Outcomes of Suspected Thoracic Malignancy Patients with Initial non-Diagnostic Bronchoscopy

: Introduction: Introduction: One of the most common causes of cancer-related mortality is lung cancer, and bronchoscopy is a crucial diagnostic procedure for the disease. The characteristics of the patient, chest imaging, the existence of an endobronchial lesion, and the diagnostic methods used all affect the bronchoscope's diagnostic yield. Aim of the study: Assessment of the outcome of patients who suspected thoracic malignancy with an initial non-diagnostic bronchoscope and evaluate the predictive value of diagnostic bronchoscopy. Subjects and Methods: This was a retrospective cohort study conducted at the chest department, Fayoum University Hospital during the period of January 2021 to January 2023 on all adult patients who suspected thoracic malignancy and underwent flexible fiberoptic bronchoscopy with transbronchial biopsies or endobronchial biopsies and the undiagnosed patients were followed up. Results: Our study was held on 175 patients who were suspected to have thoracic malignancy. 89(50.9%) patients were diagnosed by bronchoscopy, and 86(49%) patients were not diagnosed by bronchoscopy. From the diagnostic group (96.7%) had malignancy and (3.3%) had another diagnosis, but in the non-diagnostic group (82.6%) had malignancy, (6.9%) had other diagnosis, (5.8%) resolved on follow-up and (4.7%) lost to follow. Conclusions: The flexible bronchoscopy technique is a safe procedure with high diagnostic yield in patients suspected of thoracic malignancy and an increased chance of diagnosis in patients with hemoptysis, lung mass and endobronchial lesions. Patients who have a non-diagnostic bronchoscopy should be closely monitored. when necessary, ordering additional diagnostic tests.


Introduction
Lung cancer accounts for the majority of cancer-related fatalities globally, with a 17% 5year survival rate following diagnosis [1].Those who receive a diagnosis at an advanced stage typically have a very bad prognosis; in contrast, those who receive a diagnosis at an earlier stage have a 5-year survival rate of >70% [2].
Cigarette smoking habits are closely associated with both the incidence and death of lung cancer [3].One of the variables influencing the prognosis and course of treatment for lung cancer is lung cancer staging, which is an evaluation of the extent to which the cancer has spread from its original site [4].

Through
screening programs, individuals who do not yet exhibit signs of lung cancer may have their lung tumors discovered early enough to be effectively treated and have a lower death rate [5].
The flexible fiberoptic bronchoscope [FFB] is an important diagnostic tool for lung disorders.The indications and the diagnostic methods used determine the diagnostic yield of FFB [6].
For medical professionals treating patients with lung disorders, bronchoscopy is a vital tool.Ever since Shigeto Ikeda introduced flexible bronchoscopy to clinical practice in 1966, it has become a vital diagnostic and therapeutic tool for patients with lung illnesses [7].
So, the current study aimed to assess the outcome of patients who suspected thoracic malignancy with an initial non-diagnostic bronchoscope and evaluate the predictive value of diagnostic bronchoscopy.

Subjects
This was a retrospective cohort study conducted at the chest department, Fayoum university hospital during the period of January 2021 to January 2023on all adult patients who suspected thoracic malignancy and underwent (FFB) with transbronchial biopsy (TBB), endobronchial biopsy (EBB).The diagnostic yield of the bronchoscope was defined as the ratio of the total number of diagnosed patients to the total number of patients undergoing the procedure.Undiagnosed Patients were followed after a bronchoscope.
All adult patients who suspected thoracic malignancy and underwent bronchoscopy with the following criteria of inclusion and exclusion.

Inclusion criteria
Those included all patients who suspected thoracic malignancy and fit for performing bronchoscope.

Exclusion criteria
All patients who underwent inspection bronchoscopy or bronchoalveolar lavage [BAL] only as these methods have low diagnostic value in lung cancer, who were not fit for performing bronchoscope as in the acute respiratory failure

Methods
The  CT-chest report.
 Bronchoscopy report include (bronchoscopy finding and way of biopsy) (Figure 1A). CT chest guided biopsy using a true cut needle biopsy.
 Thoracoscopy used for non-diagnostic patients who developed pleural effusion.

Statistical methods
Data were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA).Data was summarized using mean and standard deviation for quantitative variables and frequencies (number of cases) and relative frequencies [percentages] for two categorical variables.Comparisons between groups were done using an unpaired t-test [8].For comparing categorical data, a Chi-square test was performed.An exact test was used instead when the expected frequency was less than 5 [9].
Logistic regression was done to detect independent predictors of the diagnostic group [10].P-values less than 0.05 were considered statistically significant.

Results
Our study was held on 175 patients who were suspected to have thoracic malignancy.The following flow chart is the summary of different outcomes (Figure 4).

Discussion
Lung cancer remains the primary cause of cancer-related fatalities in both men and women worldwide [11].The flexible fiberoptic bronchoscope (FFB) is an important diagnostic tool for lung conditions.The indications and diagnostic methods used determine the diagnostic yield of FFB [6].
The flexible bronchoscope has become the recommended procedure for all patients suspected of having bronchogenic carcinoma, showing a sensitivity for central airway lesions of 88% and an overall sensitivity for all modalities in the diagnosis of peripheral disease of 78%, varying from 36% to 88% according to the biopsy method used [12].Furthermore, it allows for correct surgical planning through the evaluation of the surface, site, and extent of the tumor, vocal cord motility, and airway lumen [13].
In this study, we reported the follow-up and outcomes of patients who had a nondiagnostic bronchoscopy.In addition, we compared diagnostic and non-diagnostic bronchoscopies and evaluated the predictors for a diagnostic bronchoscopy.between the two groups [17].
In with us, finding that in their study, squamous cell carcinoma was the most common type (51%), followed by small cell carcinoma (27%) and adenocarcinoma (5.6%) [18].Gaddam et al.
In our study, during the follow-up of the non-diagnostic group, 4.6% were lost to followup, and 5.8% of patients suspected of thoracic malignancy and with an initial non-diagnostic bronchoscopy had the lesion resolved on followup.This mismatched with Gaddam et al. (2020), who found that 54% of the non-diagnostic group were lost to follow-up, and 32% of these patients had a resolved lesion on follow-up [15].
There are various advantages to our study.First, there was a precise description of a diagnostic and non-diagnostic bronchoscope.
Second, it is one of the few studies examining the results of non-diagnostic bronchoscopy patients and following them, providing fresh information on the outcomes of these operations.
In order to find characteristics indicative of a diagnostic process, we looked at the link between clinical and radiological markers in our third analysis.

Conclusion
Flexible fiberoptic bronchoscopy is a safe procedure with a high diagnostic yield in patients suspected of thoracic malignancy.It This was a single retrospective study in an innercity community university hospital, so most patients had unique demographic features.
Bronchoscopies were performed by multiple operators, which may lead to differences in the yield of the procedures.Although multiple attempts to contact patients with an initial nondiagnostic bronchoscopy were made, some patients were lost to follow-up.The number of bronchoscopy biopsies taken was not documented in the bronchoscopy report.
Methods of bronchoscopy biopsies were limited to EBBX and TBBX, with EBUS or TBNA biopsies not available.We recommend further studies on a larger number of patients using various methods of bronchoscopy biopsies.
Further studies are needed to evaluate the relation between the number of bronchoscopy biopsies and the outcome of diagnostic bronchoscopy.
Ethical approval: This study was reviewed by the faculty of medicine Research Ethical committee in Fayoum university hospital numbered (M 657) in its session (104).

[
unless the patient is intubated and mechanically ventilated], with uncorrected coagulation profile, and with life-threatening cardiac arrhythmias were excluded Medical consent was taken from all participants.

Figure 4 :
Figure 4: Flow chart show outcome of initial bronchoscopy.
increases the chance of diagnosis in patients with lung mass, endobronchial lesions, or those who presented with hemoptysis.The clinical implications for the pulmonologist are to follow patients with a non-diagnostic procedure and to perform further diagnostic tests when indicated.

shown in Figure 2. Figure 2: Diagnostic
and non-diagnostic groups.

Table 2 .Table 2 :
Symptomatology of the study groups.
chest] of the study groups including lung mass, bilateral nodules, pleural effusion, un-resolving pneumonia and cavitary lesion, there is only a statistically significant difference in lung mass which represent [94.4%) in diagnostic group and [84.9%) in non-diagnostic group as shown in

Table 3 .Table 3 :
Radiological findings in the study groups.

Table 4 :
Bronchoscopy finding of the study groups.
Transbronchial biopsy represent [46.1%) of diagnostic group and [96.5%) in non-diagnostic group.While endobronchial biopsy had high diagnostic yield represent [53.9%) of diagnostic group and [3.5%) of non-diagnostic group as shown in Table 5.

Table 5 :
Comparison between diagnostic and non-diagnostic group according to bronchoscopy procedures.
diagnosed by thoracoscopy as shown in Table6.

Table 6 :
Methods of diagnosis in non-diagnostic group

Table 7 :
Histopathology in the group diagnosed by bronchoscope.

Table 8 :
Histopathology in the group not diagnosed by bronchoscope.