Objective: This study assessed the diagnostic yield of bronchial biopsy and bronchial brush, obtained through fibreoptic bronchoscopy, in patients with a visible endobronchial tumor diagnosed at King Hussein Medical Center (KHMC).
Methods: This prospective study included 114 patients who were referred for fibreoptic bronchoscopy in the bronchoscopy unit at KHMC to evaluate suspicious lung masses between June 2016 and January 2019. Inclusion criteria were: age > 14 years and radiological evidence of a lung mass. Exclusion criteria were: patients who did not have a visible endobronchial tumor during fibreoptic bronchoscopy or who were found not to be fit for bronchoscopy due to medical reasons. Through fibreoptic bronchoscopy, bronchial forceps biopsies followed by bronchial brush were obtained and then sent for histological and cytological study. At least five bronchial biopsy samples from the tumor were taken. Biopsy or brush results that showed suspicious cells suggestive of malignancy were considered non-diagnostic and were regarded as negative for malignancy in our study. We reviewed the results obtained by bronchial forceps biopsy and by bronchial brushing and compared the diagnostic yield of each one of them separately. Subsequently, we examined the yield when both techniques were combined in diagnosing lung cancer.
Results: Out of the 114 patients enrolled in our study, 87 (76.3%) were male and 27 (23.7%) were female. The mean age ± standard deviation was 64 ± 9.2 years (males) and 60.1 ± 12.9 years (females). Bronchial biopsy was positive in 91 patients (79.8%), while bronchial brush was positive in 30 patients (26.3%). Bronchial biopsy and bronchial brush were both positive in 29 cases (25.4%). Bronchial brush was the only positive result in 1 case (0.9%), while bronchial biopsy was the only positive result in 62 cases (54.4%). Both techniques were negative in 22 cases (19.3%). The overall positive diagnosis using both techniques was 80.7% (92 cases). The most common tumor type diagnosed by bronchial biopsy was squamous cell carcinoma, followed by small cell carcinoma. On the other hand, adenocarcinoma was the most common cytological diagnosis obtained by bronchial brush, followed by squamous cell carcinoma.
Conclusion: In our study, diagnostic fibreoptic bronchoscopy was a sensitive method for diagnosing visible endobronchial lung tumors. Bronchial biopsy was more sensitive in diagnosing lung tumors compared to bronchial brushing. Combining both techniques did not significantly improve the diagnostic yield. Future studies regarding the causes of low sensitivity of bronchial brush in our hospital should be performed in order to improve the bronchial brush diagnostic yield.
Keywords: bronchial biopsy, bronchial brush, lung tumor
JRMS August 2020:27(2) : 10.12816/0055805
carcinoma is considered to be one of the most frequent malignancies worldwide. Indeed,
it is the leading cause of death due to malignancy worldwide. Despite the fact
that the incidence of lung cancer is higher in males, the incidence is rising
Bronchoscopy was performed for the first time in 1887 by Gustav
Killian in Germany. (2) At that time, the main indications for the
use of bronchoscopy were therapeutic, e.g., removing foreign bodies. Modern
Bronchoscopies were invented in the early 20th century
by Chevalier Jackson, who significantly helped to advance bronchoscopy techniques.
(3) However, the main use of rigid bronchoscopies remained therapeutic.
1967, fibreoptic bronchoscopy (FOB) was developed by S. Ikeda. (4) Since
then, FOB has become the mainstay investigation in diagnosing patients with
suspicion of lung cancer. During FOB, samples from the visible endobronchial tumor
are usually taken by different methods, including bronchial biopsy, bronchial
brushing and bronchial lavage. These samples are sent for histological and
cytological analysis in order to identify the exact histological tumor type. This
identification will play an integral role in determining the therapeutic options.
Despite the fact that FOB is an important and essential tool to diagnose lung
cancer, it can give variable diagnostic yields. (5-8) one possible
reason for this variability is the fact that it is sometimes hard to obtain a
representative sample from the neoplastic area because of limitations in the
tissue sampling technique. The concurrent use of different sampling techniques,
such as bronchial biopsy and brush, may have a positive impact on improving the
diagnostic yield. (9)
In our study, we compared the diagnostic yield of forceps
biopsy and bronchial brush obtained through FOB in patients with lung masses suspicious
of malignancy in King Hussein Medical Center (KHMC). Our aim was to determine whether
there was a difference in the diagnostic yield between the techniques, and
whether combining the two techniques would improve the diagnostic accuracy.
In this prospective study, 114 patients—who were referred for FOB
in the bronchoscopy unit in KHMC to evaluate suspicious lung masses between
June 2016 and January 2019—were enrolled in this study. The ethics committee approved
this study. Inclusion criteria were: age > 14 years and radiological
evidence of a lung mass. Exclusion criteria were: patients who did not have a
visible endobronchial tumor during FOB or who were found not to be fit for
bronchoscopy due to medical reasons.
All patients provided
written informed consent prior to the procedure. The patients underwent proper
evaluation before the procedure, including medical history and physical
examination. Platelet count and bleeding profile were sent for all patients.
All FOBs were performed by senior pulmonologists in the bronchoscopy unit of
KHMC. Patients were fasted for at least 6 h prior to the bronchoscopy. All
patients received midazolam (Dormicum) intravenously prior to the procedure,
with an initial dose of 2 mg, after which increments of 1 mg were added to
reach the desired sedation. Xylocaine (4%) was used for topical anesthesia. Oxygen
saturation and pulse rate were monitored throughout the procedure using a pulse
oximeter. After visualizing the endobronchial tumor, bronchial forceps biopsies
were collected, followed by bronchial brush. At least five bronchial biopsy
samples from the tumor were taken using a fenestrated or toothed forceps. The
samples were fixed in 10% formalin and sent for histopathological analysis. Subsequently,
bronchial brush was performed using a sheath protected brush from the same site.
The brushes were smeared on four clean slides using a circular motion to avoid
air drying, (10) and then fixed in 95% ethanol immediately for
cytological examination. Bronchial
brush slides were stained using the Papanicolaou technique, whereas specimens
that were taken for histological examination via forceps biopsy were stained
with haematoxylin and eosin after being processed. A senior histopathologist examined
all the slides. Biopsy or brush results that showed suspicious cells suggestive
of malignancy were considered non-diagnostic and were regarded as negative for
malignancy in our study.
At the end of the study, we reviewed
the results obtained by bronchial forceps biopsy and bronchial brushing,
compared the diagnostic yield of each one of them separately and then examined
the yield when both techniques were combined in diagnosing lung cancer.
Continuous variables are expressed as mean ± standard deviation;
categorical variables are expressed as percentages.
characteristics are shown in (Table I). Of the 114 patients who underwent FOB,
92 patients (80.7%) had positive results for malignancy. Bronchial biopsy was
superior to bronchial brushing in diagnosing lung cancer in our study, as shown
in (Table II). Only 1 case had a positive bronchial brush and a negative
bronchial biopsy result. Cytology showed evidence of adenocarcinoma for this
The most common
histopathological type of lung cancer diagnosed by bronchial biopsy in our
study was squamous cell carcinoma, followed by small cell carcinoma. However,
the most common cytological type diagnosed by bronchial brush in our study was adenocarcinoma,
followed by squamous cell carcinoma (Table III). In all of the 29 cases that were
diagnosed by both techniques, there was an agreement on the cell type via histological
and cytological techniques.
Table I: Age and sex distribution of the patients included in this study.
Age range (years)
Mean age ± standard deviation (years)
64.2 ± 9.2
60.1 ± 12.9
Table II: Accuracy of bronchial brushing and bronchial biopsy in the 114
cases examined in this study.
Number (%) of
Brush positive, Biopsy positive
Brush positive, Biopsy negative
Brush negative, Biopsy positive
Brush negative, Biopsy negative
Bronchial brushing positive
Bronchial forceps biopsy positive
Comparison of cell types obtained by bronchial biopsy and bronchia brush.
Number (%) by
Number (%) by
Small cell carcinoma
Negative for malignant cells
this study, the overall positive diagnostic yield of bronchial biopsy and brushing
combined together was 80.7% (92 of 114 patients). Previous studies reported variable
results regarding the overall positive diagnostic yield of FOB: Buirski et
al. showed 80%,(11) Quorian et al. reported 58%(12) Ono
et al. stated 97.8%,(13) Matsuda et al. indicated 93.7%(14)
and Chajjed et al. showed the lowest level at 50%.(15) The
reason behind this variation could be related to the technical experience of
the pulmonologist performing the procedure, specimen handling prior to submitting
them to the laboratory and the different ways to interpret the cytological
changes depending on the histopathologist.
In our study, bronchial biopsy showed positive
results for malignancy in 91 cases (79.8%). Previous studies found a variable
positive yield of bronchial biopsy: 71% for Kvale et al.,(16) 89%
for Knight and Clarke (17) and 91% for Macdonald(18) and Webb
and Clarke.(19) However, Knight and Clarke interpreted biopsy
samples reported as "suggestive of carcinoma" as being positive for
malignancy, a decision that may explain the high sensitivity of the bronchial
biopsy in their study. Another possible explanation for the varying positive
yield based on bronchial biopsy could be attributed to the different number of
biopsy specimens taken during FOB. A study by Gellert et al. showed that
the positive diagnostic yield of bronchial biopsy increases from 75% when
taking three biopsies to 90% when taking five biopsies.(20) Popovich
et al. found that the maximum yield was reached after the fourth specimen.(21)
In our study, we took at least five bronchial biopsies from all visible
endobronchial tumours to ensure optimal diagnostic yield.
Bronchial brush was positive in only 30 cases
(26.3%) in our study. This diagnostic yield is low when compared to many studies.
Alam(22) and Fuladi et al.(10) specified a
positive bronchial brush diagnostic yield of 84% and 80.76%, respectively. Gaur
et al. reported a positive yield as high as 93.90%.(23) In
fact, many studies found that bronchial brushing was more sensitive in the
diagnosis of lung cancer compared to bronchial biopsy.(16, 24-28) The
cause of false negative bronchial brush results has been addressed in many
studies. Giti et al.(1) determined that out of the 31
patients found to have negative bronchial brush results in his study, which
constituted 31% of the patients; 12 cases (38.7%) were missed because of
sampling and fixation errors. Another 8 cases were missed (25%) due to
screening error by the pathologist. Another study by Nodit et al.(29)
found that 75% of the false negative bronchial brush results were caused by
sampling issues (i.e., crush artifacts and inadequate cells). In our study, we
did not investigate the cause of the low sensitivity of the bronchial brushing.
We can pursue this endeavour in future studies.
Combining both sampling techniques did not
significantly impact the sensitivity in detecting lung malignancies in our
study when compared to positive bronchial biopsy results alone (80.7% and 79.8%,
In 29 cases (25.4%), both bronchial biopsy
and bronchial brush were positive. In all of these cases, there was an
agreement on the cell type via histological and cytological analysis. Bronchial
brush was the only positive result in just 1 case (0.9%).
The most common tumour diagnosed by bronchial
biopsy was squamous cell carcinoma (28.1%), followed by small cell carcinoma
(24.6%). These results are consistent with previous studies. Choudhury et
al. reported that squamous cell carcinoma was the most common malignancy,
followed by small cell carcinoma (as confirmed by histological examination).(30)
Similar findings were reported by Rawat et al.(31) However,
the most common tumour diagnosed by bronchial brush was adenocarcinoma,
followed by squamous cell carcinoma. In 2 cases, lung metastases were diagnosed
only by bronchial biopsy, and the bronchial brush result was negative in both
cases. The primary origin of the metastases was identified by histological
study of the bronchial biopsy samples (one of ovarian origin and the other from
breast origin). One lymphoma case was also diagnosed only by bronchial biopsy,
as well as 2 cases of atypical carcinoid in which the bronchial brush was also negative.
our study, diagnostic FOB was a sensitive method for diagnosing visible
endobronchial lung tumours. However, bronchial biopsy was more sensitive in
diagnosing lung tumours compared to bronchial brushing. Combining both
techniques did not significantly improve the diagnostic yield. Future studies
regarding the causes of low bronchial brush sensitivity in our hospital should
be done in order to improve the bronchial brush diagnostic yield.
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