Chest
Volume 113, Issue 5, May 1998, Pages 1244-1249
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Clinical Investigations: CT Scans
Can Chest CT Decrease the Use of Preoperative Bronchoscopy in the Evaluation of Suspected Bronchogenic Carcinoma?

https://doi.org/10.1378/chest.113.5.1244Get rights and content

Background

Fiberoptic bronchoscopy (FOB) is frequently used to diagnose and stage bronchogenic carcinoma (BC). However, the value of FOB in diagnosis/staging BC presenting as a pulmonary nodule or mass (PNM) is controversial. Since chest CT is usually obtained in these patients, it may be used in patient selection for preoperative FOB.

Objective

Evaluation of the role of chest CT in determining the predictive value of FOB in diagnosing/staging a PNM, by comparing the results of CT and bronchoscopy.

Design

Retrospective review of chest CTs and medical records.

Patients

Consecutive patients with BC between 1992 and 1994 who had diagnostic FOB and CT in our institution, but without radiographic evidence of (1) pulmonary atelectasis, (2) endobronchial tumor or narrowing of the central airways, and (3) the PNM abutting the central airways.

Results

Sixty-four patients met the selection criteria. The size of the PNM ranged from 1.5 to 10 cm; the size was ≤4 cm in 62 patients. FOB provided a diagnosis in 22 patients. Bronchoscopy detected endobronchial lesions in 11 patients (17%); 3 had lesions in more than one lobe. In three patients, the PNM was <3 cm. The radiographically undetected endobronchial tumor increased the tumor stage in only two patients. The “CT bronchus” sign had a positive and negative predictive value of 75% and 68%, respectively.

Conclusions

(1) In this study, CT failed to detect endobronchial tumor in 11 of 64 patients (17%). Because of the implications of a new staging system, more studies are necessary before abandoning staging FOB. (2) The CT bronchus sign has a very high positive and negative predictive value in the use of diagnostic FOB and should be used to guide the method of biopsy of a PNM.

Section snippets

MATERIALS AND METHODS

We wanted to identify patients who satisfied the following criteria: (1) a PNM that was proven to be BC by either endobronchial biopsy, TBBX, TNB, or at surgery; (2) a preoperative diagnostic bronchoscopy performed at our institution; and (3) availability of chest radiographs and chest CT performed in our institution. Patients with the following imaging criteria were excluded: (1) presence of radiographic signs of atelectasis of a segment, lobe, or lung; (2) presence of one or more of the

RESULTS

Sixty-four patients satisfied the clinical and radiologic inclusion criteria. There were 60 men and 4 women whose mean age was 64 years (range, 38 to 89 years). The size of the PNM in these 64 patients ranged from 1.5 to 10.0 cm and their size distribution is shown in Figure 1. Mediastinal lymphadenopathy was found in 10 patients, and hilar adenopathy was found in 6 patients.

A diagnosis of malignancy was made by FOB in 22 of 64 patients (34%). TNB was performed in 37 patients and provided

DISCUSSION

In clinical practice, FOB is the mainstay of diagnosis of a PNM. Since a PNM in an immunocompetent adult >35 years old is considered malignant until proven to the contrary, the role of FOB includes obtaining a pathologic diagnosis of the PNM as well as assessment of the proximal airways for presence of endobronchial tumor. Both objectives are equally important for successful and efficient treatment of a patient with a presumed malignant PNM. Therefore, separation of diagnostic and staging

CONCLUSIONS

  • (1)

    In this study, CT failed to detect endobronchial tumor in 11 of 64 patients (17%). Because of the implication of new staging system, more studies are necessary before abandoning preoperative staging FOB.

  • (2)

    The CT bronchus sign has a very high positive and negative predictive value in the use of diagnostic FOB and should be used to guide the method of biopsy of a PNM.

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