title: Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients.
abstract: BACKGROUND
  Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification.
  
  
  METHODS
  We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis.
  
  
  RESULTS
  Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44).
  
  
  CONCLUSIONS
  Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.
authors.affiliation: Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China.
authors.forename: Xin
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China.
authors.forename: Yukun
authors.initials: Y
authors.lastname: Kuang
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Department of Medical Oncology, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Kai
authors.initials: K
authors.lastname: He
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Noah
authors.initials: N
authors.lastname: Lechtzin
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: Mingying
authors.initials: M
authors.lastname: Zeng
authors.affiliation: Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Greater Baltimore Medical Center, Towson, Maryland, USA.
authors.forename: Rex C
authors.initials: RC
authors.lastname: Yung
authors.affiliation: Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China.
authors.forename: Canmao
authors.initials: C
authors.lastname: Xie
keywords: Thoracic malignancies; bronchoalveolar lavage (BAL); bronchoscopy; lower respiratory tract infections (LRTIs); peripheral lung lesion