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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Fiberoptic bronchoscopy is the method of choice in the diagnosis of endobronchial carcinoma&#46; A combination of techniques such as forceps biopsy&#44; bronchial brushings&#44; and bronchial washings have traditionally been used for their high yield--over 80&#37;--in the classification of tumors&#46;</p><p class="elsevierStylePara"> Transbronchial needle aspiration &#40;TBNA&#41; is a relatively recent bronchoscopic technique mainly used for lymph node staging&#46;<span class="elsevierStyleSup">1</span> It is also of great utility in cases of endobronchial mass with necrosis&#44; severe bleeding&#44;<span class="elsevierStyleSup">2</span> submucosal lesions and peribronchial tumors causing extrinsic compression&#46;<span class="elsevierStyleSup">3</span> However&#44; due to the high cost of disposable needles&#44; TBNA is not recommended when endobronchial anomalies are present&#46;<span class="elsevierStyleSup">4</span> Moreover&#44; the combination of conventional diagnostic techniques such as bronchial brushings and forceps biopsy have demonstrated satisfactory cost-effectiveness&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased without adverse impact on diagnostic costs if TBNA were used in combination with conventional diagnostic techniques &#40;CDT&#41; such as bronchial washings&#44; bronchial brushings&#44; and forceps biopsy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients and Methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Patients</span></p><p class="elsevierStylePara">The cases of 140 patients diagnosed with bronchogenic carcinoma from January 1999 through December 2001 were analyzed retrospectively&#46; Fiberoptic bronchoscopy was performed on all patients&#44; with visible endobronchial lesion defined as exophytic mass&#44; mucosal infiltration &#40;consisting of abnormalities or granuloma in the bronchial wall with friable mucosa&#41;&#44; submucosal infiltration &#40;with thickening or loss of longitudinal mucosal folds&#41; and extrinsic compression &#40;swelling of lung walls or carinal widening&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Procedure</span></p><p class="elsevierStylePara">The examinations were carried out by three different specialists and bronchial washings&#44; bronchial brushings&#44; and forceps biopsy samples were essential requisites&#46; When the bronchoscopist considered TBNA was indicated&#44; it was carried out prior to other techniques&#46; For the patient to be included in our study at least 2 bronchial brushings&#44; 3 forceps biopsies&#44; and 2 TBNAs were required&#46;</p><p class="elsevierStylePara"> Cytological analysis was considered positive only when a sufficient number of definitely malignant cells was observed&#46; Cellular atypia and abnormal cells highly suggestive of malignancy were considered negative&#46; Samples were immediately fixed in 95&#37; proof alcohol&#59; all samples were assessed by the same cytologist&#44; who was blinded to the histological techniques used&#46; In all TBNA cases&#44; 22-gauge needles &#40;MW-222&#59; Mill-Rose Lab&#44; Mentor&#44; OH&#44; USA&#41; were used&#59; disposable catheters 1&#46;7 mm in diameter &#40;1601 Boston Scientific&#44; Watertown&#44; MA&#44; USA&#41; were used for bronchial brushings&#46; The choice of forceps for biopsy was left to the bronchoscopist in charge&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Exclusion Criteria</span></p><p class="elsevierStylePara"> Patients were withdrawn when thoracotomy was required to classify the neoplasm&#44; or when the cytology samples were considered inadequate&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Variables</span></p><p class="elsevierStylePara"> First&#44; the diagnostic yield for CDT was compared to the yield for CDT&#43;TBNA&#46; The diagnostic positivity by bronchoscopy was determined in both groups as a function of the visualized lesion&#46;</p><p class="elsevierStylePara"> Second&#44; the cost of diagnosis was calculated in euros using the figures provided by the billing department at our hospital&#46; The cost per diagnosis was the sum of costs needed to reach a diagnosis including endoscopic and other procedures such as transthoracic needle aspiration&#44; and lymph node biopsy&#46; The charges for diagnostic procedures used are listed in Table 1&#46; The costs of analyzing samples after the various endoscopic diagnostic procedures were included for both CDT and CDT&#43;TBNA cases&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical Analysis</span></p><p class="elsevierStylePara">The results of data analysis of quantitative variables are expressed as means &#40;SD&#41;&#46; Percentages were used for the qualitative variables&#46; Percentages were compared using &#967;&#178; tests&#46; Independent sample means were compared with Student <span class="elsevierStyleItalic">t</span> tests&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">Of the 140 patients enrolled in the study&#44; 10 were excluded on the following grounds&#58; 2 because they had undergone thoracotomy and 8 because their samples were considered inadequate&#46; Therefore&#44; the study population was made up of 130 patients&#58; 120 men &#40;91&#46;5&#37;&#41;&#44; with a mean age of 62&#46;02 &#40;9&#46;90&#41; years&#46; During the examination&#44; the following lesions were observed&#58; exophytic mass in 55 patients&#44; mucosal infiltration in 31&#44; extrinsic compression in 13&#44; and submucosal infiltration in 31&#46; The histological classification was epidermoid carcinoma for 71 patients &#40;54&#46;6&#37;&#41;&#44; adenocarcinoma for 28 &#40;21&#46;5&#37;&#41;&#44; microcytic carcinoma in 17 &#40;13&#46;1&#37;&#41; and undifferentiated large cell carcinoma in 14 &#40;10&#46;8&#37;&#41;&#46; TNBA was performed on 49 patients and its diagnostic yield of 85&#46;7&#37; was higher than that of any other technique &#40;Table 2&#41;&#46; No serious complications related to the procedure were observed except on 2 occasions in which moderate bleeding occurred&#46; Bleeding was controlled by conventional endoscopic means&#46; Figure 1 shows the number of TBNAs performed by each practitioner as well as the diagnostic yield obtained&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab02.gif"></img></p><p class="elsevierStylePara"><img src="260v39n11-13053339tab03.gif"></img></p><p class="elsevierStylePara">Figure 1&#46; Transbronchial needle aspirations and yields by endoscopist&#46; E1 indicates endoscopist 1&#59; E2&#44; endoscopist 2&#59; E3&#44; endoscopist 3&#59; TBNA99&#44; transbronchial needle aspirations in 1999&#59; TBNA00&#44; transbronchial needle aspirations in 2000&#59; TBNA01&#44; transbronchial needle aspirations in 2001&#59; TBY&#44; transbronchial needle aspiration yield&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Diagnostic Yield for Fiberoptic Bronchoscopy</span></p><p class="elsevierStylePara">CDT led to cytohistological diagnosis in 80&#46;2&#37; of cases and CDT&#43;TBNA gave positive results in 89&#46;7&#37; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;01&#41;&#46; The gain in diagnostic yield continued to be significant for the following lesions&#58; extrinsic compression &#40;CDT&#58; 37&#46;5&#37;&#59; CDT&#43;TBNA&#58; 100&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#61;&#46;01&#41;&#44; submucosal infiltration &#40;CDT&#58; 54&#46;5&#37;&#59; CDT&#43;TBNA&#58; 85&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#61;&#46;03&#41;&#44; and exophytic mass with surface necrosis &#40;CDT&#58; 80&#37;&#58; CDT&#43;TBNB&#58;100&#37;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;01&#41;&#46; Table 4 shows the diagnostic yield by the type of endobronchial lesion and presence of necrosis&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab04.gif"></img></p><p class="elsevierStylePara"><img src="260v39n11-13053339tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Study of Costs</span></p><p class="elsevierStylePara">The mean &#40;SD&#41; cost per disease diagnosed was &#8364; 393&#46;53 &#40;&#8364; 142&#46;04&#41;&#58; &#8364; 381&#46;60 &#40;&#8364; 156&#46;53&#41; with CDT and &#8364; 431&#46;25 &#40;&#8364; 112&#46;91&#41; in CDT&#43;TBNA&#46;</p><p class="elsevierStylePara"> Table 4 shows that the addition of TBNA lowered costs when submucosal disease &#40;CDT&#58;  &#8364;  488&#46;68 &#91;&#8364; 209&#46;44&#93;&#59; CDT&#43;TBNB&#58; &#8364; 419&#46;70 &#91;&#8364; 125&#46;95&#93;&#41;&#44; exophytic mass with necrosis &#40;CDT&#58; &#8364; 386&#46;59 &#91;&#8364; 169&#46;10&#93;&#59; CDT&#43;TBNB&#58; &#8364; 376&#46;74 &#91;&#8364; 24&#46;92&#93;&#41;&#44; and extrinsic compression &#40;CDT&#58;  &#8364;  557&#46;04 &#91;207&#46;56&#93;&#59; CDT&#43;TBNB&#58;  &#8364; 383 &#91;&#8364; 0&#93;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41; were present&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">For the staging of lung carcinoma TBNA has been widely studied and is recommended as part of standard medical practice in various scientific associations&#39; guidelines&#44; the same cannot be said of its use in the diagnosis of an endoscopically visible lesion&#46; Few authors have evaluated its utility in this respect&#46;</p><p class="elsevierStylePara"> TBNA diagnosed malignancy in 85&#46;7&#37; of the patients analyzed retrospectively in the present study and obtained the highest yield of all techniques&#44; proving better than forceps biopsy for all endobronchial anomalies&#46; It was also the only procedure able to establish the diagnosis in 17&#37; of cases&#46; The addition of TBNA to conventional cytology and histology techniques significantly increased the diagnostic yield of the endoscopic exploration by 9&#46;5&#37;&#44; to reach a yield of 89&#46;7&#37;&#46; Increased yield was observed for exophytic mass lesions with surface necrosis&#44; submucosal disease&#44; and extrinsic compression&#46;</p><p class="elsevierStylePara"> Other authors have reported similar results&#46; For example&#44; in a prospective analysis by Govert et al&#44;<span class="elsevierStyleSup">6</span> TBNA showed a sensitivity of 79&#37; for classifying malignancy&#59; TBNA plus forceps biopsy and bronchial brushings positivity increased positivity to 95&#37;&#44; although greatest usefulness of TBNA was observed in extrinsic compression and submucosal infiltration&#46; In a similar study by Dasgupta et al<span class="elsevierStyleSup">7</span> TBNA obtained an overall yield of 85&#37;&#59; TBNA plus forceps biopsy and brushing increased the yield to 96&#37; in cases of exophytic mass lesion&#44; submucosal disease&#44; and extrinsic compression&#46; Similarly&#44; diagnostic yields ranging from 82&#37; to 97&#37; have been reported for submucosal infiltration&#46;<span class="elsevierStyleSup">8&#44;9</span></p><p class="elsevierStylePara">In short&#44; the usefulness of TBNA seems beyond question&#46; Nonetheless&#44; it is important to remember that the aim of a new technique is to increase diagnostic yield and reduce the cost<span class="elsevierStyleSup">10</span> of diagnosing patients with lung carcinoma&#46; According to Govert el al&#44;<span class="elsevierStyleSup">5</span> a cytology diagnosis that increases the yield of endoscopy by 6&#37; is cost effective&#44; and so the regular use of endoscopy seems advisable based on our results and the literature cited&#46; We should also remember that the endoscopist&#180;s aim is to reduce the number of explorations that fail to provide a diagnosis and to avoid the use of additional techniques&#46;<span class="elsevierStyleSup">11</span> Taking all these points into consideration&#44; we analyzed the cost of both endoscopic and nonendoscopic techniques needed for cytohistological typing&#46; Table 4 shows that TBNA combined with other techniques reduces the number of endoscopies failing to provide diagnoses&#44; mainly when the lesion visualized is submucosal infiltration&#44; exophytic mass with necrosis&#44; or extrinsic compression&#46; This is reflected in lower costs&#44; although only in the case of extrinsic compression is the saving significant&#46;</p><p class="elsevierStylePara">Our deduction is based on the assumptions outlined&#44; TBNA meets the necessary requirements for regular use in the diagnosis of bronchogenic carcinoma with visible endoscopic lesions&#46;</p><p class="elsevierStylePara">Our study may suffer from a certain sampling bias given the possibility inherent to its retrospective design that there was a certain degree of variability in the criteria the 3 endoscopists used when describing and interpreting the lesions visualized&#46; Variation in the yield of bronchoscopy might also have been present&#46; Similarly&#44; although the cytology samples were always analyzed by the same pathologist&#44; 2 different groups handled the histology specimens&#46; Nevertheless&#44; in our judgment&#44; the impact on the study results of having different groups was minor&#44; since our endoscopists and pathologists have had solid experience that allowed them to define the anomaly observed in similar ways&#44; with no significant differences among them in diagnostic yield&#46; Furthermore&#44; all the data were collected by the same person using a standard protocol and for the inclusion of a case in the study we required a minimum number of samples to have been taken&#44; following previously established guidelines&#46;</p><p class="elsevierStylePara">In spite of these limitations&#44; we believe that our results are valid and they acquire particular importance for 2 reasons&#58; <span class="elsevierStyleItalic">a</span>&#41; given the importance of factors that have nothing to do with endoscopic exploration&#44; such as an effect of the observer<span class="elsevierStyleSup">12</span> or pathologist in charge&#44; any procedure which helps to optimize the yield of fiberoptic bronchoscopy would be of great assistance&#44; and <span class="elsevierStyleItalic">b</span>&#41; even though the role of TBNA is acknowledged by several expert committees<span class="elsevierStyleSup">13</span> to be quite important&#44; it remains an underutilized technique probably due to a lack of awareness of its advantages&#44; as shown by surveys&#46;<span class="elsevierStyleSup">14&#44;15</span> Further studies that demonstrate the safety and cost effectiveness of the technique will undoubtedly be of great assistance in overcoming this obstacle&#46;</p><p class="elsevierStylePara">We conclude that TBNA is a technique that substantially increases the yield of endoscopic exploration for cases of endobronchial lesions suggestive of neoplasia&#44; with no negative impact on the cost of the diagnostic process&#44; when the lesion corresponds to submucosal disease&#44; exophytic mass with necrosis&#44; or extrinsic compression&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; J&#46;A&#46; Gull&#243;n Blanco&#46;<br></br> P&#233;rez Gald&#243;s&#44; 11&#44; 5&#46;&#186; dcha&#46; 38002 Santa Cruz de Tenerife&#46; Espa&#241;a&#46;<br></br> E-mail&#58; <a href="mailto&#58;jose993&#64;separ&#46;es" class="elsevierStyleCrossRefs">jose993&#64;separ&#46;es</a></p><p class="elsevierStylePara">Manuscript received February 11&#44; 2003&#46;<br></br> Accepted for publication May 27&#44; 2003&#46;</p>"
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        "resumen" => "Background&#58; Transbronchial needle aspiration &#40;TBNA&#41; is a bronchoscopic technique whose usefulness in diagnosing endobronchial lesions has not yet been clearly established&#46; Objective&#58; We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased&#44; without a negative impact on diagnostic costs&#44; if TBNA were used in combination with conventional diagnostic techniques &#40;bronchial washings and bronchial brushings and forceps biopsy&#41;&#46; Patients and Methods&#58; The cases of 130 patients diagnosed with bronchogenic carcinoma with endoscopically visible lesions were analyzed retrospectively&#46; All had undergone conventional diagnostic procedures&#59; TBNA was also performed if the bronchoscopist considered it was indicated&#46; The final cost was calculated in euros for each diagnosis as the sum of the cost of the procedures needed to reach the diagnosis&#44; including both endoscopic procedures and others &#40;transthoracic needle aspiration&#44; lymph node biopsy&#41;&#46; Diagnostic yield and costs in cases diagnosed using only conventional techniques were compared to the yield and costs in cases in which both conventional techniques and TBNA were used&#46; Results&#58; TBNA was performed in 49 patients and provided the diagnosis in 85&#46;7&#37;&#46; Conventional techniques led to cytological and histological diagnosis in 80&#46;2&#37; of the cases&#44; and the combination of conventional techniques and TBNA gave a diagnosis in 89&#46;7&#37; &#40;P&#61;&#46;01&#41;&#46; Significant differences were observed in extrinsic compression &#40;conventional 37&#46;5&#37;&#59; conventional&#43;TBNA 100&#37;&#59; P&#61;&#46;01&#41;&#44; submucosal infiltration &#40;conventional 54&#46;6&#37;&#59; conventional&#43;TBNA 85&#37;&#59; P&#61;&#46;03&#41;&#44; and exophytic mass with necrosis &#40;conventional 80&#37;&#59; conventional&#43;TBNA 100&#37;&#59; P&#61;&#46;01&#41;&#46; The mean &#40;SD&#41; cost of diagnosis was E381&#46;60 &#40;E156&#46;53&#41; using conventional techniques and E413&#46;25 &#40;E112&#46;91&#41; for conventional techniques in combination with TBNA&#46; By adding TBNA&#44; costs decreased for diagnoses of submucosal infiltration&#44; exophytic mass with necrosis and extrinsic compression&#44; although the saving was significant only for extrinsic compression&#46; Conclusion&#58; The diagnostic yield of TBNA is high for endoscopically visible bronchial anomalies suggesting neoplasm&#44; particularly when the lesion is due to extrinsic compression&#44; submucosal infiltration&#44; or exophytic mass with necrosis&#46;"
      ]
      "es" => array:1 [
        "resumen" => "Fundamento&#58; La punci&#243;n transbronquial &#40;PTB&#41; es una t&#233;cnica broncosc&#243;pica cuya utilidad en tumores con lesi&#243;n endobronquial no est&#225; claramente establecida&#46; Objetivo&#58; Con nuestro trabajo pretendemos estudiar si la combinaci&#243;n de la PTB con las t&#233;cnicas diagn&#243;sticas convencionales &#40;aspirado&#44; cepillado y biopsia bronquiales&#41; incrementa el rendimiento de la fibrobroncoscopia&#44; sin repercutir negativamente en el coste econ&#243;mico &#40;CE&#41; del proceso diagn&#243;stico&#46; Pacientes y m&#233;todos&#58; Se analiz&#243; de forma retrospectiva a 130 pacientes diagnosticados de carcinoma broncog&#233;nico con lesi&#243;n endosc&#243;pica visible&#44; a quienes se les practicaron las t&#233;cnicas convencionales&#44; quedando a criterio del broncoscopista responsable la realizaci&#243;n de PTB&#46; Se calcul&#243; el coste final por proceso&#44; en euros&#44; constituido por la suma del coste de los procedimientos necesarios para lograr el diagn&#243;stico&#44; en los que se inclu&#237;an los endosc&#243;picos y otros &#40;punci&#243;n transtor&#225;cica&#44; punci&#243;n-biopsia ganglionar&#41;&#46; Se compararon el rendimiento y el CE entre el grupo de pacientes a los que se practicaron las t&#233;cnicas convencionales &#40;ACB&#41; y aquellos a los que se a&#241;adi&#243; PTB &#40;ACB &#43; PTB&#41;&#46; Resultados&#58; La PTB se realiz&#243; en 49 pacientes y proporcion&#243; el diagn&#243;stico de naturaleza en el 85&#44;7&#37; de los casos&#46; Con ACB se logr&#243; la filiaci&#243;n citohistol&#243;gica en el 80&#44;2&#37; de los casos&#44; y en el 89&#44;7&#37; con ACB &#43; PTB &#40;p &#61; 0&#44;01&#41;&#59; se apreciaron diferencias significativas en&#58; compresi&#243;n extr&#237;nseca &#40;ACB&#58; 37&#44;5&#37;&#59; ACB &#43; PTB&#58; 100&#37;&#59; p &#61; 0&#44;01&#41;&#44; infiltraci&#243;n submucosa &#40;ACB&#58; 54&#44;6&#37;&#59; ACB &#43; PTB&#58; 85&#37;&#59; p &#61; 0&#44;03&#41; y masa exof&#237;tica con necrosis &#40;ACB&#58; 80&#37;&#59; ACB &#43; PTB&#58; 100&#37;&#59; p &#61; 0&#44;01&#41;&#46; El CE medio fue de 381&#44;60 &#177; 156&#44;53 euros en ACB y 413&#44;25 &#177; 112&#44;91 en ACB &#43; PTB&#59; al a&#241;adir la PTB se redujo el CE en infiltraci&#243;n submucosa&#44; masa exof&#237;tica con necrosis y compresi&#243;n extr&#237;nseca&#44; aunque este ahorro s&#243;lo result&#243; significativo en compresi&#243;n extr&#237;nseca&#46; Conclusi&#243;n&#58; La punci&#243;n transbronquial es una t&#233;cnica de elevada rentabilidad en presencia de anomal&#237;as endobronquiales indicativas de neoformaci&#243;n&#44; particularmente cuando la lesi&#243;n visualizada corresponde a compresi&#243;n extr&#237;nseca&#44; infiltraci&#243;n submucosa o masa exof&#237;tica con superficie necr&#243;tica&#46;"
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Transbronchial Needle Aspiration in Bronchogenic Carcinoma With Visible Lesions: Diagnostic Yield and Cost
Punción transbronquial en el carcinoma broncogénico con lesión visible: rendimiento y coste económico
JA. Gullóna, R. Fernándeza, A. Medinaa, G. Rubinosa, I. Suáreza, C. Ramosa, IJ. Gonzáleza
a Servicio de Neumología, Hospital Universitario de Canarias, La Laguna. Santa Cruz de Tenerife, Spain.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Fiberoptic bronchoscopy is the method of choice in the diagnosis of endobronchial carcinoma&#46; A combination of techniques such as forceps biopsy&#44; bronchial brushings&#44; and bronchial washings have traditionally been used for their high yield--over 80&#37;--in the classification of tumors&#46;</p><p class="elsevierStylePara"> Transbronchial needle aspiration &#40;TBNA&#41; is a relatively recent bronchoscopic technique mainly used for lymph node staging&#46;<span class="elsevierStyleSup">1</span> It is also of great utility in cases of endobronchial mass with necrosis&#44; severe bleeding&#44;<span class="elsevierStyleSup">2</span> submucosal lesions and peribronchial tumors causing extrinsic compression&#46;<span class="elsevierStyleSup">3</span> However&#44; due to the high cost of disposable needles&#44; TBNA is not recommended when endobronchial anomalies are present&#46;<span class="elsevierStyleSup">4</span> Moreover&#44; the combination of conventional diagnostic techniques such as bronchial brushings and forceps biopsy have demonstrated satisfactory cost-effectiveness&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased without adverse impact on diagnostic costs if TBNA were used in combination with conventional diagnostic techniques &#40;CDT&#41; such as bronchial washings&#44; bronchial brushings&#44; and forceps biopsy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patients and Methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Patients</span></p><p class="elsevierStylePara">The cases of 140 patients diagnosed with bronchogenic carcinoma from January 1999 through December 2001 were analyzed retrospectively&#46; Fiberoptic bronchoscopy was performed on all patients&#44; with visible endobronchial lesion defined as exophytic mass&#44; mucosal infiltration &#40;consisting of abnormalities or granuloma in the bronchial wall with friable mucosa&#41;&#44; submucosal infiltration &#40;with thickening or loss of longitudinal mucosal folds&#41; and extrinsic compression &#40;swelling of lung walls or carinal widening&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Procedure</span></p><p class="elsevierStylePara">The examinations were carried out by three different specialists and bronchial washings&#44; bronchial brushings&#44; and forceps biopsy samples were essential requisites&#46; When the bronchoscopist considered TBNA was indicated&#44; it was carried out prior to other techniques&#46; For the patient to be included in our study at least 2 bronchial brushings&#44; 3 forceps biopsies&#44; and 2 TBNAs were required&#46;</p><p class="elsevierStylePara"> Cytological analysis was considered positive only when a sufficient number of definitely malignant cells was observed&#46; Cellular atypia and abnormal cells highly suggestive of malignancy were considered negative&#46; Samples were immediately fixed in 95&#37; proof alcohol&#59; all samples were assessed by the same cytologist&#44; who was blinded to the histological techniques used&#46; In all TBNA cases&#44; 22-gauge needles &#40;MW-222&#59; Mill-Rose Lab&#44; Mentor&#44; OH&#44; USA&#41; were used&#59; disposable catheters 1&#46;7 mm in diameter &#40;1601 Boston Scientific&#44; Watertown&#44; MA&#44; USA&#41; were used for bronchial brushings&#46; The choice of forceps for biopsy was left to the bronchoscopist in charge&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Exclusion Criteria</span></p><p class="elsevierStylePara"> Patients were withdrawn when thoracotomy was required to classify the neoplasm&#44; or when the cytology samples were considered inadequate&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Variables</span></p><p class="elsevierStylePara"> First&#44; the diagnostic yield for CDT was compared to the yield for CDT&#43;TBNA&#46; The diagnostic positivity by bronchoscopy was determined in both groups as a function of the visualized lesion&#46;</p><p class="elsevierStylePara"> Second&#44; the cost of diagnosis was calculated in euros using the figures provided by the billing department at our hospital&#46; The cost per diagnosis was the sum of costs needed to reach a diagnosis including endoscopic and other procedures such as transthoracic needle aspiration&#44; and lymph node biopsy&#46; The charges for diagnostic procedures used are listed in Table 1&#46; The costs of analyzing samples after the various endoscopic diagnostic procedures were included for both CDT and CDT&#43;TBNA cases&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Statistical Analysis</span></p><p class="elsevierStylePara">The results of data analysis of quantitative variables are expressed as means &#40;SD&#41;&#46; Percentages were used for the qualitative variables&#46; Percentages were compared using &#967;&#178; tests&#46; Independent sample means were compared with Student <span class="elsevierStyleItalic">t</span> tests&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">Of the 140 patients enrolled in the study&#44; 10 were excluded on the following grounds&#58; 2 because they had undergone thoracotomy and 8 because their samples were considered inadequate&#46; Therefore&#44; the study population was made up of 130 patients&#58; 120 men &#40;91&#46;5&#37;&#41;&#44; with a mean age of 62&#46;02 &#40;9&#46;90&#41; years&#46; During the examination&#44; the following lesions were observed&#58; exophytic mass in 55 patients&#44; mucosal infiltration in 31&#44; extrinsic compression in 13&#44; and submucosal infiltration in 31&#46; The histological classification was epidermoid carcinoma for 71 patients &#40;54&#46;6&#37;&#41;&#44; adenocarcinoma for 28 &#40;21&#46;5&#37;&#41;&#44; microcytic carcinoma in 17 &#40;13&#46;1&#37;&#41; and undifferentiated large cell carcinoma in 14 &#40;10&#46;8&#37;&#41;&#46; TNBA was performed on 49 patients and its diagnostic yield of 85&#46;7&#37; was higher than that of any other technique &#40;Table 2&#41;&#46; No serious complications related to the procedure were observed except on 2 occasions in which moderate bleeding occurred&#46; Bleeding was controlled by conventional endoscopic means&#46; Figure 1 shows the number of TBNAs performed by each practitioner as well as the diagnostic yield obtained&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab02.gif"></img></p><p class="elsevierStylePara"><img src="260v39n11-13053339tab03.gif"></img></p><p class="elsevierStylePara">Figure 1&#46; Transbronchial needle aspirations and yields by endoscopist&#46; E1 indicates endoscopist 1&#59; E2&#44; endoscopist 2&#59; E3&#44; endoscopist 3&#59; TBNA99&#44; transbronchial needle aspirations in 1999&#59; TBNA00&#44; transbronchial needle aspirations in 2000&#59; TBNA01&#44; transbronchial needle aspirations in 2001&#59; TBY&#44; transbronchial needle aspiration yield&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Diagnostic Yield for Fiberoptic Bronchoscopy</span></p><p class="elsevierStylePara">CDT led to cytohistological diagnosis in 80&#46;2&#37; of cases and CDT&#43;TBNA gave positive results in 89&#46;7&#37; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;01&#41;&#46; The gain in diagnostic yield continued to be significant for the following lesions&#58; extrinsic compression &#40;CDT&#58; 37&#46;5&#37;&#59; CDT&#43;TBNA&#58; 100&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#61;&#46;01&#41;&#44; submucosal infiltration &#40;CDT&#58; 54&#46;5&#37;&#59; CDT&#43;TBNA&#58; 85&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#61;&#46;03&#41;&#44; and exophytic mass with surface necrosis &#40;CDT&#58; 80&#37;&#58; CDT&#43;TBNB&#58;100&#37;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;01&#41;&#46; Table 4 shows the diagnostic yield by the type of endobronchial lesion and presence of necrosis&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053339tab04.gif"></img></p><p class="elsevierStylePara"><img src="260v39n11-13053339tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Study of Costs</span></p><p class="elsevierStylePara">The mean &#40;SD&#41; cost per disease diagnosed was &#8364; 393&#46;53 &#40;&#8364; 142&#46;04&#41;&#58; &#8364; 381&#46;60 &#40;&#8364; 156&#46;53&#41; with CDT and &#8364; 431&#46;25 &#40;&#8364; 112&#46;91&#41; in CDT&#43;TBNA&#46;</p><p class="elsevierStylePara"> Table 4 shows that the addition of TBNA lowered costs when submucosal disease &#40;CDT&#58;  &#8364;  488&#46;68 &#91;&#8364; 209&#46;44&#93;&#59; CDT&#43;TBNB&#58; &#8364; 419&#46;70 &#91;&#8364; 125&#46;95&#93;&#41;&#44; exophytic mass with necrosis &#40;CDT&#58; &#8364; 386&#46;59 &#91;&#8364; 169&#46;10&#93;&#59; CDT&#43;TBNB&#58; &#8364; 376&#46;74 &#91;&#8364; 24&#46;92&#93;&#41;&#44; and extrinsic compression &#40;CDT&#58;  &#8364;  557&#46;04 &#91;207&#46;56&#93;&#59; CDT&#43;TBNB&#58;  &#8364; 383 &#91;&#8364; 0&#93;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41; were present&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">For the staging of lung carcinoma TBNA has been widely studied and is recommended as part of standard medical practice in various scientific associations&#39; guidelines&#44; the same cannot be said of its use in the diagnosis of an endoscopically visible lesion&#46; Few authors have evaluated its utility in this respect&#46;</p><p class="elsevierStylePara"> TBNA diagnosed malignancy in 85&#46;7&#37; of the patients analyzed retrospectively in the present study and obtained the highest yield of all techniques&#44; proving better than forceps biopsy for all endobronchial anomalies&#46; It was also the only procedure able to establish the diagnosis in 17&#37; of cases&#46; The addition of TBNA to conventional cytology and histology techniques significantly increased the diagnostic yield of the endoscopic exploration by 9&#46;5&#37;&#44; to reach a yield of 89&#46;7&#37;&#46; Increased yield was observed for exophytic mass lesions with surface necrosis&#44; submucosal disease&#44; and extrinsic compression&#46;</p><p class="elsevierStylePara"> Other authors have reported similar results&#46; For example&#44; in a prospective analysis by Govert et al&#44;<span class="elsevierStyleSup">6</span> TBNA showed a sensitivity of 79&#37; for classifying malignancy&#59; TBNA plus forceps biopsy and bronchial brushings positivity increased positivity to 95&#37;&#44; although greatest usefulness of TBNA was observed in extrinsic compression and submucosal infiltration&#46; In a similar study by Dasgupta et al<span class="elsevierStyleSup">7</span> TBNA obtained an overall yield of 85&#37;&#59; TBNA plus forceps biopsy and brushing increased the yield to 96&#37; in cases of exophytic mass lesion&#44; submucosal disease&#44; and extrinsic compression&#46; Similarly&#44; diagnostic yields ranging from 82&#37; to 97&#37; have been reported for submucosal infiltration&#46;<span class="elsevierStyleSup">8&#44;9</span></p><p class="elsevierStylePara">In short&#44; the usefulness of TBNA seems beyond question&#46; Nonetheless&#44; it is important to remember that the aim of a new technique is to increase diagnostic yield and reduce the cost<span class="elsevierStyleSup">10</span> of diagnosing patients with lung carcinoma&#46; According to Govert el al&#44;<span class="elsevierStyleSup">5</span> a cytology diagnosis that increases the yield of endoscopy by 6&#37; is cost effective&#44; and so the regular use of endoscopy seems advisable based on our results and the literature cited&#46; We should also remember that the endoscopist&#180;s aim is to reduce the number of explorations that fail to provide a diagnosis and to avoid the use of additional techniques&#46;<span class="elsevierStyleSup">11</span> Taking all these points into consideration&#44; we analyzed the cost of both endoscopic and nonendoscopic techniques needed for cytohistological typing&#46; Table 4 shows that TBNA combined with other techniques reduces the number of endoscopies failing to provide diagnoses&#44; mainly when the lesion visualized is submucosal infiltration&#44; exophytic mass with necrosis&#44; or extrinsic compression&#46; This is reflected in lower costs&#44; although only in the case of extrinsic compression is the saving significant&#46;</p><p class="elsevierStylePara">Our deduction is based on the assumptions outlined&#44; TBNA meets the necessary requirements for regular use in the diagnosis of bronchogenic carcinoma with visible endoscopic lesions&#46;</p><p class="elsevierStylePara">Our study may suffer from a certain sampling bias given the possibility inherent to its retrospective design that there was a certain degree of variability in the criteria the 3 endoscopists used when describing and interpreting the lesions visualized&#46; Variation in the yield of bronchoscopy might also have been present&#46; Similarly&#44; although the cytology samples were always analyzed by the same pathologist&#44; 2 different groups handled the histology specimens&#46; Nevertheless&#44; in our judgment&#44; the impact on the study results of having different groups was minor&#44; since our endoscopists and pathologists have had solid experience that allowed them to define the anomaly observed in similar ways&#44; with no significant differences among them in diagnostic yield&#46; Furthermore&#44; all the data were collected by the same person using a standard protocol and for the inclusion of a case in the study we required a minimum number of samples to have been taken&#44; following previously established guidelines&#46;</p><p class="elsevierStylePara">In spite of these limitations&#44; we believe that our results are valid and they acquire particular importance for 2 reasons&#58; <span class="elsevierStyleItalic">a</span>&#41; given the importance of factors that have nothing to do with endoscopic exploration&#44; such as an effect of the observer<span class="elsevierStyleSup">12</span> or pathologist in charge&#44; any procedure which helps to optimize the yield of fiberoptic bronchoscopy would be of great assistance&#44; and <span class="elsevierStyleItalic">b</span>&#41; even though the role of TBNA is acknowledged by several expert committees<span class="elsevierStyleSup">13</span> to be quite important&#44; it remains an underutilized technique probably due to a lack of awareness of its advantages&#44; as shown by surveys&#46;<span class="elsevierStyleSup">14&#44;15</span> Further studies that demonstrate the safety and cost effectiveness of the technique will undoubtedly be of great assistance in overcoming this obstacle&#46;</p><p class="elsevierStylePara">We conclude that TBNA is a technique that substantially increases the yield of endoscopic exploration for cases of endobronchial lesions suggestive of neoplasia&#44; with no negative impact on the cost of the diagnostic process&#44; when the lesion corresponds to submucosal disease&#44; exophytic mass with necrosis&#44; or extrinsic compression&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; J&#46;A&#46; Gull&#243;n Blanco&#46;<br></br> P&#233;rez Gald&#243;s&#44; 11&#44; 5&#46;&#186; dcha&#46; 38002 Santa Cruz de Tenerife&#46; Espa&#241;a&#46;<br></br> E-mail&#58; <a href="mailto&#58;jose993&#64;separ&#46;es" class="elsevierStyleCrossRefs">jose993&#64;separ&#46;es</a></p><p class="elsevierStylePara">Manuscript received February 11&#44; 2003&#46;<br></br> Accepted for publication May 27&#44; 2003&#46;</p>"
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            1 => "Bronchogenic carcinoma"
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        "resumen" => "Background&#58; Transbronchial needle aspiration &#40;TBNA&#41; is a bronchoscopic technique whose usefulness in diagnosing endobronchial lesions has not yet been clearly established&#46; Objective&#58; We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased&#44; without a negative impact on diagnostic costs&#44; if TBNA were used in combination with conventional diagnostic techniques &#40;bronchial washings and bronchial brushings and forceps biopsy&#41;&#46; Patients and Methods&#58; The cases of 130 patients diagnosed with bronchogenic carcinoma with endoscopically visible lesions were analyzed retrospectively&#46; All had undergone conventional diagnostic procedures&#59; TBNA was also performed if the bronchoscopist considered it was indicated&#46; The final cost was calculated in euros for each diagnosis as the sum of the cost of the procedures needed to reach the diagnosis&#44; including both endoscopic procedures and others &#40;transthoracic needle aspiration&#44; lymph node biopsy&#41;&#46; Diagnostic yield and costs in cases diagnosed using only conventional techniques were compared to the yield and costs in cases in which both conventional techniques and TBNA were used&#46; Results&#58; TBNA was performed in 49 patients and provided the diagnosis in 85&#46;7&#37;&#46; Conventional techniques led to cytological and histological diagnosis in 80&#46;2&#37; of the cases&#44; and the combination of conventional techniques and TBNA gave a diagnosis in 89&#46;7&#37; &#40;P&#61;&#46;01&#41;&#46; Significant differences were observed in extrinsic compression &#40;conventional 37&#46;5&#37;&#59; conventional&#43;TBNA 100&#37;&#59; P&#61;&#46;01&#41;&#44; submucosal infiltration &#40;conventional 54&#46;6&#37;&#59; conventional&#43;TBNA 85&#37;&#59; P&#61;&#46;03&#41;&#44; and exophytic mass with necrosis &#40;conventional 80&#37;&#59; conventional&#43;TBNA 100&#37;&#59; P&#61;&#46;01&#41;&#46; The mean &#40;SD&#41; cost of diagnosis was E381&#46;60 &#40;E156&#46;53&#41; using conventional techniques and E413&#46;25 &#40;E112&#46;91&#41; for conventional techniques in combination with TBNA&#46; By adding TBNA&#44; costs decreased for diagnoses of submucosal infiltration&#44; exophytic mass with necrosis and extrinsic compression&#44; although the saving was significant only for extrinsic compression&#46; Conclusion&#58; The diagnostic yield of TBNA is high for endoscopically visible bronchial anomalies suggesting neoplasm&#44; particularly when the lesion is due to extrinsic compression&#44; submucosal infiltration&#44; or exophytic mass with necrosis&#46;"
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        "resumen" => "Fundamento&#58; La punci&#243;n transbronquial &#40;PTB&#41; es una t&#233;cnica broncosc&#243;pica cuya utilidad en tumores con lesi&#243;n endobronquial no est&#225; claramente establecida&#46; Objetivo&#58; Con nuestro trabajo pretendemos estudiar si la combinaci&#243;n de la PTB con las t&#233;cnicas diagn&#243;sticas convencionales &#40;aspirado&#44; cepillado y biopsia bronquiales&#41; incrementa el rendimiento de la fibrobroncoscopia&#44; sin repercutir negativamente en el coste econ&#243;mico &#40;CE&#41; del proceso diagn&#243;stico&#46; Pacientes y m&#233;todos&#58; Se analiz&#243; de forma retrospectiva a 130 pacientes diagnosticados de carcinoma broncog&#233;nico con lesi&#243;n endosc&#243;pica visible&#44; a quienes se les practicaron las t&#233;cnicas convencionales&#44; quedando a criterio del broncoscopista responsable la realizaci&#243;n de PTB&#46; Se calcul&#243; el coste final por proceso&#44; en euros&#44; constituido por la suma del coste de los procedimientos necesarios para lograr el diagn&#243;stico&#44; en los que se inclu&#237;an los endosc&#243;picos y otros &#40;punci&#243;n transtor&#225;cica&#44; punci&#243;n-biopsia ganglionar&#41;&#46; Se compararon el rendimiento y el CE entre el grupo de pacientes a los que se practicaron las t&#233;cnicas convencionales &#40;ACB&#41; y aquellos a los que se a&#241;adi&#243; PTB &#40;ACB &#43; PTB&#41;&#46; Resultados&#58; La PTB se realiz&#243; en 49 pacientes y proporcion&#243; el diagn&#243;stico de naturaleza en el 85&#44;7&#37; de los casos&#46; Con ACB se logr&#243; la filiaci&#243;n citohistol&#243;gica en el 80&#44;2&#37; de los casos&#44; y en el 89&#44;7&#37; con ACB &#43; PTB &#40;p &#61; 0&#44;01&#41;&#59; se apreciaron diferencias significativas en&#58; compresi&#243;n extr&#237;nseca &#40;ACB&#58; 37&#44;5&#37;&#59; ACB &#43; PTB&#58; 100&#37;&#59; p &#61; 0&#44;01&#41;&#44; infiltraci&#243;n submucosa &#40;ACB&#58; 54&#44;6&#37;&#59; ACB &#43; PTB&#58; 85&#37;&#59; p &#61; 0&#44;03&#41; y masa exof&#237;tica con necrosis &#40;ACB&#58; 80&#37;&#59; ACB &#43; PTB&#58; 100&#37;&#59; p &#61; 0&#44;01&#41;&#46; El CE medio fue de 381&#44;60 &#177; 156&#44;53 euros en ACB y 413&#44;25 &#177; 112&#44;91 en ACB &#43; PTB&#59; al a&#241;adir la PTB se redujo el CE en infiltraci&#243;n submucosa&#44; masa exof&#237;tica con necrosis y compresi&#243;n extr&#237;nseca&#44; aunque este ahorro s&#243;lo result&#243; significativo en compresi&#243;n extr&#237;nseca&#46; Conclusi&#243;n&#58; La punci&#243;n transbronquial es una t&#233;cnica de elevada rentabilidad en presencia de anomal&#237;as endobronquiales indicativas de neoformaci&#243;n&#44; particularmente cuando la lesi&#243;n visualizada corresponde a compresi&#243;n extr&#237;nseca&#44; infiltraci&#243;n submucosa o masa exof&#237;tica con superficie necr&#243;tica&#46;"
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