Affiliations: University of Calgary Calgary, AB,
Tel-Aviv Sourasky Medical Center Tel Aviv, Israel
Correspondence to: Alain Tremblay, MDCM, FCCP, University of Calgary, 3330 Hospital Dr NW, Calgary T2N 4N1, Canada; e-mail: firstname.lastname@example.org
The authors1 should be congratulated for their work (April 2006) with this fascinating new technology. Electromagnetic navigation clearly appears to improve the sensitivity of bronchoscopy in the diagnosis of pulmonary nodules and masses. Nevertheless, the application of such technology must be put in context of its clinical use, in this case the evaluation of patients with lung masses suspicious for lung malignancy. The principal advantage of attempting a diagnostic procedure in an operable patient with a solitary lung lesion suspicious for lung cancer is to reliably confirm that a malignancy is not present. In other words, the negative predictive value of the test is its most important characteristic in this setting.
This is the basis for the recommendation found in the American College of Chest Physicians (ACCP) lung cancer guidelines2 stating that, with regard to transthoracic needle aspiration (TTNA),
the false negative test result rate of TTNA is high (range, 0.20 to 0.30). Thus, TTNA is generally not useful in ruling out cancer. As such, TTNA has no role in patients who have lesions that are even moderately suspicious for lung cancer, and who appear to have early-stage disease and are candidates for surgical resection. Although a test that could reliably rule out lung cancer might be useful in this setting, the high FN [false negative] rate of TTNA makes reliance on a negative result untenable.
In essence, a patient with a positive biopsy result for malignancy will need surgical resection, and a patient with a negative finding will still need surgical resection given the poor negative predictive value of the test. In this patient population, TTNA has no impact on clinical management and can only lead to delays in definitive care and potential complications.
The negative predictive value of the described technique in this study,1 although not commented on in the text, is in fact very similar to that described for TTNA. Of the five patients with negative biopsy results for cancer, four patients had false-negative results. The negative predictive value is therefore one fifth (20%). The above ACCP recommendation on TTNA could therefore be extrapolated to this novel technique.
Until such time that a test can demonstrate a high enough negative predictive value to comfortably avoid surgical resection, the test may not lead to significant changes in management for operable patients with suspected resectable lung cancer. The utility of these tests will remain limited to confirmation of cancer in inoperable patients or those with nonresectable disease.
The author has 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.
The author has no conflicts of interest to disclose.
The discussion in the literature on the diagnostic management of patients with a peripheral lung lesion suspicious for malignancy is a never-ending saga. The findings on transthoracic fine-needle aspiration (TTNA) [or any other diagnostic procedure for lung cancer] are not always comparable because they are derived from highly varied patient populations. The predictive value of any test might change according to the prevalence of disease in any given population. If we are supposed to operate on every patient with a peripheral lung nodule, we will end up with an unacceptably high rate of surgery for benign lesions. This was clearly demonstrated by Swensen et al,1who recently showed a 90% rate of benign lesions when screening for lung cancer by CT. In our experience, the diagnostic yield of a combined fine-needle aspiration and core biopsy is 93.4% with a sensitivity of 91.5% and specificity of 100%. Core biopsy demonstrated specific benign disease in 87.8% of cases.2In the study published,3 negative electromagnetic navigation bronchoscopy biopsy findings were followed by TTNA plus core biopsy, which detected malignancy in false-negative cases. Our position is that a comprehensive preoperative evaluation including positron emission tomography and TTNA as needed will avoid unnecessary surgery in cases of benign lesions and of neoplasms, such as lymphoma or small cell carcinoma, that are best treated by chemotherapy.
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