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Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 69-72

Clinical relevance of using autofluorescence bronchoscopy and white light bronchoscopy in different types of airway lesions

Department of Respiration, School of Petroleum Clinical Medicine of Hebei Medical University, Langfang, China

Date of Web Publication13-Apr-2016

Correspondence Address:
Yan-Zong Zhang
Department of Respiration, School of Petroleum Clinical Medicine of Hebei Medical University, No. 51 Xinkai Road, Langfang - 065 000, Hebei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.147731

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 > Abstract 

Objectives: The aim of this study was to evaluate the sensitivity and specificity of autofluorescence bronchoscopy (AFB) according to the macroscopic appearance of airway lesions under white light bronchoscopy (WLB).
Materials and Methods: The bronchoscopic findings of 708 patients, who were pathologically and clinically diagnosed with airway lesions and underwent both WLB and AFB, were analyzed.
Results: We recruited 708 patients for this study, of which 336 (47.5%) had benign lesions; 300 and 254 benign lesions were detected by AFB (specificity, 89.3%) and WLB (specificity, 75.6%), respectively. In 372 (52.5%) patients with bronchiogenic carcinoma, 356 and 235 lesions were identified by AFB (sensitivity, 95.7%) and WLB (sensitivity, 63.2%), respectively. The sensitivity and specificity of AFB for diagnosing lung cancer were higher than those of WLB (P < 0.05). Moreover, AFB showed high sensitivity for detecting lung cancer in cases in which WLB revealed hyperplasia, infiltration, and stenosis (P < 0.05).
Conclusions: AFB combined with WLB could effectively improve the diagnosis of airway lesions.

Keywords: Autofluorescence bronchoscopy, endoscopic type, pathology, white light bronchoscope

How to cite this article:
Liu Z, Zhang Y, Li YP, Ma J, Shi F, Zhao DF, Li JM, Zhang YZ. Clinical relevance of using autofluorescence bronchoscopy and white light bronchoscopy in different types of airway lesions. J Can Res Ther 2016;12:69-72

How to cite this URL:
Liu Z, Zhang Y, Li YP, Ma J, Shi F, Zhao DF, Li JM, Zhang YZ. Clinical relevance of using autofluorescence bronchoscopy and white light bronchoscopy in different types of airway lesions. J Can Res Ther [serial online] 2016 [cited 2021 May 7];12:69-72. Available from: https://www.cancerjournal.net/text.asp?2016/12/1/69/147731

 > Introduction Top

The bronchoscope has evolved from a rigid device to a fiberoptic one and has played a pivotal role in the diagnosis and treatment of lung diseases, especially bronchiogenic carcinoma, during its 100-year history.[1] Lung cancer is associated with the highest mortality among malignant cancers.[2],[3] Most patients are in the advanced stage when the cancer is diagnosed because the mucosal surfaces often show no obvious abnormal changes in the early stage and the underlying tissue changes cannot be identified by white light bronchoscopy (WLB).[4] Further, the relationship among the WLB-based classification, histopathologic staging, and clinical features of lung cancer is difficult to grasp accurately.

Autofluorescence bronchoscopy (AFB) has considerably improved the detection rates of precancerous lesions, carcinoma in situ, and invasive cancer compared with WLB. Its sensitivity, specificity, lesion range, and relapse assessment for lung cancer are obvious advantages.[5],[6],[7],[8] However, the diagnostic values of AFB according to the characteristics of lung cancer under WLB have not yet been reported. The aim of this retrospective study was to evaluate the sensitivity and specificity of AFB according to the macroscopic appearance of airway lesions under WLB.

 > Materials and Methods Top


For this study, we enrolled 718 patients who were admitted to our hospital between January 2011 and December 2013, who underwent both AFB and WLB, and received a histopathologic or clinical diagnosis of airway lesions. After excluding 10 patients with other cancers, 708 patients were included in the analysis. The average patient age was 54.7 ± 15.0 (14–87) years, with 117 (16.5%) patients less than 40 years and 281 (39.7%) aged 40–59 years; the remaining (43.8%) were 60 years or older. Male patients constituted 63.1% of the study population.


The following classification was used to group WLB-based lesions [9]: (i) hyperplasia (e.g. granuloma, cauliflower-like appearance, node, mulberry-like appearance, or polyp), (ii) infiltration (e.g. ulcer, erosion, or bleeding), (iii) stenosis (e.g. external-pressure stenosis or intracavitary non-proliferative stenosis), and (iv) inflammation (e.g. hyperemia or edema).

The macroscopic findings using WLB were documented and classified into two categories [10]: (i) non-suspicious: normal appearance or non-specific changes such as general inflammation (e.g. acute reddening, thickening, or swelling), scars, or granulomas and (ii) suspicious: Malignant changes such as irregularity of the bronchial mucosa, nodular or polypoid lesions, and thickening of a carina. With the bronchoscope still in place in the trachea, the examination was repeated after changing the white light to fluorescence mode. Tissue autofluorescence during AFB was classified as follows.[11],[12],[13] AFB grade I, green fluorescence; AFB grade II, brown or dark red fluorescence; or AFB grade III, red fluorescence. Further, the lesions under AFB were divided into two categories, with grade I indicating a non-suspicious lesion and grades II and III indicating a suspicious lesion.


A fluorescent video bronchoscope (Olympus BF-F260, Olympus, Tokyo, Japan) was used for both WLB and AFB. Routine clinical and radiographic investigations were performed before the study. Fasting and drinking of water started at 2:00 p.m. on the preceding day. Before bronchoscopy, 2% lidocaine was used for local anesthesia. Arterial oxygen saturation and blood pressure were monitored and electrocardiography (ECG) was performed before and during the examinations.

Two experienced physicians performed WLB followed by AFB. For abnormal lesions, the lung tissues were obtained for analysis by performing biopsy, brush biopsy, or transbronchial needle aspiration cytology. The patients without bronchoscopic abnormalities underwent blind distal bronchial lung biopsy and/or brush biopsy, percutaneous lung biopsy, or lymph node biopsy according to the chest X-ray or CT findings. In routine biopsy, three to five specimens were collected per patient; in brush biopsy, three specimens were obtained to examine the exfoliated cells and one specimen was collected to detect acid-fast bacilli. All specimens were immediately fixed in anhydrous ethanol and were examined by an experienced pathologist.

Statistical analysis

The data are expressed as the mean and standard deviation and were analyzed by using statistical software (SPSS 17.0, SPSS, Inc., Chicago, IL). The McNemar test was used to compare the sensitivities of AFB and WLB for diagnosing lung cancer. P < 0.05 were considered statistically significant.

 > Results Top

Bronchoscopic findings

With regard to smoking history, 181 (25.6%) patients smoked with smoking index more than 400, 107 (15.1%) patients smoked with smoking index fewer than 400, and over half the study population (59.3%) had never smoked. Geographically, 329 (46.5%) patients lived in rural areas and the rest lived in urban areas.

According to the white light bronchoscopy, all lesions were divided into hyperplasia group, infiltration group, stenosis group and inflammation group. According to the autofluorescence bronchoscopy, all lesions were divided into grade I, II and III. The pathological results and the corresponding performance of WLB and AFB were shown in [Table 1]. In the 336 (47.5%) patients histopathologically diagnosed with benign lesions (inflammation, tuberculosis, etc.), 300 and 254 lesions were diagnosed as normal by AFB (specificity, 89.3%) and WLB (specificity, 75.6%), respectively. Further, in the 372 (52.5%) patients with bronchiogenic carcinoma, 356 and 235 lesions were diagnosed as abnormal by AFB (sensitivity, 95.7%) and WLB (sensitivity, 63.2%), respectively. The McNemar test revealed a significant difference in specificity and sensitivity for AFB and WLB in detecting bronchiogenic carcinoma (P < 0.05). The number of lung cancer and benign lesions according to the WLB-based lesion grouping is shown in [Table 2].
Table 1: Pathological results and the corresponding performance of WLB and AFB

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Table 2: Case grouping and pathological results

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Detection ability of AFB according to the WLB-based classification

Among the 209 (56.2%) cases of bronchiogenic carcinoma classified as hyperplasia, 207 were diagnosed as abnormal by AFB (sensitivity, 99.0%) and 178 were diagnosed as abnormal by WLB (sensitivity, 85.2%) (P = 0.00, P < 0.05). With regard to the 87 cases of infiltration, the sensitivities of AFB (85 abnormal cases) and WBL (77 abnormal cases) were significantly different (97.7% vs. 88.5%; (P = 0.021, P < 0.05).

In the stenosis group (63 cases), 55 and 47 cases were diagnosed as abnormal by AFB (sensitivity, 87.3%) and WLB (sensitivity, 74.6%), respectively (P = 0.21, P < 0.05). Finally, among the 13 cases of inflammation, nine cases were diagnosed as abnormal by AFB (sensitivity, 69.2%) and eight cases were diagnosed as abnormal by WLB (sensitivity, 61.5%), showing no significant difference between the methods (P = 1, P > 0.05). Comparison of WLB and AFB in different WLB groups in lung cancer patients is shown in [Table 3].
Table 3: Comparison of WLB and AFB in different WLB groups of lung cancer patients

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 > Discussion Top

The diagnostic performance of WLB varies, and the final diagnosis is based on the histopathologic and clinical diagnoses. Woolner et al.[14] reported that only 29% of carcinoma in situ cases are detectable by an experienced bronchoscopist. A WLB-based diagnosis is highly dependent on the operator's experience and is limited to examination by the naked eye.[15]

AFB detects fluorescence emitted by bronchial epithelial cells and evaluates the characteristics of lesions from the difference in green/red fluorescence intensity. Normal mucosa irradiated with UV light (wavelength, 442 nm) shows strong green fluorescence. In hyperplastic and tumorous tissues, red fluorescence is visible because green fluorescence is significantly weakened. Therefore, with AFB, the sensitivity for early diagnosis of lung cancer and precancerous lesions is significantly improved, the lesion can be easily located, and the boundaries of carcinoma in situ are clearly identifiable.[13],[16],[17] We used the histopathologic diagnoses to compare AFB and WLB. By using WLB, 254 of the benign lesions appeared as erosion, bleeding, chronic airway stenosis, node, polyp, or granuloma, but 18 cases were diagnosed as normal instead of abnormal. On the other hand, 300 benign lesions were correctly diagnosed by AFB.

Lung cancer evolves from a precancerous lesion to atypical hyperplasia, carcinoma in situ, and invasive carcinoma. Early lesions are not easily identifiable by WLB because they are small.[9],[18],[19] Pfannschmidt et al., and Chen et al.[6],[15] found that the 5-year survival rates of patients with stage Ia, Ib, IIb, and IIIa non-small cell lung cancer were 63-83.6%, 46-76%, 39-49%, and 19-35.8%, respectively, implying that early detection of precancerous lesions and carcinoma in situ is important. In our study, 372 (52.5%) lesions were diagnosed as bronchiogenic carcinoma by histopathologic and clinical examinations, including 149 cases of squamous cell carcinoma, 123 cases of adenocarcinoma, 95 cases of small cell carcinoma, and five cases of large cell carcinoma. WLB detected 235 cases of bronchiogenic carcinoma, with squamous cell, small cell, and large cell carcinomas appearing mainly as hyperplasia or infiltration and adenocarcinoma appearing as stenosis, infiltration, or hyperplasia.

Zaric et al.[7],[14] found that the sensitivity of AFB for diagnosing lung cancer was significantly better than that of WLB, and the sensitivity of WLB combined with AFB for severe atypical hyperplasia and canceration rose from 61.2% up to 89.9%.[20],[21] Further, Lee found that about 50% of the abnormal tissues under AFB exhibited relatively normal morphology even though the cellular genetic structures were abnormal because a follow-up study showed that lung cancer developed in these areas 8-33 months later. It could mean that AFB might be more sensitive than histopathology in the long term.[22] We found that 356 of 372 cases of early and late lung cancer were diagnosed by AFB, with a significant difference in sensitivity for diagnosis of bronchiogenic carcinoma between AFB and WLB. This result suggests that AFB is better than WLB for detecting even early bronchiogenic carcinoma.

The sensitivity of AFB for detecting hyperplasia, infiltration, or stenosis was significantly high, demonstrating over 95% sensitivity, especially for hyperplasia and infiltration. The results show that AFB can accurately diagnose the abnormal lesions detected by WLB, especially in the bronchial lumina, increasing the positive biopsy rate. The lack of a significant difference in sensitivity for detecting inflammation indicates that AFB offers no obvious advantage over WLB for the diagnosis of airway lesions appearing as inflammation.

In conclusion, AFB has more advantages than WLB for the diagnosis of bronchiogenic carcinoma and benign lung lesions. Importantly, its combination with WLB increases its sensitivity for detecting tracheobronchial lesions, which would improve the diagnosis rate of airway lesions and become indispensable in clinical practice.

 > References Top

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Sutedja G. New techniques for early detection of lung cancer. Eur Respir J Suppl 2003;39:57-66s.  Back to cited text no. 3
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Zaric B, Perin B, Becker HD, Herth FF, Eberhardt R, Jovanovic S, et al. Combination of narrow band imaging (NBI) and autofluorescence imaging (AFI) videobronchoscopy in endoscopic assessment of lung cancer extension. Med Oncol 2012;29:1638-42.  Back to cited text no. 7
Kennedy TC, Miller Y, Prindirille S. Screening for lung cancer revisited and t he role of sputum cytology and fluorescence bronchoscopy in a high-risk group. Chest 2000;117:72-9s.  Back to cited text no. 8
Häussinger K, Becker H, Stanzel F, Kreuzer A, Schmidt B, Strausz J, et al. Autofluorescence bronchoscopy with white light bronchoscopy compared with white light bronchoscopy alone for the detection of precancerous lesions: A European randomized controlled multicentre trial. Thorax 2005;60:496-503.  Back to cited text no. 9
Kenkichi O. Bronchofiberscopy in the diagnosis and treatment of pumonary Carcinoma. Department of Thoracic Surgery. Tokyo Medical College; 1975.  Back to cited text no. 10
Nakanishi K, Ohsaki Y, Kurihara M, Nakao S, Fujita Y, Takeyama K, et al. Color auto-fluorescence from cancer lesions: Improved detection of central type lung cancer. Lung Cancer 2007;58:214-9.  Back to cited text no. 11
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Zaric B, Stojsic V, Sarcev T, Stojanovic G, Carapic V, Perin B, et al. Advanced bronchoscopic techniques in diagnosis and staging of lung cancer. J Thorac Dis 2013;5:s359-70.  Back to cited text no. 13
Woolner LB, Fontana RS, Cortese DA, Sanderson DR, Bernatz PE, Payne WS, et al. Roentgenographically occult lung cancer: Pathologic findings and frequency of multicentricity during a 10-year period. Mayo Clin Proc 1984;59:453-66.  Back to cited text no. 14
Zaric B, Becker HD, Perin B, Stojanovic G, Jovelic A, Eri Z, et al. Autofluorescence imaging video bronchoscopy improves assessment of tumor margins and affects therapeutic strategy in central lung cancer. Jpn J Clin Oncol 2010;40:139-45.  Back to cited text no. 15
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Sun J, Garfield DH, Lam B, Yan J, Gu A, Shen J, et al. The Value of autofluorescence of bronchoscopy combined with white light bronchoscopy compared with white light alone in the diagnosis of intraepithelial neoplasia and invasive lung cancer: A meta-analysis. J Thorac Oncol 2011;6:1336-44.  Back to cited text no. 17
Read C, Janes S, George J, Spiro S. Early lung cancer: Screening and detection. Prim Care Respir J 2006;15:332-6.  Back to cited text no. 18
Escarguel B, D'Amore D, Chapel F, Bec J, Audigier-Valette C, Lahlah H, et al. Early diagnosis of lung cancer: Impact of autofluorescence bronchoscopy. Rev Pneumol Clin 2009;65:287-91.  Back to cited text no. 19
Venmans BJ, Boxem TJ, Smit EF, Postmus PE, Sutedja TG. Outcome of bronchial carcinoma in situ. Chest 2000;117:1572-6.  Back to cited text no. 20
Ohtani K, Lee AM, Lam S. Frontiers in bronchoscopic imaging. Respirology 2012;17:261-9.  Back to cited text no. 21
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  [Table 1], [Table 2], [Table 3]


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