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Rebecca Bascom, MD, MPH; William Evan Higgins, PhD
Author and Funding Information

Affiliations: Penn State College of Medicine Hershey, PA,  Penn State University University Park, PA

William Evan Higgins, PhD, Penn State University, 121 Electrical Engineering East, University Park, PA 16802; e-mail: weh2@psu.edu


Dr. Higgins is President of Endographics Imaging Systems, Inc., State College, PA. As such, he is involved in developing new computer systems for lung cancer management and has a financial interest in this work. Dr. Bascom reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(2):646-647. doi:10.1378/chest.09-0824
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To the Editor:

We thank Vincenten et al for commenting on our article in CHEST (November 2008).1 We agree that accurate lesion localization is crucial to efficient diagnosis. Tsuboi et al2 have pointed out the varied relationships of primary lesions to the airways: a few are endoluminal, but others are peribronchial. Guidance systems need to provide strategies for the full range of lesions found in the clinical setting.

We agree that dimensional changes in the lung arising from the ventilatory cycle are a potential source of site-localization error. In our experience, our system minimizes this sort of error because of the synchronization that takes place at each bifurcation. This in fact enables incremental adjustment to any error related to respiratory phase. This error is greatest in the lung periphery and in the lower respiratory tract (where the largest proportional ventilation occurs). The use of the four-dimensional system may be an improvement that would be more crucial to an electromagnetic bronchoscopy navigation system that relies on external reference points and does not have the capacity to synchronize at individual bifurcations.3

We wholeheartedly support the need for advances in diagnostic methods to sample tumors adjacent to bronchi. High on our wish list would be longer needles that could be threaded through a flexible thin bronchoscope and then stiffened for biopsy. Also, as our article alludes to, hybrid techniques employing a navigation system in tandem with a local imaging method, such as endobronchial ultrasound, may also be useful.

We appreciate the authors providing the 5-year experience of their institution. Preoperative diagnosis was made in 107 of 142 patients (75%) in advance of their lung cancer operations; the rate for preoperative diagnosis of peripheral lesions was 79% (58 of 73 patients). This rate is excellent by today's standards; stratification of yield by size would be useful in view of the wide range in lesion size (1 to 10 cm). We support the idea of a bronchoscopy initiative that would allow our specialty to measure individual and collective lung cancer diagnostic performance and to work toward an even higher yield.

At present, many clinicians send patients with stage T1 (< 3 cm) and T2 (> 3 cm) [N0] lesions to undergo resection without a preoperative tissue diagnosis. The most obvious limitation is that nonmalignant lesions (and normal lung) are occasionally resected. If neoadjuvant chemotherapy ever becomes the standard of care for these early-stage lesions, the need for improved preoperative diagnosis will become even more urgent.

Merritt SA, Gibbs JD, Yu KC, et al. Image-guided bronchoscopy for peripheral lung lesions: a phantom study. Chest. 2008;134:1017-1026. [PubMed] [CrossRef]
 
Tsuboi E, Ikeda S, Tajima M, et al. Transbronchial biopsy smear for diagnosis of peripheral pulmonary carcinomas. Cancer. 1967;20:687-698. [PubMed]
 
Gildea TR, Mazzone PJ, Karnak D, et al. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med. 2006;174:982-989. [PubMed]
 

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References

Merritt SA, Gibbs JD, Yu KC, et al. Image-guided bronchoscopy for peripheral lung lesions: a phantom study. Chest. 2008;134:1017-1026. [PubMed] [CrossRef]
 
Tsuboi E, Ikeda S, Tajima M, et al. Transbronchial biopsy smear for diagnosis of peripheral pulmonary carcinomas. Cancer. 1967;20:687-698. [PubMed]
 
Gildea TR, Mazzone PJ, Karnak D, et al. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med. 2006;174:982-989. [PubMed]
 
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