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

doi:10.1016/j.lungcan.2005.05.018

Lung Cancer

Volume 50, Issue 2, November 2005, Pages 221-226

https://doi.org/10.1016/j.lungcan.2005.05.018 Get rights and content

Summary

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.

Introduction

Fiberoptic bronchoscopy is the most common diagnostic method used in lung cancers. Diagnosis is made by forceps biopsy primarily, and by brushing, bronchial washing, and transbronchial needle aspiration (TBNA). Although some reports indicate that the combination of some cytologic and histologic methods increases the diagnostic rate, the combination that leads to the highest diagnostic yield remains to be defined [1], [2], [3], [4], [5].

Endobronchial lung cancers occur as exophytic endobronchial lesions, submucosal infiltration, or external compression of peribronchial disease. Use of TBNA to diagnose peripheral lesions and evaluate hilar and mediastinal lymph nodes and to stage lung cancer has been studied, and its efficacy has been demonstrated [6], [7]. However, its benefit in discerning endobronchial lesions remains to be elucidated. High diagnostic yield results from forceps biopsy in exophytic endobronchial lesion (EEL) have limited the use of TBNA in these lesions. In submucosal-peribronchial disease (SPD), forceps biopsy carries with it some diagnostic difficulties whereas TBNA may increase the diagnostic rate by two times [3], [8], [9]. Because TBNA enhances the diagnostic yield of forceps biopsy in cases of an inadequate specimen due to necrosis and crush artifact in endobronchial tumors and avoids excessive bleeding from friable tumors, it has been found to be a useful diagnostic procedure [9], [10], [11].

In our study, the diagnostic yield of each bronchoscopic method and various combinations were studied, and the contribution of TBNA to diagnosis was investigated in patients undergoing fiberoptic bronchoscopy for the diagnosis of lung cancer and displayed endobronchial lesions.

Section snippets

Materials and methods

Ninety-five of 99 patients hospitalized in our clinic, with the preliminary diagnosis of lung cancer in whom EEL or SPD was detected by routine fiberoptic bronchoscopy during a 2-year period, were included in this study. The four excluded patients underwent TBNA, brushing, and washing, but did not undergo forceps biopsy because of the possibility of bleeding complications. While submucosal disease was described as bronchial narrowing, mucosal thickening, disappearance of mucosal signs,

Results

The present study included 95 patients (mean age, 59.89 ± 8.34 years; range, 40–81 years). Samples of TBNA, forceps biopsy, brushing, and washing were collected from all patients. With these diagnostic methods, 91 patients had a diagnosis, but in 4 cases, no diagnosis was made. Of these four, one patient was diagnosed by pleural fluid cytology, one by pleural biopsy, and two by transthoracic needle biopsy sample. According to their bronchoscopic appearances, EEL and SPD were detected in 59 and 36

Discussion

Forceps biopsy is the preferred method of diagnosing endobronchial lung cancers because it leads to a higher diagnostic yield by enabling histologic sampling. When multiple biopsy samples are obtained, its diagnostic yield exceeds 90% [12], [13]. The role of TBNA in diagnosing endobronchial lesions has not been clarified. However, it may be used as an alternative technique for endobronchial tumors displaying a tendency for bleeding, covered by necrosis, or those that cannot be diagnosed by

References (21)

G. Buccheri et al.
Diagnostic, morphologic, and histopathologic correlates in bronchogenic carcinoma
Chest
(1991)
A. Dasgupta et al.
Utility of transbronchial needle aspiration in the diagnosis of endobronchial lesions
Chest
(1999)
P.A. Kvale et al.
Diagnostic accuracy in lung cancer; comparison of techniques used in association with flexible fiberoptic bronchoscopy
Chest
(1976)
J.A. Govert et al.
Cost-effectiveness of collecting routine cytologic specimens during fiberoptic bronchoscopy for endoscopically visible tumor
Chest
(1996)
D. Shure et al.
The role of transcranial needle aspiration in the staging of bronchogenic carcinoma
Chest
(1984)
P.C. Gay et al.
Transbronchial needle aspiration in the practice of bronchoscopy
Mayo Clin Proc
(1989)
D. Shure
Transbronchial needle aspiration-current status
Mayo Clin Proc
(1989)
D. Shure
Transbronchial biopsy and needle aspiration
Chest
(1989)
D.F. Jones et al.
Endobronchial needle aspiration in the diagnosis of small cell carcinoma
Chest
(1994)
D. Shure et al.
Bronchogenic carcinoma presenting as an endobronchial mass: optimal number of biopsy specimens for diagnosis
Chest
(1983)

There are more references available in the full text version of this article.

Cited by (33)

Bronchoscopic sampling techniques in the era of technological bronchoscopy
2022, Pulmonology
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.
A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.
Cancer of the Lung: Non-Small Cell Lung Cancer and Small Cell Lung Cancer
2019, Abeloff’s Clinical Oncology
Lung cancer is a highly incident disease, and the major cause of cancer death worldwide. Trends in lung cancer incidence and mortality follow an epidemiological link to the history of tobacco consumption, although a recent increase of cases in never smokers has been observed. Throughout this chapter, readers will have the chance to appreciate the major changes and advances that took place in the presentation, diagnosis, and treatment of lung cancer in the past decades. The pathology and staging classification of lung cancer has evolved over time, as has the knowledge on its genomic landscape. The discovery of driver mutations such as EGFR and ALK has revolutionized the field of targeted therapy. Molecular testing has become a standard in non-squamous NSCLC, and results are now essential to link patients to better-suited therapies. The greater understanding of cancer immunology also impacted lung cancer therapy. Immune checkpoint inhibitors are now a routine in most lung cancer cases, including metastatic and locally advanced NSCLC. The advance in imaging diagnostics and intervention allowed better detection (including screening programs), staging (mainly due to PET-CT), and treatment. Minimally invasive techniques are commonly used to help diagnose and stage lung cancer. Daily examples include CT-guided biopsies, EBUS, EUS, video-assisted and robotic surgery. Modern radiation devices have enabled the application of highly precise doses to localized nodules, adding new treatment opportunities to different disease stages. Altogether, lung cancer control requires multidisciplinary care and continuous research effort.
Cancer of the Lung: Non-Small Cell Lung Cancer and Small Cell Lung Cancer
2013, Abeloff's Clinical Oncology: Fifth Edition
Role of flexible bronchoscopic cryotechnology in diagnosing endobronchial masses
2013, Annals of Thoracic Surgery
Endobronchial masses obstruct the central airway, and cryotechnology is reportedly a feasible means of managing such masses. However, few reports have explored the role of cryotechnology in diagnosing endobronchial masses.
All endobronchial masses were sampled for pathologic diagnosis by forceps biopsy and cryotechnology, performed during flexible bronchoscopy. The diagnostic accuracy of forceps biopsy and that of cryotherapy were compared by the χ² test, and the obtained specimen sizes were compared by the t test.
Between 2007 and 2011, 75 patients with a median age of 64 years (interquartile range [IQR], 49–76; 48 men; 27 women; and 52 smokers [69.3%]) were diagnosed with endobronchial masses. The sites of these masses included the trachea (n = 17), left main bronchus (n = 16), right main bronchus (n = 11), right upper lobe bronchus (n = 11), right intermediate bronchus (n = 8), right lower lobe bronchus (n = 4), left upper lobe bronchus (n = 3), left lower lobe bronchus (n = 3), and right middle lobe bronchus (n = 2).
Fifty-nine lesions were malignant, and 16 were benign. Lung squamous cell carcinoma (n = 23) was the leading cause of malignancy, and endobronchial tuberculosis (n = 9) was the most common benign disease. The diagnostic accuracy of cryotechnology was significantly higher than that of forceps biopsy (100% vs 69.3%, p < 0.0001). The specimen size obtained by cryotechnology was also significantly larger than that obtained by forceps biopsy (13.8 ± vs 1.9 ± 0.6 mm, p < 0.0001).
The current study supports the view that cryotechnology is a good tool for diagnosing endobronchial masses. Cryotechnology also provides a better diagnostic specimen and has greater diagnostic accuracy than traditional forceps biopsy.
The challenge of NSCLC diagnosis and predictive analysis on small samples. Practical approach of a working group
2012, Lung Cancer
Citation Excerpt :
Repeated sputum sampling over several days increases the sensitivity [21,22]. The diagnostic yield of conventional (non/ultrasound guided) transbronchial needle aspiration (TBNA = without endobronchial ultrasound, synonymous “EBNAB”) is high for endoscopically visible bronchial abnormalities, suggesting neoplasia, particularly when the lesion is due to extrinsic compression, submucosal infiltration, or an exophytic mass [23,24]. Conventional TBNA has also been used for staging the mediastinum in lung cancer, with good results [25,26].
Until recently, the division of pulmonary carcinomas into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) was adequate for therapy selection. Due to the emergence of new treatment options subtyping of NSCLC and predictive testing have become mandatory. A practical approach to the new requirements involving interaction between pulmonologist, oncologist and molecular pathology to optimize patient care is described. The diagnosis of lung cancer involves (i) the identification and complete classification of malignancy, (ii) immunohistochemistry is used to predict the likely NSCLC subtype (squamous cell vs. adenocarcinoma), as in small diagnostic samples specific subtyping is frequently on morphological grounds alone not feasible (NSCLC-NOS), (iii) molecular testing. To allow the extended diagnostic and predictive examination (i) tissue sampling should be maximized whenever feasible and deemed clinically safe, reducing the need for re-biopsy for additional studies and (ii) tissue handling, processing and sectioning should be optimized.
Complex diagnostic algorithms are emerging, which will require close dialogue and understanding between pulmonologists and others who are closely involved in tissue acquisition, pathologists and oncologists who will ultimately, with the patient, make treatment decisions. Personalized medicine not only means the choice of treatment tailored to the individual patient, but also reflects the need to consider how investigative and diagnostic strategies must also be planned according to individual tumour characteristics.
Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer
2010, Lung Cancer
Citation Excerpt :
Tumors in contact with the main stem bronchi, bronchus intermedius, lobar bronchi, or segmental bronchi on chest CT scans were considered to be central tumors, otherwise tumors were considered peripheral. Findings by white-light bronchoscopy were divided into four categories: (1) no endobronchial lesions; (2) extrinsic compression without mucosal change; (3) submucosal lesions (erythema, edema, mucosal thickening, bronchial narrowing, disappearance of mucosal signs, and/or marked vascular structure) [12] without definite mucosal tumor invasion; and (4) definite mucosal tumor invasion. In cases of definite mucosal tumor invasion, the reasons for choosing EBUS-TBNA were reviewed.
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.
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.
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.
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.

View all citing articles on Scopus

View full text

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

Summary

Introduction

Section snippets

Materials and methods

Results

Discussion

Chest

Chest

Chest

Chest

Chest

Mayo Clin Proc

Mayo Clin Proc

Chest

Chest

Chest