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Communications to the Editor |

Preoperative Bronchoscopic Biopsies and Staging FREE TO VIEW

Alessandro Baisi, MD; Luigi Bonavina, MD
Author and Funding Information

Affiliations: Ospedale Maggiore Policlinico Milan, Italy,  Medizinische Klinik der Technischen Universität Munich, Germany

Correspondence to: Alessandro Baisi, MD, Dipartimento di Scienze Chirurgiche, Pad. Monteggia, Osp. Policlinico, Via F. Sforza, 35, 20122 Milan, Italy; e-mail: alessandro.baisi@unimi.it



Chest. 2002;121(6):2081-2082. doi:10.1378/chest.121.6.2081-a
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To the Editor:

We read with interest the article by Riedel et al (June 2001),1who concluded that systematic multiple biopsies and brush and washing cytology are an accurate procedure in evaluating possible airway invasion by supracarinal esophageal carcinoma. We also use biopsies in our practice,2 but we are very cautious in the interpretation because we have had a lot of negative biopsy findings in patients in whom tracheobronchial invasion was evident at bronchoscopic examination. Therefore, we do not feel confident in making a clinical choice (airway infiltrated or not, that is, operate on the patient or not) based on the results of the biopsies.

Looking in depth at the data of Riedel et al,1(Table 2) there was 1 negative biopsy finding among 5 adequate biopsies on 5 patients with an endoluminal mass, 3 negative biopsy findings among 8 adequate biopsies on 8 patients with frank mucosal infiltration, 1 negative (it was adequate) biopsy finding in a patient with malignant tracheoesophageal fistula, and 8 negative biopsy findings among 13 adequate biopsies on 13 patients with a rigid protrusion. Even more striking are the results of biopsies after CRT.1(Table 4) From these data, it is evident that there are a lot of negative biopsy findings also if taken from pathologic tissue (frank mucosal infiltration, tracheoesophageal fistulas, endoluminal mass), and that, also in the experience of Riedel et al,1 are not very reliable. Similar results are reported with brush cytology and washing cytology.1(Tables 2,4)

Certainly, if biopsy findings are positive, the airway invasion is sure and a radical resection is impossible. However, Reidel et al1(Table 5) reported a patient with a “microscopic proof of cancer at bronchoscopy” (that is, we suppose, positive biopsy or brushing findings) and “no airway invasion at surgery.” This is really surprising and shows that biopsies are not reliable.

In conclusion, we think that it is wrong to make any preoperative judgment about radical resectability based on the results of biopsies. These can be useful if considered in an integrated fashion with bronchoscopic findings (distinguishing mobile from rigid protusion), CT scan, etc.

Riedel, M, Stein, H, Mounyam, L, et al (2001) Extensive sampling improves pre-operative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer.Chest119,1652-1660
 
Baisi, A, Bonavina, L, Peracchia, A Bronchoscopic staging of squamous cell carcinoma of the upper thoracic esophagus.Arch Surg1999;134,140-143
 
To the Editor:

Drs. Baisi and Bonavina, in their comments about our article on bronchoscopic staging of esophageal cancer,1 suggest that it is wrong to make any judgment about radical resectability based on results of biopsies. They cite our findings of some negative biopsies taken from macroscopically abnormal tissue; however, they fail to realize that our decision about resectability was based on a combination of macroscopic findings, biopsies, and brush and washing cytology. With this combined mode of evaluation, the specificity and accuracy was statistically significantly better than it would be if we were to rely on the subjective interpretation of macroscopic findings only. In our series, 18 patients with macroscopic abnormalities, but without microscopic proof of cancer, eventually underwent an R0 resection; they would have been rejected for curative surgery if the diagnosis of airway invasion had been based on macroscopic findings only.

The interpretation of bronchoscopy in the assessment of airway invasion of esophageal cancer after radiochemotherapy is, without doubt, more difficult than at baseline staging; the positive predictive value of macroscopic abnormalities without microscopic proof of cancer is low.12 This underlines the importance of biopsies rather than questions their value.

The one patient reported1(Table 5) with “microscopic proof of cancer at bronchoscopy” and no airway invasion at surgery had normal results of macroscopic examination, negative biopsies, and negative washing cytology; only the results of brush cytology were evaluated as “strongly suspicious of cancer,” as clearly stated in the text of our article. The final decision to operate on this patient was made by the surgeons and was clearly the correct decision. This case certainly does not support the conclusion of Drs. Baisi and Bonavina that biopsies are not reliable.

References
Riedel, M, Stein, HJ, Mounyam, L, et al Extensive sampling improves preoperative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer.Chest2001;119,1652-1660
 
Riedel, M, Stein, HJ, Mounyam, L, et al Influence of simultaneous neoadjuvant radiotherapy and chemotherapy on bronchoscopic findings and lung function in patients with locally advanced proximal esophageal cancer.Am J Respir Crit Care Med2000;162,1741-1746
 

Figures

Tables

References

Riedel, M, Stein, H, Mounyam, L, et al (2001) Extensive sampling improves pre-operative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer.Chest119,1652-1660
 
Baisi, A, Bonavina, L, Peracchia, A Bronchoscopic staging of squamous cell carcinoma of the upper thoracic esophagus.Arch Surg1999;134,140-143
 
Riedel, M, Stein, HJ, Mounyam, L, et al Extensive sampling improves preoperative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer.Chest2001;119,1652-1660
 
Riedel, M, Stein, HJ, Mounyam, L, et al Influence of simultaneous neoadjuvant radiotherapy and chemotherapy on bronchoscopic findings and lung function in patients with locally advanced proximal esophageal cancer.Am J Respir Crit Care Med2000;162,1741-1746
 
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