Chest
Volume 134, Issue 3, September 2008, Pages 507-513
Journal home page for Chest

Original Research
Interventional Pulmonology
A Randomized Trial of CT Fluoroscopic-Guided Bronchoscopy vs Conventional Bronchoscopy in Patients With Suspected Lung Cancer

https://doi.org/10.1378/chest.08-0160Get rights and content

Background

Prior case series have shown promising diagnostic sensitivity for CT scan-guided bronchoscopy.

Methods

This was a prospective randomized trial comparing CT scan-guided bronchoscopy vs conventional bronchoscopy for the diagnosis of lung cancer in peripheral lesions and mediastinal lymph nodes. All procedures were performed using a protocolized number of passes for forceps, transbronchial needles, and brushes. Cytologists and pathologists were blinded as to bronchoscopy type. Patients with negative results underwent open surgical biopsy (for nodules or lymph nodes) or were observed for ≥ 2 years if they had a nodule < 1 cm in size.

Results

Fifty patients were enrolled into the study (CT scan-guided bronchoscopy, 26 patients; conventional bronchoscopy, 24 patients). Two patients, one from each arm, dropped out of the study. Ultimately, 36 patients were proven to have cancer, and 27 of these patients (75%) had their diagnosis made by bronchoscopy. The sensitivity for malignancy of CT scan-guided bronchoscopy vs conventional bronchoscopy for peripheral lesions was similar (71% vs 76%, respectively; p = 1.0). The sensitivity for malignancy of CT guided bronchoscopy vs conventional bronchoscopy for mediastinal lymph nodes was higher (100% vs 67%, respectively) but did not reach statistical significance (p = 0.26). On a per-lymph-node basis, there was a trend toward higher diagnostic accuracy with CT scan guidance (p = 0.09). The diagnostic yield was higher in larger lesions (p = 0.004) and when CT scanning confirmed target entry (p = 0.001).

Conclusion

We failed to demonstrate a significant difference between CT scan-guided bronchoscopy and conventional bronchoscopy for the diagnosis of lung cancer in peripheral lesions and mediastinal lymph nodes. Further study of improved steering methods combined with CT scan guidance for the diagnosis of lung cancer in peripheral lesions is warranted.

Section snippets

Materials and Methods

Consecutive patients from March 2001 to April 2004 with either peripheral pulmonary nodules (≤ 3 cm in size), peripheral masses (> 3 cm in size), or mediastinal lymphadenopathy (> 1 cm in diameter) with suspected cancer without a proven pathologic diagnosis were eligible. The inclusion criteria were age > 40 years, at least a 10–pack-year history of smoking, and the ability to tolerate video-assisted thoracoscopic surgery (VATS). This was defined as an estimated postoperative FEV1 of > 800 mL

Patient Characteristics

Seventy-two patients were eligible, and 50 patients were enrolled into the study (CT scan guidance, 26 patients; conventional bronchoscopy, 24 patients). Twenty-two patients declined to participate in the study. Two patients, one from each arm, could not complete the study. One patient was admitted to the medical ICU for treatment of pneumonia prior to the scheduled bronchoscopy and subsequently died. The other patient was randomized to the CT fluoroscopy arm, but significant hemoptysis

Discussion

This study is the first randomized, controlled trial comparing CT scan-guided bronchoscopy and conventional bronchoscopy. This study failed to demonstrate a benefit of CT scan guidance compared to conventional bronchoscopy for either peripheral or mediastinal nodal evaluation. However, when a confirmation of target entry was obtained by CT scan, the diagnostic accuracy was higher. On a per-lymph-node basis, there was a trend suggesting the superiority of CT scan guidance.

This study of CT

Acknowledgment

We thank Linda Rolnitzky, MS, Biostatistics, Department of Environmental Medicine, New York University School of Medicine, for her advice.

References (28)

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The study was supported by the American Lung Association, Clinical Research Grant program, and by a Clinical Research Grant from General Electric, with Dr. Ost denoted as the investigator.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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