Maggiore Hospital Bologna, Italy
Correspondence to: Rocco Trisolini, MD, Unit of Thoracic Endoscopy and Pulmonology, Maggiore Hospital, Largo Nigrisoli 2, 40133 Bologna, Italy; e-mail: firstname.lastname@example.org
We read the article by Nakajima et al1 on the possible negative impact of transbronchial lung biopsy (TBLB) on the postsurgical prognosis of non-small cell lung cancer (NSCLC). The authors conclude suggesting that “… a pathologic examination without preoperative bronchoscopy, but through intraoperative incisional biopsy followed by curative surgery, might be beneficial for patients with early-stage lung cancer.” We would like to comment on this.
The TNM staging system of lung cancer includes bronchoscopy in the pretreatment workup on the basis of scientifically well-proved data. Airway examination provides indispensable information on site and size of the tumor (T descriptor), as well as on the presence of synchronous lesions. Gasparini et al2found synchronous endobronchial visible lesions in 72 of 570 patients (12.6%) being studied for peripheral lesions, and such finding either contraindicated surgery or modified the therapeutic strategy in 35 patients (48.6%). Pierard et al3 submitted 43 NSCLC-operable patients to autofluorescence bronchoscopy and demonstrated synchronous carcinomas in situ or dysplasias in 8 patients (18.6%). Airway examination proves also extremely helpful to identify candidates for sleeve resection of the main bronchus or carina.
Bronchoscopy may also be useful in the definition of the N descriptor through transbronchial needle aspiration (TBNA), which precludes the need for unnecessary diagnostic or therapeutic surgical procedures when it shows malignant cells, due to its extremely high specificity.4–5 A systematic review4of 910 TBNA procedures suggested sensitivity and specificity as high as 76% and 96%, respectively. A more recent meta-analysis5 showed that the sensitivity is much lower than previously thought in populations with low prevalence of lymph node metastasis, but it confirmed that the method is highly specific.
In conclusion, pretreatment workup of NSCLC lacking bronchoscopy is incomplete and inaccurate, and it may cause inappropriate therapeutic planning. As for the diagnosis of peripheral lesions, there is no evidence in the literature of tumor implantation in the airway caused by TBLB so far, as the authors state, and we look forward to a prospective randomized trial to reliably assess the effect of TBLB on the postsurgical prognosis of NSCLC.
The authors of this article have no conflicts of interest to disclose.
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