Extensive sampling improves preoperative bronchoscopic assessment of airway invasion by supracarinal esophageal cancer - A prospective study in 166 patients

Background: The utility of fiberoptic bronchoscopy in the preoperative asse ssment of patients with esophageal cancer has not been thoroughly investiga ted, 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 preoperativ e assessment of airway invasion by supracarinal esophageal cancer, Design: We prospectively analyzed 220 bronchoscopies in 166 consecutive pat ients 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 the rapy, Endoluminal tumor mass, protrusion of the posterior tracheal wall, an d signs of mucosal invasion were visible in 5.9%, 28.6%, and 4.1% of the br onchoscopies, respectively. However, in only 8.6% of the 220 bronchoscopies , cancer invasion was proved by biopsy or cytology, Bronchoscopy with biops ies and brush and washing cytology examinations was the sole decisive stagi ng procedure, enabling the exclusion from surgery because of airway invasio n in 18.1% of otherwise potentially operable patients, with an overall accu racy of 93.3% (95% confidence interval, 86.7 to 97,3%), The results of bron choscopy were falsely negative in six patients, who all underwent surgery a fter neoadjuvant therapy, Conclusions: Fiberoptic bronchoscopy with systematic multiple biopsies and brush and washing cytology examinations is an accurate procedure in evaluat ing the possible invasion of supracarinal esophageal cancer into the airway s. Macroscopic findings alone are not reliable; errors in sole bronchoscopi c inspection would have resulted in operations that would be unlikely to he lp the patients or would have inappropriately excluded patients from surger y.