. Increasing the use of on-site cytopathology assessment may improve the quality of FOB services.

The value of transbronchial needle aspiration in the diagnosis of peripheral pulmonary lesions

BACKGROUND

Transbronchial needle aspiration (TBNA) is a bronchoscopic sampling technique used for the diagnostic workup of mediastinal lymph nodes, but the value of its routine use in evaluating peripheral pulmonary lesions is not yet firmly established.

DESIGN

Retrospective analysis of routine diagnostic bronchoscopies.

SETTING

University teaching hospital.

PATIENTS AND METHODS

One hundred seventy-two consecutive patients (126 with malignant and 46 with nonmalignant disease) who underwent bronchoscopy for a peripheral pulmonary lesion.

RESULTS

In 87 patients (51%), a final diagnosis was established by bronchoscopy; diagnoses included 81 malignant lesions (69 lung cancer and 12 pulmonary metastases) and 6 benign lesions (all tuberculosis). TBNA was used in 152 of the 172 patients (89%). Other endoscopic techniques included bronchial washing (100%), bronchial brushing (45%), and transbronchial biopsy (TBB) (27%). Concerning the different bronchoscopic sampling techniques, TBNA showed a positive result in 35% of cases, in comparison to 17% for TBB, 22% for bronchial washing, and 30% for bronchial brushing. While TBNA was diagnostic in 27.5% of the malignant lesions < 3 cm in diameter, the success rate in lesions > 3 cm was 65.5% (p = 0.03). Endoscopy-related complications included pneumothorax (n = 1), self-limiting bleeding (n = 12), prolonged coughing (n = 2), and vasovagal reactions (n = 2). None of these complications required further treatment.

CONCLUSION

TBNA is an effective bronchoscopic sampling technique in the diagnosis of peripheral pulmonary lesions. In our study, the use of TBNA increased the diagnostic yield of bronchoscopy from 35 to 51% without additional risk. The use of TBNA in the clinical routine should be encouraged.

Transbronchial needle aspiration. An underused diagnostic technique

Despite its proven usefulness, TBNA is not widely used. An American College of Chest Physicians (ACCP) survey showed that only 11.8% of pulmonologists use TBNA. Most pulmonologists in the 1980s were not formally trained in TBNA. This lack of training has unfortunately translated to minimal emphasis on TBNA in current training programs in a large number of institutions. Technical problems with the procedure (faulty site selection, incomplete needle penetration, catheter kinking that prevents adequate suction, etc.), the confusing array of needles, low diagnostic yields, unproven concerns regarding the safety of the procedure, inadequate cytopathology support, and bronchoscopic damage have all perpetuated the image of limited usefulness for this procedure. Limitations to the practice of TBNA are: Lack of training during fellowship Technical inadequacies Lack of cytopathologists trained in TBNA interpretation Fear of bronchoscope damage Safety issues Failure to reproduce published successes Reservations regarding usefulness of TBNA results Hands-on experience with TBNA, developing familiarity and expertise with only a few needles, and paying careful attention to anatomy, procedure techniques, and specimen acquisition may all help to increase yield. The following lists how better results can be obtained with TBNA: Preprocedure Review TBNA instruction tapes Attend hands-on courses Practice with lung models Review patient's CAT scans Familiarize with one-two cytology and histology needle Obtain a trained assistant Procedural Identify target site Needle to airway angle at least greater than 45 degrees Insert entire length of the needle Use scope channel to support the catheter Release suction before withdrawing needle (for staging) Specimen acquisition Avoid delay in preparing slides Adequate sampling (at least two) Use smear method for cytology specimen Analyze all samples flush solutions cell block Postprocedure Find an experienced cytopathologist Review your procedure (by watching video) Review pathology slides Acquisition of skills with cytology needles should precede the use of the histology needle. Increasing education and experience can also increase diagnostic yields. Transbronchial needle aspiration has been proven to be accurate in staging lung cancers, identifying inoperable carcinomas, and diagnosing a variety of lung diseases. Few complications have been encountered and the technique is less invasive and less costly than surgical procedures. Drawing on evidence from published literature, we suggest the following guidelines for TBNA: All patients presenting with mediastinal or hilar adenopathy or both, should have 22-ga and/or 19-ga TBNA as the initial procedure. These procedures would help diagnose malignant and nonmalignant diseases, and stage lung cancers. All patients with evidence of submucosal and peribronchial disease should have 22-ga needle cytology sampling. In patients with visible endobronchial disease, 22-ga TBNA should be optional. In the presence of a necrotic or a hemorrhagic tumor, or in a patient with a bleeding diathesis, TBNA would be helpful. In all patients with Type III and IV peripheral nodules, TBNA should be the initial diagnostic procedure. There remains no doubt about the diagnostic usefulness of TBNA. Guidelines must be developed to ensure that pulmonary fellows are adequately trained in this procedure. Regional workshops with hands-on experience targeted to practicing pulmonologists organized by the ACCP would help popularize the procedure. Initial low yields should not discourage pulmonologists from using the procedure. Collaboration between thoracic surgeons, oncologists, and pulmonary physicians is essential to set up TBNA programs within institutions. With time, as more and more pulmonologists attain expertise in TBNA, the full potential of this nonsurgical, cost-effective, and safe procedure will be realized.

Spiral CT: thoracic applications

Volumetric CT data acquisition has had a major impact on the practice of computed tomography. This article reviews the current state of knowledge of the applications of this technique to the chest disease summarising its clinical impact on the assessment of lung and airways diseases, mediastinal abnormalities (excluding vascular disorders which are covered elsewhere), and in the evaluation of lung cancer patients. The impact of spiral CT on the non-invasive detection of pulmonary thrombo-embolic disease is also considered.

[Usefulness of transbronchial punction and mediastinoscopy in mediastinal nodal staging of non-microcytic bronchogenic carcinoma. Preliminary study]

Preliminary study to compare the sensitivity and specificity of transbronchial needle aspiration (TBNA) and mediastinoscopy/anterior mediastinotomy (MED/AMED) and/or thoracotomy for staging of mediastinal nodes in non-small cell carcinoma. To determine the sensitivity and specificity of computerized tomography (CT) as a screening technique. Thirty-three patients with non-small cell carcinoma but no remote metastasis and good lung function were evaluated. A chest CT scan was performed before bronchoscopy in 27 patients and before surgery in the others. Nodular areas considered diseased based on CT images were staged by TBNA. When CT images were not available before bronchoscopy. TBNA for staging was performed in the subcarinal region. Results by TBNA were compared with those obtained by MED/AMED and/or thoracotomy. The prevalence of metastatic nodular disease was 47%. CT detected enlarged mediastinal nodes in 24 patients; the images were considered normal in 9 patients. Sensitivity and specificity of CT was 93% and 54%, respectively, with a positive predictive value (PPV) of 68% and negative predictive value (NPV) of 87.5%. The sensitivity and specificity of MED/AMED were 73% and 100%, respectively; PPV was 100% and NPV was 75%. The sensitivity and specificity of TBNA were 36% and 92%, respectively; PPV was 83% and NPV was 57%. The pneumothorax with pleural empyema suffered by one patient after MED could have been avoided, given that the earlier TBNA was positive. TBNA is a safe, useful technique for staging nodes in non-small cell carcinoma. Although the sensitivity of TBNA is lower than that of MED, regions that are difficult to reach with the latter technique can be sampled by TBNA. Furthermore, MED can be rendered unnecessary by positive TBNA results. CT imaging of the chest is sensitive but its specificity is low for detecting ganglial metastasis.

Neural networks for the analysis of small pulmonary nodules

PURPOSE

Small pulmonary nodules can be readily detected by computed tomography (CT). The goal of this detection is to diagnose early lung cancer as the five year survival at this early stage is over 70% in contradistinction to the overall 5-year survival of around 10%. Critical to the efficacy of CT for early lung cancer detection is the ability to distinguish between benign and malignant nodules. We explored the usefulness of neural networks (NNs) to help in this differentiation.

METHODS

CT images of 28 pulmonary nodules, 14 benign and 14 malignant, each having a diameter less than 3 cm were selected. All were sufficiently malignant in appearance to require needle biopsy and surgery. The statistical-multiple object detection and location system (S-MODALS) NN technique developed for automatic target recognition (ATR) was used to differentiate between these benign and malignant nodules.

RESULTS

S-MODALS was able to correctly identify all but three benign nodules. S-MODALS classified a nodule as malignant because it looked similar to other malignant nodules. It identified the most similar nodules to display them to the radiologist. The specific features of the nodule that determined its classification were also shown, so that S-MODALS is not simply a "black box" technique but gives insight into the NN diagnostics.

CONCLUSION

This initial evaluation of S-MODALS NNs using pulmonary nodules whose CT features were very suspicious for lung cancer demonstrated the potential to reduce the number of biopsies without missing malignant nodules. S-MODALS performed well, but additional optimization of the techniques specifically for CT images would further enhance its performance.

Mediastinoscopy, thoracoscopy, and video-assisted thoracic surgery in the diagnosis and staging of lung cancer

The intrathoracic staging of lung cancer involves assessment of the primary tumor and potential sites of metastases. Imaging studies of the chest are sensitive in detecting intrathoracic abnormalities, but specific staging information generally requires a tissue biopsy. The instruments used to obtain this information include the bronchoscope, mediastinoscope, and thoracoscope. The complementary application of these instruments can provide valuable staging information while limiting the morbidity of surgical staging.

Mediastinoscopy, thoracoscopy, and video-assisted thoracic surgery in the diagnosis and staging of lung cancer

The surgical approach to the diagnosis and staging of lung cancer requires the assessment of the lung parenchyma, hilum, pleura, chest wall, and intrathoracic lymph nodes. Chest computerized tomography is sensitive in defining the location of the primary tumor, but is relatively insensitive to invasion. Similarly, radiographic imaging can identify lymph node enlargement, but lymph node enlargement alone is insufficient for accurate staging. To facilitate the tissue biopsies of both the primary tumor and potential sites of metastatic disease, video thoracoscopy has provided a useful complement to traditional bronchoscopy and mediastinoscopy. These instruments provide minimally invasive access to the lung, pleura, and ipsilateral lymph nodes. The combined application of thoracoscopy, bronchoscopy, and mediastinoscopy can provide intrathoracic staging information while minimizing surgical morbidity.

Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses. Experience with 1,027 consecutive cases

A study to evaluate the usefulness of the integration of the transbronchial and percutaneous approaches in the diagnosis of peripheral pulmonary nodules or masses (PPN/M) was conducted. The authors used both procedures, performed by a single diagnostic team, a pulmonologist, radiologist, and cytopathologist, who were all simultaneously present in the radiologic suite during the maneuvers. From January 1985 to June 1993, under fluoroscopic guidance, the authors performed 557 transbronchial pulmonary biopsies (TBPB), 483 transbronchial needle aspirations (TBNA), and 652 percutaneous needle aspirations (PCNA) on 1,027 consecutive patients referred because of a PPN/M (mean diameter, 3.5 cm; range, 0.8 to 8 cm). The procedure used was as follows: (1) bronchoscopy with exploration of the upper airways and bronchial tree, followed by TBNA and immediate cytologic assessment (ICA); (2) at least three TBPB; (3) if TBNA was diagnostic, the procedure was stopped; if not, a second pass with the needle was performed and then the bronchoscope was removed; (4) if the second TBNA was not diagnostic, PCNA with ICA was performed up to a maximum of three needle passes. Diagnostic sensitivity for malignant lesions was as follows: 53.9% for TBPB, 69.3% for TBNA, 75.4% for TBPB and TBNA together, 93.2% for PCNA, and 95.2% overall. The percentage of benign nodules correctly defined was 41.4% for TBPB, 17.4% for TBNA, 45.8% for PCNA, and 59.5% overall. Examination of the upper airways and bronchial tree was positive for lesions endoscopically visible in 12.6% of cases. The authors' experience shows that transbronchial and percutaneous approaches must be considered complementary and that their integrated use not only increases diagnostic yield but also permits important information to be obtained for disease staging. The creation of teams able to use both approaches with the cytopathologist present for ICA should be encouraged to optimize the diagnostic management of PPN/M with a reduction in diagnostic and hospitalization time and consequent cost saving.

Diagnosis and staging of bronchogenic carcinoma by transtracheal and transbronchial needle aspiration

Transbronchial needle aspiration (TBNA) has been used in diagnosis and staging of bronchogenic carcinoma. However, its true effectiveness seems uncertain and some models of needles are expensive. The aim of this study was to procure new experiences on this method. TBNA was performed in 194 patients with bronchogenic carcinomas. Two models of cheap, re-usable, cytological needles were used. In diagnostic application, TBNA was positive in 34 of 39 (87%) central tumors and in 31 of 45 (69%) peripheral nodules or masses. In 19 patients, TBNA was the only positive sample. In staging application, TBNA was positive in 41 of the 90 cases (46%) in which the spread of the tumor compressed the wall of the airway. When the trachea or bronchus was endoscopically normal at the site of the puncture, TBNA was only positive in 3 of 20 cases (15%). These results suggest that TBNA is effective as a diagnostic tool. However, it appears to be less effective in staging, where the attainment of a good yield with TBNA probably demands a positive computed tomography and the use of a histological needle.

Flexible transbronchial needle aspiration in the diagnosis of sarcoidosis

The histopathologic diagnosis of sarcoidosis requires the presence of noncaseating granulomas. Transbronchoscopic lung biopsy (TBLB) has been considered the procedure of choice when less invasive tissue samples are unavailable. A total of 51 consecutive patients suspected of having sarcoidosis underwent combined TBLB and flexible transbronchial needle aspirate (TBNA). In 18 of the 30 patients (60 percent) with stage I disease, the diagnosis was confirmed by TBLB and 16 (53 percent) were confirmed by TBNA. The combined use of both procedures increased the diagnostic yield to 83 percent. The remaining 21 patients with stage II disease had their diagnosis confirmed in 16 (76 percent) cases by TBLB and 10 (48 percent) by TBNA with a combined diagnostic yield of 86 percent. Seven (23 percent) patients with stage I disease and 2 (10 percent) with stage II disease had their conditions diagnosed by TBNA. We conclude that combining TBNA with TBLB increases the diagnostic yield in pulmonary sarcoidosis; TBNA should complement TBLB in the diagnosis of this disease.

Endobronchial needle aspiration in the diagnosis of small-cell carcinoma

Endobronchial biopsy specimens of small-cell carcinoma often exhibit extensive crush artifact that precludes definitive diagnosis. Occasionally, cytologic study from the brushings and washings is also nondiagnostic, contributing to the frustration of the bronchoscopist. We reviewed our experience with this problem over the past 4 years. We identified five cases in which an endobronchial needle aspirate proved critical in establishing the diagnosis of small-cell carcinoma. We believe endobronchial needle aspiration is a valuable adjunct in the diagnosis of endobronchial small-cell carcinoma.

Radiographic screening for cancer. Proposed paradigm for requisite research

Computed tomography (CT) imaging as an excellent approach to the detection and characterization of small solitary pulmonary nodules (SSPN) raises three questions: (1) How often does CT imaging lead to detection of SSPN? (2) How often is such an SSPN malignant? (3) If malignant, how curable is it? The first question pertains to decisions about screening use of CT (clinical or mass screening), the second to decisions about screening for SSPN and diagnosis of malignancy given SSPN, and the third--in the context of known curability at ordinary clinical diagnosis--to decisions about screening for SSPN, diagnosis given SSPN and intervention given malignant SSPN. We present a three component study design that addresses these questions. The first is directed primarily to the first question. Some 1000 persons at high risk for lung cancer will be screened for SSPN using screening-type CT. The primary aim is to determine the prevalence of CT-detectable SSPN as a joint function of risk-relevant aspects of the person. The second component addresses the prevalence of malignancy among the detected cases of SSPN. To develop the prevalence function, a larger series of CT-detected SSPN will be obtained by developing a multi-center SSPN "registry." A subsequent, third component will focus on the registered cases of malignant SSPN screening incidentally detected and address their curability on the basis of long-term follow-up. This design, in lieu of a randomized trial, may represent a new paradigm for applied research on radiologic technologies in cancer screening, given its advantages in terms of research efficiency and implications to decisions about diagnostic workup and therapeutic intervention.

The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma

Metastatic spread to subcarinal lymph nodes in patients with bronchogenic carcinoma generally indicates unresectability. Transcarinal needle aspiration of the main carina (TCNA) has been used to obviate the need for more invasive procedures, particularly thoracic surgery. Of 510 transbronchial needle aspirations performed at our institution from 1983 to 1991, 88 (17 percent) were from the main carina in patients with bronchogenic carcinoma. We reviewed these 88 TCNA procedures to assess our experience with TCNA in the staging of lung cancer. The TCNA results were positive in 32 of 88 (36 percent) patients (20 non-small-cell cancers, 12 small-cell lung cancers). Following bronchoscopy, TCNA was the only evidence of unresectability in all 20 patients with non-small-cell lung cancer and was the only mode of diagnosis in 5 of 12 (42 percent) patients with small-cell lung cancer. Thirteen patients with non-small-cell lung cancer and positive TCNA also had positive bronchial secretion cytologic studies. Five of these patients had further subcarinal sampling and in all cases metastatic involvement was confirmed. TCNA was positive in 29 of 67 (43 percent) patients with radiographic evidence of mediastinal adenopathy. Of the remaining 38 patients with radiographic evidence of mediastinal adenopathy and negative TCNA results, 23 patients had further mediastinal sampling with mediastinoscopy or thoracotomy and in all cases mediastinal spread of cancer was established. Nineteen of 58 (33 percent) patients with an endoscopically normal-appearing main carina had a positive TCNA, while 13 of 30 (43 percent) patients with broadening or widening of the main carina had positive TCNA results. There were no complications. We conclude that TCNA is often a safe and useful staging modality in patients with bronchogenic carcinoma.

ACP Broadsheet No 140: July 1993. Techniques in pulmonary cytopathology

Images

Comparison of the Wang 19-gauge and 22-gauge needles in the mediastinal staging of lung cancer

Transbronchial needle aspiration (TBNA) offers the unique opportunity to pathologically stage patients with lung cancer at the time of diagnostic bronchoscopy. The purpose of this study was to compare the staging sensitivities of the Wang 22-gauge and 19-gauge needles. We studied 64 patients with bronchogenic carcinoma and mediastinal adenopathy. Before bronchoscopy each patient underwent chest CT. Three to four aspirates were obtained with each needle from endotracheal sites adjacent to paratracheal lymphadenopathy. In 47 patients malignant mediastinal adenopathy was confirmed by the 19-gauge needle. A total of 29 patients had malignant 22-gauge needle aspirates. Of the 64 patients, 9 had benign, reactive mediastinal lymph nodes. There were 20 patients in whom only the 19-gauge needle demonstrated malignancy and 2 patients with malignant 22-gauge needle aspirates as the sole identifier of paratracheal malignancy. As a staging tool, the 19-gauge needle was significantly more sensitive than the 22-gauge needle, 85.5 versus 52.7% (p = 0.0001). Overall, in 49 of 55 patients (89.1%) with malignant mediastinal lymphadenopathy paratracheal tumor was confirmed by TBNA. The 19-gauge TBNA staging of the mediastinum is an effective, safe, and cost-saving alternative to surgical mediastinal exploration that can be performed during initial diagnostic bronchoscopy.

Needle brush in the diagnosis of lung mass or nodule through flexible bronchoscopy

Transbronchial needle aspiration (TBNA), in comparison with cytology brush and forceps biopsy, in the diagnosis of a pulmonary mass or coin lesions has been studied by Shure and Wang in the past. Both studies concluded that TBNA markedly increased the diagnostic yield. A new instrument, a "needle brush" (Mill Rose Lab), has been developed and compared with the following three instruments: a regular cytology brush was used first, followed by needle brush, TBNA, and forceps biopsy under fluoroscopy. Twenty-four patients were studied. A specific diagnosis was made in 16 patients (15 malignancies; one granuloma); in three patients, results were suspicious for malignancy, three patients had negative results, and in two patients the study was not complete. "Needle brush" biopsy was positive in 11 patients (exclusively in four); TBNA was positive in eight (exclusively in two). Regular brush biopsy was positive in seven (exclusively in none). Forceps biopsy was positive in four (exclusively in one; granuloma). We conclude that the needle brush and TBNA have a higher diagnostic yield in malignant lung masses or nodules. The use of regular brush and forceps biopsy did not increase the diagnostic yield in malignancy. Forceps biopsy might be more useful in benign diseases.