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Ann Thorac Surg 2004;77:1774-1780
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Accuracy of virtual bronchoscopy to detect endobronchial lesions

^a Centre de Recherche, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l'Université Laval, Sainte-Foy, Québec, Canada
^b Department of Radiology, Hôpital Laval, Institut Universitaire de Cardiologie et de Pneumologie de l'Université Laval, Sainte-Foy, Québec, Canada

Accepted for publication October 20, 2003.

^* Address reprint requests to Dr Lacasse, Centre de Pneumologie, Hôpital Laval, 2725 Chemin Ste-Foy, Sainte-Foy, Quebec G1V 4G5, Canada
e-mail: yves.lacasse{at}med.ulaval.ca

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
BACKGROUND: Virtual bronchoscopy (VB) could obviate flexible bronchoscopy (FB) if no endobronchial lesion is detected in patients presenting with a suspicion of malignancy. Our objectives were to evaluate the accuracy (in terms of sensitivity and specificity) of VB in detecting endobronchial lesions, and to determine the anatomical limit of detection of endobronchial lesions by VB.

METHODS: This study involved, in a blind comparison of VB and FB, consecutive patients presenting with symptoms or plain chest radiography abnormalities raising the suspicion of pulmonary neoplasm. After the standard chest computed tomography (CT), additional helical CT data were acquired from the aortic arch to the origin of the segmental bronchi of the inferior lobes in one 20-second breath hold using an helicoidal CT scan (3.0-mm collimation with a pitch of 1.5 and 1.5-mm reconstruction intervals).

RESULTS: One hundred ninety patients were enrolled; 136 patients (including 63 with an endobronchial lesion at FB) contributed to the primary analysis. The sensitivity and specificity of VB to detect endobronchial lesions were 68% (95% confidence interval [CI]: 55% to 79%) and 90% (95% CI: 81% to 96%), respectively. Overall, the agreement between VB and FB regarding the location on endobronchial lesions was substantial (weighted kappa: 0.66). However, VB detected only 26 of the 34 lobar lesions (sensitivity: 76%; CI: 59% to 89%) and 11 of the 23 segmental lesions (sensitivity: 48%; CI: 27% to 69%).

CONCLUSIONS: Beyond the mainstem bronchi, VB is not accurate enough to detect endobronchial lesions and to obviate FB in patients presenting with a suspicion of malignancy.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The development of flexible bronchoscopy (FB) brought about revolutionary changes in the investigation of patients in whom lung cancer is suspected [1, 2]. Most often, it is indicated for diagnostic purposes, to evaluate lung lesions of unknown etiology that appear on the chest roentgenogram, to investigate unexplained hemoptysis, or to search for the origin of positive sputum cytology [3]. When the lesion is malignant and central, that is, when it is located in large airway and visible at bronchoscopy, FB provides a histologic diagnosis of lung cancer in up to 90% of cases [4, 5]. However, the role and cost-benefit of FB in the investigation of peripheral lesions is more controversial [6–8]. In such circumstances, the sensitivity of cytology for the diagnosis of lung cancer is not more than 40% [6]. Nevertheless, FB is still widely performed whatever the location of the lesion, as it detects another endobronchial lesion in as many as 7% of patients with lung cancer [9].

Recently, technologic advances in medical imaging permitted the introduction of tridimensional exploration of the bronchial tree [10]. The images obtained through volumetric (helical or spiral) chest computed tomography (CT) can be used to reconstruct in three dimensions the bronchial tree. Virtual bronchoscopy (VB) allows the navigation in the airways and the exact location of endobronchial lesions in relation to extrabronchial structures [11]. Virtual bronchoscopy has the potential to identify those patients with an endobronchial lesion that is accessible to FB [12]. We hypothesized that VB could obviate flexible bronchoscopy (FB) if no endobronchial lesion is detected in patients presenting with a suspicion of malignancy [13]. The objective of this study was to evaluate the accuracy (in terms of sensitivity and specificity) of virtual bronchoscopy in the detection of endobronchial lesion. Secondarily, we sought to determine the anatomical limit of detection of endobronchial lesions by VB.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patients
This prospective study was conducted at the Respiratory Clinic and Pulmonary Oncology Clinic of Laval Hospital (Quebec City). We included consecutive patients for whom a FB and a chest CT scan were ordered for the initial investigation of symptoms or plain chest radiography abnormalities raising the suspicion of pulmonary neoplasm. We excluded (1) patients in whom the bronchoscopy will be done for therapeutic purposes (bronchoaspiration); (2) patients with a history of pulmonary resection; (3) referred patients in whom the CT scan was done in another institution; and (4) patients who did not consent to participate in the study. The study protocol was approved by our local ethics committee. We obtained written consent from the patients before any procedure.

Virtual bronchoscopy
The images needed to reconstruct VB were acquired at the same time as the chest CT scan ordered for the usual investigation of the suspected pulmonary lesion. Because the infusion of medium contrast material creates artifacts [14], the standard contrast CT was first done by using a single-detector helical CT scanner (GE LightSpeed, Milwaukee, WI) with the following protocol: 7.0-mm collimation, 1.7 pitch, 120 kV, 240 mA, 0.8 second tube rotation. Then, within 5 minutes to allow the dilution of the contrast medium into the circulation, additional helical CT data for VB were obtained from the aortic arch to the origin of the segmental bronchi of the inferior lobes in one 20-second breath hold. Scans consisted of 3.0-mm roentgenogram beam collimation (slice thickness) with a pitch of 1.5 and 1.5-mm reconstruction intervals. Endoscopic views were obtained with the Navigator software (GE Medical Systems, Milwaukee, WI). All data were recorded on optical disks. Radiation exposure was estimated to be about 25% to 50% more than with a conventional thoracic CT scan.

All images were interpreted on the computer station by a pair of pulmonologists who performed the bronchoscopies (Y.L. and B.R., Y.L. and S.M., or B.R. and S.M.). Consensus was reached on site. The readers were masked to the patients' history and to results of FB and final diagnosis. However, the corresponding axial CT slices and multiplanar reconstructions were available at the time of the VB asessment. We used the scheme of interpretation described by Finkelstein and associates [15] for data analysis: the presence and location of an obstructive lesion (defined as bronchial narrowing of > 50%) or endoluminal mass (defined as a mass protruding into the lumen with 50% occlusion) or mucosal abnormalities were noted. In addition, we noted the quality of each VB: it was deemed of good quality when it allowed the inspection of all segmental bronchi at the location of a lesion seen on the axial slices in addition to all lobar bronchi without artifacts; otherwise, the VB was deemed of bad quality.

Reference standard: flexible bronchoscopy
Flexible bronchoscopy was considered the reference test from which we determined the presence or absence of endobronchial lesion when describing division of the patients into cases and controls, respectively. The technique was performed by the attending pulmonologist using Olympus BF-P200 bronchoscopes under electrocardiographic and pulse oxygen saturation monitoring and, in some cases, under light sedation according to the treating physician's prescription. Local anesthesia was first given at the level of the superior airways (nose and throat). The bronchial tree was explored systematically (trachea, mainstem bronchi, lobar and segmental bronchi) before any biopsy was performed to avoid any endobronchial bleeding making the remaining of the exploration difficult. The flexible bronchoscopies were all recorded on videotape for subsequent reassessment by a second pulmonologist who was not aware of the clinical characteristics of the patient. Any disagreement between the two pulmonologists was resolved by consensus. The pulmonologists involved in the FB interpretation were different from those involved in the VB interpretation. We also used the scheme of interpretation described by Finkelstein and associates [15] for data analysis: the presence and location of an obstructive lesion, endoluminal mass (defined above), or mucosal lesions (hemorrhage, erythema, or tissue friability) were recorded. The order in which both procedures were performed was not protocol-based and did not matter. We noted the length of time between VB and FB.

Statistical analysis
Descriptive statistics
Descriptive statistics (proportions, median and interquartile range, or mean, standard deviations [SD] and associated 95% confidence intervals [95% CI] when appropriate) were used to describe the study population.

Sensitivity and specificity
Our cohort of patients represented a wide spectrum of diseases and divided by itself in two groups according to the presence (cases) or the absence (controls) of endobronchial lesions [16]. The VB results were compared with those of FB, whatever the location of the lesion. For instance, a lesion localized in the middle lobe bronchi at the virtual bronchoscopy could be actually located in the right upper lobe bronchi. In such a circumstance, the VB was considered as a "true positive" since it will have identified a patient for whom FB is indicated. We computed the sensitivity (the proportion of patients with an endobronchial lesion at FB in whom VB was positive), specificity (the proportion of patients with no endobronchial lesion at FB in whom VB was negative), positive predictive value (the proportion of patients with an endobronchial lesion at VB in whom FB was positive) and negative predictive value (the proportion of patients with no endobronchial lesion at VB in whom FB was negative) of VB and associated 95% CI.

Uninterpretable virtual bronchoscopies
In addition, in order to take into account the uninterpretable VB (ie, VB that failed to meet the minimum standards specified for their performance), we conducted a secondary analysis according to the method described by Simel and associates [17]. In this analysis, the positive yield of VB is the probability of a positive or negative result when disease is present. The negative yield of VB is the probability of a positive or a negative result when disease is absent. We then computed the "worst case sensitivity" (ie, the sensitivity obtained when uninterpretable results are combined with negative results) and the "worst case specificity" (ie, the specificity obtained when uninterpretable results are combnined with positive results) as follows: worst case sensitivity = sensitivity x positive yield; worst case specificity = specificity x negative yield.

Anatomical limit of detection
We determined the concordance between the location of the lesion detected at VB and the actual location of the lesions detected at FB as follows. Each lesion was classified according to its location both at VB and FB (trachea, mainstem, lobar, or segmental bronchi). The agreement between VB and FB was calculated using the weighted kappa statistic. We qualified a priori the magnitude of the agreement as follows: a kappa ranging from 0 to 0.20 would denote a slight agreement; 0.21 to 0.40, a fair agreement; 0.41 to 0.60, a moderate agreement, and larger than 0.60, a substantial agreement [18]. We also computed the sensitivity of VB for each of anatomical level.

Sample size
We determined the sample size needed according to the desired precision of the expected values of sensitivity [19]. Since the main objective of this study was to identify the patients who would really benefit from flexible bronchoscopy, we assumed that all the endobronchial lesions should be detected. We therefore calculated that 60 patients with an endobronchial lesion should be studied if the lower bound of the 95% CI around the sensitivity estimate is to exclude 95%. Before our study, we conducted a retrospective chart review that indicated that, during the preceding year, 1 patient out of 3 submitted to both FB and chest CT scan for the initial investigation of symptoms or plain chest radiography abnormalities raising the suspicion of pulmonary neoplasm was actually found to have an endobronchial lesion at FB. Accordingly, 180 patients were needed to complete this study.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Population
Between April 2001 and September 2002, 190 consecutive patients were included. The data from 27 patients (14%) were excluded because of optical disk failure making the VB unaccessible for reviewing. One patient refused FB whereas the CT scan was cancelled after FB in another. Therefore, 161 had both FB and VB available for analysis. Twenty-five of these (16%; 95% CI: 10% to 22%) were deemed of poor quality, leaving 136 patients (96 men [71%]; mean age: 63 years [SD: 10]) to contribute to the primary analysis (Fig 1). The mean time interval between FB and VB was 6 days (SD: 5). No adverse effect resulted either from FB or VB.

View larger version (19K): [in this window] [in a new window]   Fig 1. Flow diagram of the study. (FB = flexible bronchoscopy; VB = virtual bronchoscopy.)

Anatomical limit of detection of VB
Overall, the agreement between VB and FB regarding the location on endobronchial lesions was substantial (weighted kappa: 0.66; 95% CI: 0.49 to 0.82; Table 5). Virtual bronchoscopy detected all 6 lesions located either in trachea or in a main stem bronchi. However, VB detected only 26 of the 34 lobar lesions (sensitivity: 76%; CI: 59% to 89%) and 11 of the 23 segmental lesions (sensitivity: 48%; CI: 27% to 69%). Typical examples of correlations between VB and FB images are presented in Figure 2.

View larger version (112K): [in this window] [in a new window]   Fig 2. Correlation between flexible (left column) and virtual (right column) bronchoscopies. (Top) Extrinsic compression by a large tumor of the right upper lobe causing complete obstruction of the right main bronchus; the compression is well demonstrated by virtual bronchoscopy. (Middle) Obstructive lesion of the left upper lobe; the lingula is free of lesion; the lesion is well demonstrated by virtual bronchoscopy. (Bottom) Neoplastic lesion obstructing the anterior and apical segments of the right upper lobe; the lesion is not well demonstrated by virtual bronchoscopy.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Our study was preceded by a number of enthusiastic reports of the accuracy of VB in detecting endoluminal lesions [13, 15, 20–27]. All reported on small cohorts of patients most often selected on the basis of a known endoluminal lesion (Table 6). The latest published was by Finkelstein and collaborators [15]. Their study differed from ours in that 1.25-mm section intervals were obtained from a multidetector helical CT scanner. Twenty patients with thoracic malignant disease contributed to the analysis, including 7 with no lesion at FB. All 7 had normal VB (specificity: 100%). The authors reported that VB detected 18 of 22 abnormal FB findings (all 13 obstructive lesions, 5 of 6 endoluminal lesions, and none of 3 mucosal lesions). When analyzed on a per-lesion basis, the sensitivity of VB was 82%. The authors did not provide any data on the location of the lesions at VB and any confidence intervals around their estimate of sensitivity and specificity. We computed them and obtained a 95% CI around the sensitivity of 60% to 95%, and a 95% CI around the specificity of 59% to 100%. When analyzed on a per-patient basis (as we did), VB detected an endobronchial lesion in 11 of their 13 patients who had one (sensitivity: 85%; 95% CI: 55% to 98%). These wide confidence intervals indicate much uncertainty around the estimates.

It is likely that the forthcoming multidetector helical CT scanners will improve the accuracy of VB to detect endobronchial lesions. Nevertheless, an obvious limitation of VB is that, whatever the quality of the images obtained, it will never enable acquisition of tissue material for cytologic or histologic analysis. Our data demonstrated that even when no endobronchial lesion is seen at FB in patients ultimately diagnosed with thoracic malignancy, FB provides a diagnosis in 36% (data not shown). Another limitation of VB over FB is that it is not as sensitive as actual endoscopy in detecting the cause of dynamic airway obstruction [23].

Is VB a diagnostic tool or a medical toy? The same question was asked 25 years ago about FB which has now become a routine procedure [1]. We conclude that VB is not accurate enough to detect endobronchial lesions and to obviate FB in patients presenting with a suspicion of malignancy. On the other hand, we submit that VB may be useful in a variety of clinical circumstances and may supplement FB in many situations. Virtual bronchoscopy visualizes areas beyond even high-grades stenoses. It may guide bronchoscopic biopsies, surgical interventions and palliative therapy (such as laser or photodynamic techniques) [13, 15]. It may represent an objective method for sequentially evaluating endobronchial abnormalities and assess treatment responses [15]. It may be helpful for postoperative follow-up examinations, such as after stent implantation [26, 28], or to design custom-made tracheotomy cannula [29]. It has been suggested as a method of detection of bronchial anastomotic complication in lung transplant recipients [30]. Virtual bronchoscopy may also be used for endoscopy training. These potential indications await further clinical assessment.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The authors would like to thank Céline Lepage, RN, Diane Page, RN, and Gaétane Racine, RN (research assistants), the CT technologists of Laval Hospital (Gisèle Deshaies, Éric Joubert, Anita Leblanc, Jacqueline Lepage, Linda Marcotte, and Jacinthe Rondeau) who kindly collaborated on our study, and Sylvie Martin, MS, for the data management. This study was supported by the Quebec Lung Association and the Fondation J. D. Bégin, Université Laval, Québec, Canada. Yves Lacasse is a clinician scientist of the Fonds de la recherche en santé du Québec.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Taylor F.H., Evangelist F.A., Barham B.F. The flexible fiberoptic bronchoscope: diagnostic tool or medical toy?. Ann Thorac Surg 1980;29:546-550.[Abstract]
2. Sackner M.A. State of the art: bronchofiberscopy. Am Rev Respir Dis 1975;111:62-88.[Medline]
3. American Thoracic Society. Guidelines for fiberoptic bronchoscopy in adults. Am Rev Respir Dis 1987;136:1066.[Medline]
4. McLean A.N., Semple P.D.A., Franklin D.H., Petrie G., Millar E.A., Douglas J.G. The Scottish multi-centre prospective study of bronchoscopy for bronchial carcinoma and suggested audit standards. Respir Med 1998;92:1110-1115.[Medline]
5. Popovich J., Kvale P., Eichenhorn M.S., Radke J.R., Ohorodnik J.M., Fine G. Diagnostic accuracy of multiple biospies from flexible fiberoptic bronchoscopy: a comparison of central vs. peripheral bronchial carcinoma. Am Rev Respir Dis 1982;125:521-523.[Medline]
6. Arroliga A.C., Matthay R.A. The role of bronchoscopy in lung cancer. Clin Chest Med 1993;14:87-98.[Medline]
7. Goldberg-Kahn B., Healy J.C., Bishop J.W. The cost of diagnosis: a comparison of four different strategies in the workup of solitary radiographic lung lesions. Chest 1997;111:870-876.[Abstract/Free Full Text]
8. Goldberg S.K., Walkenstein M.D., Steinbach A., et al. The role of staging bronchoscopie in the preoperative assessment of a solitary pulmonary nodule. Chest 1993;104:94-97.[Abstract/Free Full Text]
9. Woolner L.B., Fontana R.S., Cortese D.A., et al. Roentgenographically occult lung cancer: pathologic findings and frequency of multicentricity during a 10-year period. Mayo Clinic Proc 1984;59:453-466.[Medline]
10. Higgins W.E., Ramaswamy K., Swift R.D., et al. Virtual bronchoscopy for three-dimensional pulmonary image assessment: state of the art and future needs. Radiographics 1998;18:761-778.[Abstract]
11. Aquino S.L., Vining D.J. Virtual bronchoscopy. Clin Chest Med 1999;20:725-730.[Medline]
12. Ahmad M., Dweik R.A. Future of flexible bronchoscopy. Clin Chest Med 1999;20:1-17.[Medline]
13. Seeman M.D., Claussen C.D. Hybrid 3D visualization of the chest and virtual endoscopy of the tracheobronchial system: possibilities and limitations of clinical application. Lung Cancer 2001;32:237-246.[Medline]
14. Cesarani F., Martina M.C., Cassinis M.C., Gandini G. A virtual endoscopy artifact. AJR Am J Roentgenol 2002;178:1573.[Free Full Text]
15. Finkelstein S.E., Summers R.M., Nguyen D.M., Stewart J.H., Tretler J.A., Schrump D.S. Virtual bronchoscopy for evaluation of malignant tumors of the thorax. J Thorac Cardiovasc Surg 2002;123:967-972.[Abstract/Free Full Text]
16. Jaeschke R., Guyatt G.H., Sacket D.L. Users' guide to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid?. JAMA 1994;271:389-391.[Abstract/Free Full Text]
17. Simel D.L., Feussner J.R., Delong E.R., Matchar D.B. Intermediate, indeterminate, and uninterpretable diagnostic test results. Med Decis Making 1987;7:107-114.
18. Kramer M.S., Feinstein A.R. Clinical biostatistics. LIV. The biostatistics of concordance. Clin Pharmacol Ther 1981;29:111-123.[Medline]
19. Simel D.L., Samsa G.P., Matchar D.B. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol 1991;44:763-770.[Medline]
20. Hoppe H., Walder B., Sonnenschein M., Vock P., Dinkel H.P. Multidetector CT virtual bronchoscopy to grade tracheobronchial stenosis. AJR Am J Roentgenol 2002;178:1195-1200.[Abstract/Free Full Text]
21. Rapp-Bernhardt U., Welte T., Doehring W., Kropf S., Bernhardt T.M. Diagnostic potential of virtual bronchoscopy: advantages in comparison with axial CT slices, MPR and mIP?. Eur Radiol 2000;10:981-988.[Medline]
22. Xiong M., Zhang W., Wang D., Xu J. CT virtual bronchoscopy: imaging method and clinical application. Chinese Med J 2000;113:1022-1025.
23. Burke A.J., Vining D.J., McGuirt W.F., Postma G., Browne J.D. Evaluation of airway obstruction using virtual endoscopy. Laryngoscope 2000;110:23-29.[Medline]
24. Liewald F., Lang G., Fleiter T., Sokiranski R., Halter G., Orend K.H. Comparison of virtual and fiberoptic bronchoscopy. Thorac Cardiovasc Surg 1998;46:361-364.[Medline]
25. Ferretti G.R., Knoplioch J., Bricault I., Brambilla C., Coulomb M. Central airway stenoses: preliminary results of spiral-CT-generated virtual bronchoscopy simulations in 29 patients. Eur Radiol 1997;7:854-859.[Medline]
26. Fleiter T., Merkle E.M., Aschoff A.J., et al. Comparison of real-time virtual and fiberoptic bronchoscopy in patients with bronchial carcinoma: opportunities and limitations. AJR Am J Roentgenol 1997;169:1591-1595.[Abstract/Free Full Text]
27. Vining D.J., Liu K., Choplin R.H., Haponik E.F. Virtual bronchoscopy. Relationship of virtual reality endobronchial simulations to actual bronchoscopic findings. Chest 1996;109:549-553.[Abstract/Free Full Text]
28. Ferretti G.R., Kocier M., Calaque O., et al. Follow-up after stent insertion in the tracheobronchial tree: role of helical computed tomography in comparison with fiberoptic bronchoscopy. Eur Radiol 2003;13:1172-1178.[Medline]
29. Sichel J.Y., Attal P., Dano I., Eliashar R. Custom-made tracheostomy cannula designed by the assistance of virtual bronchoscopy. Laryngoscope 2003;113:760-762.[Medline]
30. McAdams H.P., Palmer S.M., Erasmus J.J., et al. Bronchial anastomotic complications in lung transplant recipients: virtual bronchscopy for noninvasive assessment. Radiology 1998;209:689-695.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yves Lacasse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lacasse, Y. Articles by Raby, B. Search for Related Content PubMed PubMed Citation Articles by Lacasse, Y. Articles by Raby, B. Related Collections Trachea and bronchi