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(Chest. 2003;124:1985-1992.)
© 2003 American College of Chest Physicians

Diagnostic Accuracy and Safety of Flexible Bronchoscopy With Multiplanar Reconstruction Images and Ultrafast Papanicolaou Stain*

Evaluating Solitary Pulmonary Nodules

Shuji Bandoh, MD, PhD; Jiro Fujita, MD, PhD, FCCP; Yasunori Tojo, MD; Hiroyasu Yokomise, MD; Katashi Satoh, MD, PhD; Shoji Kobayashi, MD, PhD and Toshihiko Ishida, MD, PhD

* From the First Department of Internal Medicine (Drs. Bandoh, Fujita, Tojo, and Ishida), Second Department of Surgery (Dr. Yokomise), Department of Radiology (Dr. Satoh), and Department of Diagnostic Pathology (Dr. Kobayashi), Kagawa Medical University, Kagawa, Japan.

Correspondence to: Shuji Bandoh, MD, PhD, First Department of Internal Medicine, Kagawa Medical University, 1750-1, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan; e-mail: sbandoh{at}mailbox.kms.ac.jp


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To assess the diagnostic accuracy and safety of flexible bronchoscopy with multiplanar reconstruction (MPR) images and ultrafast Papanicolaou (UFP) stain in evaluating solitary pulmonary nodules (SPNs).

Design: Prospective study of bronchoscopies performed between June 2000 and June 2002.

Patients: One hundred consecutive patients with SPNs underwent bronchoscopy with MPR and UFP (MPR and UFP group). The data on historical control were collected in a retrospective fashion, between July 1997 and June 2000.

Method: All information obtained from MPR regarding the leading bronchus of the SPNs was used to guide biopsy. Samples obtained by curette biopsies were stained with UFP and evaluated by a cytopathologist during the bronchoscopy procedure.

Results: There were 88 malignant and 12 benign lesions in the MPR and UFP group, and 97 malignant and 3 benign lesions in the historical control group. The total diagnostic accuracy of bronchoscopy in the MPR and UFP group (91%) was significantly higher compared with the historical control group (58%) [p < 0.05]. Although the yield of bronchoscopy was significantly related to the lesion size in the historical control group (p < 0.05), there was no significant association between the diagnostic yield and lesion size in the MPR and UFP group. The diagnostic yield for SPNs < 4.0 cm in the MPR and UFP group was significantly higher compared with the historical control group (p < 0.05). In addition, the diagnostic yield in both upper lobes in the MPR and UFP group was significantly higher compared with the historical control group (p < 0.05). On the contrary, the complication rate was significantly lower in the MPR and UFP group (2%) compared with the historical control group (13%) [p < 0.05].

Conclusion: Combined use of the MPR image and UFP during flexible bronchoscopy improved diagnostic accuracy and safety in evaluating SPNs using a double-hinged curette.

Key Words: flexible bronchoscopy • multiplanar reconstruction image • solitary pulmonary nodule • transbronchial biopsy • ultrafast Papanicolaou


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The flexible bronchoscope has been in regular use for many years for investigating patients with solitary pulmonary nodules (SPNs). Nevertheless, no definitive conclusion has been reached on the most effective procedure of bronchoscopic diagnostic techniques. The reported diagnostic accuracy of fluoroscopically guided transbronchial biopsy (TBB) of SPNs varies from 18 to 62%.1 2 3 4 5 6 7 This low percentage for biopsy success is not surprising when the SPNs are small and exist more peripherally. Previously published studies1 8 9 on SPNs and peripheral lung masses have consistently shown that lesion size and location are major factors leading to diagnostic accuracy of TBB. Additionally, accuracy in making a diagnosis by TBB and transbronchial needle aspiration (TBNA) greatly depends on the quality and quantity of specimens obtained from bronchoscopy.10 11 12

In this article, we introduce two methods for improving the accuracy and safety of fluoroscopically guided bronchoscopy in evaluating the diagnosis of SPN. One is helical CT with multiplanar reconstruction (MPR) images, and the other is ultrafast Papanicolaou (UFP) stain.

MPR is a method of computerized reconstruction images. It provides not only axial images but coronal and sagittal images of the lung, allowing more precision for selecting the bronchus that leads to SPNs.13 14 15 Therefore, a view of MPR findings prior to actual bronchoscopy could show the anatomy of bronchus and the exact location of peripheral masses.

UFP is the method of immediate assessment of cytology.16 17 18 It reduces the time for Papanicolaou staining to 90 s without reducing its quality. The goal of UFP is to minimize biopsy time and give the fastest results. It ensures that biopsy material is handled optimally, and those patients requiring further sampling or ancillary investigation are identified rapidly during examination. The number of unsatisfactory and false-negative results of lung cytologies may be therefore reduced. In addition, it seems likely that complications would also be minimized by decreasing the number of TBBs using both MPR and UFP methods.

This study presents our experience in diagnosing SPNs with MPR and UFP through flexible bronchoscopy under fluoroscopic guidance to improve the diagnostic accuracy and safety of flexible bronchoscopy in evaluating SPNs. In addition, we have compared our current results with historical controls from our institution and other literature.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
In a prospective study beginning June 2000, 100 consecutive patients (72 men and 28 women; age range, 37 to 85 years) underwent bronchoscopy with MPR and UFP to evaluate SPNs (MPR and UFP group). These patients met the following criteria that were described previously by Baaklini et al1 : (1) presence of a single circumscribed lung mass completely surrounded by aerated lung without associated abnormalities (including atelectasis, consolidations, satellite lesions, or cavity); (2) lesions that were not visible endoscopically (no endobronchial lesions or extrinsic compression); (3) availability of standard chest radiographs (posteroanterior and lateral) and CT scans; (4) availability of fluoroscopically guided curettings, washings, and TBBs; and (5) a final pathologic diagnosis from the bronchoscopy procedure, thoracotomy and video-assisted thoracoscopic surgery, transthoracic CT-guided biopsy, or microbiological analysis including Mycobacterium tuberculosis identification from curette rinse sample according to standard techniques.

To compare data, we retrospectively reviewed the medical records of all patients who had SPNs and underwent TBB at Kagawa Medical University as a historical control group between July 1997 and June 2000. One hundred patients (75 men and 25 women; age range, 42 to 83 years) met the same criteria described above.

Helical CT With MPR Image
CT examinations were performed on a multidetector-row CT (Aquilion Multi; Toshiba; Tokyo, Japan) in helical mode, using 3-mm collimation and 5.5 mm/s table speed at approximately 300 mA and 120 kilovolts. Images were reconstructed using the "bone" algorithm for cases of intrathoracic pathology.

The radiographic appearance of lesions was analyzed by two of the authors (S.B. and K.S.). We measured three diameters of each lesion on two chest radiograph views (posteroanterior and lateral: cephalad-caudad, ventral-dorsal, medial-lateral) and the high-resolution CT (HRCT) 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.

Using coronal and sagittal views of MPR and an axial view of HRCT images, we selected one or more bronchi that lead directly to the SPN or were involved within the SPN to represent the bronchus sign, as defined by Naidich et al.3 In addition, the order and angle of the bronchi leading to the lesion were also assessed. When two or more bronchi were involved, the more central bronchus leading to the mass lesion was selected for biopsy. All of the information obtained from MPR regarding the leading bronchus of the SPNs was used to guide the insertion of the curette catheter through the biopsy channel of the flexible bronchoscope.

Bronchoscopic Technique and UFP Stain
All bronchoscopy procedures were performed by pulmonary fellows at the Kagawa Medical University Hospital under pulmonary faculty supervision (three fellows and two attending physicians). A flexible bronchoscope (model BF 200; Olympus; Tokyo, Japan) along with double-hinged curettes (model CC-4CR-1; Olympus) and biopsy forceps (model FB-21C-1; Olympus) were used. Patients were premedicated with atropine sulfate (0.5 mg) and hydroxyzine (50 mg); IV administration of diazepam (5 mg) was used for supplemental sedation when needed. Topical anesthesia was accomplished with lidocaine spray (2%, 5 mL) of the pharynx; additional lidocaine was instilled through the suction channel of the bronchoscope. The transoral approach without an endotracheal tube was used in all patients. After complete inspection of the bronchial tree, including the subsegmental bronchi, the SPN was visualized using C-arm fluoroscope on multiple planes.

The information obtained from the MPR regarding the site of the SPN was used to guide the insertion of the double-hinged curette catheter through the biopsy channel of the bronchoscope. The curette catheter was advanced and directed to the lung lesion with the aid of fluoroscopy. The curette could be flexed and rotated with the proximal handle of the catheter. The curette scraped the lesion several times, and then it was withdrawn at the distal end of the bronchoscope. The curette specimen was put immediately onto a slide. Using another glass slide as the spreading slide, a smear was prepared on both glass slides in the same manner as a fine-needle aspiration smear. For each specimen, at least two cytologic preparations were made: one was immediately fixed in 95% ethanol for conventional Papanicolaou stain; the other was air-dried and processed with UFP within 90 s as previously described.16 While the cytopathologist was observing the curetting material, the bronchoscope was kept in the same bronchus. The cytopathologist determined the adequacy of the sample in 1 to 2 min. He usually gave his preliminary diagnosis while conferring with the pulmonologist in the special procedures room. If the first curetting was considered to be nondiagnostic, a second curetting was requested with the pulmonologist attempting to find a better position. No patient had more than four specimens obtained by curette. If all curetting specimens were considered to be nondiagnostic, TBBs were performed. If the curetted specimen immediately proved to be adequate for diagnosis, the procedure was discontinued.

The remaining 95% alcohol-fixed Papanicolaou-stained slides were examined within 2 to 3 h and the final diagnosis rendered. Tissue specimens obtained from biopsy forceps were fixed in formalin, embedded in paraffin, and stained with hematoxylin-eosin (HE) stain. The curette rinse sample was submitted for microbiological analysis in patients showing an inflammatory or reactive pattern on rapid assessment. Figure 1 shows the algorithm of the procedure used in this study.



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  		Figure 1.. Algorithm of the procedure used in this study.

 
Clinical and Pathologic Correlation
The accuracy of the diagnoses was assessed in all patients by clinical and radiologic follow-up and histologic/cytologic correlation with further specimens when these were available. Biopsy specimens were reviewed by the pathology staff of the Kagawa Medical University Hospital. The final diagnoses of small cell and non-small cell undifferentiated carcinomas were assessed by clinical and radiologic features and response to therapy with histopathologic findings. A histologic diagnosis of nonspecific fibrosis was considered to be nondiagnostic. A diagnosis of acute inflammation was considered to be nondiagnostic unless the final surgical pathology came back as pneumonia, or the lesion disappeared after a course of antibiotics.

Complications
All patients were monitored after the procedure for complications. Chest radiographs were obtained to determine whether a pneumothorax had occurred after bronchoscopy.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Of the 100 patients who underwent flexible bronchoscopy with UFP and MPR, 86 patients had primary lung cancer: adenocarcinoma (n = 54), squamous cell carcinoma (n = 24), undifferentiated non-small cell carcinoma (n = 2), and small cell carcinoma (n = 6) [Table 1 ]. Two patients had metastatic lung tumors. Twelve patients had benign diseases: pulmonary tuberculosis (n = 2), aspergillosis (n = 3), granuloma (n = 2), hamartoma (n = 1), and pneumonitis (n = 4). The diagnoses of patients in the historical control group are listed in Table 1 .


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  		Table 1.. Final Diagnoses of Patients With SPN

 
MPR images were valuable for selecting the leading bronchus of SPNs in 38 cases. Among these 38 cases, axial images of HRCT did not provide the same amount of information (Fig 2 ). As shown in Figure 3 MPR images clearly demonstrate the leading bronchus to the SPN. In addition, these images not only demonstrated the leading bronchus but also its order and angle to the lesion. Thus, bronchoscopists can easily obtain a three-dimensional image of leading bronchus to the SPNs before bronchoscopic examination.



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  		Figure 2.. Chest images of a case with primary lung cancer (adenocarcinoma). Top: Chest radiograph shows an SPN in the left middle lung field. Bottom: HRCT shows an SPN in the left lower lobe; however, the leading bronchus to the SPN is not clear in the axial view.

 


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  		Figure 3.. Chest images of case in Figure 2 . Top: The MPR image clearly demonstrates the leading bronchus (B6a) to the SPN (arrow). Bottom: A 1-mm lateral slice of the left image.

 
Curetting samples obtained from 84 of 100 patients (84%) [81 patients with malignancy, and 3 patients with aspergillosis] were deemed satisfactory and diagnostic using UFP (Table 2 ). A single curetting was adequate in 52 patients, and a second or further curettings were necessary for 32 patients. In cases with malignancy, diagnoses were made in 81 of 88 patients (92%) during bronchoscopic examination using the UFP. There was just one false-negative UFP report in patients with malignancy; however, this case was diagnosed as adenocarcinoma by the conventional Papanicolaou stain. There were no false-positive UFP reports.


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  		Table 2.. Diagnostic Yield of the UFP Staining

 
A specific benign diagnosis confirmed the UFP assessment in only three patients with Aspergillosis. In 16 cases with negative UFP reports, TBB and washing were performed after the curettings. Diagnoses were made in one patient with lung cancer, two patients with pulmonary tuberculosis, and four patients with pneumonitis after bronchoscopy by conventional Papanicolaou stain, HE stain, and microbiological analysis. In nine patients with diagnoses not made by bronchoscopy, the second procedure including CT-guided transthoracic biopsy or thoracotomy was performed. Diagnoses in these patients included bronchogenic carcinoma (n = 6), nonspecific granuloma (n = 2), and hamartoma (n = 1).

As shown in Table 3 , the total diagnostic accuracy of flexible bronchoscopy in the MPR and UFP group (91%) was significantly higher compared with the historical control group (58%) [p < 0.05]. The diagnostic yield of the MPR and UFP group for malignant and benign lesions was 93% (82 of 88 patients) and 75% (9 of 12 patients), respectively, while the historical control group was 60% (58 of 97 patients) and 0% (0 of 3 patients), respectively. The yield of bronchoscopy in SPN was significantly related to the size of the lesion in the historical control group (p < 0.05); however, there was no significant association between the yield of bronchoscopy and lesion size in the MPR and UFP group. The diagnostic yield of SPNs < 4.0 cm in the MPR and UFP group was significantly higher compared with the historical control group (p < 0.05). The total diagnostic yield of SPNs < 3.0 cm in the MPR and UFP group was 86% (89% in malignant lesion and 70% in benign lesion, respectively).


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  		Table 3.. Bronchoscopic Yield According to Sizes of the Lesions in the MPR and UFP Group and the Historical Control Group*

 
In addition, each lesion was analyzed separately according to the bronchopulmonary segments (Table 4 ). There was a trend toward lower diagnostic yield when lesions were located in both upper lobes in the historical control group (right upper lobe, 56%; left upper lobe, 43%). However, the diagnostic yields in both upper lobes (right upper lobe, 92%; left upper lobe, 96%) in the MPR and UFP group were significantly higher compared with the historical control group (p < 0.05).


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  		Table 4.. Bronchoscopic Yield by Bronchopulmonary Segments in the MPR and UFP Group and the Historical Control Group

 
Total complications during TBB were significantly lower in the MPR and UFP group (2%) compared with the historical control group (13%) [p < 0.05]. Pulmonary hemorrhage (> 25 mL), occurred in nine patients (9%) in the historical control group; however, hemorrhage occurred in only two patients (2%) in the MPR and UFP group. These hemorrhages were self-limited and believed to be caused by biopsy forceps. There were no severe hemorrhages in patients with a diagnosis by curette. Pneumothorax, which was asymptomatic and recovered without insertion of a chest tube, occurred in two patients (2%) in the historical control group. Fever after bronchoscopy also occurred in two patients (2%) in the historical control group; however, these complications were not observed in patients in the MPR and UFP group.

The mean time needed for the procedures was approximately 19 min (range, 13 to 32 min) in the MPR and UFP group. Procedure times were not recorded for the historical controls.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In the diagnosis of SPN, transbronchial approaches have become widely used as sampling techniques. Although multiple studies have investigated the diagnostic accuracy in bronchoscopy, only seven English-language studies1 2 3 4 5 6 7 have addressed SPNs. In these reports, diagnostic yield in SPN ranged from 18 to 62%, and the yield of flexible bronchoscopy was directly related to lesion size and location. The reasons for the different results of the yields can be linked to several factors, such as the size of the lesion, relationship between the SPN and the adjacent bronchi, and sampling methods used. However, no definitive conclusion has been reached on the most effective procedure of bronchoscopic diagnostic techniques so far.

In this study, we introduced MPR and UFP methods to improve the accuracy and safety of fluoroscopically guided flexible bronchoscopy in evaluating SPNs. As a result, we obtained a higher diagnostic yield of flexible bronchoscopy with MPR and UFP compared with the conventional bronchoscopic technique. In addition, our method provided a high diagnostic yield even when the diameter of SPNs were < 2 cm or existed in both upper lobes, suggesting that MPR and UFP were useful methods for bronchoscopic examination in evaluating SPNs. The diagnostic yield of benign lesions (75%) was found to be lower than malignant lesions (93%); however, this may have been due to the use of flexible bronchoscopy, which lacks specific histologic characterization of benign lesions. Previous studies1 2 3 4 5 6 7 have also reported lower diagnostic accuracy of benign lesions (18 to 38%) compared with malignant lesions. However, our data on benign lesions are more accurate than previously published data, indicating the effectiveness of our method.

The potential role of CT in enhancing bronchoscopic yield has been reported by Naidich et al.3 They reported that the presence of a bronchus leading directly to an SPN (so-called "bronchus sign") on CT is valuable in predicting the success of TBB. In their study, they obtained a positive bronchoscopic diagnosis in 60% of lesions with this sign. Several authors3 5 have also advocated the use of thin-section CT scans to predict the value of flexible bronchoscopy in diagnosing peripheral lung lesions. The finding of a bronchus sign in thin-section CT also suggests accessibility by TBB.

By providing a detailed outline of the exact relationship between airways and SPNs, MPR images provide reliable information regarding the site and direction of the bronchus that leads to the SPNs.13 14 15 Therefore, pulmonologists can guide the curette directly to the affected subsegmental orifices without exploring other subsegmental bronchi. In addition, the time spent in performing bronchoscopic examination can be reduced. An additional advantage is the ability to obtain images in oblique planes.15 Since the tracheobronchial tree is oriented in a slightly oblique plane, the ability to image it on its long axis may be advantageous. In our cases, bronchi that lead into SPNs from vertical and oblique directions were clearly demonstrated by MPR images. The order and angle of leading bronchus were also easy to visualize. In addition, the high percentage of malignant and benign diseases that were correctly diagnosed by UFP stain indicated the accuracy of selecting leading bronchus by MPR images. Therefore, MPR is useful in the prebronchoscopic evaluation of patients with SPN and, as experience accumulates, may have a potential to replace the use of conventional CT.

In 1981, Ono et al19 improved the diagnostic rate of bronchoscopy for peripheral lung cancer. They have studied bronchial-tumor relationships by prior mapping of the location of pulmonary masses with selective peripheral bronchography. A positive cytologic diagnosis for lung cancer was made in 45 of 46 patients (97.8%), leading these authors to advocate routine use of selective bronchography in evaluating peripheral lung lesions. Although bronchography is not routinely done before TBB today, this study suggests the importance of three-dimensional imaging of leading bronchus to the SPNs before bronchoscopic examination for pulmonologists. In addition, Ono et al19 emphasized the usefulness of the double-hinged curette catheter because of its flexibility and mobility. In our study, it was much easier to maneuver the curette than the forceps to the target area, based on the information provided by the MPR image. Therefore, another major factor improving the diagnostic yield in this study was the use of the curette.

UFP would, however, be especially helpful in rendering a rapid diagnosis for malignant tumors with distinctive nuclear features.16 17 18 The turnaround time for smears stained by UFP was < 3 min, fast enough for consultation during bronchoscopic examination. Since UFP procedures are basically the same as the standard Papanicolaou procedure, it is suitable for diagnosis of carcinoma rather than hematopoietic malignancy.18 In our study, approximately 90% of cases with SPN were diagnosed as primary lung cancer; therefore, UFP staining is a useful method in evaluating pulmonary SPNs. In fact, there was only one false-negative finding and no false-positive findings for malignancy using the UFP staining. The main cause of a negative UFP report in patients with lung cancer was the difficulty in selecting leading bronchus to the SPN even if the MPR image clearly demonstrated its position. Thus, other diagnostic approaches such as needle aspiration may have been preferable in this situation. Gasparini et al10 reported that TBNA is a valuable diagnostic tool in improving the yield of flexible bronchoscopy in such cases, probably due to the ability of the needle to penetrate the lesion even if the tumor does not infiltrate the bronchial wall.

A benign UFP report must be interpreted with caution, and further sampling is required when clinical and radiologic suspicion of malignancy persists. Nevertheless, a negative report is often of value in permitting initial conservative management, and it may be possible to make a specific diagnosis of inflammation or infection by UFP. In our study, a diagnosis was made immediately in three patients with aspergillosis by the UFP finding of an aggregate of Aspergillus. UFP findings of four patients with bacterial pneumonia revealed intense infiltration of neutrophils. Immediate assessment therefore reduces the requirement for further investigation, including surgery, in some patients with benign diseases. UFP was also of value in selecting those cases in which microbiological examination was indicated, since material from inflammatory lesions was necessarily submitted for culture.

The primary value of the UFP is in determining the adequacy of the specimen, although a specific diagnosis can usually be made. The technique decreased the number of biopsies needed to make a diagnosis as well as complications accompanied with bronchoscopic examination. We believe the immediate assessment of cytology using UFP will decrease major complications of the procedure. The present cases showed a dramatic decrease in the incidence of complication (from 13 to 2%) after implementation of the routine use of UFP evaluation, and the inclusion of the cytopathologist as a participant during the bronchoscopic biopsy. In the present study, three experienced cytopathologists in our hospital performed and interpreted the UFP testing. The assessment of the cytopathologists was believed to be adequate, since UFP procedure and interpretation are basically the same as the standard Papanicolaou procedure. The final goal of this study was to maximize diagnostic yield and minimize patient risk.

The fundamental question in the present study is whether the yield of flexible bronchoscopy with combined use of MPR and UFP is superior to that of a single use of each method. In 1995, Gasparini et al10 reported the diagnostic yield of bronchoscopy in evaluating peripheral pulmonary nodules and masses using immediate cytology assessment. According to this report, the sensitivity of the procedures for the malignant pulmonary nodules and masses is 53.9% and 69.3% for TBB and TBNA, respectively. Our data are more conclusive than their data, suggesting the superiority of combined use of MPR and UFP rather than a single use of immediate cytology assessment.

In conclusion, combined use of the MPR image and UFP for flexible bronchoscopy improved the diagnostic accuracy and safety in evaluating SPNs using a double-hinged curette. We encourage further studies addressing the improvement of these methods in the evaluation of SPNs with flexible bronchoscopy.


   Footnotes
 
Abbreviations: HE = hematoxylin-eosin; HRCT = high-resolution CT; MPR = multiplanar reconstruction; SPN = solitary pulmonary nodule; TBB = transbronchial biopsy; TBNA = transbronchial needle aspiration; UFP = ultrafast Papanicolaou

Received for publication October 28, 2002. Accepted for publication April 28, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Baaklini, WA, Reinoso, MA, Gorin, AB, et al (2000) Diagnostic yield of fiberoptic bronchoscopy in evaluating solitary pulmonary nodules. Chest 117,1049-1054[Abstract/Free Full Text]
  2. Torrington, KG, Kern, JD The utility of fiberoptic bronchoscopy in the evaluation of the solitary pulmonary nodule. Chest 1993;104,1021-1024[Abstract/Free Full Text]
  3. Naidich, DP, Sussman, R, Kutcher, WL, et al Solitary pulmonary nodule: CT-bronchoscopic correlation. Chest 1988;93,595-598[Abstract/Free Full Text]
  4. Wallace, JM, Deutsch, AL Flexible fiberoptic bronchoscopy and percutaneous needle lung aspiration for evaluating the solitary pulmonary nodule. Chest 1982;81,665-671[Abstract]
  5. Gaeta, M, Pandolfo, I, Volta, S, et al Bronchus sign on CT in peripheral carcinoma of the lung: value in predicting results of transbronchial biopsy. AJR Am J Roentgenol 1991;157,1181-1185[Abstract/Free Full Text]
  6. Fletcher, EC, Levin, DC Flexible fiberoptic bronchoscopy and fluoroscopically guided transbronchial biopsy in the management of solitary pulmonary nodules. West J Med 1982;136,477-483[ISI][Medline]
  7. Lai, RS, Lee, SS, Ting, YM, et al Diagnostic value of transbronchial lung biopsy under fluoroscopic guidance in solitary pulmonary nodule in an endemic area of tuberculosis. Respir Med 1996;90,139-143[CrossRef][ISI][Medline]
  8. Stringfield, JT, Markowitz, DJ, Bentz, RR, et al The effect of tumor size and location on diagnosis by fiberoptic bronchoscopy. Chest 1977;72,474-476[Abstract/Free Full Text]
  9. Radke, JR, Conway, WA, Eyler, WR, et al Diagnostic accuracy in peripheral lung lesions: factors predicting success with flexible fiberoptic bronchoscopy. Chest 1979;76,176-179[Abstract]
  10. Gasparini, S, Ferretti, M, Secchi, EB, et al Integration of transbronchial and percutaneous approach in the diagnosis of peripheral pulmonary nodules or masses: experience with 1027 consecutive cases. Chest 1995;108,131-137[Abstract/Free Full Text]
  11. Wang, KP Flexible transbronchial needle aspiration biopsy for histologic specimens. Chest 1985;88,860-863[Abstract/Free Full Text]
  12. Mehta, AC, Kavuru, MS, Meeker, DP, et al Transbronchial needle aspiration for histology specimens. Chest 1989;96,1228-1232[Abstract/Free Full Text]
  13. Padhani, AR, Fishman, EK, Heitmiller, RF, et al Multiplanar display of spiral CT data of the pulmonary hila in patients with lung cancer: preliminary observations. Clin Imaging 1995;19,252-257[CrossRef][ISI][Medline]
  14. Quint, LE, Whyte, RI, Kazerooni, EA, et al Stenosis of the central airways: evaluation by using helical CT with multiplanar reconstructions. Radiology 1995;194,871-877[Abstract/Free Full Text]
  15. Whyte, RI, Quint, LE, Kazerrooni, EA, et al Helical computed tomography for the evaluation of tracheal stenosis. Ann Thorac Surg 1995;60,27-31[Abstract/Free Full Text]
  16. Yang, GC, Alvarez, II Ultrafast Papanicolaou stain: an alternative preparation for fine needle aspiration cytology. Acta Cytol 1995;39,55-60[ISI][Medline]
  17. Yang, GC, Hoda, SA Combined use of the "scratch and smear" sampling technique and ultrafast Papanicolaou stain for intraoperative cytology. Acta Cytol 1997;41,1513-1518[ISI][Medline]
  18. Yang, GC, Papellas, J, Wu, HC, et al Application of ultrafast Papanicolaou stain to body fluid cytology. Acta Cytol 2001;45,180-185[ISI][Medline]
  19. Ono, R, Loke, J, Ikeda, S Bronchofiberscopy with curette biopsy and bronchography in the evaluation of peripheral lung lesions. Chest 1981;79,162-166[Abstract/Free Full Text]



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