Study of Bronchoalveolar Lavage to Achieve a Correct Diagnosis in Patients with Suspicion of Lung Carcinoma
Authors: Dr. Isha Bansal1 (Asst. Prof.) & Dr. Amit Varma2 (Professor & H.O.D)
Dept. of Pathology, Index Medical College Hospital & Research Centre, Indore, (M.P.)1 Dept. of Pathology, Sri Aurobindo Medical College and PG Institute, Indore, M.P.2
First Author: Dr. Isha Bansal
Corresponding Author: Dr. Amit Varma
Abstract:
Background & Method: The present study was conducted in department of Pathology at Sri Aurobindo Institute of Medical Sciences & Post graduate Institute, Indore, M.P. over a period of 2 years from May 2012 to June 2015. All the cases of suspected bronchial malignancy were included in present study in which broncho-alveolar lavage (BAL) and bronchial biopsy samples were received in pathology department for evaluation. Respective bronchial brushings & sputum samples were also studied where ever available.
Result: Out of 72 cases of malignant biopsy samples, simultaneous bronchoalveolar lavage samples received, in which 13 (54.16%) cases were positive for malignancy. Of these 72 cases, Squamous cell carcinoma was the most frequent cell-type carcinoma with 41.6% while frequency of adenocarcinoma is 25%. Frequency of Small cell carcinoma is 13.8% and other type of carcinoma’s accounts for 19.4%.
Cases of atypical Squamous metaplasia in which malignancy is highly suspected, were also taken as positive cases.
Conclusion: Endobronchial biopsy is the most sensitive and specific procedure for diagnosis of lung carcinoma. Bronchoalveolar lavage is good screening test. When endobronchial biopsy and BAL, both were studied, sensitivity of cases increases and number of false negative cases decreases for diagnosis.
Bronchial brushing have better sensitivity than BAL for diagnosis of lung carcinoma.
Keywords: endobronchial, biopsies, diagnosis & lung carcinoma.
Study Designed: Cross sectional study.
Introduction
Diagnostic cytology is the art and science of the interpretation of cells from the human body that either exfoliate (desquamate) freely from the epithelial surface or are removed from tissue sources by various clinical procedures. [1] Pulmonary cytology and histopathology are valuable tools in the diagnosis of lung malignancies. The first realization that cancer of the lung could be accurately diagnosed and typed by the microscopic study of expectorated cells is generally attributed to Dudgeon and Barret. [2]
frequency showed lung at top of the list. [3] Lung cancer is most common fatal malignant neoplasm of both men and women. [3]
The process of cancer development following exposure to carcinogens has been observed to consist of a series of gradual changes. [4] To combat the disease successfully, it should be diagnosed at earliest possible stage. [5] Fibreoptic bronchoscopy was developed in Japan in 1964, is a safe technique with few complications and can be performed quickly with minimal discomfort to the patient [6,7] and it provides excellent material for diagnosis of pulmonary lesions. [7] We can have number of material available from bronchoscopy, namely Bronchoalveolar lavage (BAL), Bronchial brush cytology, endobronchial and transbronchial biopsy, sputum cytology, fine needle aspiration cytology for early diagnosis and typing of lung carcinoma. Each technique has specific advantages and disadvantages. However their combined use yields the best results. [8]
Material & Method
The present study was conducted in department of Pathology at Sri Aurobindo Institute of Medical Sciences & Post graduate Institute, Indore, M.P. over a period of 2 years from May 2012 to June 2015.
All the cases of suspected bronchial malignancy were included in present study in which broncho-alveolar lavage (BAL) and bronchial biopsy samples were received in pathology department for evaluation. Respective bronchial brushings & sputum samples were also studied where ever available.
All the BAL, bronchial brushings, sputum & bronchial biopsy samples received in pathology department in study period were collected & further processed as follows:
Sterile wide mouth containers of 30 ml capacity with label to write details of patient like name, registration number, ward number, date of sample collection were provided to department of Respiratory Medicine for collection of sputum & BAL samples.
INCLUSION CRITERIA
• First time visiting patients.
• Clinically suspicious adult cases of bronchial cancer.
• Patients whose BAL and bronchial biopsy both were received.
EXCLUSION CRITERIA
• Patients of paediatric age group.
• Patients with known inflammatory lung disease.
• Patient with lung mass with no endobronchial component.
• Patients whose either BAL or bronchial biopsy was not received.
• Inadequate bronchial biopsy sample.
• Previously diagnosed cases of carcinoma lung or bronchial carcinoma.
Results
Table 01: Age group wise distribution of 81 cases of combined study
AGE GROUP NO. OF CASES
TOTAL (year)
MALE FEMALE
20-29 01 - 01 (01.2%)
30-39 01 - 01 (01.2%)
40-49 07 02 09 (11.1%)
50-59 16 04 20 (24.6%)
60-69 26 05 31 (38.2%)
70-79 15 01 16 (19.7%)
80-89 01 - 01 (01.2%)
90-99 01 01 02 (2.4%)
TOTAL 68 (84%) 13 (16%) 81 (100%)
Of 81 cases of combined study, peak age group at which bronchoscopy procedure for suspician of malignancy was done on 60-69 years with 38.2% patients with maximum number of female patients, followed by 50-59 years of age group with 24.6% patients. Male female ratio of 1:5.2 was observed with 84% male and 16% female patients
Present study was conducted on 72 patients in which endobronchial biopsy was positive for malignancy, correlated with BAL cytology of the same. Mean age for lung carcinoma patients was 61.3 years, ranging from 40 to 90 years. Specific mean age for Squamous cell carcinoma was 61.8 years, for adenocarcinoma was 61.7 years and for small cell carcinoma 62.5 years.
Table 02: Distribution of cases on the basis of histology, cytology and combined study
Individual Histological Individual Cytological
Diagnosis by Combined study
diagnosis diagnosis
77/117 23/117 81/117
Of 117 cases combined study of BAL and endobronchial biopsy study was done. A conclusive diagnosis was made on 81 cases. Of these, the present study was done on 72 cases which were histologicaly diagnosed as malignancy, compared with their respective BAL samples, and with bronchial brushing and sputum samples, whenever available.
Mean age for 117 cases of combined study BAL & biopsy examination in our study is 56.5 years. The age of patients ranged from 28 to 90 years, which includes cases of lung carcinoma and infections. Sex ratio for 117 cases of combined study is 1:3.5.
TABLE 03: Bronchial Brushing Cytodiagnosis in lung cancer cases Total Brushing sample Positive brushing sample
24(100%) 13 (54.16%)
Out of 72 cases of malignant biopsy samples, simultaneous bronchial brushing samples received of 24 cases, in which 13 (54.16%) cases were positive for malignancy.
Table 04: Sputum Cytodiagnosis in Lung Cancer
Total sputum sample Positive sputum sample
3 (100%) 1 (33.3%)
Out of 72 cases malignant biopsy samples, simultaneous sputum samples received of 3 cases, in which 1 (33.3%) case was positive for malignancy.
Table 05: Incidence of lung carcinoma on histological examination of 72 cases
Type of tumour Incidence
Squamous cell carcinoma 41.6% (30)
Adenocarcinoma 25% (18)
Small cell carcinoma 13.8% (10)
Carcinoma not specified 06 (8.3%)
Carcinoid tumor 01 (1.38%)
Round cell tumor 1 (1.38%)
Metastasis from
1 (1.38%) Renal cell carcinoma
Metastasis from
1 (1.38%) Hepatocellular carcinoma
Suspicious of malignancy 4 (5.5%)
TOTAL 72 (100%)
Of these 72 cases, Squamous cell carcinoma was the most frequent cell-type carcinoma with 41.6% while frequency of adenocarcinoma is 25%. Frequency of Small cell carcinoma is 13.8% and other type of carcinoma’s accounts for 19.4%. Cases of atypical Squamous metaplasia in which malignancy is highly suspected, were also taken as positive cases.
Discussion
Table 06: Comparison of incidence of lung cancer with other studies
Studies Squamous Cell Adenocarcinom Small Cell Carcinoid
Other Tumor
Carcinoma a Carcinoma Tumor
Bothe A [9] 38.70% 23.87% 27.1% 0.65% 02.58%
AS Ammanagi
65% 25% 05% - -
[10]
Clinton L [11] 84% 08% 04% - 04%
Rawat J [12] 51.4% 11.2% 17.75% - 03.73%
Present study 41.6% 25% 13.8% 0.72% 18.6%
Incidence of Squamous cell carcinoma in present study was 41.6% which is in concordance with other studies such as Bothe et al and Rawat et al with 38.7% and 51.4% cases. Ammanagi et al and Clinton et al reported higher incidence of Squamous cell carcinoma, 65% and 84% respectively.
Incidence rate of adenocarcinoma were reported 8%, 11.2%, 23.8% and 25
% by Clinton et el, Rawat et al, Bothe et al and Ammanagi et al respectively, which is similar with present study of 25% cases of adenocarcinoma. Small cell carcinoma were found to be 13.8% in present study which is similar with incidence rate of 17.75% and 27.1% cases in study conducted by Rawat et al and Bothe et al respectively.
In our study, sensitivity of endobronchial biopsy is 65.8%, which is comparable with other
[109,118-120]studies in which biopsy sensitivity ranges from
60% to 82%.
In this study, bronchoscopy was performed without fluoroscopic guidance and the number of biopsy specimens taken was confined to one. Gellert et al
[121]showed that atleast five biopsy specimens were required to give more than 90%
probability of obtaining a positive specimen and Popovich
[122]found that the maximum yield was reached after the fourth specimen. In our study, single biopsy have been taken and the yield therefore can be considered as optimum.
Since cytological sampling by BAL technique relies mainly on cells 'exfoliated' from the malignant lesion in the bronchial epithelium, the adequacy of its samples depends on several vital factors, especially a) the degree of differentiation of malignant growth; b) preservation of the morphology of cytological material obtained; and c) technical skill of the pulmonologist who is retrieving the lavage fluid from the bronchus.
[34]Comparison of the cytological characters of bronchial brushings and BAL showed that cellularity of the smear was greater in brush specimens with numerous columnar cells noted against a clear background whereas BAL samples tended to shed mostly single malignant cells with occasional cell clusters which were larger in brush than in washing samples.
Conclusion
Endobronchial biopsy is the most sensitive and specific procedure for diagnosis of lung carcinoma. Bronchoalveolar lavage is good screening test. When endobronchial biopsy and BAL, both were studied, sensitivity of cases increases and number of false negative cases decreases for diagnosis. Bronchial brushing have better sensitivity than BAL for diagnosis of lung carcinoma.
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