Diagnostic procedures in lung cancer.

W hen a suspicious lesion is noted on the chest x-ray film, a battery of procedures is employed to establish the diagnosis and extent of the disease. Bronchoscopy; lymph node biopsy, biopsy of the lesion; liver, bone and brain scanning; and efforts to determine if the lesion is primary or metastatic are all used in careful selection and staging. This discussion is limited to a brief review of surgical diagnostic procedures. Bronchoscopy The rigid bronchoscope is preferred for diagnosis of central lesions because the rigidity of the carina and displacement of the stem bronchus may be better assessed. Bronchial washings and biopsies are easily taken through the larger lumen. Rigid bronchoscopy is performed usually under general anesthesia with a ventilating bronchoscope. A right angle lens permits visualization into the upper lobes. Although saline solution washings for cytology collected at bronchoscopy are usually diagnostic, spu-tum collected for cytology for the following 48 hours will often produce the most fruitful specimens. The flexible fiberoptic bronchoscope has advantages over the rigid bronchoscope, and most surgeons are using it now, particularly in more peripheral lesions. Often, it can pass constricted or distorted areas of the bronchus. Patients tolerate it quite well with local anesthesia. The flexible bron-choscope allows subsegmental visualization. Particularly in upper lobe lesions, it is very helpful in biopsy and brushing in the distal bronchi. Direct bronchial biopsies and segmental brushing performed with the flexible bronchoscope have yielded the highest positive results.1-3 Recently, in those rare cases with positive cytology and a normal chest x-ray film, selective brushing of each segment has been helpful in detecting occult lung cancer. Our standard technique is to perform flexible bronchoscopy through a large endotracheal tube using an adapter that gives an airtight seal, so the anesthesiologist can ventilate the lungs throughout the procedure. General anesthesia is generally employed for the comfort of the patient, but topical anesthesia works as well. For local anesthesia, 4 percent lidocaine, given as an aerosol, is satisfactory. With the endotracheal tube in place, excellent ventilation is provided with suprisingly little discomfort in the awake patient. This permits easy removal and reintroduction of the bronchoscope while biopsies are taken or a lens is cleaned. Lymph Node Biopsy Scalene node biopsy and nwdiastinoscopy are performed at the same time on our services. A low transverse cervical incision from the midline to the external jugular vein gives good access to both areas. These …