ORIGINAL ARTICLE
Year : 2020 | Volume
: 18 | Issue : 3 | Page : 284--289
Histopathological patterns of endobronchial lesions and the role of flexible fiberoptic bronchoscopy in their diagnosis
Khaled M Halima, Sameh F Makled, Fareed S Basiony
Department of Chest Diseases, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
Correspondence Address:
Sameh F Makled
Cairo, Almokatam, 11571
Egypt
Abstract
Background Flexible bronchoscopy has become the most commonly used invasive procedure in pulmonary medicine used for diagnosis of multiple lesions of respiratory system presenting as endobronchial mass lesions, either benign or malignant in nature.
Aim The aim was to detect the histopathological patterns of endobronchial lesions and the role of flexible bronchoscopy in their diagnosis.
Patients and methods This is a retrospective study of bronchoscopy reports especially with endobronchial mass lesions diagnosed by fiberoptic bronchoscopy, which was performed at Chest Department, El-Hussein University Hospital, Al-Azhar University, over a period of 5 years from January 2012 to December 2016.
Results The fiberoptic bronchoscopy was helpful in the diagnosis of endobronchial mass lesions in 65 (28.7%) patients of 350 patients who underwent bronchoscopy during this period. Their age ranged from 15 to 80 years. The patients comprised 35 males and 30 females. Overall, 42 (65%) lesions were malignant, 18 (28%) lesions were benign, whereas five (7%) lesions were inconclusive. Diagnostic yield was ∼92.3%. Repeat bronchoscopy for inconclusive results improved the diagnostic yield.
Conclusion Fiberoptic bronchoscopy is the most important tool in pulmonary medicine used in the diagnosis of malignant as well as benign lesions that present as endobronchial mass lesions that mimic each other on visual impression, and thus adequate sampling is an essential diagnostic modality for confirming the diagnosis of such lesions.
How to cite this article:
Halima KM, Makled SF, Basiony FS. Histopathological patterns of endobronchial lesions and the role of flexible fiberoptic bronchoscopy in their diagnosis.Al-Azhar Assiut Med J 2020;18:284-289
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How to cite this URL:
Halima KM, Makled SF, Basiony FS. Histopathological patterns of endobronchial lesions and the role of flexible fiberoptic bronchoscopy in their diagnosis. Al-Azhar Assiut Med J [serial online] 2020 [cited 2023 Mar 22 ];18:284-289
Available from: http://www.azmj.eg.net/text.asp?2020/18/3/284/299568 |
Full Text
Introduction
Lesions in the bronchial tree can be classified as primary malignant tumors, secondary malignant tumors, and benign tumors. Primary tumors can arise from the surface epithelium, salivary glands, or mesenchymal structures of the bronchial tree. Most primary malignant tumors originate from the surface epithelium or the salivary glands [1].
Secondary malignant tumors in the bronchial tree are uncommon and may occur as a result of hematogenous spread or direct invasion by a malignancy of the lung, larynx, esophagus, thyroid gland, or mediastinum. Almost all benign tumors arise from the mesenchymal tissue [2].
Approximately 10–15% of patients are asymptomatic at the time of diagnosis. Although up to 90% of cases of lung cancer present with symptoms, those which are related to the primary tumor occur in only 30%, whereas those with symptoms of metastatic disease and systemic symptoms such as anorexia, weight loss, and fatigue account for ∼60% [3].
Endobronchial examination was first carried out in the past decade of nineteenth century for the purpose of removing inhaled foreign bodies, and was in use until 1904, when a rigid bronchoscope with provision for suction and illumination came into use. Technological advances during the next century facilitated development of bronchoscopy as a pivotal diagnostic tool in pulmonary medicine [4].
Patients and methods
A retrospective study was conducted on 65 patients with endobronchial mass lesions selected from 350 patients who underwent Flexible Bronchoscopy (FB) from Chest Department, El-Hussein University Hospital, Al-Azhar University, over a period of 5 years from January 2012 to December 2016. The study was approved by the Hospital Ethics Committee, and a written consent was obtained from each patient before the procedure.
All patients were subjected to preoperative preparation in the form of full history taking and physical examination and radiological and laboratory assessments, and then fiberoptic bronchoscopy was done and data were recorded.
Inclusion criteria
All patients undergoing diagnostic fiberoptic bronchoscopy who had suspicious of endobronchial lesions were included.
Exclusion criteria
The following patients were excluded from the study: uncorrectable hypoxemia, acute myocardial infarction, unstable angina and serious cardiac dysrhythmia, uncorrectable bleeding tendency, and uncooperative patient.
Bronchoscopic procedure
After preparation for bronchoscopy, the patient was placed on the operating table in endoscopy unit in supine position and connected to monitoring system.
The procedure was performed using PENTEX fiberoptic bronchoscope (HOYA Corporation, PENTAX Lifecare Division, Showanomori Technology Center 1-1-110 Tsutsujigaoka, Akishima-shi, Tokyo, Japan) under local anesthesia, with 2–3 ml of viscous lidocaine spray 4% applied to the nose or mouth and short-term sedation with intravenous midazolam 0.07 mg/kg to create a drowsy state before starting the procedure and after the insertion of the bronchoscope. Liquid xylocaine 2% was administered through the bronchoscope directly to the vocal cords and the bronchial tree as needed. During the bronchoscopic procedure, diagnostic materials were obtained by bronchial washing, bronchoalveolar lavage, and endobronchial biopsy, as decided by the bronchoscopist on a case-by-case basis. All participants were kept under constant supervision for postbronchoscopy complication for at least 4 h following the procedure.
Statistical analysis
Data collected were encoded into MS Excel 2017 for windows XP professional (Microsoft, Redmond Washington, USA). Age was presented as mean. Owing to the descriptive nature of this study, all other data were presented as a percentage. The calculation was done using Excel.
Results
The study includes 65 (28.7) patients selected from 350 patients who presented with endobronchial mass lesions. Patients comprised 35 (53.9%) male and 30 (46.1%) female, with age ranging from 15 to 80 years, and the mean age was 65 years, with men being older than women. Cigarette smokers accounted for 40 (61.5%) patients of studied patients. Approximately 45 (69.2%) patients were living in urban areas ([Table 1]).{Table 1}
We note that cough was the most common symptom occurring in 25 (38.46%) patients. Shortness of breath and fever and chest pain were seen in 10 (15.38%) and six (9.23%), respectively, and hemoptysis occurred in 20 (30.7%) patients. Rarer symptoms like wheeze and hoarseness of voice were seen in four (6.11%) patient in total.
Multiple symptoms simultaneously occurred in more than half of the patients ([Table 2]).{Table 2}
The main indications of bronchoscopy in 65 patients with endobronchial mass lesions in our study were unexplained chronic cough with localized clinical finding; unexplained lung collapse; nonresolving pneumonia; diagnosis and staging of lung carcinoma; and foreign body removal ([Table 3]).{Table 3}
Radiological findings among patients with malignant lesions vary from mass lesion, which was the most common finding occurring in 25 (38.4%) patients followed by 15 (23%) patients who had hilar adenopathy, whereas the patients with benign lesions vary from unresolved pneumonia in 10 (15.3%) patients, lobar collapse was seen in 10 (15.3%) patients, whereas five (7.6%) cases had normal radiology ([Table 4]).{Table 4}
Bronchoscopic examination showed that the endobronchial growth was the most common finding, seen in 25 (38.46) cases, followed by external compression seen in five (7.69%) cases. Inflammatory changes of the endobronchial lumen occurred in five (7.69%) patients, and structural changes such as fibrosis, atrophic mucosa, bronchial stenosis, and distorted anatomy were seen in seven (10.76%) patients. Foreign body in the form of a vegetable seed was seen in two patients, but could not be removed and required rigid bronchoscopic intervention ([Table 5]).{Table 5}
Among the 42 patients with definite diagnosis of malignancy, most common cell type in our study was of squamous cell carcinoma occurring in 25 (38.46%) patients. The exact cell type could not be identified in five (7.69%) patients, and they were managed in the lines of nonsmall cell lung carcinoma. Adenocarcinoma occurred in ∼15 (23.07%) patients, and other malignancies such as carcinoid were seen in two cases and 10 cases had small cell lung cancer. Regarding benign lesions in our study, TB, FB removal, and impacted secretions were three (4.61%), two (3.07%), and two (3.07%), respectively, whereas inconclusive in one (7%) case ([Table 6]).{Table 6}
The diagnostic yield of bronchoscopy showed a definitive diagnosis in more than half of the patients analyzed in our study (92.3%) with a positive yield of 65% for malignancy; however, no specific diagnosis could be obtained in 7% of patients, as shown in [Table 7].{Table 7}
Discussion
From 350 diagnostic bronchoscopies performed at Chest Department, El-Hussein University Hospital, Al-Azhar University, during 5 years from January 2012 to December 2016, we select 65 patients with endobronchial lesions included in our study. The mean age of the population studied was 48 years, with a standard deviation of 11. Males represented more than females (35 vs 30). Cigarette smokers accounted for 40 (61.5%) patients of studied patients. Approximately 45 (69.2%) patients were living in urban areas. We conclude that the endobronchial lesions are seen in all age groups and especially in smokers.
This study agrees with that done by Arun et al. [5], where the mean age of the population studied was 60.91 years, with a standard deviation of 11.69. Males constituted most of their study population, outnumbering females (46 vs 8).
However, in a study done by Gupta et al. [6], their median age was 65 years (range: 21–86 years), and there were 60 males (male : female=4.3 : 1). Patients with malignant lesions had a median age of 62 years (range: 45–84 years), whereas patients with benign lesions had a median age of 69 years (range: 21–86 years).
Analysis of the clinical profile of patients at presentation showed that cough was the most common symptom reported by 38.46% (25) of the patients, 15.38% of the study group had breathlessness, and fever and chest pain was reported in 9.23% of the patients. Hemoptysis was present in 30.7%, and 6.11% of patients had other symptoms such as hoarseness of voice and wheeze.
In a study done by Arun et al. [5], analysis of the clinical profile of patients at presentation showed that cough was the most common symptoms reported by 88.89% (48) of the patients, 61.11% of the study group had breathlessness, and fever was reported in 40.74% of the patients. Hemoptysis (29.63%) and chest pain (27.78%) were next common symptoms in that order, and 16.67% patients had other symptoms such as hoarseness of voice and wheeze.
A study by Sinha et al. [7] at All India Institute of Medical Science, New Delhi, showed hemoptysis as the most common symptom (31.9%) in their study, followed by fever in 29.6%, chest pain in 20.7%, and anorexia in 6.7% of the cases. The occurrence of cough and breathlessness was not mentioned in their study.
Our study revealed that the main clinical indications of bronchoscopy in 65 patients with intrabronchial mass lesions were unexplained chronic cough with localized clinical finding in 25 (38.46%) patients, unexplained lung collapse in 10 (15.38%) patients, nonresolving pneumonia in 15 (23.11%) patients, removal of foreign body in three (4.61%) patients, and lymphadenopathy in 12 (18.46%) patients.
In a study done by Gupta et al. [6], the main clinical indications of bronchoscopy in 74 patients with intrabronchial mass lesions were unexplained chronic cough with localized clinical finding, unexplained lung collapse, nonresolving pneumonia, diagnosis and staging of lung carcinoma, aspiration of foreign body, etc.
Our study revealed that the analysis of radiological findings among the 65 patients studied showed that mass lesion was the most common finding occurring in 25 (38.4%) patients followed by 15 (23%) patients who had hilar adenopathy, unresolved pneumonia in 10 (15.3%) patients, and lobar collapse seen in 10 (15.3%) patients, whereas five (7.6%) cases were normal radiology.
In a study done by Gupta et al. [6], the radiological findings in patients with malignant lesions were mass lesions, collapse, or nonresolving pneumonias. Patients with benign lesions showed mainly nonresolving pneumonias, collapse, or lymphadenopathy.
Our study revealed that in bronchoscopic examination, endobronchial growth was the most common finding in 25 (38.46%) patients, followed by external compression seen in five (7.69%). Inflammatory changes of the endobronchial lumen occurred in five (7.69%) patients. Structural changes such as fibrosis; atrophic mucosa, bronchial stenosis, and distorted anatomy were seen in seven (10.76%) patients. Foreign body in the form of a vegetable seed was seen in two patients.
Distortion of bronchial anatomy by extrinsic compression without any visible abnormality of the bronchial mucosa is a common bronchoscopic finding in bronchial carcinoma. It is a common practice to take mucosal biopsy specimens from the site of compression, but there is little information about the diagnostic yield in such circumstances.
In a study done by Arun et al. [5], vocal cords were involved in four (7.41%) of 54 patients in this study. Left was affected more commonly than right. This is not surprising, as it is an established fact that intrathoracic course of left recurrent laryngeal nerve is long. Intraluminal growth was seen in 24 (44.44%) patients, extraluminal compression in 20.37%, and inflammation in 18.52% of patients; however, a small number of bronchoscopies had structural changes (3.70%) and bleeding site (3.70%).
In the study by Sinha et al. [7], the commonest finding in their series was necrotic/nodular growth occurring in 39.1%, which is similar to our study. In their study, left main bronchus was involved in 12%. Extraluminal compression was present in 9.6% which was more frequent (20.37%) in our study. However, significant numbers (34.8%) of bronchoscopies were normal in their study compared with very few (7.41%) in our study; this can be explained by the fact that we had stringent inclusion criteria and a small sample size.
In our study, the diagnostic yield of bronchoscopy showed a definitive diagnosis in more than half of the patients analyzed in our study (92.3%), with a positive yield of 65% for malignancy; however, no specific diagnosis could be obtained in 7% of patients, as shown in [Table 7].
In a study done by Arun et al. [5], the diagnostic yield of bronchial washings, brushings, and forceps biopsy was 54.13, 85.71, and 95.65%, respectively, for endoscopically visible lesions, and it is 37.04, 60, and 55.56% for endoscopically not visible lesions, respectively.
Mak et al. [8] conducted a retrospective study to evaluate the diagnostic yield of lung cancer by Fibroptic Bronchoscopy (FOB). In the group with endoscopically visible tumors, biopsy gave a positive result in 76%, washings in 49.6%, and brushing in 52%. In the group where FOB had no abnormal findings in the diagnosis of malignancy, on biopsy, the specimen was positive in 36.5%, washings 38.1%, and brushings in 28.6%. Their findings were much lower than the results from our study.
Lam et al. [9] reported the diagnostic yield of BAL, brushings, and biopsy of 76, 74, and 82%, respectively, in endobronchially visible lesions, which is slightly lower than our observations; however, it was 52, 52, and 61%, respectively, in endoscopically not visible tumors, which is nearly similar to our findings.
Sharma et al. [10], at AIIMS, New Delhi, analyzed reports of 588 patients who had been bronchoscoped for suspected lung cancer. In their study, a tissue diagnosis was established by bronchoscopy in 30% of patients. A positive tissue diagnosis was found with radiological features of pulmonary collapse (50% of patients) and mass lesions (38.42%).
Saita et al. [11] performed a comparative evaluation of bronchial brushing and biopsy in diagnosis of visible bronchial lesions, and brushings showed higher sensitivity 85.5% and accuracy 86.6% than biopsy. A combination of both gives an accuracy rate of 93%.The incidences of various procedures vary in different series. The nature of indications, preference of physicians, and the availability of facilities can affect this.
In our study, forceps biopsy was the most frequently done procedure, probably because there were predominant inflammatory lesions and external compressions, and both these lesions are known to give less diagnostic yield on endobronchial biopsy. Combinations of biopsy and washings are usually done. It is well established that combination increases the yield. The reported yield for various procedures also shows variation. However, general trend is that biopsy is the most yielding procedure.
This study revealed that the malignancy diagnosed in 57 patients and the most common cell type was of squamus cell carcinoma occurring in 25 patients (38.46%) of patients then adenocarcinoma was occurred in 15 (23.07%) patients, small cell lung cancer was occurred in 10 patients (15.38%), large cell lung cancer was occurred in 5 patients (7.69%) and carcinoid tumors were occurred in 2 patients (3.07%). Benign lesions in this study were TB, FB removal and impacted secretions and they were occurred in 3 patients (4.61%), 2 patients (3.07%) and 2 patients (3.07%) respectively, While inclusive result was occurred in 1 patient (1.53%).
Regarding benign lesion in our study, TB, FB removal, and impacted secretions were seen in 10 (15.3%), three (3.6%), five (7%), respectively. Inclusive cases represented five (7%) patients.
In a study done by Gupta et al. [6], adenocarcinoma is the most common form of lung cancer followed by squamous cell carcinoma and small cell carcinoma. This could probably be owing to the central location of these tumors, which are better assessed with bronchoscopy; adenocarcinomas because of their predominantly peripheral location are not visualized on bronchoscopy. One patient who presented with fever and an opacity in the right middle zone on the chest radiograph was found to have an intrabronchial mass lesion that on biopsy was found to be an adenocarcinoma. Bronchial washings of this patient revealed AFB. This was attributed to coincidental finding in which patient had gradual clinical improvement after antituberculosis treatment, though radiological opacity persisted.
Conclusion
Fiberoptic bronchoscopy was the most important and essential tool in pulmonary medicine used in the diagnosis of malignant as well as benign lesions, which present as intrabronchial mass lesions that mimic each other on visual impression, and thus, adequate sampling is an essential diagnostic modality for confirming the diagnosis of such lesions.
Recommendation
New diagnostic tool about bronchoscopy should be aware and well trained by pulmonologists to help rapid diagnosis and management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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