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Bronchoscopic Diagnosis in Patients With Small Cell Lung Cancer
Bronchoscopic Diagnosis in Patients With Small Cell Lung Cancer
proceed with transbronchial needle aspiration (TBNA) of the mediastinum prior to approaching an endobronchial primary, and we discontinue suctioning prior to removal of the needle from the airway wall. Establishing a pathological diagnosis with this procedure with on-site evaluation may preclude further bronchoscopic procedures. The advantage to TBNA compared with endobronchial biopsy and curettage is the rapid diagnosis with on-site evaluation and the provision of mediastinal staging information in patients with non-SCLC. We also have fewer problems with crush artifact with needle aspiration than with endobronchial forceps biopsy,' and we believe that the focal needle puncture is less likely to be associated with severe bleeding. Endobronchial biopsy also has a high yield, as Satoh et al point out. We confirmed this with a positive yield of 80% in 1981 before our use of needle aspiration accelerated.' Curetting is not used commonly in the United States but has been reported to be helpful in evaluating peripheral lesions that can occur in SCLC. However, it usually requires additional radiographic mapping for lesions beyond the visible range.' We do not claim that needle aspiration is superior to other bronchoscopic techniques. Rather, we regard these approaches as complementary, affording the bronchoscopist considerable flexibility according to each patient's needs. We strongly believe BNA is a valuable bronchoscopic technique to learn, and occasionally it provides the only diagnostic material.'? The choice of diagnostic procedure in patients suspected of having SCLC depends on the patient's clinical and radiographic presentation, findings at bronchoscopy, the familiarity of the bronchoscopist with the different sampling procedures, and the confidence of the pathologists in interpreting different specimens. Certainly in patients with predominant mediastinal involvement with little endobronchial disease and those with submucosal endobronchial tumor, BNA may be the preferred approach. We are unaware of data in SCLC in particular to support the contention that the diagnostic yield for BNA is better from endoscopically visible tumor than invisible tumor, but we believe BNA can be extremely valuable in SCLC with endoscopically invisible tumor. Our complications with BNA are low. Bleeding is the most common problem, but in our experience, this has not been severe enough to require intervention . We did have a fractured needle, which required extraction with biopsy forceps. We are unable to determine the frequency of needle-induced damage to the bronchoscope during TBNA. Although we have encountered this problem, it can be minimized by following well-established procedures for needle use. Transbronchial needle aspirates of SCLC are usually quite cellular and allow tumor subtyping if it is clinically warranted. Generally, however, we follow the recommendations of the Pathology Committee of the International Association for the Study of Lung Cancer and do not distinguish between oat cell and intermediate cell subtypes of SCLC. 4 We do report either the mixed small cell-large cell or the combined small cell carcinoma
To the Editor: We read with interest the report by Chin and associates' on the use of bronchoscopic needle aspiration (BNA) to diagnose small cell lung cancer (SCLC). During the past 10 years at our institution, 88% of patients with newly diagnosed SCLC underwent bronchoscopy, and 86% of the patients had a diagnosis of SCLC established as a result of an endobronchial forceps biopsy. Cytological diagnostic procedures, including bronchial curetting, were positive in half the cases in which forceps biopsies were done and were nondiagnostic. The rest of the cases were diagnosed by the biopsy material obtained via percutaneous or mediastinoscopic approaches. We share the authors' opinion that endobronchial needle aspiration "may be more successful than endobronchial forceps biopsy in lesions that are primarily submucosal or in which crush artifact obscures the histological detail needed to confirm the diagnosis of SCLC accurately." However, we are of the opinion that both forceps biopsies and curetting are useful methods in the diagnosis because the curette is easier to direct into small areas than is a maximally flexed bronchoscope.' We would appreciate hearing about the best method for obtaining biopsy specimens from patients suspected of having SCLC. Since the approaches may differ greatly, we are interested in knowing whether the outcome in diagnostic yield for BNA varied between endoscopically visible tumor and invisible tumor. We would also appreciate the authors' comments on complications related to BNA . We question whether BNA provides a sufficient number of cancer cells to confirm the diagnosis of SCLC subtypes.
Hiroaki Satoh, MD Hiroichi Ishikawa, MD Kiyohisa Sekizawa, MD Institute of Clinical Medicine University of Tsukuba Tsukuba,Japan I.
2.
Chin R Jr, Cappellari JO, McCain TW, Case LD, Haponik EF. Increasing use of bronchoscopic needle aspiration to diagnose small cell lung cancer. Mayo Clin Proc. 2000;75:796-801. Obara M, Satoh H, Ishikawa H, et al. Diagnostic procedures in obtaining pathological materials for pulmonary nodules due to lung cancer. Oneal Rep. 1998;5: 1237-1239.
In reply: We thank Dr Satoh and colleagues for their insightful comments about our article. We use a vigorous bronchoscopic approach to our patients with presumed SCLC and attempt to stage the mediastinum as well as obtain pathological diagnosis during the same procedure, thus often obviating the need for surgical mediastinal exploration. If marked adenopathy (> 1 cm in the short axis) is noted on the radiographic studies, we usually Mayo Clin Proc. 2000;75:1339-1341
1339
© 2000 Mayo Foundationfor Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
proceed with transbronchial needle aspiration (TBNA) of the mediastinum prior to approaching an endobronchial primary, and we discontinue suctioning prior to removal of the needle from the airway wall. Establishing a pathological diagnosis with this procedure with on-site evaluation may preclude further bronchoscopic procedures. The advantage to TBNA compared with endobronchial biopsy and curettage is the rapid diagnosis with on-site evaluation and the provision of mediastinal staging information in patients with non-SCLC. We also have fewer problems with crush artifact with needle aspiration than with endobronchial forceps biopsy,' and we believe that the focal needle puncture is less likely to be associated with severe bleeding. Endobronchial biopsy also has a high yield, as Satoh et al point out. We confirmed this with a positive yield of 80% in 1981 before our use of needle aspiration accelerated.' Curetting is not used commonly in the United States but has been reported to be helpful in evaluating peripheral lesions that can occur in SCLC. However, it usually requires additional radiographic mapping for lesions beyond the visible range.' We do not claim that needle aspiration is superior to other bronchoscopic techniques. Rather, we regard these approaches as complementary, affording the bronchoscopist considerable flexibility according to each patient's needs. We strongly believe BNA is a valuable bronchoscopic technique to learn, and occasionally it provides the only diagnostic material.'? The choice of diagnostic procedure in patients suspected of having SCLC depends on the patient's clinical and radiographic presentation, findings at bronchoscopy, the familiarity of the bronchoscopist with the different sampling procedures, and the confidence of the pathologists in interpreting different specimens. Certainly in patients with predominant mediastinal involvement with little endobronchial disease and those with submucosal endobronchial tumor, BNA may be the preferred approach. We are unaware of data in SCLC in particular to support the contention that the diagnostic yield for BNA is better from endoscopically visible tumor than invisible tumor, but we believe BNA can be extremely valuable in SCLC with endoscopically invisible tumor. Our complications with BNA are low. Bleeding is the most common problem, but in our experience, this has not been severe enough to require intervention . We did have a fractured needle, which required extraction with biopsy forceps. We are unable to determine the frequency of needle-induced damage to the bronchoscope during TBNA. Although we have encountered this problem, it can be minimized by following well-established procedures for needle use. Transbronchial needle aspirates of SCLC are usually quite cellular and allow tumor subtyping if it is clinically warranted. Generally, however, we follow the recommendations of the Pathology Committee of the International Association for the Study of Lung Cancer and do not distinguish between oat cell and intermediate cell subtypes of SCLC. 4 We do report either the mixed small cell-large cell or the combined small cell carcinoma
To the Editor: We read with interest the report by Chin and associates' on the use of bronchoscopic needle aspiration (BNA) to diagnose small cell lung cancer (SCLC). During the past 10 years at our institution, 88% of patients with newly diagnosed SCLC underwent bronchoscopy, and 86% of the patients had a diagnosis of SCLC established as a result of an endobronchial forceps biopsy. Cytological diagnostic procedures, including bronchial curetting, were positive in half the cases in which forceps biopsies were done and were nondiagnostic. The rest of the cases were diagnosed by the biopsy material obtained via percutaneous or mediastinoscopic approaches. We share the authors' opinion that endobronchial needle aspiration "may be more successful than endobronchial forceps biopsy in lesions that are primarily submucosal or in which crush artifact obscures the histological detail needed to confirm the diagnosis of SCLC accurately." However, we are of the opinion that both forceps biopsies and curetting are useful methods in the diagnosis because the curette is easier to direct into small areas than is a maximally flexed bronchoscope.' We would appreciate hearing about the best method for obtaining biopsy specimens from patients suspected of having SCLC. Since the approaches may differ greatly, we are interested in knowing whether the outcome in diagnostic yield for BNA varied between endoscopically visible tumor and invisible tumor. We would also appreciate the authors' comments on complications related to BNA . We question whether BNA provides a sufficient number of cancer cells to confirm the diagnosis of SCLC subtypes.
Hiroaki Satoh, MD Hiroichi Ishikawa, MD Kiyohisa Sekizawa, MD Institute of Clinical Medicine University of Tsukuba Tsukuba,Japan I.
2.
Chin R Jr, Cappellari JO, McCain TW, Case LD, Haponik EF. Increasing use of bronchoscopic needle aspiration to diagnose small cell lung cancer. Mayo Clin Proc. 2000;75:796-801. Obara M, Satoh H, Ishikawa H, et al. Diagnostic procedures in obtaining pathological materials for pulmonary nodules due to lung cancer. Oneal Rep. 1998;5: 1237-1239.
In reply: We thank Dr Satoh and colleagues for their insightful comments about our article. We use a vigorous bronchoscopic approach to our patients with presumed SCLC and attempt to stage the mediastinum as well as obtain pathological diagnosis during the same procedure, thus often obviating the need for surgical mediastinal exploration. If marked adenopathy (> 1 cm in the short axis) is noted on the radiographic studies, we usually Mayo Clin Proc. 2000;75:1339-1341
1339
© 2000 Mayo Foundationfor Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.