Canadian Neighbor Pharmacy: Transbronchial Needle Aspiration in the Diagnosis of Endobronchial Malignant Lesions
Transbronchial needle aspiration (TBNA) is a beneficial, safe, and minimally invasive bronchoscopic technique used in the diagnosis and staging of bronchogenic carcinoma. It was first introduced by Wang et al in the late 1970s. This method is usually performed through a flexible bronchoscope and provides cytologic or histologic sampling of mediastinal lesions that lie adjacent to the tracheobronchial tree. Previously, the utility of TBNA was restricted to mediastinal lymph node and extrabronchial lesion sampling. Its use has been expanded to complement conventional diagnostic techniques (CDT) such as bronchial washing (BW), bronchial brushing (BB), and forceps biopsy (FB) in the diagnosis of lung cancer with endobronchial lesions.
Central bronchogenic carcinoma tends to manifest in one of three patterns. The growth may be predominantly in the mucosal layer, in which case the tumor presents as a bulky, exophytic mass. It can also spread predominantly in the submucosa, with endoscopic findings consisting of erythema, loss of the normal bronchial markings, narrowing of the bronchus, or thickening of the mucosa. The third pattern is that of a predominantly peribronchial spread, in which the endoscopic findings are usually narrowing of the airway due to extrinsic compression of the bronchus. Particularly in the presence of peribronchial and submucosal lesions, diagnosis with CDT such as BW, BB, and FB is more difficult. However, applying a needle into the lesion provides access to lower layers of the bronchus and adjacent lesions. Despite its advantages in diagnosis, TBNA is still an underutilized procedure in many centers because of the risk of damage to the bronchoscope, need for experienced staff, and high cost. This is a retrospective study carried out in our clinic to investigate the diagnostic yield of TBNA and its contribution to CDT in lung cancer patients.
Of 513 primary lung carcinoma cases diagnosed at the Kartal Education and Research Hospital Chest Diseases Clinic between January 1, 2001, and December 31, 2003, files of 322 patients (62.7%) who underwent bronchoscopy were reviewed. It was found that 290 patients had endobronchial lesions, and 115 patients in whom TBNA was performed in combination with CDT (FB plus BB plus BW) are reported in this study. All patients underwent chest radiography and CT of the chest. Probable locations for needle aspiration were determined prior to bronchoscopy by guidance of CT findings such as mediastinal or hilar lymphadenopathies or mass lesions. To read more info about medicine and pharmacy you may on Canadian Neighbor Pharmacy website.
Fiberoptic bronchoscopy was performed by four experienced bronchoscopists in patients receiving topical anesthesia in the supine position through the nasal or oral cavities (Olympus Co; Tokyo, Japan; Types T20D [n = 104] or BF 30 [n = 11]). The decision of TBNA application was made by each bronchoscopist during the procedure. The endobronchial lesions were classified into three groups; EML, submucosal disease, and peribronchial disease. Submucosal disease was defined as erythema, vascular flares, enhanced rugal pattern, thickening or loss of mucosal markings, and bronchial narrowing. Peribronchial disease was defined as luminal narrowing due to extrinsic compression by tumor or lymphadenomegaly. In order to avoid contamination, TBNA was performed out prior to other procedures such as BB, BW, and FB. A Wang transbronchial cytology needle (Mill Rose Laboratories; Mentor, OH; MW122 [n = 63] or MW522 [n = 52]) was used for TBNA. The transbronchial needle was introduced into the bronchoscope with the needle inside the metal hub while visualizing the trachea through the scope. When the metal hub was visible, the needle was advanced. In the presence of peribronchial disease, the needle was inserted into the lesion according to the “pushing” technique introduced by Wang. In exophitic mass lesions (EMLs), the needle was penetrated into the mass directly. In patients with submucosal disease, the needle was inserted at a 45° angle into the puncture site. One cytologic sample consisted of at least three subsequent aspirations from the same region, penetrating the bronchial wall in an area < 2 cm2. A 50-mL syringe was used to apply suction, and it was detached before retraction of the needle in order to avoid contamination. The aspirated material was blown into four or five slides, smeared, fixed with 95% alcohol, and sent for cytologic examination to the pathology department. On-site cytopathologic assessment was not performed, and fluoroscopy was not used during operation. Results of cytologic analysis were considered positive only when a sufficient number of definitely malignant cells were observed. All specimens having cellular atypia and abnormal cells highly suggestive of malignancy were considered negative. After the TBNA procedure, CDT such as FB (at least three times), BW, and BB were applied.
The diagnostic yield from TBNA, CDT, and TBNA plus CDT were evaluated according to the type of the endobronchial lesion, histologic subtypes, location of endobronchial lesion, and type of the needle. Mann-Whitney U, McNemar, x2, and Fisher exact tests were used for statistical analysis, and p < 0.05 was considered statistically significant.