Transbronchial needle aspiration in the diagnosis and staging of lung cancer

Abstracts

INTRODUÇÃO: Nos últimos anos, a punção aspirativa transbrônquica por agulha vem sendo utilizada cada vez com maior freqüência no diagnóstico e estadiamento do câncer de pulmão, principalmente nos EUA. Entretanto, muito pouco se tem publicado a respeito do método em nosso país. OBJETIVO: Avaliar a efetividade da punção aspirativa transbrônquica por agulha no diagnóstico e estadiamento do câncer de pulmão. MÉTODO: Setenta e quatro punções aspirativas transbrônquicas por agulha, realizadas no Hospital do Câncer-INCA/MS, foram revistas retrospectivamente. Todos os pacientes realizaram tomografia computadorizada do tórax previamente ao procedimento. RESULTADOS: Onze (15%) pacientes tinham massas mediastinais e 63 (85%) massas hilares. Foram encontradas 76 alterações endoscópicas: alargamento da carina principal em 44 (59%) pacientes, alargamento de carina secundária em 12 (16%), compressão paratraqueal em 5 (7%), compressão da parede posterior da traquéia em 3 (4%), e compressão de brônquio principal em 5 (7%) pacientes. O material foi satisfatório para o diagnóstico em 42 (57%) pacientes e em 34 (46%) o diagnóstico foi confirmado. O diagnóstico de doença maligna foi confirmado em 30/34 (88%) pacientes: carcinoma indiferenciado de pequenas células em 10/30 (33%), carcinoma escamoso em 7/30 (23%), adenocarcinoma em 7/30 (23%), e carcinoma não pequenas células em 6/30 (20%) pacientes. Em 4/30 (12%) pacientes foram diagnosticadas patologias benignas: tuberculose em 2/4 (50%) e sarcoidose em 2/4 (50%) pacientes. Não observamos nenhuma complicação com o método. CONCLUSÃO: Nossa experiência em 74 pacientes mostrou que o procedimento é seguro, rápido em sua realização, com mínimas complicações e de utilidade no diagnóstico e estadiamento de pacientes com neoplasia pulmonar.

Broncoscopia; Carcinoma broncogênico; Aspiração; Aspiração

ORIGINAL ARTICLE

Transbronchial needle aspiration in the diagnosis and staging of lung cancer

Mauro Zamboni^(TE-SBPT); Deborah Cordeiro Lannes^(TE-SBPT); Andreia Salarini Monteiro^(TE-SBPT); Marilene S. Nascimento; Edson Toscano^(TE-SBCT); Aureliano Mota de Sousa Cavalcanti^(TE-SBCT); Samuel Z. de Biasi Cordeiro^(TE-SBCT); Paulo de Biasi Cordeiro^(TE-SBCT)

^{Correspondence}

ABSTRACT

BACKGROUND: Transbronchial needle aspiration (TBNA) with a flexible bronchoscope has been used to diagnose bronchogenic carcinoma for many years in the United States. However, little information on the subject is available in Brazil.

OBJECTIVE: To assess the effectiveness of transbronchial needle aspiration in the diagnosis and staging of lung cancer.

METHOD: A retrospective review was made of 74 TBNA performed at the National Cancer Institute in Rio de Janeiro, Brazil. a thoracic computerized tomography had oreviouslbeen made of all patients.Eleven (15%) patients exhibited mediastinal masses and 63 (85%) hilar masses. Seventy six endoscopic alterations were detected: enlargement of the main carina in 44 (59%) patients; enlargement of the secondary carina in 12 (16%); paratracheal compression in 5 (7%); posterior tracheal wall compression in 3 (4%); main bronchus compression in 5 (7%) AND BRONCOSCOPY was normal in 5 (7%) patients.

RESULTS: Specimens were satisfactory for diagnosis in 42 (57%) patients and in 34 (46%) diagnosis was confirmed. Malignancy was confirmed in 30 of 34 patients (88%): as follows: small cell undifferentiated carcinoma in 10 of 30 (33%); squamous cell lung cancer in 7 of 30 (23%); adenocarcinoma 7 of 30 (23%); and non-small cell lung cancer in 6 of 30 (20%). Four of 30 (12%) were diagnosed as bearers of benign disease: tuberculosis 2 of 4 (50%) and sarcoidosis 2 of 4 (50%). No complications related to the method were perceived.

CONCLUSION: This preliminary study of TBNA in 74 patients indicated that this method is safe, easy to perform, with a minimum of complications and useful for the diagnosis and staging of pulmonary neoplasms.

Key words: Bronchoscopy/methods. Carcinoma, bronchogenic/diagnosis. Aspiration/methods.

Abbreviations used in this paper:

TBNA – Transbronchial needle aspiration

CT – computed tomography

Introduction

Transbronchial needle aspiration (TBNA) was first described in 1949 by an Argentinean surgeon named Schieppati. He managed to diagnose squamous cell carcinoma by aspirating subcarinal lymph nodes from a patient who had an esophageal tumor. However, TBNA did not come into common use until the beginning of the 1980s, when it began to be used in conjunction with a fiber bronchoscope for the diagnosis and staging of mediastinal lymph nodes in patients with lung cancer. When used in concert with other endoscopic procedures, it improves the diagnostic quality of fiber bronchoscopy. Nevertheless, TBNA is still rarely used.^(1,2)

Dasgupta et al.⁽³⁾ used TBNA through a fiber bronchoscope for the diagnosis of bronchogenic carcinoma presenting an endobronchial lesion with an exophytic mass. The authors realized that this type of lesion could be diagnosed more efficiently when conventional diagnostic methods, such as biopsy, bronchial brush, and bronchial lavage, were used in conjunction with TBNA.

Horsley et al.⁽⁴⁾ reported the usefulness of TBNA for the diagnosis in submucosal lesions, especially those that are covered by normal mucous, since it is not easy to reach them using habitual endoscopic procedures.

Shure and Fedullo⁽⁵⁾ used TBNA for the diagnosis of peribronchial disease when there was proven submucosal infiltration or extrinsic compression. They confirmed the superiority of TBNA over other methods.

The same authors evaluated the efficiency of TBNA in the diagnosis of mediastinal and subcarinal lymphoadenomegaly. In comparison to mediastinoscopy, TBNA was equally efficient, but presented fewer complications.⁽⁶⁾

The TBNA procedure is safe and virtually noninvasive. It has a low incidence of complications and samples can be collected for both cytological and histological studies. This method has been used for the diagnosis of mediastinal masses, submucosal lesions, nodules, and peripheral lung masses. In addition, it is useful for the diagnosis of mediastinal lymphoadenomegaly in patients with lung cancer.⁽¹⁾

Currently, TBNA is used more frequently in the diagnosis and staging of lung cancer. In such cases, TBNA has proven effective in reducing morbidity and mortality – at a lower cost than mediastinoscopy, mediastinotomy or thoracotomy.⁽¹⁾

The utility of TBNA has been confirmed in the literature. However, to date there have been no Brazilian studies evaluating the technique.^(1,3,7)

This study relates our experience with TBNA in the diagnosis of pulmonary and mediastinal lesions.

Methods

A retrospective review was made of the 74 TBNA procedures performed at the Serviço de Tórax do Hospital do Câncer – INCA/MS, in Rio de Janeiro, Brazil, from January 2000 to June 2003. Of the 74 patients, 49 (66%) were male. Ages ranged from 29 to 80, with a mean of 56 and a median of 59.

All procedures were performed using a fiberoptic bronchoscope (Pentax VB model 1830). Aspiration was performed with a 22-gauge, 13-mm needle (MW-122, Mill-Rose Laboratories, Mentor, Ohio, USA). The needle is encased in a plastic sheath that is 140 cm in length and 1.9 mm in diameter.

All patients underwent computed tomography (CT) scans of the chest prior to TBNA. Lymph nodes identified in the CT scan as larger than 1 cm (at their smallest diameter) were selected as aspiration sites. Lymph node stations were located according to the American Thoracic Society mapping system. Mediastinal (4R, 4L and 7) and hilar (11R and 11L) lymph node stations were aspirated (Figure 1).

The TBNA procedure was carried out prior to the examination of the bronchial tree. The equipment was introduced without aspiration and 3 to 5 samples were collected from each affected lymph node station. Samples were smeared on a glass slide and fixed with 95% alcohol. The needle was then washed with 5 mL of saline solution and both needle wash and smear were taken to the anatomopathology laboratory for cytopathological analysis. All exams were conducted without the aid of fluoroscopy.

Samples were classified as either satisfactory and positive (lymphocytes predominating, epithelial cells scarce, definitive diagnosis), satisfactory and negative (lymphocytes predominating, epithelial cells scarce, diagnosis undefined) or unsatisfactory (sample was not representative of the lymph node).

Since TBNA was still considered a trial procedure at our clinic, all patients later underwent either mediastinoscopy or mediastinotomy with lymph node biopsy, regardless of the TBNA results.

Results

All 74 patients in the study were subjected to chest CT scans, which revealed that 11 (15%) had mediastinal masses (at levels 4R, 4L and 7) and 63 (85%) had hilar masses (at levels 11R and 11L). In the tracheobronchial trees of those patients, we observed 76 endoscopic alterations. Enlargement of the primary tracheal carina was the most common finding, observed in 44 (59%) of the patients. Enlargement of the secondary tracheal carina was seen in 12 (16%) of the patients, right or left paratracheal contraction in 5 (7%), posterior tracheal wall compression in 3 (4%) and right or left main bronchus compression in 5 (7%). Two distinct endoscopic alterations were found in 2 (3%) of the patients. Bronchoscopies were normal in 5 (7%) (Figure 2).

Of the samples collected, 43% (representing 32 of the patients) were not representative of lymph nodes and were classified as unsatisfactory for diagnostic purposes, and 57% (representing the remaining 42 patients) were considered satisfactory. Of those 42 patients from whom satisfactory samples were obtained, 34 (81%) were definitively diagnosed, and 8 (19%) remained undiagnosed.

In our study, the diagnostic efficiency of the method was 46% (34 out of 74 patients). Of the 34 cases in which a diagnosis was made, malignancy was confirmed in 30 (88%). Of those 30, 10 (33%) had small cell cancer, 7 (23%) had squamous cell carcinoma, another 7 (23%) had adenocarcinoma and 6 (20%) had non-small cell lung cancer (Figure 3). The remaining 4 patients (12%) had benign masses: 2 were diagnosed with sarcoidosis and 2 with tuberculosis.

No complications related to the method were observed in the patients studied.

Discussion

Although TBNA has been recognized as an effective tool in the diagnosis and staging of lung cancers, only a small number of bronchoscopists in Brazil have been using the procedure routinely. This is due to a combination of factors, including a general lack of knowledge about TBNA, limited experience on the part of practitioners and simple complacency (since conventional techniques are believed to be adequate).

Patients whose chest CT scans revealed mediastinal or hilar lesions underwent TBNA. Most of the patients presented endoscopic alterations corresponding to the CT findings. Normal fiberoptic bronchoscopy and the absence of lymph node enlargement do not contraindicate the use of TBNA, although they lower its rate of positivity.⁽⁷⁾

Chin et al.⁽⁸⁾ observed that when the smallest diameters of lymph nodes (as seen in chest CT scans) were greater, higher TBNA positivity resulted. The authors reported that TBNA positivity was 44% for lymph nodes whose smallest diameters were larger than 2 cm, and 4% for lymph nodes with smallest diameters of less than 1 cm.

We detected no differences in TBNA positivity rates between those for hilar and those for mediastinal lymph node aspirates (45% and 55% positivity, respectively). This is in accordance with data from a study of 360 patients conducted by Harrow et al.⁽⁹⁾, who reported 43% efficiency for mediastinal lymph nodes and 46% for hilar lymph nodes.

Although the positive predictive value of TBNA can be as high as 100%, it has a low negative predictive value. Therefore, when TBNA results are negative, other diagnostic tests must be performed. False positive results are rare and can be avoided if technical guidelines are strictly followed.^(1,5,9) It is recommended that suction not be used until after TBNA has been performed. If there is bronchial fluid present, the area under examination should be rinsed with saline solution or lidocaine. Aspiration is performed after puncture and prior to the examination of the tracheobronchial tree. The lymph nodes with the worst prognoses should be aspirated first, and the negative pressure must be interrupted prior to retracting the needle from each lymph node.⁽¹⁾ We adhered to these guidelines during the TBNA procedures performed in this study.

A consensus has not been reached as to the ideal number of aspirations for each lymph node station. However, a recent study showed that there is no additional improvement in efficiency after the seventh consecutive aspirate.⁽⁸⁾

Among our patients diagnosed with malignant diseases, the most common histological type was small cell cancer. This histological type presents a higher diagnostic positivity when compared to other types of lung cancers.⁽¹⁰⁾

In various series described in the literature, overall efficiency of TBNA ranges from 25% to 80%.^(9-11) In our study, overall efficiency was 46%. Malignant diseases predominated (diagnosed in 88% of our patients). Among those, the most common was small cell lung cancer (in 33%). Our results show that this type of neoplasia is more easily diagnosed with TBNA than are other types of lung cancer. This is in accordance with the findings of other studies.^(3,7) A probable explanation for this is that small cell cancer is more likely to produce metastases in mediastinal lymph nodes.

The efficiency of TBNA is directly related to the training and the experience of the practitioner.^(12,13) The American College of Chest Physicians guidelines recommend that a bronchoscopist perform the procedure at least 25 times before being considered qualified.⁽¹⁴⁾

Through TBNA, access to 11 lymph node stations can be gained. However, only 5 stations are useful for the staging of lung cancer: station 7 (subcarinal lymph nodes), station 4R (right inferior paratracheal lymph nodes, station 4L (left aortopulmonary window), and stations 11R and 11L (right and left hilar lymph nodes).⁽¹⁾

In the literature, the diagnostic efficiency of TBNA in cases of visible endobronchial neoplastic lesion ranges from 65 to 87%.^(1,2,5,6) Although the efficiency of bronchial biopsy ranges from 67% to 100% in such cases, TBNA can still be useful when lesions are occluded by necrotic tissue or when there is a high likelihood of bleeding, as in cases of carcinoid tumor or small cell lung cancer. ^(5,6,10)

Conventional procedures such as bronchial brush and bronchial biopsy present low efficiency in the diagnosis in submucosal and peribronchial lesions. This can be explained by the fact that peribronchial lesions are inaccessible with biopsy forceps since they are located external to the airway. In addition, submucosal infiltrate can harden the tissues, making conventional biopsy more difficult, and the infiltrate may become covered with normal tissue. Under these circumstances, the inclusion of TBNA with traditional bronchoscopic methods (bronchial biopsy, brush, and lavage) improves diagnostic efficiency.^(2,5,6)

Shure and Fedullo⁽⁵⁾ studied 31 patients with submucosal and peribronchial disease. The sensitivities of conventional biopsy, TBNA, conventional biopsy combined with TBNA and all diagnostic methods employed together were, respectively, 55%, 71%, 89% and 97%.

Since sarcoidosis can only be definitively diagnosed through the detection of non-caseous granuloma, TBNA with a fine needle plays a limited role in the diagnosis of the disease. Using TBNA concomitantly with transbronchial biopsy or even bronchial biopsy improves diagnostic efficiency.⁽¹⁾ In our study, sarcoidosis was diagnosed in 2 (6%) of the patients through the identification of non-caseous granuloma, which, together with the clinical history and the radiological findings, confirmed the diagnosis. Also, tuberculosis was diagnosed in another 2 patients (6%) by identifying a Langhans foreign-body type giant cell granuloma and caseous necrosis in the aspirate.

The TBNA procedure is contraindicated for non-cooperative patients, patients with constant cough and patients who present any untreated coagulation problems. Also, TBNA is contraindicated for patients with pulmonary arterial hypertension.⁽¹⁵⁾

The most severe complications related to the method are pneumothorax, pneumomediastinum, and hemomediastinum. Some slight bleeding in the puncture site may occur. This is usually due to dilated blood vessels in the tracheobronchial wall and not to the puncture of a large blood vessel. There was a rare case reported in which hepatic puncture occurred in a patient who presented an elevated right diaphragmatic dome. Fever and temporary bacterial infections may arise after the procedure, but the use of prophylactic antibiotics has not been sanctioned. The most common problem associated with TBNA is the damage caused by the needle passing through the airway during the procedure. In order to avoid this problem, the bronchoscope must be held unbent during the progress of the needle, which should be sheathed.^(1,2)

Our preliminary experience indicates that TBNA is a safe and effective technique. When combined with other bronchoscopy methods and performed by trained, experienced practitioners, TBNA improves diagnostic efficiency. It is recommended for patients suspected of having lung cancer and for those with mediastinal lymphoadenomegaly. Therefore, TBNA is useful for the diagnosis and staging of lung cancer.

References

Submitted: 18 August 2003.

Accepted, after revision: 10 November 2003.

* Study carried out at the Serviço de Tórax do Hospital do Câncer- INCA/MS

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Publication Dates

• Publication in this collection
  08 June 2004
• Date of issue
  Apr 2004

History

• Received
  18 Aug 2003
• Accepted
  10 Nov 2003