Extensive sampling improves preoperative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer: a prospective study in 166 patients.

Abstract

BACKGROUND: The utility of fiberoptic bronchoscopy in the preoperative assessment of patients with esophageal cancer has not been thoroughly investigated. More accurate staging could improve the design of clinical trials and avoid inappropriate surgical decisions in individual patients. STUDY OBJECTIVE: To evaluate the utility of bronchoscopy in the preoperative assessment of airway invasion by supracarinal esophageal cancer. DESIGN: We prospectively analyzed 220 bronchoscopies in 166 consecutive patients with supracarinal esophageal cancer and correlated the findings with operative results and survival. RESULTS: In 126 bronchoscopies (57.3%), no abnormal findings could be seen in the airways. Compared with histologic and cytologic results, the normal macroscopic appearance of the airways had a negative predictive value of 94.4%, but the positive predictive value of all macroscopic abnormalities for the diagnosis of airway invasion was low, particularly after radiation therapy. Endoluminal tumor mass, protrusion of the posterior tracheal wall, and signs of mucosal invasion were visible in 5.9%, 28.6%, and 4.1% of the bronchoscopies, respectively. However, in only 8.6% of the 220 bronchoscopies, cancer invasion was proved by biopsy or cytology. Bronchoscopy with biopsies and brush and washing cytology examinations was the sole decisive staging procedure, enabling the exclusion from surgery because of airway invasion in 18.1% of otherwise potentially operable patients, with an overall accuracy of 93.3% (95% confidence interval, 86.7 to 97.3%). The results of bronchoscopy were falsely negative in six patients, who all underwent surgery after neoadjuvant therapy. CONCLUSIONS: Fiberoptic bronchoscopy with systematic multiple biopsies and brush and washing cytology examinations is an accurate procedure in evaluating the possible invasion of supracarinal esophageal cancer into the airways. Macroscopic findings alone are not reliable; errors in sole bronchoscopic inspection would have resulted in operations that would be unlikely to help the patients or would have inappropriately excluded patients from surgery.