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The use of fiberoptic bronchoscopy in the diagnosis of bronchogenic carcinoma

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Published in Basra Journal of Surgery at March 1997

Text of The use of fiberoptic bronchoscopy in the diagnosis of bronchogenic carcinoma

  • 1. B. ) S BIS.March ,3 ,tw-THE [SE OF FIBEROPTIC BRONCHOSCOPE IN THE DIAGVIS OF. .BRO(HOGENlC CARCINOMA * A hthll Sci/ tiiii lirxeeii / Li/7cI.* . l. B Cli B . F I C . l 5..Lecturer and coiisiiliant Cardiotlioracic & Vascular Surgeon. Dcpzimnent of SlIl: !Cl"_,College ol . 1ediciiic. Uiii'ersity of Basrah.and consultant Saddam Tcaclting Basrzilt - Iraq .SI ITIJI. -l R lT/ ii./ irmpei-Iii'e . IIIt/ _I' repre. s'ent. ' the persniml experieiice n/the authnr in a. 'ing the y/7e. 'ihIe /7I(IllL'/ Ill. (, (I[lL in the iliagrm. i'i. r Qfht'(1IlC/ I0_[_'L'IIIL' carcinoma.The slmly wasL(IIll/ IlLTL'tI at the Set-tirrri n/ ' Tlmrueic & CariIiol"u. s'eulur Surgery of Basruh L'niver. iti 'l'eac/ Iiuing Hm/ vital.II is lI'0If/ l_I' to nnte that we are the only center in the south of Iraq that per/ nrni._fi/ zernptie hrnrii. 'Izn. s'cnpy nan & . IIlLL' I 996. Between Dec.7995 and Dec.799/).Kiri patients (56 males & I l)fi. 'maIe') . m.s'pecterl to Iran. / irnnc/ iagenic eaeinuma on clinical & raziiulugicul / unis were iiilijet-teil tii / iIieI'optie hrnm-lin. 'L'ap_r.Their a_ge.riIn_t(ezl from 10 In I/ Myer/ r.V.Fiber/ /ptie liriuiL-/ in. t-np_i- was / re/ j/it/ 'niezI iimler Inuil iinae. s't/ ie. ria rriimnasal/ _i' in the sitting pasitiaii a.ian nut/ iiltient procedure.T/ Iere lItl.71!!martaIit_i' attrihulilhle tn hrwiit-Iti: .e1ip_1' & the niily IlCL'(lII)Iltli / ia: ,uriI was moderate [JiL'LI/ illg on one patient which ll'(l.1' LUllIItI/ /Li[ coimservatii-eh..~l t/ e/iriite rIiugIm. 'i. ' (ff hmnelmgenie LUl'LIIItlI}1(l was canrmeil in J8 patieliti (. "3'/ h) ivltile the remaining IS patient were ennsir/ ererl SllS]Iicir)lt. ea..5.The $11!! /l' reveaiezl ii high incidence of the r/ ixease in th _/ iftli & . i. 'th tI(L'(l(IE. . with more men it/ _/eeteil than iiwmen.The branchaxeopicrirlingi in [7(lTIL'III'. with /7l(I| '{. lI hrzmcliogenic earcinmna were stmlierl in well as the locations of visible tiiinoiirs.It is ii/1/III_i' tn rinte that I/ ) nut nf35 i'i. 'iI1Ie IIlllItHlt.ll'('lL itIL'/ .I7L'ti in the upper lobes ii/ iieh Twill]! /V/1(I'L been I1liS. 'ct/by the righl bI'l)IIL'/ lU. L()/ it.I/ IL/ lfttllL/ IItLII/ tiL'/ illtlillgfST/ 'UIIgiI' correlated ii'it/ I the eliriieal & railingraplzie _fim/ ii1g. . The prerliuiiiniint / i[. ti2Iiigiti type was . qutunnu. s cell eareilmmu (3 ".5 '51:).The exact cell type coiihl not he iletrerminezl in 1'/ iatieiirs (35.4 '56).All patients were innperahle L. 'l. L]}f tow (95.8 '55).The L'(lIlIIll(ltlL. 'I eaiue of imzperahlity tires pm/ r resjziriitrzry_tIuictian. . In cutie/ iisiiui._/7e. 'ibIe [W17/l(. /l(). L()[[l is an L/ "/it-ieiit & safe prncezhrre in the rliilgriosis ofliI'iiIieIiugeiiit- eareimmia. Introduction The exible bronclioscope.first Bi'onclioscop_' is an essential part ofthe designed by Ol_'lTTpl. l5 Optical Coiiipany diagnostic iiork up of bronchogenic and Machida Endoscopy carcinoina The i'igid_' bronclioscope.COlTTp1lT_' in 1964. has a superior devised initially by Killian at the end of diagnostic rate permitting visuali-zatioii the last century and improved by of segmental & SLllIS6glTT-lilal lironclii Cliealiei' . lacI70 1 3 l 9. 70 Total 66 100j. _j__j. :_j_ Table l 2 Distribution of 66 patients(56males & 10 females) with BronchogcnicCiircinomii by Age. The bronchoscopic ndings in patients with proven bronchogenic carcinomaare showing in Table II. Finding No.of OccaisioiisNo.visible tumour 5 Visible endobronchial tumour 35 Left vocal ctird_p_aralysis 9 Tracheal compression T Fxtenial Bronchial comprision l2 Wideiied it immobile cariiia 2 Hiper aemic mucosa 1-l / bm>mial traclieobroiicliial I4 secretion Blccdiiiv Z3Tzible ll :Bronchoscopic Fiiidiiigs in Patients with Provcii Bmiicliogeiiic Curciiioiiia. Thirty ve patients had visible endobronchial tuinmours. Table Ill,displays the locations of visible tumours.Sixteen patients had upper loble tumours. 3. Location No.of tumours Carinal Tumour 2 Main stem 9 bronchusBronchus 2 intermediusLUL* ,12 RUL* 4 RML* 2 RLL* 2 LLL* 1 Apicolower 1 segmental bronchusTotal 35Table III :Location of Visible Endobronchial Tumours.*LU'L : Left upper lobe,RUL : Right upper lobe, RML : Right middle lobe,RLL : Right lower lobe. The procedures performed during bronchoscopy are detailed in table IV which shows that bronchial washing were obtained from all patients while bronchial brushings were obtianed in 36.Procedure No.of Occasion Bronchial washing 5 48 Bronchial brushing 36 Bronchial biopsy 9 ' Unsuccessful bronchial 3biopgy Table IV :Procedures Performed During Bronchoscopy. Table V,shows the histological types of.bronchogenic carcinoma in . -the proven cases.The predominant cell types was squamous-cell carcinoma (37.5%) .The exact histological type could not be determined in 17 patients(35.4 %t.Histilogical type No of Percentage PatientsSquamous-cell 18 h 37.5 % CarcinomaAdenocacinoma 5 12.5 % Large-cell 2 4.1 % Oat-cell 3 4.1 % Anaplastic 1 2 % Poorly - 2 4.1 %" dierentiatedBronchogenicCarcinomaNonspecied 17 35.4 % malignanttumoursTotal 48 100 %Table V :Histopathological Diagnosis in Bronchogenic CarcinomaAll patients proven to have bronchogenic carcinoma were inoperable except 2 (95.8%).One patient refused operation & one patient had left upper lobectomy for adenocarcinoma. The various causes of inoperiblity are mentioned in Table VI.The commonest one was poor respiratory functions. Cause No of Cause No.of Patients patients Poor RFTs* 32 Chest wall 6 involvemenls Distant metastases 1 Rib erosion 2m. __: __m_Subcutanepus l Phrenic nerve 3 nodules palsy _ Cervical [N5 5 Cyto| ogically- 5 Axillary LNS l malignantPleuraleiisioii Contralateral 2 L.Vocal Cord 9 Mediastinal LN paralysis 4involvement ofCarina SVC obstruction 3 Main stem 8 Pancost tumour 7 bronchustumour close tocarina .Concomitant l Oat-cell 3 medical carcinoma DisorderraemiaTable VI : Causes oflnoperablity in Patients with Proven Bronchogenic Carcinoma." RI-Ts :Respiratory function lest."SVC :Superior vena cava. DiscussionBronchogenic carcinoma,in Iraq, is being diagnised with increasing frequency gaining the position of being the commonest malignant tumour in men & sixth most common tumour in womeng. In agreement with other studies,this study revealed a higher incidence of bronchogenic cancer in males than females (male:female ratio of 5.6 to 1),with the majority in the fifth or be at 55 65 years 4. The positive diagnostic yield of beroptic bronchoscopy in this study is 72% which is comparable to other studies.It has ranged from 76% (Bedrossian-CW & Rybka DL) to 97% (Funahshi-A et at) . An expert cytologist & experienced bronchoscopy team are essential fora high percentage of reliable positive diagnosis in bronchogenic carcinoma. In contrast with beroptic bronchoscopy,the bronchial secre-tions obtained via the rigid brochoscope yielded the lowest positive rate(5 1%)Most studies indicate that bronchial brushing is very accurate for cytodioiagnosis of lung cancer & it is superior to bronchial washingms.This difference.appe-ared to be related to cell degneration which was minimal in brush material & maximum in sputum cytologies.Chopra-SK et al beleive that bronchial brushing is even superior to forceps biopsy as the former can be obtained from peripheral lesion under uoro-scopic guidancems.Failure to diagnose visible tumours is related to inability to obtain deep biopsies . It is worthy to notice that the bronchoscopic ndings in patients with proven bronchogenic cancer in this study strongly correlated with . the clinical & radiographic ndings. In regard to the site of visible tumours,16 out of 35 tumours were located in the upper lobes which would have been missed by the rigid bronchoscope. There was no mortality attributable to bronchoscopy and the only occasional hazard was moderate hemoptysis encoutered in one patient with an advanced inoperable tumour which was managed conservatively.This ent-ails the extreme safety of the procedure yvghich is agreed upon by most authorsThe most prevalent histological type of bronchogenic carcinoma in this study34and in other studies was squamous cell carcinoma'.The exact cell type could not be determined in l7 patients which may be due to inadequate bioposis,cellular degeneration &the low experience of the cytologist .It is interesting to note that all the patients in this study were inoporable except 2(95.8 %) .Causes ofinoperablity are related in Table VI.Many patients had more than one sign ofinoperablity.The commonest was poor respiratory functions.Some of these signs wereclinical ex:superior vena caval obstruction,radiological ex rib erosion,while others werebronchoscopic ex:vocal cord paralysis,widened & immobile carina,carinal tumour & main stem bronchus tumour close to carina. The reasones why most our patients were inoperable are 1. The aggressive nature of the disease so when the symptoms develop it is too advanced 2. The patient consults doctors usually too late as respiratory sympotoms are attributed to smoking & chronic bronchitis 3. There is unfortunatly a delay in referral of patients to bronchoscopy by the physicians;the patient either receives sympto-matic treatment only or he is misdiagnosed & treated as pulmo-nary tuberculosis. We failed to obtain cytological diagnosis of bronchogenic carcin-oma in 18 patients.All of them had no visible tumours while 2 patients had bronchial narrowing only .Six patients had peripheral pulmonary lesions which could have been diagnosed by transbronchial biopsy with uoroscopic guidance.The fiberoptic bronchoscope can conrm the diagnosis in some of these patients provide that certain procedures are done like transbroncliial lung biopsy,tiansbronchial needle aspiration,detection of uorescence alter injection or llpD'5 & detection of tumour 5. markers in alveolar cells16'19.Unfortunately we do not have such facilities in our institute.Invasive diagnostic procedures such as mediastinscopy,mediastinotomy" &_open lung biopsy were considered ofhigh risk in these patients with poor respiratory . lllCiIlOI1S & advanced age. Conclusionsl. People especially elderly smok-ers should seek medical advice when presistent respiratory symptoms dev- elop. 2.Physicians should suspect bron- chogenic carcinoma.in the predisposed people when any respiratory symptom persists and chest radiography followed by bronchoscopy are indicated. 3.The tlexibie bronchoscope is= an extremely safe procedure despite the poor respiratory reserve of the patients in our study & their advanced age.4.Most of the patients in the study are elderly with poor respiratory reserve rendering them either unt or too risky for general anaesthesia;thus exibl bronchoscopy under local anaesthesia is ideal for them5.Being performed under local anaesthesia,exible bronchoscopy saves the use of general anaesthetic drugs whose supply is very limited in our locality because of the unjustied blo_ckade on the people of Iraq since l990.6.Fle>; ible bronchoscopy is performed as an outpatient procedure thus it reduces the cost ofthe patients care & saves the hospital resources especially with the circumstances of blockade.7.There is an urgent need to haveexperienced cytology service to increase the diagnostic yield of bronchoscopy.This is especially importan' in the inoperable cancer patients Who are unt for invasive diagnostic procedures ex.mediast inotomy.A positive cytologicaldiagnosis would enable such patients to receive palliative radiotherapy & /or chemotherapy.8.Early diagnosis of bronchogenic carcinoma will enable more patients to benet from surgical resection which is the best treatment for this disease.9.The diagnostic yield of beroptic bronchoscopy can be increased by the newer techniques of transbronchial needle aspiration,transbronchial biopsy under uorscopic guidance,quant- itation of tumour markers in bronch- oalveolar lavage uid & detection of uorescence from HpDcontaining cells.Referencesl.Azhar K.Kassab.The role ofthe exible beroptic bronchoscope in the bronchogenic carcinoma.J Fat:Med Bag.1996, Vol.38, No.124-262 Romcevicl/ I. The role ottiberoptic bronchoscopy in the detection of bronchopulmonary carcinoma.Plucne- Bolesti.1990 JulDec;42(3-~l)20373 AIrOligaAC.f4atthayR~.The role of bronchoscopy in lung cancer,ClinChest Med.1993 Mar;14(1):8798.4. Donlan-Cl Jr;Foreman-DR;Vlayton R].Fiberoptic bronchoscopy in nonhospitalized patients Arch-Intertn-Med.I978 May,I38(5e)'(398-9.5. Hamm-J.Clinical and endoscopic diagnosis of bronchogenic cancer.Langenbecks-ArchChir.l98l;355:l04-6.6 Cosello-BF;Funahashi-A,Hranicka-Ll Flexible beroptic bronchoscopy:its role in diagnosis oflung lesions.Postgrad-Med.1982 Aug;72(2):95- l05,lO8.7. Savage-P];Donovan-Wn;Dellinger RP.Sputum cytology in the management of patients with lung cancer South-Med-J l'I. 'l Jul,l l(l):840-2 6. 8. Bajwa4MK;HeneinS,Kamh0lzSl.Fiberoptic bronchoscopy in the presence ofspace occupying intracarnial lesions.Chest.1993 Jul,104(1):1013.9 Nazar B.Elhassani.Plain radiographic ndings in bronchogenic cacinoma.J.Fac.Med.Baghdad 1996, Vol.38, No.2 88- 93.10. KingTC,Smith CR.Chest wall,pleura,lung & mediastium.ln Schwartz SI,Shires GT,Spencer FC.Principles of Surgery.5th Ed,New York.McGraw Hill Book Company.1988, 627-770.1 l.Bedrossian~ CW;Ryb1