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ORIGINAL ARTICLE
Year : 2007  |  Volume : 24  |  Issue : 4  |  Page : 139-141 Table of Contents   

Usefulness and cost effectiveness of bronchial washing in diagnosing endobronchial malignancies


1 Department of Pulmonary Medicine, Himalayan Institute of Medicial Sciences, Swami Ram Nagar, Doiwala, Dehradun, Uttaranchal., India
2 Department of Oncosurgery, Himalayan Institute of Medicial Sciences, Swami Ram Nagar, Doiwala, Dehradun, Uttaranchal., India
3 Department of Pathology, Himalayan Institute of Medicial Sciences, Swami Ram Nagar, Doiwala, Dehradun, Uttaranchal., India

Correspondence Address:
G Sindhwani
105, Awas Vikas Colony, Rishikesh, Uttaranchal.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.44378

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   Abstract 

Objective : To evaluate the usefulness and cost effectiveness of bronchial washing in addition to endobronchial biopsies and/or bronchial brushing for the diagnosis of endoscopically visible lung cancer.
Material and method : We retrospectively analyzed the medical records of all fi­beropticbronchoscopies at Himalayan institute of medical sciences from January 2002 to August 2005. All patients with endoscopically visible tumours in whom a definite cytological or histological diagnosis of pulmonary malignancy was made were included in the study. We analyzed usefulness and cost effectiveness of three potential specimen collection stragetgies. These stratgies were (1) Bronchoscopy with biopsy, brushing, and washing (2) Bronchoscopy with biopsy and washing; and (3) Bronchoscopy with biopsy and brushing.
Results : 107 cases of endoscopically visible abnormality underwent forceps biopsy, brushing and washing. Ninety-nine of these 107 patients had atleast one of the three endoscopic procedures (bronchial washing, endobronchial biopsies and bronchial brushing) positive for lung cancer (92.52%). The sensitivity of endobronchial biop­sy, brushing and bronchial washing for diagnosing lung cancer was 83.17%, 69.15% and 47.66% respectively. Bronchial washing was the only diagnostic procedure in two patients (1.86%). Cost effectiveness analysis revealed that bronchial washing as an additional diagnostic tool to endobronchial biopsies/or bronchial washing for diagnosis of endoscopically visible lung cancer may not be cost effective.
Conclusion : The best yields for diagnosis of lung cancer is obtained with endobronchial biopsy and brushing. The addition of bronchial washing to either endobronchial biopsy or bronchial brushing is beneficial, but it may not be cost effective.

Keywords: Fiberoptic bronchoscopy, endoscopically visible tumors, lung cancer, Bronchial Brushing


How to cite this article:
Rawat J, Sindhwani G, Saini S, Kishore S, Kusum A, Sharma A. Usefulness and cost effectiveness of bronchial washing in diagnosing endobronchial malignancies. Lung India 2007;24:139-41

How to cite this URL:
Rawat J, Sindhwani G, Saini S, Kishore S, Kusum A, Sharma A. Usefulness and cost effectiveness of bronchial washing in diagnosing endobronchial malignancies. Lung India [serial online] 2007 [cited 2019 Oct 19];24:139-41. Available from: http://www.lungindia.com/text.asp?2007/24/4/139/44378


   Introduction Top


For the diagnosis of endobronchial lung carcinoma, no method has proven more valuable than endoscopic examination of the tracheobronchial tree [1],[2],[3] . Washing, brushing, and forceps biopsies are often combined to increase the diagnostic yields. The diagnostic yield of bronchoscopic procedures for a centrally-located tumour by using endobronchial biopsies is higher (80-90%) followed by bronchial brushing (50 to 77%) [3],[4],[5],[6] , however the benefit of bronchial washing which provides the diagnostic yields for endoscopically visible tumours between 30-90%, is still controversial. [7] There have been many studies that support the role of bronchial washing in addition to endobronchial biopsies and bronchial brushing [6],[8] where as other researchers have failed to show any benefits. [5],[9],[10],[11] Of increasing interest are the costs of several bronchoscopic techniques to obtain a diagnosis in lung cancer. Since the diagnostic yield of washing is relatively modest, one might consider omitting this procedure altogether. However further diagnostic tests like, Transthoracic needle aspiration, Transbronchial needle aspiration and open lung biopsy used if the result of the above test are negative, impose a burden on the patient in form of incurring considerable cost. Therefore even with a relatively low yield, washing may still be worthwhile. Therefore, we performed this retrospective study to see whether bronchial washing had any additional use over either endobronchial biopsies or bronchial brushing in the diagnosis of bronchoscopically visible lung cancer. We also tried to assess different strategies in terms of diagnostic yield and cost.


   Material and Methods Top


We retrospectively analyzed medical records of all fiberoptic bronchoscopies at HIMS (a large tertiary care centre and only post graduate teaching institute in Uttaranchal) from Jan 2002 to August 2005. All patients with endobronchially visible tumors were included in the study. An endoscopically visible tumour was defined as an exophytic tumour or mass or mucosal infiltration. Of these, only patients in whom a definite cytological or histological diagnosis of pulmonary malignancy was made were included in the study.

Transnasal bronchoscopy was performed in most of the cases. Premedication included intamuscular injection of atropine and inhalation of 10ml of 4% lidocaine through jet nebulization. Local administration of 3ml of 2% lidocaine through the working channel of the fiberoptic bronchoscope at the vocal cord, subglottic area and carina was also carried out. After inspecting the airway and identifying the endobronchial tumour, endobronchial biopsies or brushing, bronchial washing was performed. At our institution, bronchoscopies for endobronchial lesions generally include three to five endobronchial biopsy specimen, two to four endobronchial brushing and 20-40ml of saline solution washing obtained in 10-20ml aliquots.


   Cost Effective Analysis Top


We planned three potential specimen collection strategies for bronchoscopy of visible endobronchial lesion. We compared cost effectiveness of following three approaches : (1) Bronchoscopy with biopsy, brushing, and washing (2) Bronchoscopy with biopsy and washing; and (3) Bronchoscopy with biopsy and brushing.


   Results Top


107 cases of endoscopically visible abnormality underwent forceps biopsy, brushing and washing. In 99 patients bronchoscopy revealed a clear diagnosis (92.52%). The visible endobronchial abnormalities (107 patients) were exophytic tumours in 77 (71.96%), mucosal infiltration in 23 (21.49%), and extrinsic compressioin with submucosal infiltration in 7 (6.54%) patients.

The sensitivity of endobronchial biopsy, brushing and washing for diagnosing lung cancer was 83.17%, 69.15% and 47.66% respectively. The diagnostic yield in patients with endobronchially visible tumors was 92.52%, 90.65% and 85.04%, respectively, for biopsy, washing and brushing; for biopsy and brushing; for biopsy and washing [Table 1].

Histopathological subtypes of lung cancer were non-small cell lung cancer in 88 patients ( 55 squamous cell carcinoma, 12 adenocarcinoma , 17 unclassified non small cell carcinoma and 4 large cell carcinoma) and small cell lung cancer in 19 patients [Table 2].

Eight patients had a non-diagnostic bronchoscopy result; in these patients a diagnosis of pulmonary malignancy was established by a second bronchoscopy (1 patients), by Transbronchial needle aspiration of mediastinal mass (1 patients) by percutaneous transthoracic needle aspiration (4 patients), by open lung biopsy (1 patients) and biopsies of extrapulmonary lesion (1 patients).


   Cost Effective Analysis Top


The cost of each bronchoscopy, histology and cytology (from brushing or washing) at our centre was Rs. 1000, 400 and 300 respectively. The cost of various combinations of procedures and yield is mentioned in [Table 3].


   Discussion Top


Bronchoscopy and guided techniques have a definite role in diagnosis of endobronchially visible tumors. We found that addition of either washing or brushing to forceps biopsy increasing the sensitivity from 83.17% to 85.04% and 90.65% respectively. Similar observations have been reported by other studies [2],[5],[12] . There is still no clear cut agreement on the addition of bronchial washing to the Endobronchial biopsy/bronchial brushing for the diagnosis of centrally located lung cancer. Many studies showed that bronchial washing did not increase diagnostic yield for endoscopically visible lung cancer when compared with endobronchial biopsy and brushing [5],[9],[10],[11] . In contrast to those studies, Chaudhary et al [8] , who performed bronchial washing after endobronchial biopsy, found that bronchial washing should be done after endobronchial biopsy to increase the malignant cells with in the washing specimen. At our center, same strategy was applied for collection of samples, but we were able to make additional diagnoses of lung cancer from bronchial washing in only 1.86% of the patients. Although the bronchial washing was positive in only 47.66%, which was quite different from study of Chaudhary et al and additional yield of 1.86% by this procedure might be useful, however in terms of cost effectiveness, the benefit of this procedure has to be reconsidered.

From the present study, we found that 107 additional bronchial washing were performed to diagnose two patients only. Therefore rupees thirty-two thousands more were spent to diagnose two patients. Not only the higher cost, but the addition of bronchial washing to endobronchial biopsy or brushing also increased the time and work for the pathologists in processing the specimen. If bronchial washing were not added to endobronchial biopsy or brushing, 2 patients would have been misdiagnosed. The total cost of rebronchoscopies and repeated histocytology for these 2 patients were Rs. 4000, which was 8 times cheaper then the cost of doing bronchial washing in all patients. Moreover, though this approach can cause diagnostic delay, the prognosis of patient may not be changed due to the end stage of lung cancer.

Govert et al [8] found that the addition of bronchial washing to endobronchial biopsy increased sensitivity for the diagnosis of lung cancer from 80.8% to 84.8%. They concluded that the addition of bronchial washing to endobronchial biopsy was cost effective by assuming $500 as a threshold of cost-effectiveness in terms of reduced quality day (days of reduced quality of life due to morbidity and diagnostic delay). This threshold might not be applicable to developing countries such as India. Mak and Jones suggested the idea of holding washing specimens for processing until a time when the endobronchial biopsy/brushing results were negative in highly suspicious cases of lung cancer. This would be the best approach if the pathologists were available all the time.

To conclude, bronchial washing, as an additional diagnostic tool to endobronchial biopsies/bronchial brushing for pathologic diagnosis of endoscopically lung cancer is beneficial, but may not be cost effective. Processing bronchial washing specimens only when the histocytological results of endobronchial biopsies/bronchial brushing are negative is the best diagnostic approach if the pathologists are available all the time.

 
   References Top

1.Arroliga AC, Matthay RA. The role of bronchoscopy in lung cancer. Clin Chest Med 1993; 14:87-98.  Back to cited text no. 1    
2.Lundgren R, Bergman F, Angstrom T. Comparison of transbronchial needle aspiration biopsy, aspiration of bronchial secretion, bronchial washing, brush biopsy and forceps biopsy in the diagnosis of lung cancer. Eur J Respir Dis 1983;•64.378-85.  Back to cited text no. 2    
3.Lam WK, So SY, HSU C. Fiberoptic bronchoscopy in the diagnosis of bronchial cancer : comparison of washings brushings and biopsies in central and peripheral tumors. Clin Oncol 1983;9:35­-42.  Back to cited text no. 3    
4.Schzeiber G,McCiorXDC. Performance characteristics of different modalities for diagnosis of suspected lung cancer. Chest 2003;123(suppl):115.-128S.  Back to cited text no. 4    
5.Kvale PA, Bode FR, Kini S. Diagnostic accuracy in lung cancer: comparison of techniques used in association with flexible fiberoptic bronchoscopy. Chest 1976; 69:752-727.  Back to cited text no. 5    
6.Lam WK, So SY, Hsu C et al. Fiberoptic bronchoscopy in the diagnosis of bronchial cancer: comparison of washings, brushing and biopsies in central and peripheral tumours. Clin Oncol 1983; 9:35-42.  Back to cited text no. 6    
7.Mazzone P, Jain P, Arroliga AC, Matthay RA. Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer. Clin Chest Med 2002; 23:137-58.  Back to cited text no. 7    
8.Chaudhary BA, Yoneda K, Burki NK. Fiberoptic bronchoscopy. Comparison of procedures used in the diagnosis of lung cancer. J Thorac Cardiovasc Surg 1978;76.33-7.  Back to cited text no. 8    
9.Solomon DA, Solliday NH, Gracey DR. Cytology in fiberoptic bronchoscopy : comparison of bronchial brushing, washing and post-bronchoscopu sputum. Chest 1974; 65:616-9.  Back to cited text no. 9    
10.Struve-Christensen E, Michaelsen M, Mossing N. The diagnostic value of bronchial washing in lung cancer. J Thorac Cardiovasc Surg 1974; 68:313-7.  Back to cited text no. 10    
11.Chopra SK, Genovesi MG, Simmons DH, Gothe B. Fiberoptic bronchoscopy in the diagnosis of lung cancer : comparison of pre-and post-bronchoscopy sputa, washing, brushing and biopsies. Acta Cytol 1977; 21:524-7.  Back to cited text no. 11    
12.Fopp W, Raucher H, Ritschka L. Diagnostic sensitivity of different techniques in the diagnosis of lung tumors with the flexible fiberoptic bronchoscope : comparison of brush biopsy, imprint cytology of forceps biopsy, and the histology of biopsy. Cancer 1991; 67:72-5.  Back to cited text no. 12    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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