20  Bronchoscopy Role in the Evaluation of Peripheral Pulmonary Lesions: An Overview	359

ROSE. Diagnostic yield was higher in the ROSE group, both for lesions >20 mm (88.0% vs. 77.6%) and for PPLs ≤20 mm (88.0% vs. 77.6%). Furthermore, in the non-ROSE group, the number of biopsies, the hemorrhage rate and the operation times were all higher than that of the ROSE group [58].

In the meta-analysis by Mondoni et al. [54], evaluating the yield of fuoroscopic-guided TBNA on 18 studies, a signi cant improvement of diagnostic yield is reported when ROSE was performed. Furthermore, the authors underline the possible role of a positive and adequate material on ROSE in stopping additional sampling, thus potentially avoiding the use of useless forceps biopsy and reducing risk.

The meta-analysis by Sainz Zuniga et al. [35], evaluating 51 studies performed with rEBUS, reports that the use of ROSE was associated with a higher sensitivity, even if only a small number of studies (n = 4) used ROSE in this review, leading the author to conclude that this nding requires further consideration.

From the above mentioned data, there is some evidence that ROSE may be useful in the transbronchial approach to PPLs, while it would be desirable to have more large randomized trials to de nitely assess the real advantage of rapid on-­ site evaluation with the different guidance systems and with different sampling techniques employed.

Conclusions

Even though many years have passed and great progress has been made since the rst papers on the possibility of bronchoscopy to diagnose pulmonary peripheral lesions, the transbronchial approach to PPLs still remains a challenging task for bronchoscopists.

The aim is to diagnose smaller and smaller lesions and to improve the diagnostic yield, making the bronchoscopic sampling equivalent in terms of sensitivity to the percutaneous biopsy, which is burdened by a higher risk of complications. The major obstacle that limits the diagnos-

tic yield of the transbronchial sampling, whatever guidance system is used, is represented by the location of some PPLs that have no relationship with the airways.

In this chapter, we have provided an overview of all the techniques at this moment available.

The accuracy of all the guidance systems mentioned could be further increased with the use of ultrathin bronchoscopes and of robotic bronchoscopy, which we have not considered, since there are speci c dedicated chapters in this book.

Although, from comparison of different papers and from meta-analyses it seems that the new guidance systems may provide better results, especially for small lesions, there are no large randomized trials the compare the various technologies. The heterogeneity of results makes dif cult the comparison between different studies, since several variables play a role in determining the diagnostic yield of the transbronchial approach to PPLs (size and nature of the lesions, their location, their relationships with the bronchial tree, the type and the number of sampling instruments, operator experience, multiple guidance system used at the same time, time employed, availability of ROSE).

Furthermore, the problem of costs should also be considered. The new technologies are burdened by high costs, for both the equipment and the disposable material, and cannot be available everywhere. The identi cation of Centers of excellence, where high technologies must be concentrated, should be part of health policy programs of each Country.

Due to these reasons, the use of one or more guidance systems and of one or more sampling instruments is still linked to the operator’s experience and/or to the local availability of facilities and resources.

The interventional pulmonologist community would deserve more scienti c evidence and more well conducted randomized trials, that could allow a standardization of the transbronchial approach to PPLs and to de ne the best strategy to be followed.

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360	S. Gasparini and L. Zuccatosta

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Early Lung Cancer: Methods	21
for Detection

Takahiro Nakajima and Kazuhiro Yasufuku

Introduction and De nition of the Procedure

Lung cancer is the leading cause of cancer mortality worldwide [1]. Despite evolving knowledge of lung cancer molecular genetics and improved lung cancer detection technology, the overall lung cancer survival is still quite poor (18–21%-5-year survival) [1]. National Lung cancer Screening Trial showed a dramatic, 20% relative decrease in lung cancer mortality with low dose CT chest screening in high-risk groups [2], proving the concept that early lung cancer detection which allows prompt surgical intervention, offers survival bene t. However, screening CT thorax detects smaller peripheral lung lesions, but is insensitive for detection of microscopic tumors arising from the central airways [3]. Microscopic tumors arising in the central airways require other techniques for early detection [4].

Squamous cell carcinomas, accounting for approximately 25–30% of all lung cancers, arise in central airways. Pathobiologically, progression

T. Nakajima

Department of General Thoracic Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan

e-mail: [e-mail]

K. Yasufuku (*)

Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada

e-mail: [e-mail]

from normal bronchial epithelium to squamous metaplasia followed by dysplasia, carcinoma in situ (CIS), and nally invasive carcinoma has been well described [5, 6]. Studies have shown that patients with preinvasive bronchial lesions progress to develop CIS/invasive carcinoma over the median time of 24 months (range: 6–54 months) [7]. Approximately 11% of patients with moderate dysplasia and 19% to as high as 50% with severe dysplasia develop invasive carcinoma [8, 9]. The existence of COPD or heavy smoking history are at high risk of developing lung cancer [7]. Therefore, prompt detection through screening of high-risk patients (heavy smokers especially) could potentially offer early diagnosis of early preinvasive or early invasive lesions and allow for prompt therapeutic intervention and improved survival. However, conventional airway imaging modality, white light bronchoscopy (WLB) has been shown to be relatively insensitive in inspection of bronchial mucosa with only 30% sensitivity to detect early-stage carcinoma in the central airways [10].

New bronchoscopic modalities with higher spatial resolution are able to take advantage of intrinsic properties of healthy and abnormal tissues to change appearance when illuminated with different wavelengths of light, have been developed to serve the purpose of more advanced central airway imaging for the purpose of abnormal airway diagnosis [11]. Currently available in clinical practice modalities for detecting bron-

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363

J. P. Díaz-Jiménez, A. N. Rodríguez (eds.), Interventions in Pulmonary Medicine, https://doi.org/10.1007/978-3-031-22610-6_21

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