Flexible Fiberoptic Bronchoscopy and Percutaneous Needle Lung Aspiration for Evaluating the Solitary Pulmonary Nodule

doi:10.1378/chest.81.6.665

Chest

Volume 81, Issue 6, June 1982, Pages 665-671

https://doi.org/10.1378/chest.81.6.665 Get rights and content

We reviewed the records and chest roentgenograms of 133 patients who underwent flexible fiberoptic bronchoscopy (FFB) for a solitary pulmonary nodule (SPN), defined as a circumscribed density less than or equal to 4 cm in diameter surrounded by aerated lung with no associated radiologic abnormalities. Each patient had a complete medical examination followed by FFB with collection of bronchial washings and brushings, transbronchial biopsy (when technically possible), and postbronchoscopy sputum collection. Subsequently 50 patients underwent percutaneous needle aspiration (NA) and 32 diagnostic thoracotomy (DT). Eighty-two (62 percent) of the evaluations resulted in a histologic diagnosis. Prebronchoscopy sputum was diagnostic in three patients. Of 143 FFBs performed, 27 (19 percent) were diagnostic, and 26 were the first procedure of the evaluation to provide a diagnosis. Following nondiagnostic FFB, a diagnosis was provided by 50 (36 percent) NA, 32 of 32 (100 percent) DT, and 3 of 3 (100 percent) cervical and mediastinal node biopsy procedures. For both FFB and NA, there was a strong correlation between nodule size and diagnostic yield. FFB visualized a vocal cord lesion in five patients and an endobronchial mass in five. The combination of FFB and NA provided a diagnosis in 45 of 51 (88 percent) patients ultimately proved to have a malignant SPN. Neither procedure was diagnostic in any of the 24 patients with a benign SPN. We conclude that FFB and NA have complementary roles in the evaluation of SPN.

Section snippets

MATERIALS AND METHODS

We reviewed the medical records and chest roentgenograms of patients who underwent FFB for a pulmonary density at the University of California San Diego Medical Center between January 1977 and December 1980 and at the Veterans Administration Hospital between January 1978 and December 1980. Of these patients, 113 met the following criteria for inclusion in the study: (1) they had a SPN less than or equal to 4 cm in diameter which did not appear calcified on routine roentgenograms. An SPN was

RESULTS

The 133 patients who had a SPN that fulfilled our criteria underwent 143 FFB procedures. There were 96 men and 37 women, ranging in age from 24 to 83 years. Of the patients studied, 122 had a smoking history of at least one pack per day for five years. The nodules ranged in size from 0.7 to 4.0 cm in greatest diameter. Sixty-two patients had nodules smaller than 2.0 cm; 44 had nodules 2.0 to 2.9 cm; and 27 had nodules 3.0 to 4.0 cm.

DISCUSSION

The patient in whom a SPN is discovered presents a common management dilemma. The ultimate decision is whether a thoracotomy should be done or the patient should be followed up.⁷ However, the critical antecedent questions are: (1) What is the most appropriate diagnostic sequence? and (2) Can the results of this sequence be used to guide the thoracotomy/follow-up decision?

Criteria such as radiologic appearance (particularly the presence and pattern of calcium deposition) and stability of the

ACKNOWLEDGMENT

The authors thank John V. Forrest, M.D., for his critical review of the manuscript.

REFERENCES (20)

GA Lillington
The solitary pulmonary nodule–1974
Am Rev Respir Dis
(1974)
WB Ford et al.
“Coin” lesions of the lung
Am Rev Tuberc
(1956)
EW Davis et al.
The solitary pulmonary nodule
J Thorac Surg
(1956)
RJ Jackman et al.
Survival rates in peripheral bronchogenic carcinomas up to four centimeters in diameter presenting as solitary pulmonary nodules
J Thorac Cardiovasc Surg
(1969)
JF Ray et al.
The coin lesion story: update 1976
Chest
(1976)
HM Nathan
Management of solitary pulmonary nodules
JAMA
(1974)
KM Moser
Solitary pulmonary nodules
JAMA
(1974)
DC Zavala
Diagnostic fiberoptic bronchoscopy
Chest
(1975)
AF Lalli et al.
Aspiration biopsies of chest lesions
Radiology
(1978)
RG Reich et al.
Sensitivity and specificity of needle biopsy in lung malignancy
Am Rev Respir Dis
(1980)

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

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Using miR-10b, miR-1 and miR-30a expression profiles of bronchoalveolar lavage and sputum for early detection of non-small cell lung cancer
2017, Biomedicine and Pharmacotherapy
Lung cancer is one of the most common leading causes of cancer related death in the worldwide, thus its early detection might be a critical strategy to improve patients’ prognosis and survival. The present study was designed to assess if microRNAs expression profiling of bronchoalveolar lavage cell fraction and sputum could help to non-small cell lung cancer early detection.
Relative expression of 3 selected microRNAs (miR-10b, miR-1 and miR-30a) were quantified using Real-time polymerase chain reaction in bronchoalveolar lavage cell fraction and sputum samples from non-small cell lung cancer cases (n = 30) and cancer-free group (n = 30). Written informed consent from all enrolled individuals was obtained. So, the Ethical and Scientific Committees of the participating institution confirmed the present study in accordance with the ethical standards (as laid down in 1964 Declaration of Helsinki).
miR-1 and miR-30a were significantly downregulated in non-small-cell lung cancer patients^, bronchoalveolar lavage and sputum while miR-10b was significantly upregulated. Overexpression of miR-10b has a positive strong correlation with clinical stages of cancer. ROC curve analysis of miR-10b (as oncomir) and miR-1 (as tumor suppressor) in bronchoalveolar lavage and sputum samples showed that miR-10b with 0.931 and 0.927 AUC values and miR-1 with 0.786 and 0.788 AUC values, could be an excellent and a fair candidate microRNA to distinguish non-small-cell lung cancer patients from cancer-free subjects, respectively.
This study reported significant differences in microRNAs expression in bronchoalveolar lavage and sputum samples of lung cancer patients compared to cancer-free subjects which represent a potential role as a highly specific and sensitive test to Improved early detection of non-small cell lung cancer.
Endobronchial Ultrasound for the Diagnosis of Peripheral Pulmonary Lesions. A Controlled Study With Fluoroscopy
2014, Archivos de Bronconeumologia
La broncoscopia guiada por fluoroscopia se utiliza para el diagnóstico de las lesiones pulmonares periféricas (LPP), pero su rendimiento es muy variable en función de los estudios. La ultrasonografía endobronquial (USEB) radial podría incrementar el rendimiento diagnóstico de la broncoscopia para estas lesiones.
Comparar el rendimiento diagnóstico de la broncoscopia guiada por fluoroscopia y USEB radial con la broncoscopia guiada por fluoroscopia para el estudio de LPP.
Se incluyeron de forma prospectiva todos los pacientes que se sometieron a broncoscopia con fluoroscopia para el estudio de LPP desde enero de 2009 a diciembre de 2012. Los 145 pacientes se aleatorizaron en 2 grupos: fluoroscopia y USEB radial (50 pacientes, 71,3 ± 8,2 años) o fluoroscopia únicamente (95 pacientes, 68 ± 10,5 años). El diámetro medio de las lesiones fue de 41,97 ± 19,22 mm. Se tomaron muestras de cepillado bronquial citológico y biopsia transbronquial. Todas las exploraciones se realizaron bajo control fluoroscópico y con sedación intravenosa. Para la USEB se utilizó un procesador ecográfico equipado con una ultra-minisonda ecográfica de 20 MHz que se introducía por una guía. Broncoscopista, citólogo, protocolo de estudio, técnicas y utillaje fueron los mismos durante todo el estudio.
Ciento veintinueve (89%) pacientes presentaban patología maligna. Se obtuvo el diagnóstico por broncoscopia en 105 (72,4%) enfermos. En el grupo con fluoroscopia y USEB radial se diagnosticaron el 78% de los pacientes y en el grupo con solo fluoroscopia el 69,5% (n.s.). Sin embargo, para lesiones menores de 30 mm la fluoroscopia con USEB radial incrementaba significativamente el rendimiento diagnóstico comparado con la fluoroscopia únicamente (90 vs. 52%; p = 0,05).
La USEB radial asociada a fluoroscopia es una técnica especialmente útil para el diagnóstico de las LPP de un tamaño inferior a 30 mm.
Fluoroscopy-guided bronchoscopy is usually performed for the diagnosis of peripheral pulmonary lesions (PPL), but the diagnostic yield varies widely among studies. Endobronchial ultrasound (EBUS) can increase the diagnostic yield of bronchoscopic diagnosis of PPL.
To compare the diagnostic yield of fluoroscopy-guided bronchoscopy and EBUS with fluoroscopy-guided bronchoscopy in the study of PPL.
All patients who underwent bronchoscopy to study PPL from January 2009 to December 2012 were prospectively included. 145 consecutive patients were randomly distributed in two groups: EBUS and fluoroscopy (50 patients, 71.3 ± 8.2 years) or fluoroscopy alone (95 patients, 68 ± 10.5 years). The mean diameter of the lesions was 41.97 ± 19.22 mm. Cytological brushing and transbronchial biopsies were obtained. All procedures were performed under fluoroscopic guidance with intravenous conscious sedation. EBUS was performed using an endoscopic ultrasound system equipped with a 20-MHz radial miniprobe introduced via a guide-sheath. Bronchoscopist, cytologist, study protocol, techniques and tools were the same throughout the whole study.
129 (89%) patients had malignant disease. A diagnosis with bronchoscopy was established in 105 (72.4%) patients. EBUS plus fluoroscopy obtained a diagnostic yield in 78% of patients and fluoroscopy alone in 69.5% (non-significant). In contrast, for lesions smaller than 30 mm, EBUS plus fluoroscopy guidance provided significantly greater diagnostic performance than fluoroscopy alone (90 vs. 52%; P = .05).
Bronchoscopy under EBUS plus fluoroscopy guidance is a technique that has become useful for the diagnostic of LPPs, especially those smaller than 30 mm in diameter.
Newer Modalities in the Work-up of Peripheral Pulmonary Nodules
2013, Clinics in Chest Medicine
Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
Citation Excerpt :
The sensitivity of bronchoscopy for peripheral lesions is most affected by the size of the lesion. Ten studies were identified that reported on the sensitivity of bronchoscopy (brush and/or biopsy) for peripheral lesions with a size < 2 or > 2 cm in diameter (Fig 576,88,105–107,110,121,122,129,130 The sensitivity for peripheral lesions < 2 cm in diameter was 34%. Peripheral tumors with a diameter > 2 cm resulted in a sensitivity of 63%.
Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.
To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article “Methodology for Development of Guidelines for Lung Cancer” in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.
Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions < 2 or > 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.
The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.
Optimizing health care resource utilization in the surgical management of patients with suspected lung cancer
2012, Annals of Thoracic Surgery
Surgical resection for tissue diagnosis of lung nodules exposes patients to unnecessary risks and consumes health care resources for questionable benefit. We describe the impact of routine percutaneous lung biopsy on the management of suspicious lung nodules.
A retrospective review of consecutive patients referred to a regional cancer assessment center for evaluation of suspected primary or metastatic lung cancer was performed.
From 2008 to 2010, 901 patients (male to female ratio, 0.97:1 [443 to 458]; mean age, 69.4 ± 0.3 years) underwent 1,016 percutaneous lung biopsy (fluoroscopy, 77%; computed tomography–guided, 20%). Diagnoses were non–small cell lung cancer (602 of 901; 66.8%), other malignancy (159 of 901; 17.6%), indeterminate (61 of 901; 6.8%), benign (47 of 901; 5.2%), or nondiagnostic (32 of 901; 3.6%). Of these, 393 (43.6%) were surgical candidates. Operation was avoided in 16.0% (63 of 393; benign, 36; indeterminate, 13; nondiagnostic, 14). Computed tomography follow-up in 82.5% (52 of 63) showed no change or resolution at 14.0 ± 1 months. Only 2.7% (9 of 330) underwent resection of a pathologically benign nodule. Diagnostic yield of percutaneous lung biopsy was 82.7%. Sensitivity, specificity, and positive and negative predictive values, respectively, were 100% (95% confidence interval, 98 to 100), 75% (95% confidence interval, 22 to 99), 99.7% (95% confidence interval, 98 to 100), and 100% (95% confidence interval, 31 to 100). The mean operating room time saved with this strategy was 165 ± 13.2 hours. The total cost of performing routine percutaneous biopsy ($395,500) was 44.5% of the cost of upfront wedge resection for tissue diagnosis ($888,300).
In surgical candidates, routine needle biopsy of suspicious lung nodules may lead to decreased costs, more efficient use of limited operating room resources, and a low probability of resecting pathologically benign lesions.
Does the operator's experience influence the diagnostic profitability of the bronchoscopy in the diagnosis of malignant focal pulmonary lesions?
2012, Revista de Patologia Respiratoria
La fibrobroncoscopia (FB) es una técnica de gran utilidad en el diagnóstico del nódulo pulmonar solitario (NPS) y de las masas pulmonares. La rentabilidad de la biopsia transbronquial (BTB) es variable y depende de distintos factores como la experiencia del operador. El objetivo del estudio fue determinar la rentabilidad de la BTB en el diagnóstico de la lesión pulmonar focal (LPF) maligna coincidiendo con la incorporación de dos nuevos médicos en nuestra Unidad sin experiencia previa en esta técnica, comparando los resultados con los datos previos de nuestro centro.
Se consideró LPF toda lesión pulmonar intraparenquimatosa bien circunscrita, rodeada de tejido pulmonar normal. Se incluyeron los pacientes remitidos desde febrero de 2008 a agosto de 2009 por una LPF (sin lesión endobronquial visible) y diagnóstico definitivo de malignidad. Se estudiaron 85 pacientes.
La rentabilidad diagnóstica de la BTB fue 0,55. La rentabilidad de la BTB fue mayor en lesiones > 2 cm (≤ 2 cm frente a > 2 cm; 0,38 frente a 0,62; p = 0,02) pero no hubo diferencias según la localización (central frente a periférica; 0,67 frente a 0,54; p = 0,16). La rentabilidad previa era de 0,76; sin diferencias según el tamaño (≤ 2 cm frente a > 2 cm; 0,72 frente a 0,78; p = 0,48), ni la localización (central frente a periférica; 0,83 frente a 0,74; p = 0,39).
La experiencia del broncoscopista influye en la rentabilidad diagnóstica de la BTB en LPF malignas.
The fiberoptic bronchoscopy (FB) is a useful technique in the diagnosis of focal pulmonary nodules and masses. The profitability of the FB and transbronchial biopsy (TB) is variable and depends on different factors such as the operator's experience. The aim of this study was to determine if the diagnostic profitability of these techniques, in the diagnosis of malignant focal pulmonary lesions (FPL), changed with the incorporation of a new medical staff compared with previous data of our center.
A FPL was defined as an intra - parenchymatous pulmonary lesion that is well circumscribed and completely surrounded by healthy lung.
We analyzed all the FBs between 02/2008 and 08/2009 in patients with a FPL with a definitive diagnosis of malignancy. 85 patients were included.
The diagnostic profitability of the TB was 0.55; it was higher when the FPL was > 2 cm (≤ 2 cm vs > 2 cm; 0.38 vs 0.62; p = 0.02) but no difference was found by site (central vs. peripheral; 0.67 vs 0.54; p = 0.16). The previous profitability of TB was 0.76 without differences by size (≤ 2 cm vs > 2 cm; 0.72 vs 0,78; p = 0,48) or site (central vs peripheral; 0.83 vs 0.74; p = 0,39).
We conclude that the operator's experience influences in the diagnostic profitability of the TB, in the malignant FPL.

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Manuscript received August 18; revision accepted October 23.

This study was presented in part at the 47th Annual Scientific Assembly, American College of Chest Physicians, San Francisco, October 25-29, 1981

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Chest

Clinical InvestigationsFlexible Fiberoptic Bronchoscopy and Percutaneous Needle Lung Aspiration for Evaluating the Solitary Pulmonary Nodule

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENT

The solitary pulmonary nodule–1974

Am Rev Respir Dis

“Coin” lesions of the lung

Am Rev Tuberc

The solitary pulmonary nodule

J Thorac Surg

Survival rates in peripheral bronchogenic carcinomas up to four centimeters in diameter presenting as solitary pulmonary nodules

J Thorac Cardiovasc Surg

The coin lesion story: update 1976

Chest

Management of solitary pulmonary nodules

JAMA

Solitary pulmonary nodules

JAMA

Diagnostic fiberoptic bronchoscopy

Chest

Aspiration biopsies of chest lesions

Radiology

Sensitivity and specificity of needle biopsy in lung malignancy

Am Rev Respir Dis

Clinical Investigations
Flexible Fiberoptic Bronchoscopy and Percutaneous Needle Lung Aspiration for Evaluating the Solitary Pulmonary Nodule