Safety and feasibility of prolonged bronchoscopy involving diagnosis of lung cancer, systematic nodal staging, and fiducial marker placement in a high-risk population.
BACKGROUND
Stereotactic body radiation therapy (SBRT) is considered the standard treatment for medically inoperable early stage lung cancer. Bronchoscopy has shown to be effective in obtaining diagnosis of peripheral lung tumors, staging the mediastinum (with endobronchial ultrasound- EBUS-), and placing fiducial markers (FMs). However, the combination of these 3 procedures in a single bronchoscopy has not been studied. The aim of this study is to describe safety and feasibility of performing diagnosis, systematic nodal staging, and placement of FMs in a single bronchoscopic procedure.


METHODS
Retrospective review of patients who underwent bronchoscopy with diagnosis of peripheral lung cancer, EBUS for nodal staging, and FM placement in a single procedure at Michael E. DeBakey VA Medical Center between January 2011 and July 2015.


RESULTS
Twenty-one patients met our criteria, one having 2 synchronous tumors. 95% of patients had an ASA score of at least 3. Twenty-two tumors were diagnosed with a size of 2.72±1.06 cm. Distance from pleura was 1.33±1.42 cm. Median duration of bronchoscopy was 96 minutes (range, 75 to 136 minutes). Guided-bronchoscopy provided diagnosis of lung cancer in all cases. Fluoroscopy and RP-EBUS were utilized in 21 patients, "hybrid" scope in 14, and electromagnetic navigational bronchoscopy in 3. A total of 100 lymph nodes (LN) were sampled with EBUS-TBNA, with 95% of the patients having at least 4 LN sampled. A total of 71 FM were placed for 22 tumors. All markers were retained and allowed for successful SBRT. There were no pneumothoraces and no major complications.


CONCLUSIONS
Although it results in lengthy procedures, a single bronchoscopy obtaining diagnosis of peripheral lung nodules, systematic nodal staging, and FM placement can be safely performed in high-risk patients. Our "all-in-one" strategy could potentially expedite treatment, decrease complications, and reduce costs. Further prospective studies are needed to corroborate our findings.
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Harman
H
Kular
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Lakshmi
L
Mudambi
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Donald R
DR
Lazarus
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Lorraine
L
Cornwell
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Angela
A
Zhu
1 Section of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA ; 2 Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA ; 3 Division of Cardiothoracic Surgery, Michael E. DeBakey, Department of Surgery, 4 Department of Radiation Oncology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA.
Roberto F
RF
Casal
Lung cancer; bronchoscopy; interventional techniques