Invasive Diagnostic Procedures from Bronchoscopy to Surgical Biopsy-Optimization of Non-Small Cell Lung Cancer Samples for Molecular Testing

Abstract

Background and Objectives: Treatment of advanced lung cancer (LC) has become increasingly personalized over the past decade due to an improved understanding of tumor molecular biology and antitumor immunity. The main task of a pulmonologist oncologist is to establish a tumor diagnosis and, ideally, to confirm the stage of the disease with the least invasive technique possible. Materials and Methods: The paper will summarize published reviews and original papers, as well as published clinical studies and case reports, which studied the role and compared the methods of invasive pulmonology diagnostics to obtain adequate tumor tissue samples for molecular analysis, thereby determining the most effective molecular treatments. Results: Bronchoscopy is often recommended as the initial diagnostic procedure for LC. If the tumor is endoscopically visible, the biopsy sample is susceptible to molecular testing, the same as tumor tissue samples obtained from surgical resection and mediastinoscopy. The use of new sampling methods, such as cryobiopsy for peripheral tumor lesions or cytoblock obtained by ultrasound-guided transbronchial needle aspiration (TBNA), enables obtaining adequate small biopsies and cytological samples for molecular testing, which have until recently been considered unsuitable for this type of analysis. During LC patients' treatment, resistance occurs due to changes in the mutational tumor status or pathohistological tumor type. Therefore, the repeated taking of liquid biopsies for molecular analysis or rebiopsy of tumor tissue for new pathohistological and molecular profiling has recently been mandated. Conclusions: In thoracic oncology, preference should be given to the least invasive diagnostic procedure providing a sample for histology rather than for cytology. However, there is increasing evidence that, when properly processed, cytology samples can be sufficient for both the cancer diagnosis and molecular analyses. A good knowledge of diagnostic procedures is essential for LC diagnosing and treatment in the personalized therapy era.

Keywords: advanced lung cancer; bronchoscopy; liquid biopsies; rebiopsy; tumor molecular biology.

Figure 1

Endoscopy visible tumor in the right main bronchus [17].

Figure 2

Transbronchial cryobiopsy of the peripheral LC. (A)—endoscopic view of the cryoprobe; (B,C)—macroscopic view of cryobiopsy [23].

Figure 3

Radial EBUS (A). Axial computed tomography scans of the chest and ultrasound images related to the location of the radial probe endobronchial ultrasound (B). Upper images—RP within the lesion. Bottom pictures—RP near the lesion [29].

Figure 4

Axial chest computerized tomography (CT) scans (A) and a convex probe—EBUS transbronchial needle aspiration (B) of the right paratracheal lymph node and the central lung mass [29].

Figure 5

CT image of transthoracic needle puncture (TTNA) of the left lung tumor lesion [50].