Preoperative bronchoscopic assessment of airway invasion by esophageal cancer: A prospective study

Background: Bronchoscopy is frequently used to assess invasion of esophageal cancer into the tracheobronchial tree. Prospective studies evaluating the role of bronchoscopy in pretherapeutic staging of esophageal cancer are lacking. Study objectives: To evaluate the diagnostic utility of fiberoptic bronchoscopy for the assessment of airway involvement by esophageal carcinoma and its resectability. Patients and methods: In a prospective study, we analyzed 150 bronchoscopies in 116 consecutive patients with potentially operable esophageal carcinoma, and correlated the findings with other staging modalities, intraoperative evaluation, and histopathologic data. Results: One unknown additional bronchial cancer was found. In 32% of bronchoscopies performed in patients with esophageal cancer located above the tracheal bifurcation, some macroscopic abnormality was detected in the trachea and main bronchi, with mobile protrusion of the posterior tracheal wall being the most frequent abnormality (20.7%). When compared with histologic results, normal macroscopic appearance of the trachea and main bronchi had a negative predictive value of 98.5%, but the positive predictive value of all macroscopic abnormalities for the diagnosis of airway involvement was low, particularly after radiation therapy. The overall accuracy of bronchoscopy with multiple brush cytology and biopsy sampling in proving or excluding airway invasion in patients with otherwise operable conditions was 95.8% (95% confidence interval, 88.3 to 99.1%). Bronchoscopy was the sole decisive staging procedure, resulting in exclusion from surgery because of airway invasion, in 9.7% of patients with otherwise potentially operable conditions. The results of bronchoscopy and CT were discordant in 40% of the patients; the specificity and positive predictive value were higher for bronchoscopy than for CT. Conclusions: When Performed as the last investigation in the staging workup, bronchoscopy with biopsy and brush cytology is a very accurate procedure in evaluating possible airway invasion of esophageal cancer; macroscopic findings alone are not reliable.