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* From the Division of Pulmonary and Critical Care Medicine, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX.
Correspondence to: Walid A. Baaklini, MD, Veterans Affairs Medical Center, Pulmonary Department (111-I), 2002 Holcombe Blvd, Houston, TX 77030; e-mail: Wbaaklini{at}aol.com
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
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Design: Retrospective analysis of bronchoscopies performed over a 4-year period.
Setting: A tertiary teaching hospital.
Patients: One hundred seventy-seven patients with pulmonary nodules without endobronchial lesions who underwent bronchoscopy with brushing, washing, and transbronchial biopsy.
Results:
There were 151 malignant and 26 benign lesions. The diagnostic accuracy
of bronchoscopy in malignant and benign lesions were 64% (97 of 151)
and 35% (9 of 26), respectively. The yield of bronchoscopy was
directly related to lesion size (p < 0.001, 
2). When
lesions were grouped according to distance from the hilum, yields of
bronchoscopy in central, intermediate, and peripherally located lesions
were 82, 61, and 53%, respectively (p = 0.05, 2).
When we stratified distance from the hilum by lesion size, the
difference in yield was not significant. However, lesions 
2 cm had
a diagnostic yield of 14% (2 of 14) when located in the peripheral
third vs 31% (5 of 16) when located in the inner two thirds of the
lung. There was a trend toward higher combined diagnostic yield in
right middle and lingular lobes when compared to all other segments
(p = 0.09, 2). Transbronchial biopsy, washing, and
brushing were complementary in improving the yield of
bronchoscopy.
Conclusions: Size is the strongest
determinant of diagnostic yield in bronchoscopy when evaluating SPNs.
The yield of bronchoscopy is particularly low in lesions 2 cm that
are located in the outer third of the lung. Thus, alternative
diagnostic approaches may be preferable in this
situation.
Key Words: bronchial brushing • bronchial washing • diagnostic accuracy • fiberoptic bronchoscopy • solitary pulmonary nodule • transbronchial biopsy
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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All bronchoscopy procedures were performed by pulmonary fellows at the HVAMC under pulmonary faculty supervision (26 fellows and 8 attending physicians). A variety of fiberoptic bronchoscopes (models BF P20D, BF IT10, and BF IT30; Olympus; Tokyo, Japan) along with brushes and biopsy forceps supplied with them were used. All procedures were performed via the transnasal route under local anesthesia and sedation. After complete inspection of the bronchial tree, including the subsegmental bronchi, the mass was visualized using C-arm fluoroscope in multiple planes, and multiple brushings, washings, and TBBs were performed. All the biopsy specimens were reviewed by pathology staff at the HVAMC. A histologic diagnosis of nonspecific fibrosis was considered nondiagnostic. A diagnosis of acute inflammation was considered nondiagnostic unless the final surgical pathology came back as pneumonia, or the lesion disappeared after a course of antibiotic.
The radiographic appearance of the lesions was analyzed retrospectively by two of the authors (WB, MR). We measured the three diameters of every lesion on two chest radiograph views (posteroanterior and lateral: cephalad-caudad, ventral-dorsal, medial-lateral) and the CT scan (ventral-dorsal, medial-lateral). For stratification purposes, the greatest diameter among the three images was considered to be the actual size of the lesion. We also determined the segmental location of the lesions. If the segment could not be determined from the radiographs, the segment from which sampling was done at the time of bronchoscopy was considered to be the actual site of the lesion. We divided the area around the hilum on CT scans into three elliptical regions: lesions located within the inner third ellipse were called central, lesions located within the middle third ellipse were called intermediate, and lesions located within the outer third ellipse were called peripheral. When a nodule overlapped two contiguous elliptical regions, it was assigned to the ellipse that contained greater than half the area of the nodule. Finally, we determined if the CT scan cuts contained the bronchus sign3 5 16 17 (the finding on CT scan of a bronchus leading directly to or contained within the nodule or mass).
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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One hundred fifty-one lesions were malignant (80 adenocarcinoma, 58 squamous cell carcinoma, 3 undifferentiated nonsmall cell carcinomas, 6 small-cell carcinomas, and 4 carcinoid tumors). Twenty-six lesions were benign (12 noncaseating granuloma, 6 caseating granuloma, 1 hamartoma, 1 Dirofilaria immitis, 4 organizing pneumonias, and two patients whose nodule remained unchanged on chest radiograph for 2 years following bronchoscopy).
In 71 patients, bronchoscopy was nondiagnostic. In 42 of these patients, diagnosis was established following thoracotomy. In 22 patients, we established the diagnosis by either transthoracic fine-needle aspiration (n = 18), or by TBNA (n = 4). In four patients, biopsy of a metastatic lesion was successful. One patient with a nondiagnostic bronchoscopy had a subsequent sputum cytology positive for carcinoma. In two patients with nondiagnostic bronchoscopies, the appearance of the lesion on chest radiograph remained stable for 2 years, and these lesions were designated as benign.
The yield of bronchoscopy in all lesions was 60% (106 of 177). The
diagnostic yield of bronchoscopy in malignant and benign lesions was
64% (97 of 151) and 35% (9 of 26) respectively (p = 0.005,
2; Table 2
). As shown in Table 2
, the yield of bronchoscopy in SPN was directly
related to the size of the lesion (p < 0.001,
2).
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2; Table 3
). To neutralize the effect of size on yield of bronchoscopy, we
stratified the lesions by distance from the hilum within each of the
four size categories. The diagnostic yield of bronchoscopy was 14% (2
of 14) when lesions were 2 cm and peripherally located, as compared
to 31% (5 of 16) when lesions were > 2 cm and intermediately located
(p = 0.3, Fisher’s Exact test; Table 4
). There were no central lesions 2 cm; the two positive lesions that
were peripheral and 2 cm were both tuberculosis (one had positive
BW culture, and the other had positive TBB).
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2).
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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In this study, we found that yield of bronchoscopy in malignant lesions
is much greater than in benign lesions. The most important determinant
of diagnostic accuracy is the lesion size, and location of the lesion
peripheral to the hilum is an important factor in influencing yield
when lesions are 2 cm. Additionally, there is a trend toward higher
combined yield in lesions located in the right middle and lingular
lobes. All three diagnostic modalities are complementary in improving
the yield of bronchoscopy.
The lower diagnostic yield in benign compared to malignant lesions may
be due to the nature of these lesions, as well as to the fact that a
large proportion of benign lesions in our series were 2 cm in size
(54%; 14 of 26), as compared to malignant lesions, where only 11% (16
of 151) were 2 cm in size (p < 0.001,
2). The effect of lesion size on yield has
been demonstrated in our own and prior studies.4
6
7
8
9
10
11
12
13
14
However, the effect of location on yield has been
inconclusive.8
9
10
13
Lesion position can be defined by
lobar or segmental location, or by position relative to some reference
point, such as distance from the hilum. Radke and
colleagues10
found that when lesions were 
2 cm in
size, the location of the lesions had no further independent effect on
the yield of bronchoscopy. Cortese and McDougall9
obtained
their best results when lesions were > 5 cm from the hilum (67%
positive yield). Moreover, none of the four lesions that were < 1.5
cm from the hilum were diagnosed. Stringfield and
associates8
found the best diagnostic yield was obtained
when lesions were > 2 cm in size and located within 2 to 6 cm from
the hilum (71%; 10 of 14); only one in four of the lesions located
> 6 cm from the hilum was diagnosed. In our series, we defined the
location of our SPNs based on the CT scan, rather than the chest
radiograph, because this better estimated the distance from the central
airways. We found a very low diagnostic yield in lesions 2 cm and
located in the outer third of the lung, when compared to lesions 2
cm and located in the middle third (2 of 14, 14% vs 5 of 16, 31%;
p = 0.30, Fisher’s Exact Test). Even though the difference in
diagnostic yield did not reach statistical significance, we believe
that, based on our own and prior observations, the odds of obtaining a
positive yield in peripheral lesions that are < 2 cm in size is very
low. Thus, routine bronchoscopy of peripheral lesions that are < 2 cm
and peripheral is not always justifiable. Cases should be
individualized based on accessibility of a lesion to transthoracic
fine-needle aspiration, risks of malignancy, and patients’ tolerance
of thoracotomy.
Chechani12
found a lower combined diagnostic yield in
basal segments of the lower lobes and the apical segment of the upper
lobes as compared to all other segments (58% vs 83%; p = 0.05). In
his series, all patients underwent TBNA in addition to TBB, BB, and BW.
In the present study, we did not find any significant difference
between these two bronchopulmonary segment groups (29 of 49, 59% vs 77
of 128, 60%). We did find, however, a trend toward increase in
combined diagnostic yield in RML and lingular segments as compared to
all other segments (p = 0.09, 2). The
reason for this finding might be a more direct accessibility of biopsy
forceps to these particular segments.
Several authors3 5 16 have advocated the use of high-resolution CT (HRCT) scans to predict the value of bronchoscopy in diagnosing peripheral lung lesions. The finding of a bronchus transiting the lesion (bronchus sign) suggests accessibility by FFB. HRCT is also useful in delineating the calcification of SPNs that routine chest radiography or CT scanning (8- to 10-mm sections) might miss.16 In our series, using regular CT, we found only three cases with a positive bronchus sign. Naidich and colleagues3 first described the bronchus sign in SPN. In their study, they obtained a positive bronchoscopic diagnosis in 60% of lesions with this sign. This is no different from our yield in an unselected series (60%). All 14 central lesions (the inner one third of the lung by CT scan) in their series had a positive bronchus sign, 10 of which (71%) had positive bronchoscopy. Of 51 peripheral lesions (corresponding to our intermediate and peripheral categories), 20 had a positive bronchus sign (39%). A positive bronchoscopic diagnosis was obtained in 11 of these 20 patients (55%). Again, this is not significantly different from our yield in an unselected series (88 of 155; 57%). In the series presented by Gaeta and others,5 no TBB was positive in lesions beyond the fifth-order bronchi, even when a positive CT bronchus sign was noted (2 of 16 patients). Eight out 10 lesions with third- to fifth-order positive CT bronchus sign had a positive TBB biopsy at bronchoscopy. We can conclude from these data that central lesions are more likely to have positive bronchoscopy, and peripheral lesions are less likely to have positive bronchoscopy. Thus, we find it difficult to justify the additional expense of a HRCT in selecting patients with SPN for bronchoscopy. Routine CT scan is sufficient to provide information regarding the location of nodule relative to the hilum, the presence or absence of enlarged mediastinal lymph nodes, and the assurance that we are dealing with SPN, rather than multinodular disease.
It has been debated whether the additional yield of BW justifies its cost. In the series of Cortese and McDougall,9 BW did not add to the yield of bronchoscopy; TBB and BB were complementary. In addition, Fletcher and Levin11 found that BW was positive in only 2 out of 54 bronchoscopies (4%), but TBB was also positive in both of these cases. Gracia and associates17 conducted a prospective study to determine the value of BW in a series of 35 peripheral lung cancer patients undergoing bronchoscopy without use of fluoroscopy. BW was positive in 7 of 35 cases (20%), and it was the only diagnostic modality positive in only 1 case. Our series has the highest positive yield with BW to date. We obtained a positive BW in 71 of 177 of cases (40%). In seven patients, the diagnosis would have been missed if these specimens had not been collected and reviewed. BW entails minimal effort, time, and cost during routine bronchoscopy. Given the frequency with which TBB is positive, we believe that protocols should be developed in which BB and BW are acquired, minimally processed, and then held until it is known whether the TBB is diagnostic. The availability of these samples for further processing and interpretation when the TBB is negative might obviate the need for an additional procedure, involving both cost and risk to the patient.
In conclusion, we have found that lesion size is the strongest
determinant of the yield of FFB in SPN or a discrete lung mass. The
yield of FFB is particularly low in lesions 2 cm that are located
in the outer third of the lung. Thus, other diagnostic approaches may
be preferable in this situation. We also found that BW seems to be a
valuable diagnostic tool in improving the yield of bronchoscopy.
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Footnotes |
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Received for publication July 1, 1999. Accepted for publication November 17, 1999.
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References |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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