Staging Of Bronchogenic Carcinoma Research Articles

Bronchogenic carcinoma: the added value of FDG PET/CT advanced volumetric and metabolic parameters in initial evaluation and their impact on prognosis and clinical outcome

Abstract Background Bronchogenic carcinoma is considered to be one of the most common causes of cancer-related mortalities. It is divided into two main subtypes; small cell and non-small cell carcinoma. CT is considered the most commonly used radiological modality for early detection and staging. PET/CT can efficiently give both structural and functional information about the tumoral mass and malignant activity overall the body and hence can accurately assess the tumor staging and tumor response to therapy. Our study aim was to evaluate the different 18F-FDG PET/CT advanced volumetric and metabolic parameters in initial staging of bronchogenic carcinoma and their capability to predict the impact on prognostic pathway and hence the clinical outcomes. Results Forty patients with pathologically proven bronchogenic carcinoma were included in this study, and all of them did PET/CT in which different volumetric and metabolic parameters were measured and showed significant differences in different tumor grades. Conclusion PET/CT can give both structural and functional data about the tumor mass adding to its proper assessment of the initial evaluation and predicting its prognostic pathway.

Assessing the Diagnostic Role of Multidetector Computed Tomography in Bronchogenic Carcinoma: Histopathological Correlation and Clinical Insights

Background: Lung cancer is a global health issue, and Multi Detector Row Computed Tomography (MDCT) plays a crucial role in diagnosing and staging bronchogenic carcinoma. Purpose: To document bronchogenic carcinoma’s MDCT features and assess CT scan accuracy compared to histopathological diagnosis. Materials and Methods: Between June 2020 and November 2021, 70 patients with suspected bronchogenic carcinoma underwent clinical assessment and 128-slice MDCT scans from lung apices to upper abdomen, including adrenal glands. MDCT findings were compared to histopathological examination. Statistical analysis using SPSS 16 and Excel determined CT’s positive predictive value against histopathological diagnosis as the reference standard. Results: Out of the 70 patients, 41% were female, and 59% were male. Among those with suspected bronchogenic carcinoma in CT, 86% were confirmed as malignant through histological analysis. The mean age of patients with bronchogenic carcinoma was 61.5 years. Squamous cell carcinoma (43%) was the most common histological subtype, followed by adenocarcinoma (38%). There was a notable male predominance (68%) for bronchogenic carcinoma, with distinct patterns observed for different histological subtypes. MDCT exhibited an 86% positive predictive value in diagnosing bronchogenic carcinoma compared to histopathology. Conclusion: Squamous cell carcinoma emerged as the most prevalent subtype of bronchogenic carcinoma, with MDCT demonstrating high diagnostic accuracy. The study advocates for routine MDCT utilization in the diagnosis and staging of bronchogenic carcinoma. Consider limitations like absent interobserver variation and challenges in distinguishing reactive hyperplasia from metastatic lymphadenopathy. Future research could explore potential implications and applications of the study’s findings.

PET/CT implication on bronchogenic carcinoma TNM staging and follow-up using RECIST/PERCIST criteria: a comparative study with CT

BackgroundTo evaluate the role of PET/CT on bronchogenic carcinoma staging as well as treatment response evaluation on follow-up compared to CT study alone.MethodsA prospective study of 60 patients confirmed histopathologically to have non-small cell bronchogenic carcinoma, 30 of them came for staging (group T) while the rest 30 came for follow-up (group F) to assess therapy response. All patients underwent PET/CT with data analysis done using the eighth edition tumor, nodal, metastatic staging (TNM) staging for group T and RECIST/PERCIST criteria for group F. The CT data alone transferred to a blind radiologist for analysis using the same parameters. The results were collected and compared.ResultsRegarding group T, 12 patients showed different TNM staging between PET/CT and CT alone, 5 cases with different T stagings, 4 cases with different N stagings, and 5 cases with different M stagings. Also, 8 cases showed different surgical stagings. Regarding group F, 9 cases showed a difference between RECIST obtained by CT and PERCIST obtained by PET/CT with most of the cases (6 cases) showed change from partial or stable response to progressive response.ConclusionPET/CT has a significant role in TNM staging of bronchogenic carcinoma more at T2 staging due to its ability to differentiate the tumoral mass from the nearby pulmonary reaction. Also, PET/CT makes a difference in tumoral follow-up by its ability to detect the functional changes even before structural changes. Finally, PET/CT is a very important tool in management strategy.

Staging of Bronchogenic Carcinoma at Tertiary Health Care Centre with Multidetector Computed Tomography and Histopathological Correlation

Staging of Bronchogenic Carcinoma at Tertiary Health Care Centre with Multidetector Computed Tomography and Histopathological Correlation

Contrast computed tomography versus PET/CT in the assessment of bronchogenic carcinoma

Background In the past decades, diagnostic imaging modalities of bronchogenic carcinoma were chest radiography and computed tomography (CT) to determine the tumor size and mediastinal lymph nodes involved, as well as liver and adrenal metastases. Now PET/CT has become a routine procedure for the primary assessment (initial staging) in the detection of functional tumor activity (viable cells). Objective The objective of this study was to compare between contrast CT and PET/CT in the assessment of bronchogenic carcinoma (initial staging) and impact of weight and BMI on it. Patients and methods This was a cross-sectional study that involved 100 patients for initial staging of newly diagnosed bronchogenic carcinoma examined by contrast CT and PET/CT. In addition to anthropometry measures, weight and height were taken and BMI was calculated. Results The initial staging of bronchogenic carcinoma showed significant differences between PET/CT versus contrast CT (P=0.001). Upstaging done by PET/CT in six patients (stages I and II), as well as an agreement between CT and PET/CT in stage III and IV was detected. The evaluation showed a sensitivity and specificity of 75.2–89.4% and 78.2–90.0% for CT and 97.2–100% and 98.5–100% for PET/CT, respectively. There is a significant positive correlation between tumor size and its metabolic activity measured by the maximum standardized uptake value. However, there was no significant correlation between BMI and maximum standardized uptake value; moreover not any significant association between BMI and metastatic deposits was detected. Conclusion PET/CT is a powerful imaging modality for the assessment of functional behavior of tumor cells to avoid false results depending on the morphology only as contrast CT, which leads to change the decision taken for the management of bronchogenic carcinomas.

Role of PET/CT in Differentiating Bronchogenic Carcinoma from Inseparable Pseudo-Neoplastic Lesions

Background: Bronchogenic carcinoma is the single most important cause of cancer-related deaths with approximately 1.5 million cases worldwide every year. Computed tomography (CT) scanning can only estimate the proximal extent “with difficulty in visualization the real borders” of a tumor. The role of MRI in local staging of bronchogenic carcinoma is limited by the signal loss secondary to respiratory motion and heterogeneity of the magnetic field caused by the tissue/air interfaces. Positron Emission tomography combined with CT (PET/CT can accurately delineate the viable tumor from surrounding atelectasis and collapse/consolidation, this information cannot only demarcate the size and extent of the tumor for accurate T staging, but also provide guidance for biopsies if histological confirmation is required Purpose: It was to emphasize the role of PET/CT in differentiation the bronchogenic carcinoma from its inseparable pseudo-neoplastic lesions for better staging and increase the accuracy of follow up by ruling out the pseudo progression as well as pseudo regression. Patients and Methods: The study involved 32 patients proved histo-pathologically to have bronchogenic carcinoma and referred for PET/CT scanning. Each patient included in the study was subjected to full history taking, reviewing medical sheet and PET/CT examination. The study was done in private center (Techno-scan holding center, Heliopolis branch using PET-CT machine (GE Discovery VCT 64 PET/CT, USA); in which PET-CT examination was followed by diagnostic contrast enhanced CT examination and processed at Ain Shams University, Radiology department. Results: In this study we found presence of inseparable pseudo neoplastic lesions among 20 patients out of 32 patients and the mean diameter of the bronchogenic mass lesion was 6.89 +/- 3.65 SD as measured by CT, while it was 5.77 +/-3.38 SD as measured by PET/CT in centimeters. Conclusion: The combined PET/CT using 18F-FDG is the best oncologic imaging modality with valuable role in local staging and follows up in patients of bronchogenic carcinoma.

Role of PET/CT in Differentiating Bronchogenic Carcinoma from Inseparable Pseudo-Neoplastic Lesions

Background: Bronchogenic carcinoma is the single most important cause of cancer-related deaths with approximately 1.5 million cases worldwide every year. Computed tomography (CT) scanning can only estimate the proximal extent “with difficulty in visualization the real borders” of a tumor. The role of MRI in local staging of bronchogenic carcinoma is limited by the signal loss secondary to respiratory motion and heterogeneity of the magnetic field caused by the tissue/air interfaces. Positron Emission tomography combined with CT (PET/CT can accurately delineate the viable tumor from surrounding atelectasis and collapse/consolidation, this information cannot only demarcate the size and extent of the tumor for accurate T staging, but also provide guidance for biopsies if histological confirmation is required Purpose: It was to emphasize the role of PET/CT in differentiation the bronchogenic carcinoma from its inseparable pseudo-neoplastic lesions for better staging and increase the accuracy of follow up by ruling out the pseudo progression as well as pseudo regression. Patients and Methods: The study involved 32 patients proved histo-pathologically to have bronchogenic carcinoma and referred for PET/CT scanning. Each patient included in the study was subjected to full history taking, reviewing medical sheet and PET/CT examination. The study was done in private center (Techno-scan holding center, Heliopolis branch using PET-CT machine (GE Discovery VCT 64 PET/CT, USA); in which PET-CT examination was followed by diagnostic contrast enhanced CT examination and processed at Ain Shams University, Radiology department. Results: In this study we found presence of inseparable pseudo neoplastic lesions among 20 patients out of 32 patients and the mean diameter of the bronchogenic mass lesion was 6.89 +/- 3.65 SD as measured by CT, while it was 5.77 +/-3.38 SD as measured by PET/CT in centimeters. Conclusion: The combined PET/CT using 18F-FDG is the best oncologic imaging modality with valuable role in local staging and follows up in patients of bronchogenic carcinoma.

The usefulness of thoracic ultrasonography in diagnosis and staging of bronchogenic carcinoma.

To evaluate (1) the usefulness of thoracic ultrasound in diagnosis and staging of bronchogenic carcinoma by comparing lesion detectability between thoracic- ultrasound and computed tomography and (2) the outcome of thoracic-ultrasound-guided biopsy in diagnosing bronchogenic carcinoma. We conducted a cross-sectional study on 53 patients of confirmed bronchogenic carcinoma. All patients had been investigated by thoracic-ultrasound and chest-computed tomography; data regarding the presence of mass (its size, necrosis), lymph nodes invasion, peritumoural atelectasis, consolidations, pleural effusion, chest wall invasion, and paralysis of the diaphragm were recorded. Thoracic-ultrasound-guided biopsy was done for 41 patients. Thoracic-ultrasound had significantly higher detection rate of peritumoural atelectasis, paralysis of the diaphragm, and supraclavicular lymph nodes invasion, while it has significantly lower detection rate of pulmonary masses and mediastinal lymph nodes invasion than computed tomography. It has nonsignificant higher detection rate of pleural effusion, consolidations, chest wall invasion and necrosis within mass than computed tomography. Thoracic-ultrasound detects static air-bronchogram and/or fluid bronchogram in 53.3% of bronchogenic carcinoma-associated consolidation. Thoracic-ultrasound-guided biopsy revealed positive yield in 78.0% (32/41) of patients. All patients with negative thoracic-ultrasound biopsy had mass size >5 cm with necrosis within the mass. Self-limited complications occurred in 26.8% after thoracic-ultrasound-guided biopsy (haemoptysis 22.0%, pneumothorax 2.4% and subcutaneous emphysema 2.4%). Thoracic-ultrasound has a significant complementary role to computed tomography in diagnosis and staging of bronchogenic carcinoma. Thoracic-ultrasound-guided biopsy revealed good positive yield (78%), its yield was negatively affected by mass size and necrosis. It is a simple, practical and accurate procedure without significant patients' risks.

Mediastinoscopy in Assessing Mediastinal Lymphadenopathy and Lung Disease

Background: Mediastinoscopy is the gold standard procedure for the pathological staging and diagnosis of mediastinal diseases. The aim of the study is to describe the significance of anterior cervical Mediastinoscopy in evaluating patients with mediastinal lymphadenopathy and lung parenchymal disease. Material and Methods: From January 2014 until June 2017 we conducted a retrospective study of 52 consecutive patients with mediastinal lymphadenopathy and lung parenchymal disease who underwent anterior cervical Mediastinoscopy. The main indications for cervical Mediastinoscopy were isolated mediastinal lymphadenopathy, undetermined lung mass with mediastinal lymphadenopathy, and the clinical staging of patients with lung cancer. Results: The study subjects consisted of 37 men and 15 women, aged 13 to 87 (mean age 50.8). Eight patients had mediastinoscopy for staging lung cancer, 27 patients had mediastinoscopy to diagnose isolated mediastinal lymphadenopathy, and 17 patients had mediastinoscopy for an undetermined lung parenchymal mass. Among the patients with isolated mediastinal lymphadenopathy, sarcoidosis was diagnosed in 6, tuberculosis in 9, reactive lymph nodes in 4, metastasis in 5 and lymphoma in 3. Lymph node metastasis (N2, N3) was found in 5 patients with lung cancer. There was no surgical-related mortality or morbidity. Conclusions: Mediastinoscopy is a safe and reliable procedure in diagnosing mediastinal diseases and is still the first choice among the investigative modalities in the clinical staging of bronchogenic carcinoma.

Endoscopic ultrasound making resonance in cancer research

Endoscopic ultrasound (EUS) is a novel technology that is being increasingly used for the diagnosis and management of cancers involving various organ systems. The technology was introduced three decades ago and its use has expanded exponentially in the past two decades. EUS-guided fine needle aspiration (FNA) is the best modality for tumor detection and tissue diagnosis even if the mass is weakly identified by other imaging modalities (1). EUS-FNA is capable of taking samples from masses that are not imaged by computed tomography or magnetic resonance imaging and lesions too deeply encased by adjacent vascular structures to allow percutaneous biopsy (2). EUS-guided FNA as well as EUS guided Trucut biopsy (TCB) has proven to be beneficial for benign and malignant diseases as well as staging of malignant tumors of the GI tract and adjacent structures (3). The application of EUS-guided therapy is especially appealing for malignancies because it provides accurate and effective palliative treatment. This is possible primarily due to two EUS characteristics: (I) its ability to deliver direct treatment to lesions unreachable by other means; and (II) the minimal invasiveness of EUS, which provides superior results with a low complication rate (4). EUS is being used to locally stage esophageal tumors (T staging), and it can be used for the assessment of esophageal submucosal tumors as well. Based on the EUS characteristics, we can positively identify the lesions that arise from exterior layers. This approach is particularly useful for evaluating invasion of local disease (especially esophageal cancer), tumor depth, nodal involvement, and detection of distant metastases (5). CT and magnetic resonance imaging lack the ability to differentiate the layers of the esophageal mucosa. Thus, these modalities cannot accurately discern the T stage of esophageal cancer (6). Therefore, EUS is a prerequisite before performing esophageal endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Esophageal leiomyomas, esophageal cancers, cystic lesions, lipomas, vascular lesions, and esophageal extraluminal compressions are some of the lesions that are commonly identified using EUS. EUS can be used to obtain cytology specimens from mediastinal nodal enlargement for the diagnosis and staging of bronchogenic carcinoma (7). EUS has a definitive role for evaluation of early gastric cancers and gastric submucosal lesions. Early gastric cancers can be staged using EUS and the feasibility of EMR or ESD can be determined. Gastrointestinal stromal tumors (GISTs) and other submucosal lesions can be diagnosed as well using EUS and their potential for ESD can be determined using EUS.

Conventional transbronchial needle aspiration in community practice.

Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.

Enhancement of conventional TBNA outcome after EBUS Training.

Conventional transbronchial needle aspiration (C-TBNA) is a well-established technique for the diagnosis and staging of bronchogenic carcinoma. Because of the implementation of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), the C-TBNA is being used less frequently. Despite its proven diagnostic utility some of the pulmonary fellowship programs have chosen to eliminate training for C-TBNA from their curriculum. The objective our study was to compare the outcomes of C-TBNA before and after the implementation of EBUS in our unit. We compared the diagnostic performance of C-TBNA in 2 groups of non-small cell lung cancer patients with mediastinal lymph nodes >10 mm in short axis as seen on the computed tomography scan of the chest. Patients underwent C-TBNA before (group A, N=147) or after (group B, N=67) implementing EBUS technology in our unit. C-TBNA technique was performed by the same bronchoscopists before and after being proficient in EBUS. The overall accuracy in group B was higher than in group A (23.9% vs. 9.5%, respectively; P=0.0001). Overall test accuracy and sensitivity of C-TBNA was 66% versus 86% and 63% versus 86% in groups A and B, respectively. The negative predictive values of C-TBNA improved after EBUS training (19% vs. 33%, P<0.001). Inadequate samples were less frequent in group B than in group A (31.1% vs. 49.7%, respectively; P=0.00001). Diagnostic performance of C-TBNA improves after EBUS training. C-TBNA should remain in the armamentarium of every bronchoscopist and on the curriculum of all pulmonary fellowship training programs even if EBUS technology is available.

ACR Appropriateness Criteria Non-invasive Clinical Staging of Bronchogenic Carcinoma

In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Importance of systemic mediastinal lymphadenectomy in exact staging of bronchogenic carcinoma

Constituent part of radical lung resection for lung cancer is a dissection of mediastinal lymph nodes. Lymphadenectomy is a standard procedure in an assessment of clinical stage of the disease. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of mediastinal lymphadenectomy for exact staging and survival. Study of 31patients with lung resection and systematic mediastinal lymphadenectomy operated from August 2004 to January 2007, with pre-operative stage Ia to IIb (TNM classification) - according to CT without mediastinal lymph nodes invasion and with positive histological finding after systematic mediastinal lymphadenectomy. Tumors in right upper lobe metastasized in 45.5 % into group 1 nodes (stages N1-N4) and group 3 nodes (stages N7) and in 9 % into group 4 nodes (stages N8-N9). Tumors of the right middle lobe metastasized in 100 % into group 3 nodes (stage N7).Tumors of the right lower lobe metastasized in 87.5 % into group 3 nodes (N7) and in 12.5 % into group 4 nodes (stages N8-N9). Tumors of the left upper lobe metastasized in 9.0 % in group 1 nodes (stages N1-N4), in 82 % into group 2 nodes (stages N5-N6) and in 9.0 % were found skip metastases into group 4 nodes (stages N8-N9). Tumors of the left lower lobe metastasized in 26.7 % in group 4 nodes, 46.6 % into group 3 nodes, in 20,0 % into group 2 nodes and in 6,7 % into group 1 nodes. Systematic mediastinal lymphadenectomy is crucial for determining the stage of the disease according to the TNM classification. Systematic lymphadenectomy is essential for the diagnosis of stage IIIa disease and setting of additional therapy that prolongs survival (Ref. 17).

Extended cervical mediastinoscopy: mature results of a clinical protocol for staging bronchogenic carcinoma of the left lung

The objective of this study is to evaluate the accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung based on our updated experience. From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, routine positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. Following this protocol, from 2004 to 2010, we performed 132 selective ECM. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. Patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection (SND). Two hundred and twenty-one ECMs were performed from 1998 to 2010 (89 routine and 132 selective). In the routine ECM protocol, four cases were positive and thoracotomy was contraindicated. The remaining 85 patients were operated and five had nodal disease in subaortic (LN5) or para-aortic (LN6) stations. In the selective ECM protocol (n=188), 132 patients underwent ECM and in 19 it was positive; the remaining 113 patients underwent thoracotomy and SND found involved LN5 or LN6 in six patients; the other 56 patients underwent direct thoracotomy and four had positive LN5 or LN6. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ECM were 0.67, 1, 1, 0.94 and 0.95, respectively. The staging values of routine/selective ECM protocols were 0.44/0.65, 1/1, 1/1, 0.94/0.94 and 0.94/0.95, respectively. Selective ECM protocol according to CT and PET findings has high negative predictive value and accuracy. Therefore, its selective use is recommended because it saves around 30% ECM without decreasing staging values of the current protocol.

Comparison of the quality of smears in transbronchial fine‐needle aspirates using two staining methods for rapid on‐site evaluation

Transbronchial needle aspiration (TBNA) via flexible bronchoscopy is a well-established sampling modality for lung masses. The procedure is useful in the diagnosis of neoplastic and non-neoplastic lesions as well as for staging of bronchogenic carcinoma. Rapid on-site evaluation (ROSE) adds value as it has the advantage of triaging material during the procedure so avoiding a battery of investigations. Frequently used rapid stains are the modified Wright-Giemsa water-based stain (WG-ROSE) and the alcohol-based modified Papanicolaou stain (Pap-ROSE). Final review of laboratory-based Giemsa and Pap stains supplemented by ancillary investigations is essential for quality assurance. To investigate whether and how ROSE influenced the quantity and quality of the material submitted to the laboratory we randomized 126 patients to WG-ROSE, requiring only one pathologist on-site, or combined WG- and Pap-ROSE, requiring an additional person on-site to assist with staining. In those patients with positive TBNA we graded the laboratory-based slides of the first pass containing diagnostic material into insufficient, suspicious, adequate and excellent. The first diagnostic pass was found after 3.06 ± 1.94 (SD) passes and 3.13 ± 2.16 passes with WG-ROSE and combined ROSE (P = 0.87), respectively. Following WG-ROSE and combined ROSE 69% and 71.1% (P = 0.509) of slides were diagnostic (adequate or excellent) on laboratory-based Giemsa stains, and 93.3% and 100% (P = 0.134) were scored adequate or excellent on laboratory-based Pap stains. We concluded that the less costly and labour intensive WG-ROSE procedure is adequate for TBNA. This has cost implications especially in resource poor settings.

ACR Appropriateness Criteria® Noninvasive Clinical Staging of Bronchogenic Carcinoma

In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criteria is designed to provide an overview of the value of different imaging techniques in the non-invasive staging of lung cancer and allow for the rational selection of imaging studies to arrive at the appropriate clinical stage.

Transbronchial needle aspiration with or without endobronchial ultrasound.

Transbronchial needle aspiration (TBNA) has been used for over three decades in the diagnosis and staging of mediastinal adenopathy and masses. Although first described in Argentina in 1949 by Dr. Eduardo Schieppati, this rigid bronchoscope technique received very little attention until 1978 at Johns Hopkins Hospital where Wang and colleagues described in detail the diagnosis of a paratracheal mass by TBNA biopsy through a rigid bronchoscope using a 25-gauge esophageal variceal needle. In 1983, a novel flexible needle that could be used with the flexible bronchoscope to perform TBNA was developed and introduced for diagnosis and staging of bronchogenic carcinoma. Immediately to follow was the expansion of its use in the diagnosis of peripheral pulmonary nodules and benign mediastinum and hilar disorders by obtaining histological core specimens. Recent development of the endobronchial ultrasound-guided TBNA is most exciting and promising. Whether this will enhance the result of TBNA and spread the TBNA technique as a standard lung cancer staging procedure is yet to be seen. TBNA is simpler and easier. Endobronchial ultrasound-guided TBNA currently is more complicated and more difficult. Its future relies on a hybrid instrument and methodology to be widely applied to the diagnosis and staging of bronchogenic carcinoma.

Revista del año de Archivos de Neumología en neumología intervencionista, enfermedades intersticiales y trasplante pulmonar

A review has been made of original articles on invasive pneumology techniques, interstitial diseases and lung transplantation, published in the Archivos de Bronconeumología during the year 2008. We have selected the publication by Martínez-Olondrins et al on the mediastinal staging of bronchogenic carcinoma by «blind» transbronchial needle aspiration to highlight the role of this simple, safe and cost-effective technique at a time when aspiration by ultrasound-guided bronchoscopy is profiled as an alternative to staging by mediastinoscopy. Besides its usefulness in the study of lymph nodes, transbronchial needle aspiration increases the overall performance of bronchoscopy by 20%, which means that it should be considered as a basic tool in the study of lung cancer. We also comment on the work by Galvis-Caravajal et al, who describe percutaneous radiofrequency as an alternative to radiotherapy in small lung or metastasic tumours. In diffuse interstitial disease, Morell et al analysed the diagnostic methods in 500 patients with this clinical-radiological presentation in which a definitive diagnosis was achieved in 85%, with 25% of them being obtained by non-invasively. Baloira et al analysed the characteristics of 19 patients with desquamative interstitial pneumonia and respiratory bronchiolitis associated-interstitial lung disease obtained from the National register of Interstitial Diseases.

Extended cervical mediastinoscopy in the staging of bronchogenic carcinoma of the left lung

To evaluate the technical feasibility and the sensitivity, specificity and accuracy of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma (BC) of the left lung. From 1998 to 2003, 89 patients underwent routine ECM for staging of BC of the left lung. In 2004, positron emission tomography (PET) was included in our staging protocol and ECM was reserved for those with positive mediastinal or hilar PET images, large lymph nodes on computed tomography (CT) scan or central tumours. From 2004 to 2007 we performed selective ECM in 67 patients. ECM was considered positive when metastatic nodes or tumour involvement directly in the subaortic or para-aortic regions was confirmed pathologically. One hundred and forty-three patients with negative ECM underwent subsequent thoracotomy for tumour resection and systematic nodal dissection. Pathological findings were reviewed and staging values were calculated. One hundred and fifty-six patients underwent ECM (89 routine and 67 selective). In 13, ECM was positive and thoracotomy was contraindicated. The rest of the patients were operated. We performed 88 lobectomies, 34 pneumonectomies, 6 wedge resections, 13 exploratory thoracotomies and 2 parasternal mediastinotomies. Lymphadenectomy specimens showed tumour involvement of subaortic lymph nodes in 8 patients. Complication rate was 2%: two cases of mediastinitis, one ventricular fibrillation, and one superficial surgical wound infection. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of routine/selective ECM were: 0.45/0.75, 1/1, 1/1, 0.94/0.95, 0.94/0.95, respectively. ECM is a feasible staging technique that allows ruling out subaortic and para-aortic nodal disease with high negative predictive value, accuracy and sensitivity. Its indication based on the CT and PET findings seems more advisable that its routine use to stage bronchogenic carcinoma of the left lung.