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Diagnostic, morphologic, and histopathologic correlates in bronchogenic carcinoma. A review of 1,045 bronchoscopic examinations. G Buccheri, P Barberis and M S Delfino Chest 1991;99;809-814 DOI 10.1378/chest.99.4.809 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/99/4/809

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1991by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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Diagnostic, Morphologic, and Histopathologic Correlates in Bronchogenic Carcinoma* A Review of I ,045 Bronchoscopic Gianfranco and

Maria

Buccheri,

M. D.

S. Delfino,

M.D.

F. C. C.P;

Tholo

Examinations

Barberis,

M.D.;

on the correlation between bronchoscopically histopathologic classification, and diagnostic yield is very scarce. To contribute to the knowledge of the subject, we reviewed the bronchoscopic charts of 1,045 patients with lung cancer who were seen in the years from 1983 to 1989 at the Bronchology Service of the A. Carle Hospital. Tumors were more often located centrally and Information

visible

aspects,

superiorly.

No preference

were,

carcinomas Forceps

biopsies,

percent,

specimens,

percent,

carcinomas

tumor-like

lesions,

was

found.

percent

of the

Bronchoscopically, were

which

Squamous

the most frequent and washings were

and

respectively.

small-cell

as to side

by far, brushings,

were

Adenocarcinomas,

on the contrary, were more infiltrative, compressive, or aspecific findings. In these latter tumors, cytologic studies were more fruitful. Large-cell anaplastic carcinomas had an intermediate behavior. Cell type, endoscopic appearance, and diagnostic success are interrelated features. Visible characteristics at bronchoscopy can therefore anticipate the more likely histotype and guide the diagnostic approach. (Chest 1991; 99:809-14) frequently

peripheral

and

as central

diagnosed

by forceps

aspecific findings; SC squamous carcinoma; ACadenocarcinoma;

carcinoma, no than endoscopic

with the FB.” other methods

examination of the tracheobronchial duction ofthe fiberoptic bronchoscope 1960s further enhanced the diagnostic

tree. The intro(FB) in the late potential of the

to percutaneous

examination. The flexibility of the new instrument ameliorated both the acceptability to patients and the security of the procedure.2 Bronchoscopy, which includes both visual inspection and collection of specimens for cytohistologic studies, is now an essential part of the routine work-up of any patient suspected of having

lung cancer. years ago,

Fifteen application ifications chial

biopsies,

aspirations,5’6

sions,7

Sackner

reviewed

of flexible bronchoscopy. in the use ofthe FB, such

have

the

been

clinical

Since then, modas lung transbron-

adopted.

Nevertheless,

racy

studies have investigated of the diagnostic techniques

*Fmm Presented

the A. Carle Hospital ofChest in part at the 8th Congress

the overall accuused in association

Diseases, of the Sept

Pneumology, Freiburg, West Germany, the XVI World Congress on Diseases of the 30-Nov3, 1989. Manuscript received April 25; revision accepted Reprint requests: Dt Buccheri, Via Repubblica (CN), Italy 1-12018

Cuneo,

Boston,

July 17. 10/C, Roccavione

Oct

carcinoma; LCC

of the

5CC large-cell

have compared them to sampling (for example,

needle

capability

same

techniques

recently, making

correct diagnosis of cell type has been the object of diverse 1214 Unfortunately, most of the previously mentioned information is oflittle value to the bronchoscopist who is examining a new patient. As a matter of fact, the

needs what

has no knowledge of what the pathowill be; and he is faced, at best, with endoscopic signs of malignancy; so he

to know, above all, what the diagnosis is the histotype, and what is the

potential

for that given

bronchoscopic

ingly, we thought it important ship existing between visible

cancer, phology curacy.

MATERIALS The underwent at the

patients

fiberoptic Bronchology

this

bronchoscopy Service

ofthe

finding.

bronchoscopic seven years examined

AND

series

could be, diagnostic Accord-

to examine the relationaspects and the other

laying particular emphasis pathologic classification,

Italy.

European Society of 10-14, 1989, and at Chest,

Other studies ofcytohistologic

diagnostic elements ofthe In this study, we reviewed and 1 ,045 bronchoscopically

even today, the majority ofdiagnoses are substantiated by biopsy, brushing, and washing specimens obtained during a routine fiberoptic bronchoscopy. Several

the

bronchoscopist logic diagnosis recognizable

lymph node transbronchial needle or alveolar lavages for peripheral lesometimes

showed

small-cell carcinoma

diagnosis of bronchogenic has proven more valuable

the method

and

obtained

squamous visualized

often

better

cell type. positive in

biopsies.

examination. of experience cases of lung

on endoscopic and diagnostic

morac-

METHODS

were

selected in the

years

A. Carle

from from

Hospital.

3,292 who 1983 to 1989 Examinations

were carried out at the request of physicians of the medical both the A. Carle Hospital and the surrounding hospitals.

CHEST/99/4/APRIL,

1991

units of Nearly

809

all patients

were

or hemoptysis

were

patients

whatever

the

because

of the

copy

a carcinoma

tissue

biopsied

analysis

made

of abnormal

chest

roentgenograms.

with

ofthe and

lung

reports

not

used

kept

sole

plished

procedures

(including

one

the

at the

bronchial

early

version

undertaken

beginning

of the

the

either

irregular

area

service,

additional

ie,

cannula

specimens

compression: of

often

and with (AS):

localized

swelling

and

irregularity

absence

of localized

four

and

the

description

study,

only

basis

of the

one

biopsy

the

type

who

muc()sal

signed

of abnormality

(the

was using

the

performed (Olympus

all (4)

patients,

with

always

used

brush

duty

this

drying

significant

the

transport

patient.

in a large, BF1T1O

well-

or BFP1O

Bronchial onto

motion.

For

three

alcohol

(Olympus).

rubbed

inspection

They

to prepare

95 percent

report.

for each

laboratory.

brush

a limited

area

Rubbing to the

was

performed.

Bronchial

With

open,

abnormal

mucosal

Smears

were was

where

biopsies forceps

area

histo-

and

was pressed

immediately

standard

the

unsheathed

from

seconds

the

with to

using

carefully firmly,

minimize

a forceps

before

air-

fixative

interpretation placed

and

a circular

in ethanol and

fixed

Papanicolaouâ&#x20AC;&#x2122;s

with

immersed done

local

and the sediment

slide

staining

were

Following hours.

withdrawn

to a few

from

in nearly

in the

of a microscope then

done

of biopsy.

obtained

then

taken

for two to three

were the

to obtain

were

electively

with

were

the

type

stained

(three specimen.

impossible were

withheld

endo-

of biopsy

first

washings

smears.

laboratory,

the

cytocentrifuged,

limited

Slides

number

multiple

it was

processed

brushings The

artifacts.

cups

and

in all patients,

taking

prior

were were

segments

Washings

of the were

from were

usually

bronchial

was instru-

there The

was

solution.

drink

and

washings

technique.

normal:

of the

the

food

Bronchial was

a saline

independently

pathologic

reduced

using

feared.

when

Then

of the

performed

followed

performed

biopsies.

site

was

taken

lesion

blindly

since

patient

were

visible

channel

obtained were

bleeding

were

forceps

bronchoscopy,

and

(6)

biopsies

the biopsy

without

visual

final

most

considered

were

examples

were

the

Brush

the

FB. The a complete

samples

Any

of by

a curved

same

After

tree,

opacities,

bleeding

through

all patients.

through

for each

solution followed

ofthe

abnormal.

Biopsies

life-threatening

reliable

(5) aspecific

and

1 . The

findings

examinations room

layer;

in Figure both

or as a

channel

were

abnormalities.

unless

medication

tracheobronchial

biopsies

was accom-

(Novesine),

in nearly

to radiologic

significant

of either

engorgement,

In 25 cases,

anesthesia

same

to be

to the

premedicated

of a 4 percent

suction

or forceps,

six),

vessels;

mucosa;

vessel

by brush

obtained

mass

and

appeared

specimens

and surrounded

fixity

visible

that

unless

deformation,

with

of the

areas

used

were

topical spray

the

was

The

infiltration:

blood

Paradigmatic

shown

description-report)

Bronchoscopic

and

of endoscopic

operators,

swollen

well-preserved

abnormalities. are

(3)

inspection

bronchial

fast;

of the

through

best

patient.

coating

compression,

redness

the

then

contraindications

diathesis,

hydrochloride

approach

biopsied,

absolute

an overnight

instillations and

ment.

no bleeding

(oxybuprocaine)

corresponding

since

vegetation

associated

an apparently

categories two

often

team

endobronchial

necrotic

engorgement

of extrinsic

bronchi,

the

tumors;

surface, and

findings

first

polypoid

of the

our

to give

for an

300

as a simplified

cauliflower-like

frankly

form

developed

white

than

A classification used

tumor:

(2) necrosis:

mucosal

motility,

equipped

(1)

redness

any

narrowing

at least

are

used:

after

had

a rhino-oropharyngeal

transnasal from

bronchoscopists

in an attempt

responsible

ofthe

halo

by Ikedaâ&#x20AC;?

physician

growth;

lesions

study. been

was

as an irregular

fleshy

mucosal

has

classification

Categories

Percent

Total CAll differences positive

results

percent

were

significant

out

of actually

percent

xâ&#x20AC;&#x2122;

test.

Percent

performed

positive

results

out

evaluable

patients.

central tumors (67 percent and vice versa was the case vs 19 percent; p<O.OOl). valid for the yield of forceps the cellular type patients, biopsies mors,

1#{128}, in the

(Table were SSC

vs 57 percent; p<O.Ol); for brushings (11 percent Similar observations are biopsies, as a function of

2); accounting more effective

and

the

On the contrary, brushings yielded more in peripheral LCCs

were

forceps behavior.

very

well

SC variants

diagnosed

by both with an important,

crable

3) shows that forceps biopsies tive in the tumor-like morphology cases) and less effective in infiltrative

sions, lesions,

(36

brush

and

effecof all (72

On the contrary, cytologic studies had yield in infiltrative or quasi-infiltrative ie, in the nonspecific only the yield ofwashings

percent).

associated

Necrotic with

techniques

and

a quite

low

their le-

yield

in any

of the

ofparticular needed to important choscopy. literature the

optimal

fined. yield

has diverse

results

but

has one

interest. The number ofbiopsy obtain an optimal diagnostic consideration

in applying

number

of specimens

In 1982, Popovich of 92 percent, after

et six

has

not

correctly

diagnose

carcinomas

examining

only

abnormalities

their

the series.

subjects and

third This

with no

been

de-

found a diagnostic biopsies of each endo-

lesion and 40 histologic sections In contradistinction, Shure et by

the

alh8

bronchial specimen.

chial

bronin

biopsy was

tumor-like more

than

of each alâ&#x20AC;&#x2122;s could all

obtained

the by

endobronnine

tissue

from

our

study

of a particular technique light of the endobronchial

each bronchoscopist, associate

particular

using his endobron-

diagnostic

technique

which

can to the

has

potential for success, we are unaware of the of any previous study specifically directed to quantify this association. In his classic treatise on flexible bronchoscopy, Ikeda15 gave some insight into the relationship existing between bronchoscopic findings, bronchial location, and histopathologic classifi-

perform

all three diagnostic procedures concerned patient, but, instead, brush biopsies were forceps biopsies were judged unfeasible.

radically, washings

also the same forceps biopsies and were not obtained. This prevented

and and not on done Spo-

bronchial us from

comparing directly, making reference to each morphologic category, the yield of the three techniques. Nonetheless, we believe that we have demonstrated

are the easiest diagnosed although effective

spectively); nosed by

specimens yield is an

fiberoptic

findings

three

message

Although recommendations exist for performing up to six forceps

message

with have

the best existence

is best success), relatively

DISCUSSION

study

chial

surface

considered.

This

experience,

were

lesions

The

yield in the

the forceps patients would

the following: (1) cancers presenting endoscopically as exophytic masses or frankly infiltrating the mucosal

findings. In invisible was relatively good

compressive

the

probably

own

each when

intermediate correlation

were very (83 percent appearances

inferior.

using

studied results

cation, but not between endoscopic morphology diagnostic efficiency. Our study is retrospective has at least one important limitation. We did

(p<(0.001).

and, significanfly, washings tumors, ie, in ADs. The

biopsies, still acting The last, and more

percent). maximum

for all of the in central tu-

biopsied

morphology.

Although

techniques; 1,045

been

is therefore that must be evaluated

1 , percent

diagnostic

fruitfully

Should they have bronchial lesions,

certainly

findings Normal

to be more

to diagnose;

(2) the first pattern

by forceps biopsies (85 percent brushing and washing are also (40 percent and 37 percent, re-

(3) the second tissue biopsies

pattern is still well diag(80 percent), but cytologic

studies and, particularly, brushings are also effective (this latter has its maximum yield in this type of lesion); (4) necrosis, bronchial compression, and nonspecific

findings have the visible lesions for percent, 37 percent, and brushings (12 percent, 11 among

lowest diagnostic potential forceps biopsies (overall 57 30 percent of positivity) or percent, and 16 percent) or

washings (22 percent, 19 percent, also, invisible lesions, either washed,

have

a nonmarginal

38 percent); and blindly biopsied

rate

of positivity.

There are other merit a comment.

findings in the current The overall diagnostic

forceps

biopsies,

even

direcfly

visible

through

accounting the

FB,

CHEST

study which efficiency of

for is well

tumors comprised

I 99 I 4 I APRIL

Downloaded from chestjournal.chestpubs.org by guest on October 28, 2010 ÂŠ 1991 American College of Chest Physicians

(5) or

1991

not in 813

the range of the contrary, brushings inferior

reported sensitivity.9”0’8’9 had a quite low yield,

the

remembered

reported

that

rates,”

limited

but

our

tion. Professor Savino Run, Chiefofthe Laboratory of Histopathology of the Cuneo City Hospital System (USSL-58), is responsible for the pathologic data. Mr. James Beauchamp provided English editing.

On the generally it

brush

must

biopsies

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Diagnostic, morphologic, and histopathologic correlates in bronchogenic carcinoma. A review of 1,045 bronchoscopic examinations. G Buccheri, P Barberis and M S Delfino Chest 1991;99; 809-814 DOI 10.1378/chest.99.4.809 This information is current as of October 28, 2010 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/99/4/809 Cited Bys This article has been cited by 2 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/99/4/809#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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