 |
|
ORIGINAL ARTICLE |
|
| Year : 2017 | Volume
: 12
| Issue : 3 | Page : 171-176 |
|
| Predictive factors for a successful diagnostic bronchoscopy of ground-glass nodules |
|
|
Toshiyuki Nakai1, Yuji Matsumoto1, Fumi Suzuk2, Takaaki Tsuchida1, Takehiro Izumo3
1 Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, Tukiji Chou-ku, Japan
2 Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, Tukiji Chou-ku; Department of Pulmonary Medicine, Kameda Medical Center, Kamogawa City, Chiba, Japan
3 Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, Tukiji Chou-ku; Department of Respiratory Medicine, Japanese Red Cross Medical Center, Hiroo, Shibuya-ku, Tokyo, Japan
| Date of Submission | 28-Dec-2016 |
| Date of Acceptance | 18-Apr-2017 |
| Date of Web Publication | 13-Jul-2017 |
Correspondence Address:
Yuji Matsumoto
Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tukiji, Chou-ku, Tokyo 104-0045
Japan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/atm.ATM_428_16
|
|
 Abstract | | |
Introduction: Since the National Lung Screening Trial demonstrated the utility of low-dose computed tomography screening for lung cancer, the detection rate of ground-glass nodules (GGNs) has increased. Endobronchial ultrasound with a guide sheath (EBUS-GS) is widely performed to diagnose peripheral pulmonary lesions, but there are not enough reports on the predictive ability of EBUS-GS in diagnosing GGNs. The aim of this study is to investigate the predictive factors for a successful diagnostic bronchoscopy for GGNs.
Methods: Consecutive patients who underwent diagnostic bronchoscopy for GGNs from September 2012 to January 2016 were enrolled in this study. From these, cases who underwent EBUS-GS were selected. They were reviewed and analyzed to examine the association between the diagnostic yield and the following clinical factors: lesion size, lobar position, location, consolidation-to-tumor ratio, visibility on X-ray, use of virtual bronchoscopy, bronchus sign, guide sheath size, and number of biopsies.
Results: We enrolled 254 cases, of which 167 were diagnosed using EBUS-GS (65.7% diagnostic yield). Univariate analysis indicated that a positive bronchus sign was a significant factor for higher diagnostic yield (72.9% vs. 34.0%; P < 0.001). The use of virtual bronchoscopy also tended toward a higher yield, but the result was not significant (69.0% vs. 54.4%; P = 0.058). However, multivariate analysis indicated that both were significantly associated with higher diagnostic yield (P < 0.001, odds ratio [OR]: 5.35; P < 0.001, OR: 1.97, respectively).
Conclusions: Our results suggest that a positive bronchus sign and the use of virtual bronchoscopy are positive predictive factors for successful diagnostic bronchoscopy of GGNs.
Keywords: Bronchoscopy, ground-glass nodule, lung cancer, radial endobronchial ultrasound with a guide sheath, virtual bronchoscopy
How to cite this article:
Nakai T, Matsumoto Y, Suzuk F, Tsuchida T, Izumo T. Predictive factors for a successful diagnostic bronchoscopy of ground-glass nodules. Ann Thorac Med 2017;12:171-6 |
Since the National Lung Screening Trial demonstrated the utility of low-dose computed tomography (CT) screening,[1] the detection and diagnosis rate of solid peripheral pulmonary lesions (PPLs) has increased.[2] Accordingly, diagnoses of ground-glass nodules (GGNs), including part-solid and nonsolid nodules, have also increased. Although localized GGNs exhibit a high incidence of lung cancer,[3] GGNs can also represent benign conditions. Therefore, a definitive diagnosis is important for determining the appropriate treatment for GGNs. Diagnostic modalities for GGNs include surgery, transthoracic needle biopsy, and bronchoscopy.
When there is a strong suspicion that the GGN is malignant, surgery is recommended. However, this involves the risk of unnecessary resections of benign lesions.[4] Another diagnostic option is transthoracic needle biopsy. According to the guidelines of the American College of Chest Physicians,[5] the diagnostic yield of transthoracic needle biopsy for PPLs is at least 90%. Similarly, a recent meta-analysis demonstrated the validity of transthoracic needle biopsy for GGNs as well as solid lesions [6] although it was associated with a 29.8% risk of pneumothorax. Moreover, transthoracic needle biopsy carries serious risks of hemoptysis, hemothorax, tumor seeding, and air embolism.[7]
In contrast, bronchoscopy is a well-established and safe procedure for diagnosing PPLs. The most frequent complication of bronchoscopy is pneumothorax, with an incidence of only 1.5%.[8] However, while bronchoscopy has greater safety, until recently its diagnostic value was insufficient. However, the diagnostic yield of bronchoscopy for PPLs has improved since the advent of new guided techniques such as radial endobronchial ultrasound (R-EBUS), guide sheath, virtual bronchoscopy, electromagnetic navigation bronchoscopy, and ultrathin bronchoscopy.[9],[10] In these reports, diagnostic bronchoscopy is acknowledged to be more difficult for GGNs than for solid nodules, for several reasons. First, it is not easy to detect GGNs on chest X-rays or real-time X-ray fluoroscopy. Second, identifying accessible routes to the target GGNs during the procedure is difficult. Third, GGNs often represent minimal changes in histology, such as adenocarcinoma in situ, minimally invasive adenocarcinoma, and lepidic predominant adenocarcinoma.[11] Thus, it is difficult to confirm overt malignancy. However, the diagnostic efficacy of bronchoscopy for GGNs with a new guided technique, R-EBUS, has recently been reported.[12],[13],[14] To avoid invasive procedures for diagnosing GGNs, it is important to improve the diagnostic yield of bronchoscopy for GGNs and therefore to confirm the predictive factors for successful transbronchial diagnoses of GGNs.
The aim of this study was to clarify the predictive factors for successful transbronchial diagnoses of GGNs using a radial endobronchial ultrasound with a guide sheath (EBUS-GS).
| Methods | |  |
Study design and objectives
Consecutive patients who underwent diagnostic bronchoscopy with EBUS-GS for GGNs in our institution from September 2012 to January 2016 were enrolled in this study. This study was approved by the National Cancer Center Institutional Review Board (No. 2012-278). Written informed consent was obtained from all patients before they underwent bronchoscopy. All GGNs were defined as PPLs with an area of increased attenuation and preservation of the underlying vessels and bronchi. They were divided into two types depending on the presence of solid components. A nonsolid nodule was defined as a lesion with no solid components, and a part-solid nodule was defined as a lesion having heterogeneous attenuation with some solid components. If malignancy was suspected when a definitive diagnosis was not established by bronchoscopy, the lesion was diagnosed by additional procedures, i.e., either transthoracic needle biopsy or surgery. The diagnostic yield of bronchoscopy was defined as the proportion of positive diagnostic cases to the number of overall cases. Among those patients, the clinical variables were analyzed to investigate the predictive factors for successful bronchoscopy. The clinical variables analyzed were as follows: lesion size (≤20 mm or >20 mm), lobar position (right upper lobe/left upper segment, right middle lobe/left lingula, or bilateral lower lobes), location area (outer or inner), the consolidation-to-tumor ratio (≤25% or >25%), visibility on a chest X-ray (fine, equivocal/invisible, or not taken before bronchoscopy), use of virtual bronchoscopy (Ziostation2®, Ziosoft, Tokyo, Japan; LungPoint ®, Bronchus, Mountain View, California, USA; or Bf-NAVI ®, Olympus, Tokyo, Japan) (used or not), the bronchus sign on thin-section CT (TSCT) (positive or negative), the guide sheath size (small or large), and number of biopsies taken (≤5 or >5).
All patients underwent a TSCT scan with a thickness of ≤1 mm within 1 month of the bronchoscopy. The size of the lesion was determined based on the major diameter on axial TSCT images. Lesion location area was defined based on a previous study and was designated as “outer” if the lesion was in the outer third ellipse or “inner” if the lesion was in the inner- or middle-third ellipses.[15] The consolidation-to-tumor ratio was defined as the maximum diameter of consolidation to the maximum lesion diameter. The bronchus sign on TSCT, defined as a CT finding of bronchi leading directly to or contained within the target lesion,[16],[17] was evaluated.
Procedures and equipment
All bronchoscopies were performed through the oral route, under local anesthesia with conscious sedation. On reaching the target bronchus, the guide sheath (K-201 or K-203, Olympus, Tokyo, Japan) in combination with an R-EBUS probe (UM-S20-17S or UM-S20-20S, Olympus, Tokyo, Japan) was inserted through the working channel of the bronchoscope and advanced toward the target GGN under real-time X-ray fluoroscopic guidance (VersiFlex VISTA ®, Hitachi, Japan). When the target GGN could not be detected on the chest X-ray or through real-time X-ray fluoroscopy, we utilized virtual fluoroscopy as a reference for forceps guidance.[18] If the EBUS image could not be visualized, as in cases of solid lesions, we manipulated the probe under fluoroscopic guidance until a whitish acoustic shadow, which we previously reported as blizzard sign or mixed blizzard sign, was generated.[12] When evaluating the location of the probe against the GGN, EBUS images were divided into three groups according to a previously published report:[19] “within” (the probe was located in the bronchus inside the GGN), “adjacent to” (the probe was located in the bronchus alongside the GGN), or “invisible” (the probe was located in the bronchus, but the GGN could not be seen). After confirming the location of the target GGNs through R-EBUS, transbronchial sampling through the guide sheath was repeated using forceps, brush, and transbronchial needle aspiration (TBNA).[20],[21]
Diagnostic criteria in bronchoscopy
The samples obtained through bronchoscopy were considered diagnostic when malignant histology findings or Class IV/V cytology findings were confirmed. Cases of benign lesions were diagnosed when the samples showed specific benign findings (e.g., granuloma, fibrotic change, and inflammation on histopathology or the presence of bacteria in microbial culture) and when subsequent clinical outcomes were consistent after a 12-month follow-up period. Bronchoscopy was considered nondiagnostic if the sample was inadequate (e.g., peripheral lung tissue and peribronchial tissue).
Statistical analysis
Descriptive statistics presented in this study are frequency, percentage, and median (range). We investigated the factors influencing the diagnostic yield using Chi-square test. Variables selected through univariate analyses (P < 0.20) were analyzed using multivariate logistic regression. All statistical tests were two-sided, and a P < 0.05 was considered statistically significant. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan),[22] which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria).
| Results | | |
A total of 254 patients were enrolled and analyzed; a summary of patient characteristics is shown in [Table 1]. The diagnostic yield of bronchoscopy with EBUS-GS was 65.7% (167 of 254 GGNs). [Table 2] shows the histology of the GGNs. Of 21 benign lesions, 14 were successfully diagnosed through bronchoscopy (66.7% diagnostic yield), and one was diagnosed as nontuberculous mycobacteria through surgery. The remaining six lesions were clinically diagnosed as inflammation, based on the reduction or complete disappearance of the lesions after anti-inflammatory therapy. | Table 1: Baseline characteristics of patients with ground-glass nodules diagnosed with malignancy (n=254)
Click here to view |
 | Table 2: The results of bronchoscopy using endobronchial ultrasound with a guide sheath for evaluation of ground-glass nodules
Click here to view |
Of 233 malignant lesions, 153 were successfully diagnosed through bronchoscopy (65.7% diagnostic yield). In the nondiagnostic cases, diagnosis was established through surgery in 77 patients and transthoracic needle biopsy in 3 patients. Of these cases, almost all were invasive adenocarcinoma (216/233, 92.7%). There were six other malignant tumor cases: three of malignant lymphoma and one each of adult T-cell leukemia, metastasis of renal cancer, and metastasis of pancreatic cancer. With respect to complications, 2 patients (0.8%) had small self-limiting pneumothorax and another 2 (0.8%) had mild bleeding. There were no severe complications during this study.
The clinical factors associated with the diagnostic yield are shown in [Table 3]. In the univariate analysis, a positive bronchus sign was a significant factor for a higher diagnostic yield (72.9% vs. 34.0%, P < 0.001). The use of virtual bronchoscopy also tended to have a higher yield, but there was not a significant difference (69.0% vs. 54.4%, P = 0.058). Conversely, in the multivariate analysis, the use of virtual bronchoscopy and a positive bronchus sign were both significantly associated with a higher diagnostic yield (P < 0.001, odds ratio [OR]: 1.97, 95% confidence interval [CI]: 1.04–3.72, and P < 0.001, OR: 5.35, 95% CI: 2.70–10.60, respectively). | Table 3: Clinical factors affecting diagnostic yield of endobronchial ultrasound with a guide sheath available before bronchoscopy
Click here to view |
[Figure 1] is a representative case of a successful bronchoscopy for GGN evaluation. | Figure 1: A 59-year-old male with a part-solid ground-glass nodule in the right upper lobe. Computed tomography showed part-solid nodule located at right segment 1b (a), but invisible on X-ray (b). We approached it referring to virtual bronchoscopy (c) and virtual fluoroscopy (d), and radial endobronchial ultrasound showed blizzard sign (e). The biopsy specimen revealed lepidic predominant adenocarcinoma (f)
Click here to view |
| Discussion | | |
Although several groups have reported the utility of EBUS-GS for diagnosing GGNs,[12],[14],[23] few reports have investigated the clinical factors affecting the diagnostic yield of this procedure. Our study showed that the diagnostic yield (167/254, 65.7%) and the complication rate (4/254, 1.6%) were comparable to those for solid nodules reported in previous studies.[8],[9],[24],[25] Positive bronchus signs on TSCT and the use of virtual bronchoscopy were positive predictive factors of EBUS-GS for GGNs, which may be helpful when choosing a diagnostic modality.
Previous studies have reported a relationship between a CT bronchus sign and the diagnostic yield for diagnosing PPLs through EBUS-GS.[17],[26],[27] Similarly, in the present study, the CT bronchus sign was significantly associated with successful diagnosis, according to both the univariate and multivariate analyses. The diagnostic yield of positive bronchus sign cases was 72.9%. Considering its diagnostic effectiveness and safety, bronchoscopy with EBUS-GS seems to be a feasible first modality for undiagnosed GGNs with a positive bronchus sign. For solid lesions with a negative bronchus sign, TBNA, which directly punctures the lesion through the bronchial wall, has been generally recommended.[28] We previously demonstrated the diagnostic utility of TBNA for PPLs.[20],[21] In the same way, if the GGN shows negative bronchus sign, TBNA may be a useful way to improve the diagnostic yield.
We highlight virtual bronchoscopy as an important technique for diagnosing GGNs because it was significantly related to successful bronchoscopy in the multivariate analysis. In addition, virtual fluoroscopy constructed with virtual bronchoscopy facilitates confirmation of the location of the GGN even if the GGN cannot be detected on chest X-rays or by real-time fluoroscopy.[18] In such cases, using this technique, we can move the bronchoscope as close as possible to the target lesion through the preplanned bronchial route generated by the virtual bronchoscopy and select the biopsy site based on virtual fluoroscopy guidance and EBUS images. The use of virtual bronchoscopy and virtual fluoroscopy would resolve the problems (e.g., complicated access routes to the target and poor visibility in fluoroscopy) that make transbronchial diagnosis for GGNs difficult. Although Ikezawa et al. have reported that the size and visibility of GGNs affect the diagnostic yield,[14] our study did not reveal any significant relationship of this kind. We assume that this difference was the result of our use of virtual bronchoscopy.
Our study has several limitations. First, it was a retrospective, nonrandomized study in a single cancer center, so there may have been a bias in patient selection. For example, the rate of benign lesions in all GGNs was much lower than that of malignant lesions (8.3% vs. 91.7%). Second, the bronchoscopy procedures were not all performed by the same bronchoscopist. The effect of differences in bronchoscopist's skill levels on lesion visibility and diagnostic yield was not measured. Instead, teaching staff supervised all procedures performed by residents and ensured that the quality of the procedures was maintained. Third, the type of bronchoscope and sampling devices (e.g., forceps, brush, and needle) was independently decided in each case. Finally, the effect of the use of rapid on-site examination during the procedure on the diagnostic yield was not evaluated. The latter method has the potential to improve the diagnostic yield of bronchoscopy with EBUS-GS.[29],[30] Prospective, randomized studies are recommended in the future.
| Conclusions | | |
This study demonstrated that a positive bronchus sign on TSCT and the use of virtual bronchoscopy are positive predictive factors for successful diagnosis of GGNs using bronchoscopy with EBUS-GS. We therefore suggest that physicians consider using virtual bronchoscopy and evaluating the bronchus sign on TSCT.
Acknowledgments
We thank Koji Tsuta and Noriko Motoi for supporting the pathologic examinations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395-409.  |
| 2. | National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med 2013;368:1980-91. |
| 3. | Li F, Sone S, Abe H, Macmahon H, Doi K. Malignant versus benign nodules at CT screening for lung cancer: Comparison of thin-section CT findings. Radiology 2004;233:793-8. [ PUBMED] |
| 4. | Rubins JB, Ewing SL, Leroy S, Humphrey EW, Morrison V. Temporal trends in survival after surgical resection of localized non-small cell lung cancer. Lung Cancer 2000;28:21-7. [ PUBMED] |
| 5. | Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3 rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143 5 Suppl: e142S-65S. |
| 6. | Yang JS, Liu YM, Mao YM, Yuan JH, Yu WQ, Cheng RD, et al. Meta-analysis of CT-guided transthoracic needle biopsy for the evaluation of the ground-glass opacity pulmonary lesions. Br J Radiol 2014;87:20140276. [ PUBMED] |
| 7. | Tomiyama N, Yasuhara Y, Nakajima Y, Adachi S, Arai Y, Kusumoto M, et al. CT-guided needle biopsy of lung lesions: A survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol 2006;59:60-4. [ PUBMED] |
| 8. | Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest 1995;107:430-2. [ PUBMED] |
| 9. | Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest 2012;142:385-93. [ PUBMED] |
| 10. | Oki M, Saka H, Ando M, Asano F, Kurimoto N, Morita K, et al. Ultrathin bronchoscopy with multimodal devices for peripheral pulmonary lesions. A randomized trial. Am J Respir Crit Care Med 2015;192:468-76. [ PUBMED] |
| 11. | Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, et al. International Association for the study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Classification of lung adenocarcinoma. J Thorac Oncol 2011;6:244-85. |
| 12. | Izumo T, Sasada S, Chavez C, Matsumoto Y, Tsuchida T. Radial endobronchial ultrasound images for ground-glass opacity pulmonary lesions. Eur Respir J 2015;45:1661-8. [ PUBMED] |
| 13. | Sasada S, Izumo T, Chavez C, Tsuchida T. Blizzard Sign as a specific endobronchial ultrasound image for ground glass opacity: A case report. Respir Med Case Rep 2014;12:19-21. [ PUBMED] |
| 14. | Ikezawa Y, Sukoh N, Shinagawa N, Nakano K, Oizumi S, Nishimura M. Endobronchial ultrasonography with a guide sheath for pure or mixed ground-glass opacity lesions. Respiration 2014;88:137-43. [ PUBMED] |
| 15. | Park HS, Harder EM, Mancini BR, Decker RH. Central versus peripheral tumor location: Influence on survival, local control, and toxicity following stereotactic body radiotherapy for primary non-small-cell lung cancer. J Thorac Oncol 2015;10:832-7. |
| 16. | Naidich DP, Sussman R, Kutcher WL, Aranda CP, Garay SM, Ettenger NA. Solitary pulmonary nodules. CT-bronchoscopic correlation. Chest 1988;93:595-8. [ PUBMED] |
| 17. | Gaeta M, Pandolfo I, Volta S, Russi EG, Bartiromo G, Girone G, et al. Bronchus sign on CT in peripheral carcinoma of the lung: Value in predicting results of transbronchial biopsy. AJR Am J Roentgenol 1991;157:1181-5. [ PUBMED] |
| 18. | Fukusumi M, Ichinose Y, Arimoto Y, Takeoka S, Homma C, Matsuoka H, et al. Bronchoscopy for pulmonary peripheral lesions with virtual fluoroscopic preprocedural planning combined with EBUS-GS: A pilot study. J Bronchology Interv Pulmonol 2016;23:92-7. [ PUBMED] |
| 19. | Kurimoto N, Miyazawa T, Okimasa S, Maeda A, Oiwa H, Miyazu Y, et al. Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically. Chest 2004;126:959-65. |
| 20. | Takai M, Izumo T, Chavez C, Tsuchida T, Sasada S. Transbronchial needle aspiration through a guide sheath with endobronchial ultrasonography (GS-TBNA) for peripheral pulmonary lesions. Ann Thorac Cardiovasc Surg 2014;20:19-25. [ PUBMED] |
| 21. | Hayama M, Izumo T, Chavez C, Matsumoto Y, Tsuchida T, Sasada S. Additional transbronchial needle aspiration through a guide sheath (GS-TBNA) for peripheral pulmonary lesions that cannot be detected by radial EBUS. Clin Respir J 2015;doi: 10.1111/crj.12413. [Epub ahead of print]. |
| 22. | Kanda Y. Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transplant 2013;48:452-8. |
| 23. | Izumo T, Sasada S, Chavez C, Tsuchida T. The diagnostic utility of endobronchial ultrasonography with a guide sheath and tomosynthesis images for ground glass opacity pulmonary lesions. J Thorac Dis 2013;5:745-50. |
| 24. | Hsu LH, Liu CC, Ko JS, Chen CC, Feng AC. Safety of interventional bronchoscopy through complication review at a cancer center. Clin Respir J 2016;10:359-67. |
| 25. | Herth FJ, Eberhardt R, Becker HD, Ernst A. Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: A prospective trial. Chest 2006;129:147-50. |
| 26. | Evison M, Crosbie PA, Morris J, Martin J, Barber PV, Booton R. Can computed tomography characteristics predict outcomes in patients undergoing radial endobronchial ultrasound-guided biopsy of peripheral lung lesions? J Thorac Oncol 2014;9:1393-7. |
| 27. | Minezawa T, Okamura T, Yatsuya H, Yamamoto N, Morikawa S, Yamaguchi T, et al. Bronchus sign on thin-section computed tomography is a powerful predictive factor for successful transbronchial biopsy using endobronchial ultrasound with a guide sheath for small peripheral lung lesions: A retrospective observational study. BMC Med Imaging 2015;15:21. |
| 28. | Trisolini R, Cancellieri A, Tinelli C, Paioli D, Scudeller L, Forti Parri SN, et al. Performance characteristics and predictors of yield from transbronchial needle aspiration in the diagnosis of peripheral pulmonary lesions. Respirology 2011;16:1144-9. |
| 29. | Oki M, Saka H, Kitagawa C, Kogure Y, Murata N, Adachi T, et al. Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing lung cancer: A randomized study. Respiration 2013;85:486-92. |
| 30. | Chen CH, Cheng WC, Wu BR, Chen CY, Chen WC, Hsia TC, et al. Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: Combination of radial probe endobronchial ultrasound and rapid on-site evaluation. J Thorac Dis 2015;7 Suppl 4:S418-25. |
[Figure 1]
[Table 1], [Table 2], [Table 3] |
|
| This article has been cited by | | 1 |
Computed Tomography Bronchus Sign Subclassification during Radial Endobronchial Ultrasound-Guided Transbronchial Biopsy: A Retrospective Analysis |
|
| Tatsuya Imabayashi, Yuji Matsumoto, Keigo Uchimura, Hideaki Furuse, Takaaki Tsuchida | | Diagnostics. 2023; 13(6): 1064 | | [Pubmed] | [DOI] | | | 2 |
Findings of virtual bronchoscopic navigation can predict the diagnostic rate of primary lung cancer by bronchoscopy in patients with peripheral lung lesions |
|
| Atsushi Kitamura, Yutaka Tomishima, Ryosuke Imai, Naoki Nishimura, Kohei Okafuji, Shosei Ro, Torahiko Jinta, Tomohide Tamura | | BMC Pulmonary Medicine. 2022; 22(1) | | [Pubmed] | [DOI] | | | 3 |
Diagnostic role of liquid-based cytology of bronchial lavage fluid in addition to bronchial brushing specimens in lung cancer |
|
| Chao Cao, Xuechan Yu, Tingting Zhu, Qingwen Jiang, Yiting Li, Xinjian Li | | Tumori Journal. 2021; 107(4): 325 | | [Pubmed] | [DOI] | | | 4 |
Ciliated Muconodular Papillary Tumor of the Lung: a Surgical Case Report |
|
| Yoshiaki Takase, Sachiko Nakano, Toshiteru Nagashima, Tsukasa Suzuki, Osamu Kawashima | | SN Comprehensive Clinical Medicine. 2020; 2(7): 1003 | | [Pubmed] | [DOI] | | | 5 |
Sensitivity of Radial Endobronchial Ultrasound-Guided Bronchoscopy for Lung Cancer in Patients With Peripheral Pulmonary Lesions |
|
| Paula V. Sainz Zuñiga, Erik Vakil, Sofia Molina, Roland L. Bassett, David E. Ost | | Chest. 2020; 157(4): 994 | | [Pubmed] | [DOI] | | | 6 |
Technologies for targeting the peripheral pulmonary nodule including robotics |
|
| David Fielding, Masahide Oki | | Respirology. 2020; 25(9): 914 | | [Pubmed] | [DOI] | | | 7 |
First Human Use of a New Robotic-Assisted Fiber Optic Sensing Navigation System for Small Peripheral Pulmonary Nodules |
|
| David I.K. Fielding, Farzad Bashirzadeh, Jung Hwa Son, Maryann Todman, Adrian Chin, Lionel Tan, Karin Steinke, Morgan N. Windsor, Arthur Wai Sung | | Respiration. 2019; 98(2): 142 | | [Pubmed] | [DOI] | | | 8 |
Computed Tomography Bronchus Sign and the Diagnostic Yield of Guided Bronchoscopy for Peripheral Pulmonary Lesions. A Systematic Review and Meta-Analysis |
|
| Muhammad S. Ali, Jaskaran Sethi, Amit Taneja, Ali Musani, Fabien Maldonado | | Annals of the American Thoracic Society. 2018; 15(8): 978 | | [Pubmed] | [DOI] | |
|
|
|
|
|
|
|
|
|
