Bronchoscopy
Figure 2: Autofluorescence Bronchoscopy Image Showing an Autofluorescence Bronchoscopy-positive Lesion with Autofluorescence in Lower Intensity
In conclusion, AFB, as well as NBI, provides early lung cancer detection, allowing subsequent rapid treatment and thus improving outcomes in lung cancer patients.
Therapeutic Bronchoscopy
Besides the diagnostic procedures, bronchoscopy also offers many therapeutic modalities. One frequent indication for therapeutic bronchoscopy is the management of severe haemoptysis due to lung cancer34
and inflammatory processes such as tuberculosis, bronchiectasis or bronchitis, depending on the local circumstances. Endoscopic methods include cold saline lavage, instillation of topical vasoconstrictive agents or fibrinogen-thrombin, balloon or stent tamponade, endobronchial airway blockade, laser therapy, argon plasma coagulation (APC) and electrocautery.35
Furthermore,
bronchoscopy provides management of central airway obstruction (CAO) that is often caused by lung cancer due to intraluminal tumour growth or extraluminal compression.36
To achieve rapid symptom
sensitivity of 2.04 compared with 1.15. However, the trials showed lower specificity with AFB, compared with WLB, due to the presence of lesions that are positive on AFB although negative on pathology. But these false-positive findings seem to be not entirely normal.31 Increased amounts of chromosomal aberration could be detected within these lesions, suggesting a potential for progression. According to the ACCP guidelines,29
control in a life-threatening situation, laser-assisted resection, electrocautery and cryodebridement are available. To prevent recurrence of obstruction due to intraluminal tumour growth or to treat obstruction due to extraluminal compression, the insertion of an airway stent re-establishes the patency of obstructed airways. Brachytherapy is another option for CAO treatment, but the effects of brachytherapy are delayed and should only be considered in respiratorily stable patients. Recently developed therapeutic modalities are endoscopic lung volume reduction (ELVR) in patients with severe chronic obstructive pulmonary disease and bronchial thermoplasty (BT) in patients with severe asthma.7
Laser Therapy AFB is recommended for the evaluation of
high-grade sputum dysplasia, in patients with known or previous lung cancer for the assessment of the presence of synchronous lung cancer, in patients with early lung cancer eligible for curative endobronchial treatment and for follow-up of known preneoplastic lesions. Figure 2 demonstrates one endobronchial image acquired by an autofluorescence bronchoscope with AFB-positive lesions.
In a prospective pilot study published in 2007, 22 patients with known or suspected dysplasia or malignancy underwent WLB followed by NBI. The detected lesions were targeted for endobronchial biopsy. In these patients, one malignant and four dysplastic lesions were found by NBI that were not detected by WLB. Therefore, NBI improves the detection of preneoplastic lesions when WLB findings are considered as normal. In another prospective study comparing WLB, AFB and NBI, 57 patients with intraepithelial neoplasia were analysed.33
NBI is an alternative method for early lung cancer detection. This wavelength-capture system uses narrow bands in the blue and green spectrum for illumination covering the haemoglobin absorption, whereby the blood vessels are more pronounced, permitting the evaluation of altered blood vessel morphology in preneoplastic tissue.32
In 30 %, the biopsies resulted in diagnoses
of CIS or high-grade dysplasia. The relative sensitivities of AFB, NBI and the combination of AFB and NBI, when compared with WLB, were 3.7, 3.0 and 4.0, respectively, without a statistically significant difference between the methods. The relative specificities of AFB and NBI were 0.5 and 1.0. Thus, NBI is an alternative to AFB in the detection of airway neoplasia at a pre-invasive stage, because it has a comparatively higher specificity without significantly compromising the sensitivity.
140
Endoscopic laser produces a beam of monochromatic light that can induce tissue, coagulation, carbonisation and vaporisation necrosis.37 There are different types of laser corresponding to a precise wavelength. The laser types used in the airways are the yttrium–aluminium–garnet (YAG) laser, yttrium–aluminium–perovskite (YAP) laser, potassium titanyl phosphate (KTP) laser, argon laser and dye laser, where the neodymium–YAG laser is the most widely used laser for bronchoscopic interventions, with a very good coagulation effect and enough power for vaporisation.38
Laser therapy is often combined with mechanical coring to achieve more rapid debulking. The first step of this so-called laser-assisted resection is to coagulate the lesion with the laser followed by mechanical resection.39 bleeding, perforation and fire.39
In general, laser therapy is one of the most important methods for bronchial debulking in the case of endoluminal tumour growth.39
The risks of laser therapy are hypoxia, To prevent the latter risk, reduction of
the inspiratory oxygen fraction to 50 % prior to laser therapy is necessary. The first publication referring to laser therapy in malignant airway stenoses was by Lafort in 1976.40
Since then, several papers have
demonstrated the effectiveness of laser therapy in the management of malignant as well as of benign airway obstruction.41–43
Electrocautery and Argon Plasma Coagulation The use of electrical current that is called electrocautery induces tissue destruction by coagulation and vaporisation.38
APC, which provides a
non-contact mode of electrocautery, is very similar to conventional electrocautery technique but uses argon gas to conduct the electrons.44 The advantage of APC compared with electrocautery is its acute superficial tissue destruction with subsequent quick haemostasis. Therefore, APC can be especially used not only in case of airway obstruction but also to manage severe haemoptysis due to endoluminal
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