Abstract

Peripheral lung tumors, frequently presenting as nodules or masses, usually are beyond the visual scope of fiberoptic bronchoscope; more difficulties can be encountered in their diagnostic work-up. To increase the diagnostic yield, an efficient method to be added to transbronchial biopsy (TBB), brushing and bronchial lavage is transbronchial needle aspiration (TBNA). TBNA under fluoroscopic guidance provides a contribution of 20% (7-35%) over the yield of these methods while providing a yield of 35-69%. Its diagnostic yield is associated with the diameter, marginal irregularity, tumor-bronchus relation, malignancy/benignancy and location of the lesion. The yield of TBNA is higher in malignant tumors larger than 2-3 cm. Whereas diagnosis mostly cannot be made by TBB, brushing and bronchial lavage in Tsuboi type III (bronchus compressed) and IV (bronchus narrowed-thickened) tumors out of the four types of tumor-bronchus relationship also visible on thin-section thoracic computed tomography scans, TBNA gives diagnosis (70-83%) through its penetrability and maneuver capacity. However, its yield is not low also in type I (bronchus cut-off) (60%) and II (bronchus contained within) (62%) tumors. In tumors of the inner and middle 1/3’s of the lung, TBNA has higher yield than in those of more distal locations; for those in the distal 1/3, transthoracic needle aspiration (TTNA) is a suitable choice with higher diagnostic and less complication rates. In benign lesions and non-lung cancer malignancy, the yield of 22-gauge TBNA is low. All complications of it do not exceed 10% and are usually not serious. Methods such as TBB, brushing, bronchial lavage, and bronchoalveolar lavage, each by itself, cannot provide sufficient diagnostic yield; with a 75% yield, the most efficient and economical combination is TBB+TBNA. TBNA should be tried first in the operable cases since it can be beneficial in diagnosis and staging; in those remaining undiagnosed, TTNA can be performed. Thus, TBNA and TTNA should be considered as complementary methods increasing diagnostic efficiency. In conclusion, TBNA is an efficient method with a low complication rate in the diagnosis and staging of peripheral lung tumor, and can also provide significant diagnostic contribution when added to the other bronchoscopic methods, or used sequentially with TTNA.