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• W2420231805 abstract "Letters to the EditorCell Type Diagnosis of Advanced Central Bronchogenic Carcinoma without Resorting to Major Thoracotomy Aly Mohamed Abdel-WahabMD Aly Mohamed Abdel-Wahab Cardiothoracic Surgery Unit Assiut University Hospital Arab Republic of Egypt Assiut, Egypt Search for more papers by this author Published Online:1 Mar 1992https://doi.org/10.5144/0256-4947.1992.224aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: The methods utilized in the diagnosis of 73 patients who had central bronchogenic carcinoma revealed positive diagnosis in all specimens of palpable scalene lymph gland while non-palpable nodes reported negative in all specimens. Bronchoscopic biopsy was positive in all cases with visualized lesions while blind biopsy was positive in 9% of non visualized lesions. The patients with nonvisualized growth and nonpalpable scalene node could be diagnosed safely by anterior mediastinostomy without resorting to thoracotomy.A variety of examinations have proved to be useful for definitive diagnosis of bronchogenic carcinoma. It is important to identify the histological type of carcinoma as this will affect further management. Chest x-ray and clinical history of the patients may indicate which of the surgical procedures will be contributing and in what sequence they should be performed.The aim of this work is to determine methods for achieving rapid and definitive histopathological diagnosis in advanced central bronchogenic carcinoma without resorting to thoracotomy.This study was carried out on 73 patients (45 male, 28 female) from 17 to 74 years of age. All patients had a central bronchogenic carcinoma. Their clinical, radiological and/or bronchoscopic features indicated inoperability. The methods used in their diagnosis were reviewed and analyzed to determine the most rapid and effective diagnostic approach.The patients were subjected to the following procedures: chest x-ray posteroanterior view (PA) and lateral view; sputum cytology; bronchoscopic examination (rigid type) and performing bronchial wash, bronchoscopic biopsy (44) from visible lesions (22) or broad carina (7) or areas of extrensic compression (15), scalene lymph gland biopsy (55) either palpable (33) or nonpalpable (22). The palpable scalene glands were excised wherever carcinoma was sited. In nonpalpable glands, the right side was biopsied for all lesions of the right and lesions of the left below the upper third of the left lung. Bilateral biopsy was performed in four cases.Anterior mediastinotomy as described by McNeill and Chamberlain [1] was performed on 30 patients after other procedures failed to achieve histopathologic diagnosis.Bronchoscopically, the patients were classified into those with visible mucosal lesions (22) or non-visible lesions (51). The diagnosis of bronchial carcinoma was achieved in 73 patients (27 squamous cell carcinoma, 21 adenocarcinoma, 18 oat cell carcinoma and 7 mixed cell carcinoma). Sputum cytology was positive in 41% and bronchial wash in 38% of the patients. Bronchoscopic biopsy was positive for malignancy in 54% (24 of 44 specimens). Palpable scalene lymph gland biopsy showed deposit of malignant cells in all specimens (100%) while the nonpalpable nodes were negative in all specimens including the four cases of bilateral biopsies.The carcinomatous lesions were visualized via the bronchoscope in 22 patients (six cases of total lung atelectasis, six of 16 with paratracheal lesion, eight of 30 with paracardiac lesions and two of five with more than one of the above mentioned features). None of the hilar and parahilar lesions (16) were visualized.The diagnostic role of different procedures utilized in presence of visualized growth were: sputum 81%; bronchial wash 100%; bronchoscopic biopsy 100% (the biopsy was repeated in four cases) palpable scalene lymph gland 100% and the nonpalpable scalene lymph gland has no role. The same procedures have the following diagnostic roles in nonvisualized lesions: sputum 29%: bronchial wash 2%, bronchoscopic biopsy 9%. palpable scalene lymph gland 100% and the non-palpable gland has no role.Anterior mediastinotomy achieved the pathologic diagnosis in 30 cases (14 of 16 with parahilar shadow, eight of 30 with paracardiac, and eight of 16 with paratracheal shadow) when other procedures failed.Diagnosis of lung cancer depends on the coordination of different diagnostic procedures after evaluation of clinical history and investigations including chest x-ray. These may indicate which of the surgical procedures will be required and in what sequence they should be performed. In this study, diagnosis of bronchial carcinoma was achieved in all cases of palpable scalene lymph gland (100%). Results reported by others ranged from 84% to 100% [2]. The high percentage in our cases may be attributed to central location and advanced stage of the cancer. Therefore, biopsy of palpable node should be done regardless of the site of the carcinoma. On the other hand, no positive diagnosis was achieved in nonpalpable nodes. Other reported low diagnostic yield (6%) [3], so this type of biopsy is not recommended as a rapid diagnostic approach to these patients.Bronchogenic carcinoma can spread along the mucosal surface and in the submucosal lymphatics or in the peribronchial tissues. The type of spreading affects the diagnostic yield by bronchoscopy. When the growth is mainly mucosal, the diagnostic yield is reported to be close to 100% with bronchoscopic biopsy [4]. This is in line with our results. Bronchial wash was positive in 100%. This high yield could be explained by central tumor location and friability and ulceration of the growth which meant that fragments of the tumor were sucked out in the wash, as reported by the pathologist in most cases. In nonvisualized lesions, the diagnostic yield reported by others was 3% by the biopsy and 6% by the wash [5]. Therefore, lesions other than mucosal types are difficult to detect on standard biopsy. Because of the low diagnostic yield in these lesions and the hazards of blind biopsy, this type of biopsy is not recommended in these patients.Patients with nonpalpable scalene lymph gland and nonvisualized lesions could be diagnosed by anterior mediastinotomy with the following advantages: it is a direct approach and a simple and safe procedure which achieves solid histopathologic diagnosis, carries no mortality rate; furthermore, it was less expensive and caused less discomfort to the patients with that involved in major thoracotomy with the same success in diagnosis (100%).Thus, the proper use of clinical and radiological examinations helps in selecting a direct and rapid diagnostic approach with minimal risk to the patient. The diagnosis could be achieved by biopsy of palpable scalene lymph gland, bronchoscopy in mucosal lesions or by anterior mediastinotomy in the absence of both. More than one procedure could be performed at the same sitting to save time and cost.ARTICLE REFERENCES:1. McNeil TM, Chamberlain SM. Diagnostic anterior mediastinotomy . Ann Thorac Surg. 1966; 2: 532. Google Scholar2. Gondos B, Rcingold IM. Pathology of scalene lymph nodes: analysis of 373 biopsies . Cancer. 1965; 18: 84. Google Scholar4. Kvale PA, Bode FR, Kini S. Diagnostic accuracy in lung cancer . Chest. 1976; 69: 752–7. Google Scholar5. Byrd RB, Carr DT, Miller WF. Radiographic abnormalities in carcinoma of the lung as related to histological cell type . Thorax. 1969; 24: 573. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 12, Issue 2March 1992 Metrics History Published online1 March 1992 InformationCopyright © 1992, Annals of Saudi MedicinePDF download" @default.
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