19  The Newly Proposed Lung Cancer TNM Classifcation: Review and Clinical Implications	337

Summary

The UICC seventh edition of the TNM Classi cation System was undoubtedly a major improvement in our scienti c basis for the staging of lung cancer, supported by a large international database and subject to thorough internal and external validation process. The much richer and prospectively collected database that supports the recommendations for the eighth edition TNM has allowed the IASLC committees to propose multiple key modi cations to the T and M descriptors as well as to the stage groupings. As these proposals are accepted and placed in practice, more ambiguities will come up to light, and it is paramount to gather, scrutinize, and share this data to better comprehend the limitations of this TNM system and to rise above them.

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338	R. F. Casal and R. F. Morice

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Part V

Diagnosing and Staging of Lung Cancer

Bronchoscopy Role	20
in the Evaluation of Peripheral

Pulmonary Lesions: An Overview

Stefano Gasparini and Lina Zuccatosta

Introduction

The de nition of peripheral pulmonary lesion (PPL) is generally used to indicate an area of consolidation (nodule, mass, in ltrates, or ground glass opacity) located in the peripheral one-third of the lung. Since a well precise radiological landmark that is able to distinguish central from peripheral lesions has not yet been de ned, from the bronchoscopic point of view a PPL implies a lesion that originates outside the visible range of a standard fexible bronchoscope.

The widespread use of chest CT scan and the advent of lung cancer screening programs with low-dose CT, have greatly increased the detection of PPLs allowing to identify even small subcentimeter lesions. The results of lung cancer screening projects show that the discovery of noncalci ed PPLs is very common in asymptomatic smokers or ex-smokers (20–50%). Even if in patients without any previous history of cancer less than 1% of PPLs <5 mm are malignant, the

S. Gasparini (*)

Department of Public Health and Biomedical Sciences, Polytechnic University of Marche Region, Ancona, Italy

Pulmonary Diseases Unit, Department of Internal Medicine, Azienda “Ospedali Riuniti”, Ancona, Italy e-mail: [e-mail]

L. Zuccatosta

Pulmonary Diseases Unit, Department of Internal Medicine, Azienda “Ospedali Riuniti”, Ancona, Italy

likelihood of malignancy increases with lesion size, being 18% for lesions between 8 and 20 mm and reaching value of about 80% for PPLs greater than 20 mm [1].

Although some guidelines on diagnosis and management of lung cancer suggest an immediate surgical resection when a PPL has a moderate or high probability of malignancy by imaging features and/or by PET positivity, most of the patients have an indeterminate pattern of the lesion and/or are poor candidate for surgery due to age or comorbidities. Consequently, in clinical practice, a bioptic approach with cytohistological de nition of a PPL is often required.

A PPL may be approached for bioptic purposes both percutaneously and transbronchially.

The percutaneous or transthoracic biopsy, generally performed under CT guidance, will be the topic of a dedicated chapter in this book. It is well known that the percutaneous approach of PPLs has a better diagnostic sensitivity in comparison to the transbronchial approach, but it does not provide any information about staging (central airways involvement and/or simultaneous central endobronchial lesions) and it is burdened by a higher incidence of complications, especially pneumothorax [1].

The role of bronchoscopy with exploration of central airways in the diagnostic pathway of PPLs is still debated.

In an old retrospective study performed on 91 patients with a PPL less than 6 cm in size,

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

341

J. P. Díaz-Jiménez, A. N. Rodríguez (eds.), Interventions in Pulmonary Medicine, https://doi.org/10.1007/978-3-031-22610-6_20

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