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(Chest. 1999;116:704-708.)
© 1999 American College of Chest Physicians

The Value of Transbronchial Needle Aspiration in the Diagnosis of Peripheral Pulmonary Lesions*

Frank Reichenberger, MD; Jano Weber, MD; Michael Tamm, MD; Christoph T. Bolliger, MD, FCCP; Peter Dalquen, MD; André P. Perruchoud, MD, FCCP and Markus Solèr, MD, FCCP

* From the Division of Pneumology (Drs. Reichenberger, Weber, Tamm, Bolliger, Perruchoud, and Solèr), Department of Internal Medicine, and the Institute of Pathology (Dr. Dalquen), University Hospital Basel, Basel, Switzerland.

Correspondence to: Markus Solèr, MD, FCCP, Division of Pneumology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
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.

Key Words: bronchoscopy • peripheral pulmonary lesion • transbronchial needle aspiration


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Peripheral pulmonary lesions are mostly detected accidentally on chest radiographs in asymptomatic patients.1 Although there is a high chance that lesions > 2 cm in diameter are of malignant origin, nodules < 2 cm in diameter are often but not always benign,1 and a histologic diagnosis is warranted in order to offer a chance of cure in case of malignancy. Preoperative diagnosis and staging are important to evaluate the appropriate surgical approach of either open pulmonary resection or video-assisted thoracoscopic surgery.2

Although peripheral pulmonary lesions are, by definition, not visible endoscopically, fiberoptic bronchoscopy is a common method to obtain a histologic or cytologic specimen. It is a safe procedure with a low complication rate and allows examination of the central airways before pulmonary resection. However, compared with fluoroscopy- or CT-guided transthoracic needle biopsy (TNB), bronchoscopy has a lower sensitivity and more often produces false-negative results,3 4 especially in benign lesions. Therefore, some centers prefer CT-guided TNB instead of fiberoptic bronchoscopy as the initial diagnostic procedure in peripheral lesions3 5 ; with a low incidence of pulmonary granulomas at our institution, however, bronchoscopy is the first diagnostic step in this situation.

The standard bronchoscopic procedures—bronchial washing, bronchial brushing, and transbronchial biopsy (TBB)—show a diagnostic efficacy ranging from 43 to 78%, depending on the size of the lesion and its biological behavior.3

The technique of flexible transbronchial needle aspiration (TBNA) first described 50 years ago has been primarily used for mediastinal lymph node staging in bronchial carcinoma.6 In the early 1980s, TBNA was adopted for use in peripheral pulmonary lesions, too.6 7 8 9 But up to now, bronchoscopists have remained somewhat hesitant to use TBNA, eg, because of a lack of technical expertise and fear of damage to the bronchoscope.10 11

We report our experience with TBNA for the diagnosis of peripheral pulmonary lesions in a clinical routine setting. Bronchoscopies were performed in a teaching hospital with a team of bronchoscopists with greatly varying levels of expertise. The impact of TBNA on the diagnostic yield of bronchoscopy was analyzed.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
At the University Hospital of Basel, 4,208 flexible bronchoscopies were performed within a 5-year period. In this time, 172 patients (mean age, 63 years; range, 26 to 85 years) underwent diagnostic bronchoscopy for a peripheral pulmonary lesion (4% of all bronchoscopies).

If a diagnosis could not be made with the use of bronchoscopy, the further workup for the pulmonary lesion included CT-guided biopsy, surgical procedures, sputum cytology, and extrathoracic needle aspiration. Data were acquired from the patients' charts. When no histologic diagnosis could be made, clinical follow-up information was obtained from the patient's family physician. Furthermore, information from autopsies was used.

Bronchoscopy
After premedication with 0.5 mg atropine IM, hydrocodone 7.5 mg subcutaneously, and inhaled lidocaine 4%, bronchoscopy was performed using standard flexible bronchoscopes (Pentax Precision Instrument Corp; Orangeburg, NY; or Olympus America Inc; Melville, NY). During the procedure, endobronchial material was obtained by bronchial washing, TBNA, bronchial brushing, or TBB, as decided by the endoscopist.

Bronchial washing was performed by instilling >= 10 mL sterile isotonic NaCl solution into the affected bronchus followed by immediate aspiration.

Bronchial brushing and TBB of the lesion were performed under fluoroscopic guidance.

TBNA was performed with MW 522 needle catheters (Mill-Rose Laboratories; Mentor, OH). The retractable 22-gauge needle with a length of 13 mm lies within a catheter of 1.8 mm outer diameter with a rounded hub at its distal end. The needle is connected to a wire with a flexible, 10-cm-long portion at its distal end.12 During bronchoscopy, the catheter is guided under fluoroscopic control. After the needle is advanced into the tissue, suction is applied with a 20-mL syringe via a side port at the proximal end of the catheter.13

Not all of the different bronchoscopic procedures (washing, brushing, TBB, and TBNA) were used in parallel in all patients. Therefore, we analyzed the frequency of use of the different methods and their impact on the diagnostic yield of bronchoscopy. The procedure was regarded as successful when a final diagnosis could be made based on the obtained specimen. For nonmalignant pulmonary lesions, only a positive culture result for tuberculosis (TB) was regarded as sufficient to be diagnostic.

Determination of Pulmonary Lesion Size
In a subset of 96 patients with proven malignant disease, we analyzed the success rate of TBNA in regard to the size of the pulmonary lesion. Malignant lesions were chosen because they are usually possible to diagnose clearly by TBNA cytology, in order to exclude a confounding influence of the patient selection and underlying diagnosis. The size of the lesion was determined by measuring the greatest diameter on chest radiograph in posterior-anterior and lateral positions, and on thoracic CT scan. The mean of all three diameters was considered to represent the size of the lesion.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Diagnosis
Overall, 126 of the 172 patients had malignant disease (103 bronchial carcinomas and 23 metastases of extrapulmonary malignancies). In 46 patients, a benign lesion was diagnosed either clinically (n = 22) or by histology (n = 24); benign lesions included 24 chronic nonspecific inflammatory processes, 12 cases of TB, and 10 benign tumors (Table 1 ).


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  		Table 1. Characteristics and Final Diagnosis of Pulmonary Lesions

 
In 87 of 172 patients, the diagnosis was obtained via bronchoscopy (50.5%). Of the remaining 85 patients, 39 underwent diagnostic thoracotomy. In 16 patients, the diagnosis was made using CT-guided TNB. In three patients, fine needle aspiration cytology of an extrathoracic lesion led to the diagnosis of metastatic bronchial carcinoma (two patients) or pulmonary metastasis of an extrapulmonary malignancy (one patient). After bronchoscopy, two patients had positive sputum specimens, one patient for TB and one for malignant disease. Two other patients died before a definite diagnosis could be made. Autopsy revealed one squamous cell carcinoma and one pulmonary metastasis. One patient with a positive tuberculin skin test was considered to have TB and was treated accordingly. In 22 patients, the history, chest radiograph, and clinical follow-up confirmed a benign process in 20 patients and a malignant disease in 2 patients (Table 2 ).


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  		Table 2. Diagnostic Procedures in the Workup of Peripheral Pulmonary Lesions*

 
Result of Different Bronchoscopic Procedures
The use of TBNA was considered in all 172 patients. In 19 of the 172 patients, TBNA was not attempted because of the lack of accessibility of the lesion under fluoroscopy. TBNA was used in 153 patients (89%), providing a diagnostic specimen in 54 cases (35%). In 30 patients, TBNA was the only technique with a diagnostic result. Under fluoroscopic guidance, the TBNA needle could be placed adequately in 116 cases, with a success rate of 46% (53 positive specimens). In the remaining 37 patients, TBNA could not be performed under fluoroscopy; in one of these patients, TBB and bronchial washing specimens were positive for TB.

Bronchial washing was the only technique performed during every bronchoscopy. A positive result was obtained in 37 cases (22%). In 10 cases, bronchial washing was the only technique with a positive result.

Bronchial brushing was used in 77 bronchoscopies (45%), with a positive result in 23 cases (30%). In eight cases, this was the only technique with a positive result.

TBB was used in 47 cases (27%) and led to a diagnosis in eight patients (17%). It was never the only positive technique applied (Table 3 , 4 ).


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  		Table 3. Diagnostic Yield of Different Bronchoscopic Sampling Techniques

 
For all 172 bronchoscopies, bronchial washing, brushing, and TBB together had a sensitivity of 33%. TBNA alone provided a positive result in 35% of all bronchoscopies. The additional use of flexible TBNA under fluoroscopic guidance increased the overall diagnostic yield of bronchoscopy to 51% (Fig 1 ).



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  		Figure 1. Bronchoscopic workup of 172 pulmonary lesions in regard to the impact on the diagnostic yield of different bronchoscopic methods.

 
Size Dependency
In the 96 patients with malignant disease, TBNA had a diagnostic yield of 44%. Fifty lesions were < 3 cm and 46 lesions > 3 cm in diameter. The success rate of TBNA was significantly greater in lesions > 3 cm than in lesions < 3 cm in diameter (67% vs 28%; p = 0.03, {chi}2 test; Fig 2 ).



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  		Figure 2. Percentage of positive TBNA results by pulmonary lesion size in a subgroup of 96 malignant lesions.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
At our institution, fiberoptic bronchoscopy is the first diagnostic step in the routine workup of a peripheral pulmonary lesion. In this consecutive series of 172 patients, the overall diagnostic yield of bronchoscopy increased from 35 to 51% by adding flexible TBNA to the conventional diagnostic techniques of bronchial washing, bronchial brushing, and TBB. TBNA applied under fluoroscopic guidance was the only successful bronchoscopic sampling technique in 20% of cases. Its use was not related to any additional risk.

Previous studies considered TBNA to be a beneficial and safe technique in the diagnosis of peripheral pulmonary lesions.7 9 In a prospective study of 37 patients with peripheral pulmonary lesions, the diagnostic yield of bronchoscopy increased from 46 to 70% when TBNA was added to bronchial washing and TBB.14 Similar results were obtained in other small series.7 8 13 14 15 16 Only Chechani16 reported a comparable diagnostic yield for TBNA (51%), bronchial brushing (52%), and TBB (57%), with a lower sensitivity for bronchial washing (35%). While some of the series were restricted to malignant lesions only (Table 5 ), we analyzed the value of TBNA in a large consecutive series of patients with malignant and nonmalignant pulmonary lesions. Furthermore, in contrast to the studies mentioned above, our results were obtained in the routine clinical setting of a teaching hospital. During the reported period, > 10 different bronchoscopists had been introduced to bronchoscopy and the different diagnostic methods, including handling of TBNA. These facts might explain the slightly lower diagnostic yield of TBNA and other bronchoscopic methods in our study compared with that reported elsewhere in the literature.7 8 14 15 16 17


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  		Table 5. Diagnostic Yield of Bronchoscopy With and Without TBNA in Peripheral Pulmonary Lesions

 
The low diagnostic yield of TBB in our study—only 17%—might be an underestimation of its true potential. TBB was used very reluctantly in this study because many lesions were not accessible to the biopsy forceps under fluoroscopy. In other situations, the risk of bleeding was considered too high, especially in more centrally located or probably inflammatory lesions. TBB is known to have a higher incidence of bleeding (up to 20%) and pneumothorax (one case in our study) than TBNA.1 However, TBB is the only bronchoscopic method that can be used to obtain a histologic specimen, allowing a diagnosis in benign lesions beyond mycobacterial infection.

The size of a peripheral lesion clearly influences its accessibility and, therefore, the diagnostic yield of bronchoscopy. Our data show a significantly lower diagnostic yield of TBNA in nodules < 3 cm in diameter. However, malignancy could still be diagnosed in 28% of lesions < 3 cm, and in 23% of lesions < 2 cm in diameter. In a study by Shure and Fedullo,8 the percentage of positive results for bronchoscopy, including TBNA, increased from 33% in malignant lesions <= 2 cm to 76% in larger lesions. Similar results were reported by Wang et al.7

A previous study not recommending routine preoperative bronchoscopy for solitary pulmonary lesions did not consider TBNA during bronchoscopy.5 Because this sampling technique significantly increases the diagnostic yield, bronchoscopy with liberal use of TBNA can be advocated in the clinical setting.

During the study period, no bronchoscope was damaged because of incorrect handling of TBNA needles or other endoscopic devices. Furthermore, no complaints about the quality of the specimen were raised by the pathologists; on the contrary, the pathologists noted excellent cell preservation in the TBNA samples. Therefore, we cannot confirm the reported reasons for reluctance to the use of TBNA,10 and believe this technique should be an integral part of any bronchoscopic training.11

The alternative approach of TNB using fluoroscopic or CT guidance has a much higher risk of complicating pneumothorax, and it may also be difficult depending on the exact location of the lesion. However, these techniques may certainly be considered as a first diagnostic step, especially in very small, peripheral, and easily accessible lesions.

In summary, TBNA is a very useful and safe bronchoscopic sampling technique in peripheral pulmonary lesions. It increases the diagnostic yield of bronchoscopy without additional risk, even in the clinical setting of a teaching hospital with differently experienced bronchoscopists. Therefore, TBNA deserves more widespread application in fiberoptic bronchoscopy.


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  		Table 4. Diagnostic Yield of Different Bronchoscopic Sampling Techniques With Regard to Benign and Malignant Lesions*

 

   Footnotes
 
Abbreviations: TB = tuberculosis; TBB = transbronchial biopsy; TBNA = transbronchial needle aspiration; TNB = transthoracic needle biopsy

Received for publication August 25, 1998. Accepted for publication April 21, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Libby, DM, Henschke, CI, Yankelevitz, DF (1995) The solitary pulmonary nodule: update 1995. Am J Med 99,491-496[CrossRef][ISI][Medline]
  2. Mack, MJ, Hazelrigg, SR, Landreneau, RJ, et al (1993) Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. Ann Thorac Surg 56,825-832[Abstract]
  3. Westcott, JL (1996) Diagnostic approach to solitary pulmonary nodule: pro transthoracic needle. J Bronchol 3,316-323
  4. Bode, FR (1996) Diagnostic approach to solitary pulmonary nodule: pro bronchoscopy. J Bronchol 3,324-327
  5. Torrington, KG, Kern, JD (1993) The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule. Chest 104,1021-1024[Abstract/Free Full Text]
  6. Schiepatti, E (1949) La punction mediastinal atraves del esolon traqueal. Rev Med Argent 663,497-499
  7. Wang, KP, Haponik, E, Britt, J, et al (1984) Transbronchial needle aspiration of peripheral pulmonary nodule. Chest 86,819-823[Abstract/Free Full Text]
  8. Shure, D, Fedullo, PF (1983) Transbronchial needle aspiration of peripheral masses. Am Rev Respir Dis 128,1090-1092[ISI][Medline]
  9. Tsuboi, E, Ikeda, S, Tajima, M (1967) Transbronchial biopsy smear for diagnosis of peripheral pulmonary carcinomas. Cancer 20,687-698[CrossRef][ISI][Medline]
  10. Prakash, UB, Offord, KF, Stubbs, SE (1991) Bronchoscopy in North America: the ACCP survey. Chest 100,1668-1675[Abstract/Free Full Text]
  11. Haponik, EF, Shure, D (1997) Underutilization of transbronchial needle aspiration: experiences of current pulmonary fellows. Chest 112,251-253[Abstract/Free Full Text]
  12. Salathé, M, Solèr, M, Bolliger, CT, et al (1992) Transbronchial needle aspiration in routine fiberoptic bronchoscopy. Respiration 59,5-8
  13. Wang, FP, Britt, EJ (1991) Needle brush in the diagnosis of lung mass or nodule through flexible bronchoscopy. Chest 100,1148-1150[Abstract/Free Full Text]
  14. Katis, K, Inglesos, E, Zachariadis, E, et al (1995) The role of transbronchial needle aspiration in the diagnosis of peripheral lung masses or nodules. Eur Respir J 8,963-966[Abstract]
  15. Schenk, DA, Bryan, CL, Bower, JH, et al (1987) Transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma. Chest 92,83-85[Abstract/Free Full Text]
  16. Chechani, V (1996) Bronchoscopic diagnosis of solitary pulmonary nodules and lung masses in the abscence of endobronchial abnormality. Chest 109,620-625[Abstract/Free Full Text]
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